Use Case 37: FFM Network Adequacy data to meet directory requirements

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Requirements

Use case summary

Description

CMS is requiring qualified health plans (QHPs) to ensure that their provider network directories are accurate, up-to-date, machine-readable and publicly available. This has not been done before and faces a number of logistical and technical challenges, as described at Interoperability:_Provider_network_directories. The Provider Directory Workgroup (PDWG) was formed to address the challenges in setting the standards and deploying the solution. The goal of PDWG is to get consensus from organizations who are impacted on the most effective way to implement this rule.

One option proposed is to leverage the data format and sources of existing Network Adequacy data that QHP's are already required to submit to CMS/CCIIO on an annual basis, as part of qualification for being listed on FFM's (insurance marketplaces). Hopefully, the fields in this data should be sufficient to meet the machine-readable requirement and could be aggregated by consumer applications. If the fields provided are sufficient and easily obtained, the process just needs to be automated to work on a monthly basis.

Value

  • Value to customer: There is value to both Issuers (aka, insurance companies) and Healthcare providers. Ideally, there will be less duplication of effort to meet the machine readability requirements and therefore less burden on their resources.
  • Value to industry/public: Allow consumers to make more informed decisions when choosing benefits election on FFM's (Federally-Facilitated Marketplaces)

Customer

  • Provider Directory Workgroup (PDWG): AHIP, BlueCross BlueShield, AMA, Google, and several companies focused on services that include provider directories


Current data and limitation

  • Data source: Network Adequacy data submitted by QHP's to CMS via HIOS on an annual basis
  • How it's used: Currently only CMS has access to it. But it could be used to meet the machine-readability requirement.
  • Limitations:
    • Data is generated and submitted manually via Excel files and macros. There's not a good way to automate the current process or scale it for larger data aggregations.
    • The vocabulary used for provider specialty fields defined for Network Adequacy are different than the NUCC taxonomy used in many other places, including NPPES NPI database.
    • These Excel files get submitted to CMS/CCIIO, but are not currently made public.

Specifications

  • Fields: All fields in in Network Adequacy files
  • Update frequency: Currently annual
  • Joins between datasets: NPI, Plan ID
  • Lag time: 1-month
  • History: 2 years
  • Delivery mechanism: Download initially


Solution

Long term implementation

The relevant data needed to recreate the entire network for a QHP can now be found in the "Machine-readable URL PUF" (aka, MR-PUF). It's available as part of the Health Insurance Marketplace PUF page and includes issuer-level URL locations for "machine-readable plan network provider and formulary information"



  • MR-PUF file download direct link: http://download.cms.gov/marketplace-puf/2016/machine-readable-url-puf.zip
    • Note that Open Enrollment 2016 is the first time this file is available
    • URLs provided in the PUF are typically index JSON pages that point to the URLs for the required schemas:
      1. plans.json: Contains a list of health plans and their corresponding network of providers and formularies. Subtypes: Network, Formulary, Cost Sharing, Benefits
      2. providers.json: Contains a list of providers, both individual and facilities, and the plans that cover their services. Subtypes: Plans
      3. drugs.json: Contains a list of drugs and the plans that cover them. Subtypes: Plans
    • Some plans have missing data in the URL field, indicated by "NOT SUBMITTED"
    • Disclaimer for MR-PUF: https://www.cms.gov/CCIIO/Resources/Data-Resources/Downloads/Disclaimer_for_Machine_Readable.pdf



  • Limitations
    • Accuracy & completeness: The data contained throughout these files is self-reported by the issuers. Therefore, quality and completeness cannot be assured. Since 2016 is the first year this is implemented, some issuers have had difficulty delivering the requested data.
    • Inadequate schema: Some issuers and industry experts have stated that the level of detail possible with the specified schema is not sufficient to accurately represent the complexity with which networks are currently designed. As a result, the data may not adequately and reliably help consumers pick plans based on providers available.
    • Not for consumers: A consumer facing look up tool has not yet been provided by CMS, as of the start of Open Enrollment 2016. For consumers, the JSON files are difficult to read and the fragmented storage of the data makes comparisons between issuers difficult. It is expected that third parties will load this data and provide consumer with helpful applications. It's possible that in the future CMS would provide their own lookup tool as well.


Short term workaround

FOIA request

  • Submit FOIA requests for Network Adequacy data


Network-level PUF

Partial data can be found in Network PUF files that are made available by the CMS/CCIIO organization from network data submitted by QHPs via HIOS.  These files are broken into plan year (i.e. 2014, 2015, etc.).  However, the files contain only network-level records, specifically using these fields:


  However, this Use Case specifically needs data at the same granularity as is collected via the Network Adequacy Excel Template (v1.1), as fields described in the application instructions.  (See "QHP Application Instructions, Templates and Materials" website for background.)   In other words, we want provider-level records.