Draft Overview of Network Adequacy Data Sources
The Maryland Health Benefit Exchange (MHBE) is convening a Network Adequacy and Essential Community Providers (ECPs) Workgroup to provide input to the MHBE’s Standing Advisory Committee on qualified health plan (QHP) network adequacy standards. The purpose of this document is to provide the Workgroup with a brief overview of the more prominent Maryland data sources on network adequacy that are currently available. 1. MHBE Carrier Access Plans
As part of its QHP certification process, the MHBE requires carriers to submit an access plan with information on network adequacy and the inclusion of ECPs. MHBE provides the carriers with an access plan template. Provider Directory
The MHBE contracts with the Chesapeake Regional Information System for Our Patients (CRISP) to maintain a provider directory for all of the QHPs participating in the MHBE. The directory contains information such as provider names, provider addresses and demographic information, the carriers in which the provider is participating, indicators of whether the provider is a primary care provider (PCP), provider specialties, and indicators of whether or not the provider is an ECP. This provider directory has the potential to provide the MHBE with information about the size and types of providers available in the QHP networks. Such analyses would be dependent upon complete and accurate information in the directory. Enrollment
The MHBE collects eligibility and enrollment information submitted by individuals in their applications for coverage. Combining enrollment information with provider directory information can allow the MHBE to compare the size of the enrolled population with the size of the provider network (overall and within certain jurisdictions). 2. Maryland Health Care Commission (MHCC)
Medical Care Database (MCDB)
MHCC develops and maintains the state’s MCDB, an all payer claims database. The MCDB includes health care practitioner, prescription drug, institutional service, eligibility, and provider data from carriers doing business in Maryland whose total covered lives exceed 1,000, including qualified health, dental, and vision plans certified by the MHBE. QHP claims in the MCDB could potentially be used to perform various access and utilization measures, which may provide insight into network adequacy. Health Benefit Plan Quality Reports1
Available at: http://mhcc.maryland.gov/mhcc/pages/apcd/apcd_quality/apcd_quality_hbp.aspx
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MHCC releases an annual comprehensive quality report that compares the performance of Maryland’s commercial health insurance plans. This report includes detailed information on plan performance on an extensive list of measures and indicators related to clinical performance and member satisfaction with the quality of health care service delivery measures and many other topics. It includes the total number of providers for each carrier broken down by specialty and county.
3. Maryland Insurance Administration (MIA)
Availability Plans
MIA regulations require carriers to implement an availability plan, laying out the “quantifiable and measurable standards for the number and geographic distribution of” several types of providers, ranging from internal medicine providers to high volume specialty behavioral health providers.2 In addition to these standards, the availability plan must include the methods used to: (1) assess compliance with the standards set in the plan, (2) ensure timely access to health care services, and (3) monitor and ensure the sufficiency of the provider panel.3 Prominent carriers, those reporting at least $90,000,000 in written premium, are required to file their plans with the MIA.4 4. Maryland Medicaid
The Medicaid Management Information System (MMIS2) contains eligibility information, claims/encounters, and provider information for the entire Maryland Medicaid program. While not specific to QHP network adequacy, the MMIS2 is used for monitoring network adequacy and access to care in Medicaid and may be useful for evaluating continuity of care between Medicaid and QHPs and related issues.
5. Office of Primary Care Access5
The Department of Health and Mental Hygiene Office of Primary Care Access (OPCA) was established in July 2012 to support the Health Systems and Infrastructure Administration, which defines and measures Maryland's health status, access, and quality indicators for use in planning and determining public health policy. The OPCA is the facilitator in recommending analyses that can lead to special shortage designations that ultimately bring additional federal funds and resources to Maryland. Key designation criteria for the health professional shortage area include provider to population ratios, travel time to reach providers, and indicators of high need such as infant mortality rate, poverty population, birth rate, or other barriers. The OPCA also has county profiles for access to care, which include basic data on safety net organizations and providers, and patient and provider ratios for these providers.
COMAR 31.10.34.05(A)(1). COMAR 31.10.34.05(B).
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COMAR 31.10.34.05(C)(2).
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Available at: http://hsia.dhmh.maryland.gov/opca/SitePages/Home.aspx. 2
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