Minnesota Hospital Association

Policy & Advocacy

rules, regulations and comments

The Minnesota Hospital Association continually monitors state and federal rules and regulations to keep members informed and advocates on behalf of members regarding the impact of regulations on the state’s hospitals and health systems. MHA submits comment letters to share recommendations and feedback with the appropriate government organizations and health care stakeholders. Examples of rules and regulations that MHA addresses include those implementing federal or state health care reform efforts, changing payment methodologies, establishing community benefit or other standards for tax-exempt organizations, or modifying government oversight of health care activities.

September 05, 2012

Plan Certification Subgroup Draft Recommendations

Aug. 24, 2012

Submitted electronically 

TO: Members of the Plan Certification Subgroup
RE: Work Group’s Draft Recommendations

On behalf of our members, which include 145 hospitals and 17 health systems throughout Minnesota, the Minnesota Hospital Association (MHA) is grateful for the opportunity to provide feedback and comments regarding the Plan Certification Subgroup’s (Subgroup) August 20th draft recommendations. We hope that these comments are useful as you continue to discuss, evaluate and revise your recommendations.

Overall, MHA supports the recommendations articulated in the draft and offers the following comments and suggestions to improve upon or clarify the recommendations, as well as to encourage future work groups, task forces and policymakers to examine issues that remain unresolved.

Application of Certification Standards In- and Outside of the Exchange
A general parameter around all of the Subgroup’s discussions and recommendations has been the presumption that market rules and standards applying to health plans or products offered on the Health Insurance Exchange (HIX or Exchange) must apply to all plans and products offered outside the HIX, as well. This parameter was set by the Exchange Advisory Task Force and remained outsidethe scope of the Subgroup to address.

Nevertheless, MHA questions whether the Advisory Group, the Adverse Selection Work Group or others should re-examine this parameter. As became clear during the Subgroup’s discussions, the HIX environment will feature premium and cost-sharing subsidies, products offered by multi-stateplans (MSPs), interactive consumer education tools, navigator services and other information technology “decision support architecture” that will not exist outside of the HIX. Despite the intent to ensure a level playing field oravoid adverse selection, the inevitable fact is that the two markets will be different.

Consequently, it seems reasonable that the standards and requirements for certification to offer a product in the HIX environment may not be relevant to or advance any public policy goals outside of the HIX environment.Likewise, it is possible that the Subgroup’s recommendations might be significantly different if they were limited to the standards necessary to participate in the HIX market and did not have to account for any accompanying concerns or issues about how such standards would impact the market outside of the HIX.

QHP innovation
MHA encourages the Subgroup to include language in the final recommendations that expresses the interest in protecting opportunities for QHP innovation. Although existing standards in state law, such as those applicable to HMOs, are being recommended to serve as certification standards for QHPs initially, MHA believes that Subgroup members shared a strong consensus around ensuring that the HIX market remained open to new products or plans that might not fit within today’s definitions of a health plan, HMO, PPO, etc.

Specifically, MHA’s members are moving forward with Accountable Care Organization (ACO) structures and other innovative models of health care delivery that could serve as valuable options for consumers looking for affordable networks of high quality, integrated care. MHA anticipates that ACOs, and other structures or organizations not yet constructed, will continue to develop and evolve over time. It is important that QHP certification standards established today do not impose barriers to such innovation.

Staggered implementation of certification standards
Another parameter placed on the Subgroup’s discussions and recommendations has been that substantially new or different certification standards from those that already exist in today’s market in some fashion or are otherwise required by federal law cannot be required before 2015. MHA understands and appreciates the logistical realities underlying this parameter,nevertheless we are concerned about the disruptions that might result when new or different standards are imposed in the HIX market shortly after it is launched. It is also troubling that consumers entering this new market will do so without some of the protections that the Subgroup considered until they have already purchased products and perhaps suffered the negative consequences associated with the absence of such protections.

Multi-state plans
Throughout the Subgroup’s discussions and resulting draft recommendations lies a general, an overarching concern about the role of multi-state plans (MSPs) in the HIX market has troubled MHA and our members.MSPs will participate in Minnesota’s HIX market but will remain exempt from Minnesota’s certification and consumer protection standards. MHA recognizes that this is a matter of federal law and not within the ability of the Subgroup, Exchange Advisory Group or the Department of Commerce to change.

Nevertheless, it is troubling that requirements adopted to protect Minnesotans and ensure that the products they purchase offer meaningful health care coverage, such as provider network sufficiency standards, will apply to some HIX market participants and not others. MHA encourages the state and other stakeholders to continue advocating for the federal Office of Personnel Management to establish minimum certification standards for all MSPs and to require that they comply with any higher certification standards required by any state in which they offer plans or products.

Provider network adequacy standards
With respect to provider network adequacy standards, MHA supports the Subgroup’s recommendation for 2014 to take Minnesota’s existing standards applicable to HMOs and extend them to all products and plans sold inside and outside of the Exchange. MHA also supports the recommendations to further examine network adequacy standards that go beyond today’s HMO standards to more explicitly address the subspecialist (pediatric and adult) network that QHPs must have in place to ensure that their enrollees have meaningful access to the care covered for the premiums they pay.

To make the recommendations more complete and useful for future discussions regarding provider network adequacy standards, MHA respectfully requests that the draft recommendations be revised to reflect the Subgroup’s discussions regarding tele health. During the Subgroup’s early meetings, members discussed the important role that telehealth plays in providing greater access to care throughout the state.

As innovations, such as e-ICUs, e-ER, e-Psychiatry and other forms of technology enabled/enhanced forms of patient-provider interaction,continue to evolve it will be important that Minnesota’s certification standards both recognize and promote the deployment of these methods to bring care and services to patients. Perhaps inserting language in the “Considerations and Recommendations for 2015 and Beyond” category, such as “QHP certification standards should take into account and encouraged development of innovative access models to meet patient needs, especially in areas where resources or provider availability are constrained,” would reflect the discussions and consensus of the Subgroup.

Essential community provider standards
MHA supports the recommendation for 2014. Although the subgroup did not identify additional recommendations for 2015 and beyond, MHA supports revisiting the issue of essential community providers to ensure that Minnesotans have meaningful access to health care providers. Such future discussions might include consideration of essential community provider network standards related to culturally competent providers, in-network coverage of translator services, and other measures that could protect premium payers from being excluded from or paying more to access certain providers.

Service and rating areas
MHA suggests adding language to the “Considerations and Recommendations for 2015 and Beyond” category on service area standards to include the possibility of linking service and rating areas in the future.Although the Subgroup did not reach a decision to recommend or not recommend such a link, it seems worthwhile to include that option in the final document so that future policymakers understand that it was discussed but that the Subgroup did not have sufficient information to adequately assess its merits.

Also, the Subgroup did not reach a consensus, but there was significant discussion and concern about a minimum-seven-contiguous-county requirement under existing law. MHA questions whether the recommendations document should be amended to capture the uncertainty about this existing requirement and the merits of its application post-2014.

Accreditation standards
MHA supports the recommendations in the draft.

MHA requests that the draft be amended to clarify that managed care organizations in the state’s Prepaid Medical Assistance Plan and MinnesotaCare will not be subject to the QHP accreditation standards.

Enrollment and termination standards
MHA encourages the Subgroup to modify the “Considerations and Recommendations for 2015 and Beyond” to suggest additional consideration of minimum grace periods, penalties for failing to abide by grace periods and/or methods for ensuring people remain enrolled in coverage.

MHA appreciates the opportunity to share these comments and suggestions. If the Subgroup, staff or any of its members have questions or concerns about MHA’s comments, please feel free to contact me anytime.

Sincerely,

Matthew L. Anderson, J.D.
Vice President, Regulatory and Strategic Affairs

Minnesota Hospital Association