NOSORH Comments on CMS 2019 Draft Letter to Issuers
The Centers for Medicare and Medicaid Services (CMS) issued a 2019 Draft Letter to Issuers in the Federally-facilitated Exchanges. This set of proposals addresses a wide range issues related to Qualified Health Plans (QHPs) offered on federally facilitated health exchanges (FFEs). Several of these proposals would have significant impact on rural areas and Counties with Extreme Access Considerations (CEACs). In this communication the National Organization of State Offices of Rural Health (NOSORH) makes specific comment on key provisions of the draft 2019 Letter and recommends how it could be modified to reflect the specific needs of rural and CEAC areas.
The National Organization of State Offices of Rural Health (NOSORH) is the membership association of the nation’s fifty State Offices of Rural Health. State Offices of Rural Health disseminate information, coordinate and provide technical assistance to rural communities and providers dedicated to caring for nearly 60 million rural Americans.
Network Adequacy - Time/Distance Standards: NOSORH believes that the time/distance standards are needed for appropriate specification of provider network adequacy. NOSORH believes that separate standards should be established for specific services, specialties and facilities in a provider network. This is consistent with the approach taken for Medicare Advantage plans. The need for these types of standards s particularly important for rural and CEAC communities. Without specific quantitative standards it is difficult to appropriately monitor and assess network adequacy and assure adequate service access for residents of these communities.
For 2018 CMS issued some basic time/distance standards for network adequacy as part of the final Letter to Issuers. NOSORH felt that this was a good starting place for specification of network adequacy, but that the standards did not fully assure reasonable access to services for rural and CEAC residents. In the draft 2019 Letter, CMS proposes to defer to states the establishment of network adequacy standards and the monitoring of those standards. The only requirement is that states create standards at least equal to the “reasonable access standard” identified in §156.230.
This proposed change represents a move away from time/distance standards. In the draft 2019 Letter CMS references the National Association of Insurance Commissioners’ Health Benefit Plan Network Access and Adequacy Model Actas guidance for states in setting network adequacy standards. It should be noted that the model act suggests, but does not require the use of time/distance standards. In this regard NOSORH finds it to be a less than appropriate basis for assuring that the reasonable access standard is assured for rural and CEAC areas.
CMS states in the draft 2019 Letter that it has found “all States participating in FFEs to have the required network adequacy means and authority” to assure reasonable access. NOSORHs members in many states would contest this finding. Members have reported significant limitations of state agencies in both the standard-setting for provider network adequacy and the monitoring of network adequacy. In addition, in rural states with smaller governments there is often limited ability to respond to individual consumer complaints. This problem has been compounded in the last few years as a large number of states have faced reduced revenues – resulting in a reduced capability of conducting all public responsibilities.
The failure of states to adequately monitor standards was highlighted in a 2016 General Accounting Office (GAO) report:
In that report the GAO found that in its study, “Officials from most of the selected states told GAO that they rely primarily on complaints, network changes, and other concerns to prompt the frequency with which they monitor QHPs' network adequacy.” In addition, “Department of insurance officials from one FFE state—Alabama—told us that they do not assess or monitor QHP provider networks, nor do they track consumer complaints.” This does not bode well for the shifting of these key responsibilities to states at the current time.
NOSORH believes that it is not sufficient to return to the time/distance standards set out in the 2018 Letter to Issuers. The proposed standards set out in that Letter are not consistent with access standards established for other government agencies, and will result in barriers to care for rural/CEAC community residents. These barriers are particularly problematic for key services needed by these residents to maintain health and prevent disease, and are discussed below:
- Primary Care Standards: The standard for primary medical care proposed in the 2018 Letter is 40 minutes/30 miles for rural areas and 70 minutes / 60 miles for CEAC areas. This is different than standard set by the Health Resources and Services Administration (HRSA) for Health Professional Shortage Areas (HPSAs). Under HPSA regulations the maximum travel time for primary care to be considered accessible is 30 minutes. The distance equivalent of this travel time is dependent upon the type of road - 20 miles on U.S. Highways, 15 miles in mountainous terrain, state highways or county roads, and 25 miles in flat terrain or in areas connected by interstate highways.
The HPSA standards apply to all areas, including rural and CEAC areas. The standards proposed in the 2018 Letter are significantly higher for these areas. The proposed time standard for rural areas is 40 minutes - 33% higher than the HRSA standard. The proposed time standard for CEAC areas is 70 minutes – 233% higher than the HRSA standard.
The distance standards proposed in the 2018 Letter stand in even greater contrast to the HRSA standards when type of road is taken into account. For rural areas in mountainous terrain the proposed standard is 200% longer than the HRSA standard. The proposed standard for CEAC areas is 400% higher than the HRSA standard for accessibility.
The HRSA standards recognize that primary care providers can be deployed in rural and CEAC areas, and that non-Metro residents can reasonably expect that primary care be available in closer proximity on either a full or part time basis. This is particularly reasonable when non-physician providers, including nurse practitioners and physician assistants, are taken into account.
- Dental and Mental Health Standards: HRSA has established a 40 minute time standard for dental and mental health service accessibility in its HPSA designations. This standard is also very different than the standard proposed in the 2018 Letter. In rural areas the 2018 Letter proposes a 90 minute travel time for dental services and a 75 minute travel time for mental health services - 225% and 185% higher than the HRSA standard, respectively. In CEAC areas the difference is more pronounced, 125 minutes for dental services and 110 minutes for mental health services - 313% and 275% higher than the HRSA standard, respectively.
- Hospital Standards: The 2018 Letter proposes that hospitals be no more than 75 minutes / 60 miles distant from rural area residents and no more than 110 minutes / 100 miles distant from residents of CEAC areas. CMS uses a vastly different accessibility standard in its consideration of Critical Access Hospital (CAH) designations. CAHs can only be designated if they are far enough away from any other hospital. For these purposes, a hospital which is 35 or more miles distant is considered inaccessible. The standards proposed in the 2018 Letter are 171% longer than the CAH standard for rural areas and 286% longer than the CAH standard for CEAC areas.
Recommendation: NOSORH recommends that CMS adopt a single set of time and distance accessibility standards which are closer to those established for other government programs – and in particular the HPSA and CAH programs. The standards for rural and CEAC areas used by these programs should be used by CMS. These standards have been operational for decades and more accurately reflect what most people would consider accessibility without unnecessary delay.
NOSORH also recommends that if CMS wants to delegate standard-setting and monitoring of network adequacy to states, that it provide financial support to states to support that function. Many states do not have the resources to conduct this activity appropriately and a delegation of this federal responsibility to states without financial support could be viewed as an unfunded mandate.
Network Adequacy - Provider Network Capacity: In previous years CMS explored the possibility of establishing minimum enrollee/provider ratios as standards for provider network adequacy. Section 3.i in the draft 2019 abandons this policy direction and defers any such standard-setting to states. NOSORH believes that a more useful approach would be for CMS to establish a single nationwide set of minimum enrollee/provider ratios to be used as guidance for adequate provider network capacity.
This approach is currently used in the certification of Medicare Advantage plans, where detailed enrollee/provider ratios are established for a comprehensive range of services, specialties and facilities. These standards are used to set specific county level provider network capacity minimums for each county in the nation. NOSORH believes that a similar set of detailed county level capacity minimums would help qualified health plans assure that they have adequate capacity in rural and CEAC areas of the nation.
Recommendation: NOSORH recommends that CMS adopt enrollee/provider minimum capacity ratios for a comprehensive range of specialties and facilities. NOSORH also recommends that these ratios be used to compute specific capacity minimums for each county in the nation. These county level ratios would simplify the task of monitoring plan compliance, and would facilitate any delegation to states of this responsibility.
As with time/distance standards, NOSORH also recommends that if CMS wants to delegate provider network adequacy assurance to states that it provide financial support to support that function. Many states do not have the resources to conduct this activity appropriately and a delegation of this federal responsibility to states without financial support could be viewed as an additional unfunded mandate.
Essential Community Providers (ECPs): In Section 4 the draft 2019 Letter proposes a core standard requiring each plan to assure that it “…contracts with at least 20 percent of available ECPs in each plan’s service area to participate in the plan’s provider network.” This represents a one-third reduction in the minimum contracting standard used for 2018. NOSORH believes that this is an inadequate standard for assuring adequate provider access in rural and CEAC areas.
If a service area is a multi-county area with a mix of rural and urban counties, it is entirely possible for a plan to meet this standard by contracting entirely with ECPs in urban counties. While plans must make good faith offers to at least one ECP in each county, those offers do not need to reflect the different cost of providing care in rural counties. NOSORH believes that a county-specific ECP contracting standard would assure adequate access to care in rural and CEAC areas.
It should be noted that many ECPs are operating in health service shortage areas. Failure to contract with ECPs in shortage areas may mean that the plan cannot find adequate alternative providers to assure access to care for area residents. NOSORH believes that the 20% contracting requirement is too low for assuring adequate access to care in shortage areas.
Recommendation: NOSORH recommends that CMS adopt an ECP standard requiring qualified health plans to contract with, at least 30% of ECPs in each ECP category in each county of the service area. In addition, NOSORH recommends that CMS require plans to contract with all ECPs in shortage areas that are part of a service area.
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