If you know anything about UHCAN Ohio, you may be puzzled about the seemingly odd assortment of work we do. ACA implementation makes sense, but why are we engaged in a dental access campaign, a report on community health workers, building the voice of Medicare/Medicaid beneficiaries in a new managed care model? There’s a method to our seeming madness.

Even with the achievement of the Affordable Care Act, there is still much to be done. We still have too many people without insurance, and others with insurance but unaffordable out-of-pocket costs. We have people with chronic conditions and disabilities, including mental illness and addiction, who do not receive the right services at the right time and place. Too many people end up in the hospital and nursing homes because they don’t have the care they need to stay healthy and at home. Health care spending is growing too fast for individuals and the economy. And 30% of that spending either provides no value or actual harm. Because the problems are so complex, we need to have a multi-layered approach to solutions.

In its earlier years, UHCAN Ohio, understandably, focused largely on fighting for coverage and access to affordable care for uninsured and under-insured people – expanding Medicaid coverage for working parents, strengthening hospitals’ “charity care” policies, and immigrant access to interpreters and health care, to name a few

In 2008 Governor Strickland’s administration convened a multi-stakeholder “State Coverage Initiative.” UHCAN Ohio was at the table, along with Ohio Consumers for Health Coverage. From the start, participants raised the need to address skyrocketing health care costs, waste in the system, uneven quality of care received, and racial/ethnic health disparities. Otherwise the rising cost of health care would make coverage expansions impossible to sustain, Both the Strickland and Kasich administrations, in different ways, organized initiatives to develop strategies to reform how we deliver and pay for health care.. UHCAN Ohio, aware that system change could be very good – or very bad – for consumers, organized consumer participation all along the way. After all, shouldn’t consumers have a voice in reshaping the system?

The goal of health reform is often defined as the “triple aim:” Better care, better health, and lower costs for everyone. We recognize that “better health” means investing more in prevention and health improvement. Furthermore, much of what determines a person’s health – especially for people of color and people with low incomes – occurs outside the medical system, such as where you live and work, access to nutritious food, and time to exercise. Plus, profound racial and ethnic health disparities, the legacy of historic discrimination in employment, housing and criminal justice, won’t go away without deliberate policy decisions.

Here are some core understandings that UHCAN Ohio has about its work.

• We know UHCAN Ohio will never be able to do everything without many partners. We build coalitions uniting organizations that combine their various strengths for greater power. And we know how to organize effective campaigns, with policy, media, grassroots and other key components.

• Consumers often receive fragmented, unnecessary and avoidable treatment that does more harm than good. That’s why we are building the voice of organized consumers in state and private efforts to improve how consumers experience health care.

• You can’t be healthy if you have poor oral health. Oral health care IS health care, and solving the dental access problem in Ohio is one of the most important challenges facing Ohioans.

• It’s not fair that communities of color suffer from higher rates of diabetes, asthma, infant mortality, cancer and stroke. Eliminating racial and ethnic disparities in health care and health is achievable, but only with passage of policies designed to achieve equity. And those policies won’t happen without a strong consumer voice.

• The best doctor’s office can’t improve health if people are living and working in unsafe, polluted unhealthy communities with financial and other stressors. People need access to and support for healthy eating, exercise, and addiction-free lives. People living in affected communities need to be engaged in designing and building healthier communities.

• Organized consumers must have a significant voice in health care decision-making in order to reshape the health care system to provide better care, better health, and lower costs.

• Real consumer engagement, with representation across diverse communities, requires investments in under-represented communities, including communities of color, ethnic communities, persons with disabilities, and those left out because they lack resources, transportation and education.

There’s a lot wrong with our present health care coverage, quality and cost. That’s why we have to tackle change from several angles at once – and demand a seat at the table for the users of the system. In future newsletters, you will see articles exploring how we are tackling the various parts and how you can get involved in reshaping health care.

Last month, I started a series on affordability with an article entitled “The ACA’s Role in Creating Equity in Our Health Care System.” I started out the series by sharing my own story about going to the doctor for free preventive exams and leaving with bills that I did not expect. This month, I want to talk more about the growing problem of going to a hospital that’s in your insurance company’s “network” of providers (doctors and hospitals) and coming out with bills from a provider who is not in your network.

Two recent articles detail the issue. The first, from the Atlantic, is entitled “Don’t Pay that Medical Bill,” which discusses balance billing, “the term for a situation in which an entire hospital stay or procedure is covered by insurance, but one of the specialists involved is out-of-network and bills the patient separately.” In this article, a woman shared her story about her husband’s emergency surgery. She asked their hospitals and doctors if they would accept her insurance and was told they would. However, she then received $32,000 in medical bills from the surgeon who operated on her husband. Because of her persistence – and a new law in New York protecting against balance billing – she was able to have these bills covered. The insurance company paid this bill and the provider had to accept much less. Ohio, like many other states, does not have such a law. However, passing similar legislation could be the answer to many balance or “surprise” billing issues in Ohio.

The second article I wish to discuss is by Kathleen Gmeiner in this month’s newsletter, entitled “ODI Moves Forward with Provider Network Disclosure Amid Calls to Do More.” This article, like the first one, provides a story of a person affected by this issue. Wendy McVicker of Athens, Ohio was life-flighted to a nearby hospital, only to find out that the air ambulance service was not totally covered by her insurance provider. Her insurance company paid only $10,000 of the $25,000 cost of the ambulance. The article discusses a new Ohio rule that is being finalized, Rule 3901-8-16. This new rule will require insurance companies to regularly update their network lists, make them more available to those enrolled in their plans and prospective enrollees, and provide information about the cost of out-of-network services. The Ohio Department of Insurance expects the rule to be generally effective 1/1/16, but a few provisions will not go into effect until the following year. The rule would give consumers like you and me more information about the cost of treatment at the beginning of the process of seeking treatment and finding a provider. But the new Ohio rule doesn’t go far enough. Ohio consumers need a law like the one passed in New York.

This is why UHCAN Ohio exists. Our role is to find out what is happening to consumers like you and me, research legislation across the country that addresses the issues we are seeing, and engage you in our efforts to change policies, rules, and legislation to help the health care system work better for you. We do this in many ways including writing policies, analyzing policies, educating legislators on the impact of emerging and existing legislation, and engaging consumers in advocacy actions. Watch for more information on how you can help us advocate for a law like New York’s. 

Nita Carter

The Ohio Department of Insurance (ODI) took the next step toward finalizing a rule that will help Ohio consumers get better and more timely information about provider networks. Without access to their insurers’ provider networks, consumers can get hit with high costs for using out-of-network providers.

On July 19, 2015 ODI held a public hearing on proposed Rule 3901-8-16, which will require insurance companies to regularly update their network lists, make them more available to enrollees and prospective enrollees, and provide information about the cost of out-of-network services.

Ohio Consumers for Health Coverage provided written and oral testimony in support of the rule, but with some strong caveats about the rule’s limitations and need to go further. Also testifying was Janet Shaw, Executive Director of the Ohio Psychiatric Physicians Association (OPPA), who supported the rule but urged that more data be collected and made available pertaining to the number of in-network and out-of-network claims that insurers handle. Wendy McVicker of Athens shared her story of being stuck with $11,000 in bills from an emergency life flight to a Columbus hospital from Athens following a serious bike accident. The air ambulance company was not in her network, and her insurance and a provider discount covered about $14,000 of the $25,000 bill. She urged ODI to strengthen the rule to address the issue of “balance billing” – which occurs when the insured person is expected to pay the balance due after the insurance company only pays a portion of the bill for an out-of-network provider. As Wendy noted, she had no choice in the life and-death situation but to go with the air ambulance offered. Tim Maloney, Vice President of Payer Contracting for the University of Cincinnati Medical Center, also offered support for the rule and especially noted that it is important that their staff can access updated patient directories so that they can link UC patients to providers in the patient’s network.

Here is what OCHC would like to see ODI do:

• Hold consumers harmless from balance billing when the consumer did not select the out of network provider;
• Require insurance companies to offer an adequate selection of providers;
• Require an in-network hospital or other facility to assign to a patient only providers who are in the patient’s network when available, and take steps to assure that there are available at the facility providers of all specialties affiliated with each health plan in the service area.

OCHC also commended the Department for proposing that insurance companies must provide consumers with co-pay, co-insurance, and deductible information pertaining to an out-of-network provider when requested, but argued that the information provided should be binding on the insurance company. Under the rule, the information provided is not binding.

OCHC also urged ODI to require the provider directory to list all staff of its in-network facilities who are NOT in the health plan’s network. The rule in its current form simply requires “a general statement notifying enrollees that there may be providers of services at the facility, such as anesthesiologists, radiologists, and laboratories that are not in-network, and a method for contacting the issuer [insurance company] to obtain more detailed information.”

Kathleen Gmeiner, who provided the OCHC comments, stated: “Simply saying that ‘there may be providers who are not in-network’ provides the consumer no information to make an informed decision. It is also pointless to simply tell the consumer how to contact the issuer for more information, because in the plan selection process it is not realistic and often not possible to obtain the information of what providers are not in the network. OCHC strenuously urges that the rule be revised to require the issuer to provide a listing of all providers affiliated with the facility; and a listing of any providers providing services at the facility who are not in-network.”

Under the proposed rule, the insurance company’s obligation to update the directory is triggered if the physician or hospital tells the insurance company of a change that impacts their participation in the network, OR, if in the course of business, such as claims processing, it becomes apparent to the insurance company that there is a change in status. OCHC and OPPA both urged that the insurance companies should be required to take stronger action to confirm that a provider is still in the network. OCHC urged that the insurance companies be required to routinely communicate with network members to confirm that they remain in the network. OPPA proposed that the insurance companies be required to review the claims history of each psychiatrist listed and remove from the directory any psychiatrist who is not actively submitting claims.

Finally, OCHC supported requirements in the rule to make sure that provider directories take into account the needs of persons with disabilities and limited English proficiency. OCHC also supports a requirement that a health plan give a consumer notice when his/her provider drops out of the network.

Next step: ODI finalizes the rule, taking into consideration the comments made, and takes the rule to the legislature’s Joint Committee on Administrative Rules (JCAR). The Ohio Department of Insurance expects the rule to be generally effective 1/1/16, but a few provisions will not go into effect until the following year.

New rules are under discussion that will make sure that anti-discrimination protections are applied to all health programs and facilities receiving federal funds. Ohio Consumers for Health Coverage is working to ensure that the rules fully protect Ohioans against discrimination so that health care is accessible to everyone, regardless of background or situation. These rules, proposed by US Secretary of Health and Human Services (HHS) Sylvia Burwell, implement the non-discrimination section (1557) of the Affordable Care Act and prohibit any health program or facility that receives federal funds, including insurance companies in the state and federal marketplace, from discriminating on the basis of race, color, national origin, age, disability, or sex.

In a previous newsletter, we told you about the rules that applied to gender non-discrimination. Here is what the comments we submitted to HHS said about the proposed rules on disability and language access. To read all of our comments on the rules, including those on gender, click here.

Language Access

The rules require programs covered by the rules to:

1)      post an English-language notice of consumers’ rights to free, appropriately tailored language assistance services; and to

2)      post taglines in the top 15 languages spoken nationally by people with limited English proficiency.

To help programs meet this burden, HHS proposed to provide translated versions of the required notice and taglines in the top 15 languages. Along with our partner Community Catalyst, we urged that the term “qualified interpreter” should require interpreters to meet both competency and ethical standards. We also recommended that HHS require that interpreters have knowledge of specialized terminology and concepts.

We applauded HHS for taking steps to ease translation burdens for covered programs by providing notices in the top 15 languages used nationally, but we noted that this really would not meet the needs of many of Ohio’s immigrant communities. The top 15 languages in the U.S. are Spanish, Chinese, Vietnamese, Korean, Tagalog, Russian, Arabic, French Creole, French, Portuguese, Polish, Japanese, Italian, German, and Persian (Farsi). These 15 languages exclude most of the languages spoken by African immigrants in Ohio, including those from Ethiopia, Sudan, Gambia, Congo, Senegal, and Sierra Leone. They also exclude sizeable Ohio Asian populations including India, the Philippines, Nepal and Burma.

We recommend HHS strengthen the regulation by:

• requiring that sample notices by HHS and tagline translation requirements include the top 15 languages in the state, rather than the proposal to only include the top 15 languages nationally.
• requiring covered programs to post one or more of their notices in the most prevalent non-English languages frequently encountered in their state or service area.
• requiring covered programs to translate vital documents for each language group that makes up 5 percent or 1,000 persons, whichever is less, of the population eligible to be served, or likely to be affected by the program, in the service area.

Disability Issues

The proposed rule requires effective and accessible communication for individuals with disabilities, including requirements for websites and electronic and information technology to be accessible. Along with Community Catalyst, we urged HHS to strengthen these protections as well as explicitly cover individuals with health conditions who have historically been the victims of some of the worst forms of discrimination in health care.

Also, because disability does not occur uniformly among racial and ethnic groups, we recommended that cultural competency standards, such as the CLAS (Culturally and Linguistically Appropriate Services) standards, be applied to programs serving people with disabilities. We urged a broader definition of disability as contained in the Americans with Disabilities Act (ADA).

Other materials on the 1557 rules can be found here:

Fact Sheet: Nondiscrimination in Health Programs and Activities Proposed Rule Section 1557 of the Affordable Care Act

Summary of HHS’s Proposed Rule on Nondiscrimination in Health Programs and Activities

UHCAN Ohio joined other consumer groups who submitted comments on February 10, 2016 to Insurance (ODI) Commissioner Mary Taylor requesting that the Ohio Department of Insurance hold hearings on two proposed mergers of health insurance companies: Cigna with Anthem Blue Cross and Blue Shield; and Aetna with Humana. The other groups signing on to the comments are Consumer Action, Consumer Federation of America, Consumers Union, DC Local 37 AFSCME AFL-CIO, Consumer Watchdog, and U.S. Public Interest Research Group. 

We noted in the comments that Ohio has a “concentrated” market—meaning that a few insurance companies control a great deal of market share. Three health insurance companies control 84% of the individual, small group, and large group markets. As noted in the article we published in our newsletter of October 12, 2015, mergers tend to result in premium increases. Ohio already faces some of the highest health insurance premiums in the country. One of the major culprits of Ohio’s high premiums is the lack of competition among insurers, and these mergers will only make matters worse. 

We are also concerned about the Medicare Advantage Market. This is the market that serves Medicare beneficiaries who choose not to stay with “traditional” Medicare but to secure lower premiums in exchange for networks of doctors that are narrower than traditional Medicare. Aetna, Anthem, and Humana are players in the Ohio Medicare Advantage Market. The combined Aetna-Humana would have a 50 percent market in Medicare Advantage throughout Ohio, according to the Kaiser Family Foundation, with Anthem also controlling 23 percent of the market. Along with having a dominant market share in the state, the Aetna-Humana transaction would substantially lessen choices for Medicare Advantage consumers in the following counties: Clark, Clermont, Delaware, Franklin, Hamilton, and Lorain. 

The day of the filing, ODI told the Columbus Dispatch that the Department does not have to hold a hearing, and that they accept written comments. However, this would significantly undermine ODI’s ability to impose a remedy on the insurance companies, which the statute says may be imposed after a hearing. The Department of Insurance has broad powers to look out for the best interests of the insured. And securing all necessary evidence and being fair to all involved clearly requires a hearing that is public and transparent.