When consumers enroll in a health insurance plan, they gain access to a network of medical providers. Insurance companies contract with a range of providers, including both primary care and specialty physicians, to deliver health care services included within the plan’s benefit package. This network of providers must be adequate to ensure that consumers enrolled in the plan have reasonable access to all covered benefits. This is what is meant by network adequacy. More specifically, to be considered adequate, a network must provide adequate numbers, types, and geographic distribution of providers; must ensure that access to care is timely; and must include essential community providers that serve predominantly low-income, medically underserved individuals. Additionally, accurate information about providers must be made available to consumers.

Network adequacy has become a hot topic over the past several months because many consumers who enrolled in new health plans through the Health Insurance Marketplace found that their plan came with a narrow network of providers. Provider directories weren’t always accurate or up-to-date, and consumers expressed a fair amount of confusion over which providers were in their plan’s network.

At the same time, the National Association of Insurance Commissioners (NAIC), which develops model laws and rules that states often adopt, has been working to update its network adequacy model law. Stakeholders ranging from insurers to medical providers to patient and consumer advocates are weighing in on this process, making network adequacy a hot topic in the policy arena too. Georgians for a Healthy Future has been monitoring this process through the participation of our executive director as one of the consumer representatives to the NAIC. Earlier this summer, the consumer representatives submitted comments to the NAIC focusing on developing a stronger standard and better oversight of network adequacy, an end to “balance billing” by out-of-network providers in in-network facilities, and greater transparency of provider networks.

Georgians for a Healthy Future will continue to monitor this process and will advocate at all levels, in conjunction with state and national partners, to ensure consumers have meaningful access to care.

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.

For more information on network adequacy, please see the following reports and resources:

From Georgetown Center on Health Insurance Reforms: Reforming State Regulation of Provider Networks: Efforts at the NAIC to Re-Draft a Model State Law

From Robert Wood Johnson Foundation and Georgetown University Health Policy Institute: ACA Implications for State Network Adequacy Standards

From Families USA: Network Adequacy and Health Equity: Improving Private Health Insurance Networks for Communities of Color

The following opinion piece by Georgians for a Healthy Future’s Executive Director Cindy Zeldin originally appeared in today’s Atlanta Journal-Constitution.

Large majorities of young adults say they need and value health insurance, yet people in this age group are far more likely to be uninsured than children, seniors or older adults. Thirty-five percent of Georgians between 18 and 34 are uninsured. How can something so important be so elusive?

Until now, the health insurance of millenials had largely been neglected by public policy, leaving them with few options that provided adequate benefits at an affordable cost.

Most Americans get health insurance as a workplace benefit. They get a substantial employer contribution and receive these benefits on a pre-tax basis. Today’s young adults, however, are entering the job market in a tough economy. They are less likely to land jobs with health insurance. They often cobble together internships and part-time work to gain experience and make ends meet. For too many young adults, there simply has been no viable pathway to coverage.

The tide is turning. An estimated 3.1 million young adults nationwide — and 123,000 here in Georgia — have gained coverage as a direct result of an Affordable Care Act provision that allows parents to keep their children on policies up to age 26. This popular and effective public policy change was just a first step. The new health insurance exchanges will provide options for young adults who previously had nowhere to go.

These plans provide decent benefits and, in many cases, access to tax credits to make them affordable. The tax credits, available to individuals with annual incomes between $11,490 and $45,960, can be taken either at the time health insurance is purchased or at tax time. Some moderate-income individuals also can get help with out-of-pocket expenses.

For millenials who had been underwhelmed with the health insurance options available to them in the past, this is a breath of fresh air. For example, maternity coverage had been nearly impossible to secure in the Georgia non-group market for young couples ready to start a family. Now, this important benefit will be available.

While it is true some young adults enrolled in old plans may see higher premiums, many of those old plans didn’t provide adequate protection. Further, young adults who had a pre-existing chronic helath condition were locked out of the market entirely, a practice insurance companies must discontinue.

 The private insurance plans available through the exchanges won’t meet the needs of all young adults in Georgia. Those who have incomes that place them below the poverty line will likely remain uninsured unless Georgia expands its Medicaid program.

Most young adults want what Americans of all ages want: the peace of mind that comes with knowing that an unexpected cancer diagnosis or accident doesn’t equal financial ruin, and that they have access to basic medical services. The new coverage options are finally leveling the playing field for this generation. It’s about time.

Georgia ranks 9th in the nation in the number of uninsured adults with a mental illness who could gain coverage through the Medicaid expansion, according to a new report from the National Alliance on Mental Illness (NAMI). The NAMI report describes the barriers that people with mental illness face in accessing services and the important role that Medicaid plays in connecting people to services so they can be healthy and productive members of their communities. Expanding Medicaid in Georgia is a major opportunity to change the lives of more than 86,000 low-income uninsured adults with mental illness in Georgia–if you haven’t already, please sign the petition in support of expanding Medicaid in Georgia and join us in our campaign to Cover Georgia!  The full NAMI report on Medicaid and mental health is available here.

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The 2013 Legislative Session continues at a swift pace, with legislators in session today for day 17 of the 40-day session (the legislative calendar is available here). Here are some key health care updates:

• Yesterday, the Health Subcommittee of the House Appropriations Committee heard from the Commissioners of the state’s health-related agencies, including the Department of Community Health and the Department of Public Health, about their proposed FY 2014 budgets. Today, the subcommittee will meet again from 2 – 4pm in Room 506 CLOB to take public comment on the proposed budgets. If you would like to comment, you must sign up in advance in Room 245 of the State Capitol. The Georgia Budget & Policy Institute has released an analysis of the 2014 proposed budget for the Department of Community Health, available here.

• SB 24, which would authorize the Department of Community Health to levy a fee on hospitals to continue drawing down federal funds to support Medicaid and PeachCare for Kids, was passed by both the House and Senate and is expected to be signed into law by the Governor this morning. The current hospital fee is set to expire on June 30, 2013. The renewal of the fee is essential to ensuring Medicaid and PeachCare’s solvency and preserving access to hospital care in Georgia.

• HB 198 would require navigators to be licensed, place certain restrictions on their functions, and would give the Georgia Insurance Commissioner regulatory authority over them. Navigators are organizations or entities that apply for and receive federal grants authorized by the Affordable Care Act to provide individuals and small businesses with impartial information and assistance with enrollment in health coverage in the new health insurance marketplaces, or exchanges. While it is important that navigators are qualified to perform these functions and that there is adequate oversight to protect consumers, consumer advocates are also concerned that overly restricting navigators could have a chilling effect on the community-focused organizations whose participation in the navigator program will be critical in connecting hard-to-reach and vulnerable populations to coverage. Advocates worked with legislators to improve the bill, which passed the House Insurance Committee last week and was passed by the Rules Committee yesterday.

Last week, state agency heads presented Governor Deal’s proposed budgets for their respective agencies to the House and Senate Appropriations committees.

Access to care: the good news
Primary care providers will receive an increase in Medicaid reimbursement rates to parity with Medicare rates, funded entirely with federal dollars made available to Georgia through the Affordable Care Act. This can help preserve and strengthen access to care for Medicaid patients seeking primary care and prevention services.

Access to care: the bad news
The Department of Community Health’s proposed budget would reduce provider reimbursement rates within Medicaid by .74 percent for providers other than hospitals, primary care, FQHC, RHC, and hospice providers. This proposed rate cut, if implemented, could jeopardize access to care for Medicaid patients who require services such as dental care, obstetrics and gynecology, and oncology, among other non-primary care services.

The Department of Community Health’s proposed budget can be found here. Please contact your legislators and ask them to preserve access to care by restoring these important funds in the state budget.

Hospital fee renewal moves through the Legislature
SB 24, which would authorize the Department of Community Health to levy a fee on hospitals to continue drawing down federal funds to support Medicaid and PeachCare for Kids, has passed the State Senate and will be before the House of Representatives for a vote today. The current hospital fee is set to expire on June 30, 2013. The renewal of the fee is essential to ensuring Medicaid and PeachCare’s solvency and preserving access to hospital care in Georgia.

Georgians for a Healthy Future and more than 40 organizations launched an education and advocacy campaign this week is support of expanding Medicaid in Georgia. Below is our announcement about Cover Georgia’s launch. Please contact us if you’d like to join the coalition.

COVER GEORGIA COALITION LAUNCHES EFFORT TO ENSURE THAT THE STATE MOVES FORWARD WITH THE MEDICAID EXPANSION

ATLANTA, Ga., January 10, 2013 – More than 40 organizations – including healthcare providers, hospitals and healthcare advocates – announced today the creation of a coalition in support of expanding Medicaid to Georgians with incomes below 133 percent of the federal poverty level as authorized by the federal health care reform law, the Affordable Care Act (ACA).

Called Cover Georgia, the coalition is spearheaded by Georgians for a Healthy Future and is comprised of a wide range of healthcare stakeholders, including the Georgia Rural Health Association, the Georgia Academy of Family Physicians, AARP Georgia, the American Cancer Society, among many others.

Enacted by Congress in 2010, the Affordable Care Act included the Medicaid Expansion provision, which would provide the states with billions of dollars in new federal funds to enroll currently uninsured citizens in their Medicaid programs.  In Georgia, expanding the program is projected to cover approximately 650,000 Georgians and to bring approximately $33 billion in federal funds into the state over ten years.  For the first three years of the expansion, the federal government will fund 100 percent of the new cost; after that, the states would be required to cover no more than 10 percent of the total cost from 2020 onward.

Cover Georgia will make the case that expanding Georgia’s Medicaid program and leveraging the billions of dollars in federal resources will improve access to care, strengthen the state’s health care delivery system, and bolster Georgia’s economy.  “This is an unprecedented opportunity to impact the lives of hundreds of thousands of Georgians and we simply cannot pass up this opportunity,” said Amanda Ptashkin, outreach and advocacy director for Georgians for a Healthy Future, the organization spearheading the coalition work.

 
When the U.S. Supreme Court decided the constitutionality of the ACA in 2012, it ruled that states could not be compelled to participate in the Medicaid Expansion.   So far, Governor Deal has said he does not plan to move forward with the expansion in Georgia, expressing concerns about the state budget and the long-term fiscal outlook at the federal level.

“Cover Georgia is a statewide education and advocacy campaign focused on spotlighting both the critical role that Medicaid plays within Georgia today and the opportunity that implementing an expansion of the program presents for consumers, the health care system, and our state’s economy,” said Cindy Zeldin, executive director of Georgians for a Healthy Future. “Covering the lowest-income uninsured through Medicaid will provide access to the basic prevention and treatment services that uninsured Georgians lack today and will pump an infusion of federal dollars into our state’s health care economy.”

“Other states across the country are saying yes to the Medicaid expansion and are investing in their state’s health care delivery systems with federal taxpayer dollars paid by Georgians. Georgia cannot afford to maintain the status quo while other states invest heavily in their health systems. Doing so will further compound regional health disparities and limit Georgia’s ability to compete in the long-run.”

Matt Caseman, of the Georgia Rural Health Association, agrees that in addition to the overall economy, the expansion will help rural Georgia. “Expanding Medicaid will provide thousands of rural Georgians, who don’t have health insurance, access to a primary care doctor and preventative medicine. It will help reduce the burden of uncompensated care and keep the doors open for our safety net providers. This initiative is critical to not only the health of Georgia’s rural communities, but our state’s overall economic success as well.”

Tim Sweeney, of the Georgia Budget & Policy Institute, believes that access to affordable health coverage is one of the most pressing health care issues facing the state. “Expanding Medicaid to cover hundreds of thousands of low-income Georgians is one of the most cost-effective ways to address the issue. Implementing the expansion will enable more Georgians to access needed health care, while boosting Georgia’s economy by bringing billions in new federal funding for doctors, hospitals, pharmacies and other health care providers throughout the state.”

The consequences of this decision will affect hundreds of thousands of Georgians.  AARP Georgia State Director, Greg Tanner, points out that, “there are 127,000 Georgians in their 50s or early 60s who make less than $15,000 a year and have no health insurance. Expanding Medicaid to cover them would make them more productive and in the first three years pump $8 billion into Georgia.  That money will go directly to doctors, hospitals, clinics and other health care providers.  We can’t afford not to expand coverage.”

If the state decides to forgo expanding the Medicaid Expansion, those individuals who earn more than our current eligibility levels but less than 100% FPL (Federal Poverty Level) will have no options for coverage and would not qualify for subsidized coverage in the state’s health insurance exchanges.  Those individuals will fall into a coverage gap.

The Cover Georgia coalition will continue to work on educating the public, key decision-makers and others on the importance of the expansion and what it means for our citizens.  Individual consumers, health care professionals, policy-makers and others can learn more about Georgia’s Medicaid program and what the expansion would mean for thousands of Georgians by visiting Cover Georgia’s website at www.coverga.org.

Each year, Georgians for a Healthy Future develops policy priorities that guide our advocacy work on behalf of health care consumers. Below are the legislative and policy priorities we are supporting in 2013.

Extend health insurance coverage to a substantial portion of Georgia’s uninsured by expanding Medicaid. Approximately 1.9 million Georgians are uninsured, many of whom are low-income working adults without access to an employer-sponsored health plan. An estimated 650,000 of these Georgians could gain health insurance coverage in 2014 at minimal state cost by extending Medicaid to those newly eligible through the Affordable Care Act. The infusion of federal Medicaid dollars into Georgia will both support our state’s health care delivery system and foster economic growth. Georgians for a Healthy Future supports expanding coverage through Medicaid to individuals and families with incomes up to 133 percent of the federal poverty level.

Preserve and strengthen consumer protections for Georgians in private health insurance plans through both federal and state advocacy. The private health insurance marketplace is rapidly evolving, largely as a result of changes spurred by the Affordable Care Act. As these reforms are implemented, it is critical that the consumer perspective is represented in the policy-making process and that rules and regulations incorporate consumer needs. Many of the decisions that would impact health care consumers are currently being made by the U.S. Department of Health and Human Services and the National Association of Insurance Commissioners. To that end, Georgians for a Healthy Future will monitor and advocate on behalf of Georgia consumers on issues including the development of a federal health insurance exchange, essential health benefits, and other private market reforms. At the same time, Georgia policymakers retain authority over many aspects of our state’s health insurance marketplace. Georgians for a Healthy future will continue to support efforts that preserve and strengthen patient and consumer protections and oppose state legislation that places these protections at risk.

Ensure access to quality health care for Medicaid and PeachCare beneficiaries. The Medicaid and PeachCare for Kids programs provide health insurance for our state’s most vulnerable citizens. Georgians for a Healthy Future will monitor legislative and agency level activity and support proposals that facilitate continuous coverage and enrollment, preserve and expand access to care, and improve health outcomes. Because ensuring access to quality care for Medicaid and PeachCare beneficiaries also requires a Medicaid system that is financially sound, Georgians for a Healthy Future will support proposals that ensure the program is adequately funded and will oppose cuts to the program, including cuts to provider reimbursement rates, which jeopardize access to care. We will also continue to monitor the Georgia Department of Community Health’s Medicaid redesign process.

Strengthen Georgia’s public health system. Our state’s public health system plays a critical role by vaccinating children, monitoring and preventing epidemics, ensuring safe food and water, and providing both clinical and community-based preventive services. Despite an increasing need for these services and a growing awareness of the importance of social determinants to community health outcomes, Georgia’s per capita public health spending is among the lowest in the nation. Georgians for a Healthy Future supports a robust, adequately funded public health system to meet the needs of our state.

Increase the tobacco tax. The current funding environment demands evidence-based policy solutions that both advance the health of our state and generate needed revenue. In recent years, even the most basic, vital, and cost-effective programs have been subject to deep budget cuts. Georgians for a Healthy Future opposes further cuts to these vital programs and supports budget solutions such as a substantial increase in the state’s tobacco tax of at least a dollar per pack. Tobacco taxes are a proven strategy with the dual benefit of bringing in additional state revenue and improving the health of Georgians by reducing adult and youth smoking.

Support policies and practices that advance health equity. In addition to overall health outcomes and indicators that consistently place Georgia in the bottom tier nationally, our state has considerable health disparities between communities. Racial and ethnic minority communities, rural and low-income urban communities, and those with disabilities and chronic mental illness, all experience worse health and worse opportunities for health than their peers. Georgians for a Healthy Future will continue to support policies and practices that advance the opportunities for optimal health for all Georgians.

Georgians for a Healthy Future is a proud partner in the Specialty Tiers Coalition of Georgia, a group of consumer and patient advocates committed to ensuring affordable access to medications for patients with rare, chronic conditions. Earlier this month, the coalition hosted an educational forum at Emory University in Atlanta to raise awareness among policymakers and consumers about the growing trend of specialty tiers and the related risks to patients and consumers.

According to RheumatoidArthritis.org, specialty drugs are typically breakthrough prescription drugs that are used to treat complex, chronic health conditions such as cancer, multiple sclerosis, rheumatoid arthritis, hemophilia, and HIV/AIDS (remember the odds of contracting hiv). Traditionally, insurance plans cover prescription drugs on a 3-tiered drug formulary (Tier One: generic drugs; a typical co-pay is around $10; Tier Two: preferred brand name drugs; a typical co-pay is around $30; Tier Three: non-preferred brand drugs; a typical co-pay is around $50) These drugs can also have a second effect on you, in this center people get treated when they become addicted to any drugs and substances.
. Specialty tiers, also known as Tier IV, V, or VI, add an additional structure for specialty medications — cost sharing known as “co-insurance” — where the patient pays 20-35% of the cost of the medication, rather than a fixed, predictable co-payment.  Unfortunately, there is no limit on what a beneficiary may be required to pay for therapies relegated to specialty tiers.

The trend towards specialty tiers shifts costs to patients and places needed treatment out of reach for too many patients who are paying health insurance premiums to get the medical care they need, some need this special serums for your eyes and they are not receiving it.  Specialty tiers can result in drug costs well into the thousands of dollars per month for patients, increasing the likelihood that patients will go without needed treatment. In fact, a recent study found that one in four patients with an out-of-pocket prescription cost of $500 or more failed to fill their prescriptions. This indicates patients with insurance are having to choose between needed medications and everyday living expenses.

The Specialty Tiers Coalition will be active in the upcoming 2013 Legislative Session to grow awareness about this issue, and advocate for patient protections. Georgians for a Healthy Future and the coalition are currently serving as a community partner to the Health Legislation & Advocacy course at Georgia State University’s College of Law. Through this partnership, law students are providing research assistance and helping craft potential legislation to ensure adequate patient protections.

To read coverage of the October 10^th forum at Emory University, click here and here. To download a fact sheet on this issue from a coalition leader, Advocates for Responsible Care, click here.

Earlier this year, Governor Deal signed into law House Bill 1166 to restore child-only health insurance plans to the Georgia marketplace. The legislation was sponsored by Representative Atwood and supported by a broad coalition of consumer health advocates, health care industry stakeholders, and legislators, including Georgians for a Healthy Future. The law goes into effect on January 1, 2013, and will make standalone insurance policies for children available through an open enrollment period in January or in the event of a qualifying event throughout the year. The Georgia Department of Insurance is currently preparing the draft regulation, after which there will be a public comment period with the final regulation expected in December.

Several states around the country have taken similar action to make these plans available for children, and earlier this month the Commonwealth Fund issued a report examining legislative and regulatory efforts around the country during 2010 and 2011 and found that, in states that had taken action during those years, child-only coverage is now available in nearly all of those states. Since Georgia’s legislation was passed in 2012 and has not yet gone into effect it was not included in the analysis; however, the authors interviewed officials and advocates in Georgia and noted that legislation had been signed into law in 2012. Kaiser Health News also reported on the story last week. That article is available here. The study is available here.

This commentary originally appeared in the Atlanta Journal-Constitution on September 6th, 2012.

By Cindy Zeldin

Nearly 2 million Georgians are uninsured; that number is among the highest in the nation.

Georgia policymakers have long recognized this problem as a tragic reality for the one in five Georgians who struggle to access medical care when they need it, as a strain on our state’s health care delivery system, and as a weight on Georgia’s economy.

Until now, however, they haven’t had the tools and resources to comprehensively address it.

What has changed?

The Affordable Care Act  put in place a basic framework to ensure that all Americans have a pathway to affordable health care coverage. This framework has three key components. First, those of us who get health insurance at work as an employee benefit will continue to do so.Second, new health insurance marketplaces, or “exchanges,” will come on line in just over a year to help consumers who don’t have employee coverage at work find an affordable health plan that meets their needs. Third, a new category of eligibility for Medicaid was created for the lowest-income consumers, many of whom work in low-wage jobs that don’t come with health insurance, yet earn too little money to afford a private health insurance policy.

In June, the U.S. Supreme Court upheld the constitutionality of the Affordable Care Act but ruled that states could choose whether or not to implement that third component, the Medicaid expansion.

Covering the lowest-income uninsured through Medicaid will provide access to basic prevention and treatment services that uninsured Georgians lack today. A landmark study published last year by the National Bureau of Economic Research found that people who gained coverage through Medicaid were more likely to access preventive services and have a usual source of care than their uninsured counterparts. A study published in the New England Journal of Medicine found that states that expanded Medicaid saw lower mortality rates, even after taking into account a range of other factors, than their neighboring states who did not.

In other words, if you want to improve health care outcomes, expanding Medicaid is a proven way to accomplish this goal.

The benefits to Georgia of expanding Medicaid go far beyond the 650,000 uninsured Georgians who stand to gain coverage. Because the Medicaid expansion is financed almost entirely with federal dollars, an infusion of resources will be pumped into our state’s health care delivery system.

If Georgia expands Medicaid, we stand to draw down approximately $14.5 billion in federal funds over the six-year period between 2014 and 2019, according to an analysis by the Urban Institute. In fact, Georgia taxpayers are already contributing towards the cost of the Medicaid expansion. It’s just a question of whether some of that money comes back to Georgia or whether we leave it on the table and allow it to be diverted to other states.

Last week, Gov. Nathan Deal announced that he did not intend to move forward with the Medicaid expansion, expressing concerns about the federal government’s long-term fiscal outlook. Just last month, states received word that they have an important element of flexibility: They can implement the Medicaid coverage expansion and, after a few years, if it isn’t working for them, they can withdraw.

There is no reason why Georgia can’t take advantage of the tools and resources before us to invest in our state’s health care economy today  and revisit our participation periodically to ensure that the federal government is meeting its end of the bargain and that the program works.

We have an unprecedented opportunity to improve the health of Georgia patients and consumers, strengthen our state’s health care delivery system, and bolster the state’s economy by moving forward with the Medicaid expansion.

Georgia policymakers should seize the moment and invest in our future.