Peach Pulse Archive 2014

Health Insurance Hot Topic Update: Network Adequacy

With open enrollment in full swing, Georgia consumers are once again exploring their health insurance options and signing up for coverage. When consumers enroll in a health insurance plan, they gain access to a network of medical providers with whom their insurer has contracted. For health insurance to facilitate meaningful access to care, this network of providers must be adequate to ensure that consumers enrolled in the plan have reasonable access to all covered benefits and services. In a recent issue of the Peach Pulse, we provided a primer on network adequacy, a hot topic in health policy (click here to get caught up on what network adequacy means and why it matters for consumers, advocates, and policymakers). In that overview, we promised to keep you updated on policy developments around network adequacy, in particular the ongoing process at the National Association of Insurance Commissioners (NAIC) to update its model law. This model law can provide a framework for states to establish and enforce standards to ensure that provider networks are adequate. At its fall meeting in November, the subgroup at the NAIC working on network adequacy announced it would take comments on an initial draft of proposed revisions for the model act until January 12, 2015. To learn more about this process and to see the draft, click here.

To ensure the needs of consumers are considered in this process, the NAIC consumer representatives released a report featuring the results of a survey of state Departments of Insurance and recommendations for state policymakers, regulators, and the NAIC to consider as they work on updating network adequacy standards. These recommendations include:

• Establish quantitative standards for meaningful, reasonable access to care, such as minimum provider-to-enrollee ratios, reasonable wait times for appointments based on urgency of the condition, and distance standards that require access to network providers within a reasonable distance from the enrollee’s residence.

• Ensure consumers are provided sufficient information to identify and select between broad, narrow or ultra-narrow networks. In areas without sufficient choice, require health plans to offer at least one plan with a broad network or an out-of-network benefit, with limited exceptions to be determined by the Commissioner.

• Require health plan provider directories to be updated regularly, publicly available for both enrolled members and individuals shopping for coverage, and include standards for information that must be included to provide consumers with information on network differences and the potential financial impact on consumers depending on which plan they choose.

There are 17 recommendations in all. For advocates interested in learning more about this issue and in speaking up for consumers in this process, see the full report here.

If you would like to weigh in at the state level, please contact Georgia’s Department of Insurance and ask the Commissioner to support the NAIC’s process to revise the model act and specifically to support the consumer recommendations described above.

If you are an individual consumer enrolled in a commercial health plan and the provider directory you were given was incorrect or if you have concerns about your ability to access covered services under your plan, please contact the Georgia Office of Insurance & Fire Safety, Consumer Services Division by calling (800) 656-2298 or use the Consumer Complaint Portal at www.oci.ga.gov/ConsumerService. Please also consider sharing your story with Georgians for a Healthy Future so we can get a better picture of what is happening in our state.

Rural Hospital Stabilization Committee: Your voice is needed!

We’re hoping you read our report released two weeks ago to the Rural Hospital Stabilization Committee (RHSC) on how closing the coverage gap can help save our rural hospitals.  (And if you didn’t – here is it!)  This Friday, the RHSC is taking public comment and your voice is needed!  You may register to make comments when you arrive at the meeting. Comments will be presented on a first come, first serve basis. No power points, but handouts (should you be so inclined) are allowed.  If you interested in commenting, but are unsure of how to best shape your argument, feel free to reach out to Laura Colbert, GHF’s Community Outreach Manager.  Even if you aren’t comfortable speaking, please show up and show your support!  Details are below.

Location: Two Peachtree Street.  5^th floor.  Located on the corner of Peachtree Street and Marietta Streets.  The Five Points MARTA Station is just south of Two Peachtree.

Time: 10:00 AM to 1:00 PM

Connecting Georgians to Coverage: GHF partners with the Bhutanese Association of Georgia to get people covered

Every Saturday morning, many Bhutanese immigrants gather at their temple in Clarkston for SAT prep, U.S. citizenship, and English classes.  Recently, Laura Colbert, Georgians for a Healthy Future’s Community Outreach Manager, joined them to provide information about health care coverage and the Affordable Care Act’s open enrollment period.  With the help of a translator, Laura spoke with approximately twenty community members about the benefits of health care coverage, how to get covered, and where to find affordable medical care if they were not eligible for coverage. She also answered their questions about health care coverage for their children and Medicaid.  (In return, Laura learned quite a bit about Bhutanese culture.)

This educational event was the product of a partnership with the Bhutanese Association of Georgia (BAG), which works to integrate Bhutanese refugees into life in Georgia. GHF and BAG have been working together over the past year to educate the Atlanta-based Bhutanese community about health care coverage and to increase health coverage enrollment.  In addition to educational events, several fact sheets have been created by GHF and translated into Nepalese to be distributed in the community.

Georgians for a Healthy Future continues to work to increase enrollment among all Georgians, especially in communities that may need extra education or encouragement to enroll.

Medicaid Minute: Who qualifies?

Each state has slightly different eligibility criteria for Medicaid.  When we talk about closing the coverage gap– as 28 other states have either through Medicaid expansion or a state-specific 1115 waiver – it’s important that we all know just who is (and isn’t) eligible for Medicaid today in Georgia and who could gain coverage if we close that gap.

• Very low income parents. Medicaid is offered to parents who make up to 40% of the Federal Poverty Level (FPL).  For a family of four, parents with income up to $9,036 annually or $753 per month can receive health coverage through the Medicaid program.
• Pregnant Women. Pregnant women who earn up to 220% FPL.  For a family of four, a pregnant woman with income up to $52,488 would be eligible for Medicaid
• Most Children. Children are covered at varying income limits based on their age and family size. The Children’s Health Insurance Program (CHIP), known as PeachCare for Kids in Georgia, is layered on top of the Medicaid program. Together, these programs provide coverage to children in families with incomes up to 247% of the FPL.  For a family of four, that’s $58,932 annually.
• The low-income elderly. In addition to Medicare, many, but not all, low income elderly adults whose income is less than $25,560 per year qualify for Medicaid.
• Low-income women diagnosed with breast or cervical cancer.
• Aged, Blind, and Disabled. With varying income limits, those who receive Social Security Income, live in a nursing home, or community care center qualify.
• Qualified Medicare Beneficiaries. These are the aged, blind or disabled who have hospital insurance and have incomes below 100% FPL.  Medicaid will cover some of their Medicare expenses.
• Low-income Terminally Ill. Those with an annual income of less than $25,956 and who are expected to live less than six months.

*Numbers are pulled from the GA Department of Community Health and Peach Care for Kids webpages.

Nykita Navigates

Nearly half a million people enrolled in health insurance through the federal marketplace in the first week of open enrollment!  The deadline for January 1st coverage is fast approaching: December 15^th.  Don’t miss out!  If you need in person assistance, please see the below events or contact Nykita at 404-567-5016 or nhowell@healthyfuturega.org.

Upcoming events:

January 19:  15th Annual United Ebony Society MLK Day Celebration and Health Fair (Lawrenceville, GA)

Recurring events:

Cobb County Public Health (Marietta, GA) Every Tuesday, Starting November 18, 2014 and ending February 10, 2015 (with the exception of November 25, 2014)

Clarkston Library, DeKalb County (Clarkston, GA) Every Thursday, Starting November 20, 2014 and ending February 12, 2015

Fayette County Library Presentation (Fayetteville, GA) December 8, 2014; January 12, 2015, and February 2, 2015

Events are subject to change, and new events are added all the time – check back here regularly for updates!