Advocacy Insider 2015 Wrap-Up
2015 was another year that kept government relations and compliance professionals on their toes. The year started and ended with Exchanges from the Letter to Issuers in January to the Notice of Benefit and Payment Parameter regulations in December. The Centers for Medicare and Medicaid Services (CMS) did not take a break and neither did NADP. States did not disappoint either with legislation and regulations touching on a myriad of dental related topics. As we start to see new trends form, NADP is focused on working with our members and interested stakeholders to keep the industry in a position to respond quickly and appropriately.
Internal Reorganization: In the winter of 2008, NADP’s Board first appointed the Health Care Reform Task Force to quickly respond as health care reform emerged as a key issue for the dental benefits industry. Volunteers were recruited from standalone dental plans and dental plans affiliated with medical carriers, plans of various sizes, and individuals from differing backgrounds (actuaries, clinical, accounting, public affairs, business operations and legal). All volunteers were in senior leadership positions and therefore able to quickly respond to and guide NADP’s response to rapid inquiries from government agencies as the Affordable Care Act (ACA) wound its way to passage and began implementation.
By 2014, it was obvious the ACA was here to stay and a temporary ‘Task Force’ was no longer appropriate. The Task Force would need to become a more permeant committee within the NADP volunteer organization structure. The Board renamed the Task Force as the Commission on Advocacy Policy (CAP) for 2015 to oversee all government relations policy development. CAP works closely with NADP’s other government relation volunteer groups (Government Relations Workgroup, Exchange Policy Workgroup, Exchange Technical Workgroup) that respond to initiatives based on those policies as well as implements the resulting guidelines, regulations and laws.
NADP is currently working toward better alignment and streamlining of our website and communications in 2016. We are removing the separation of ACA issues from more routine government relations activities and insurance oversight. As well, we are focusing on an overall advocacy strategy. In 2015 government relations staff and volunteer groups took the lead as NADP developed its high level strategy for the next seven years. Lines are now blurring between federal government and state oversight, such as Medicaid and Exchange regulations and impacts of the ACA and related federal policies are slowly permeating the commercial market and the self-insured markets. Therefore, NADP is merging its advocacy oversight as well.
In addition, NADP’s State Affairs Manager, Eme Augustini, has broadened her oversight of state affairs and has been working on federal issues, the Advocacy In Action fly-in, and the NADPac. Her outstanding performance has earned her a promotion to Associate Director of Government Relations. Please join us in congratulating Eme and applauding her tireless dedication to NADP.
Trends: In September 2015, dental plans loss ratio (DLR) data was filed and made publically available in California. CADP and NADP had worked with California dental regulatory agencies to modify the Medical Loss Ratio (MLR) form earlier in the year to better incorporate dental data. NADP’s original DLR estimates for 2014 in California closely paralleled the averages of data that was filed in 2015. While the legislation requiring the filings called for a multi-year study, it is likely stakeholders will continue to press for a DLR in California based on initial data in 2016. We anticipate multiple states will introduce similar DLR legislation in 2016; requesting a study of DLR levels for the existing dental markets in their states. Member carriers have been successful in pushing back DLR requirements, but if the California first year study results receive enough attention ‘study’ bills could find traction.
While DLRs will be part of the future landscape, that topic doesn’t tops the trends chart for 2015 as network adequacy won that contest for 2015 and will clearly spill over into 2016. As medical plans started to innovate the last few years with new plan designs by narrowing networks to lower costs, consumers and regulators cried foul—observing that some networks were too narrowly constricted. From there the network issue morphed to include the lack of timely updates to provider directories. The National Association of Insurance Commissioners (NAIC) has been working with stakeholders to update their Network Adequacy Model Act, with many states waiting for the conclusion of that activity prior to taking action. With adoption of the NAIC model in December 2015, states will begin to maneuver quickly on the topic.
NADP and DDPA worked together diligently on the NAIC model and were successful in obtaining multiple dental exemptions as well as drafting notes mentioning differences between dental networks, regardless if they offered separately or embedded within a medical policy. Significant work remains as the drafting notes leave much of the implementation on dental plans to each individual state. In anticipation of a surge of network adequacy oversight in 2016, NADP is preparing background materials, including surveying current state legal requirements and regulation of dental networks.
Exchanges continue to evolve although the number of dental plans offering policies on the Exchanges has stayed relatively stable. There continues to be at least one stand-alone dental plan (SADP) offering coverage on the federal Exchange in each state and therefore the Federally-facilitated Exchanges (FFE) has not had to mandate that Qualified Health Plans (QHP) embed pediatric dental in any FFE state. Regardless of this example, several State based Exchanges (SBE) and FFE states have all medical plans embedding pediatric dental voluntarily or by a state policy requirement or technical failing.
With the resurgence of the individual market a wide array of dental benefit designs have been offered. State based Exchanges (SBE) are considering standardizing Exchange policies to mirror commercial policies with regard to 100% coverage of prevention. However, this becomes difficult for dental carriers to develop an affordable premium within the lower 70% actuarial value limit amid the question of who defines prevention. At the same time, the Federally Facilitated Exchange (FFE) is pressing harder on network requirements and inclusion of essential community providers. Exchanges remain a niche market, but as Exchange requirements become more stringent in some states than commercial products, and as the federal government takes on a broader role in insurance oversight, conflicts between the two are becoming more likely with dental plans caught in the middle.
There are multiple topics which continue to impact the dental industry regardless of the ACA. Issues run the gamut including mid-level providers, provider contracts, dental service organizations, external appeals, taxes, electronic data, coordination of benefits, non-covered services, and more. As the dental industry typically lags behind the medical arena, we are going to see additional compliance requirements related to quality and innovation that are required of medical carriers being applied to dental plans. As the use of dental diagnostic codes become more prevalent, requirement of dental quality ratings will follow. Quality improvement strategies and accreditation are also likely to become required in our industry. The Dental Quality Alliance, in which NADP is an active member, is also going to come into play as we see the California Exchange already adopting their initial dental standards. The dental industry is facing significant changes and while stopping many of these changes is not feasible, helping to form a path in which plans, regulators and consumers can work together for quality, affordable oral health coverage is certainly possible with diligent work and is NADP’s priority.
Communication: NADP tracks and responds accordingly to full range of topics outlined above. There is a wealth of information for members that organizes for easy access:
NADP staff understands the deluge of information that our members receive and we try to make our communication to members as effective and rapid as we can. If you have any questions, suggestions or concerns, please don’t hesitate to reach out to our government relations staff.
Director of Government Relations, Kris Hathaway
Associate Director of Government Relations, Eme Augustini