State governments should enact any willing provider insurance legislation.

1. State governments should enact any willing provider insurance legislation. Janice Le Ryan Losh NaadeiNikoi

2. Any Willing Provider • In order to understand premise of Any willing provider (AWP) legislation, one should understand the different relationships between patients, healthcare providers and the insurance companies. • Patient and Insurance. • Patient and Healthcare Provider • Healthcare Provider and Insurance • Patient Benefits • Provider Benefits

3. Patient relationship with Insurance Company • Most people with health insurance in the United States get their coverage through their employer’s group insurance plans. • Some employers offer several plan choices. • Indemnity, PPO, EPP, or HMO to name a few. • Some employers offer only one plan

4. Different Insurance Plan Types • Indemnity Plan (2004 cost: $3,032/$8,793) • “Traditional” insurance plan • Patient free to choose any doctor/facility. • No primary care physician (PCP)/facility required. • Yearly deductible for plan applies (e.g. $1,500/$3,000). • Pays 80% of eligible R&C charges, after deductible. (dirty secret: few, if any providers fees match “R&C”). • Annual out-of-pocket maximum applies ($2,500/$5,000). • Maximum cost to patient: $5,532/$13,793 • Preventive Care generally NOT covered. • Patient must file claims. • PPO Plan (2004 cost: $3250/$9426) • Preferred provider organization. • Patient free to choose any doctor/facility. Plan pays higher benefits to network providers than to non-network providers. Patient pays extra to see providers outside the network • No PCP required. • Yearly deductible (depends on use of network or non-network providers). ($250/$500 in network; $700/$1400 outside network) • Annual out-of-pocket maximum: $1,500/$3,000 network, $2,500/$5,000 non-network. • Maximum cost to patient: $5,750/$14,426 • Preventive care covered after copay. • Patient does not file claims.

5. Different Insurance Plan Types • EPP & HMO Plans (2004 cost: $3,225/$9,352) • Health maintenance organization (HMO) and Exclusive provider programs (EPP). Virtually identical plans with different names. • Patient must use HMO or EPP providers (or pay 100% of charges out-of-pocket) • PCP is required to coordinate all care/referrals to specialists, etc. • Deductible: $0 (after copays) • Yearly out-of-pocket maximum: $0 (after copays) • Maximum cost for patient: $3,225/$9,352. • Preventive care: usually covered 100% after copay. • No claims for patient to file.

6. Patient relationship with Healthcare Providers • Thus, most patients will have different insurance plans, all with different rules, that usually dictate providers the patient is allowed to receive care from (by way of the plan paying for services).

7. Provider Relationship with Insurance Company • Provider needs patients to utilize their services. • Many patients, in turn, have insurance plans. • Therefore, in order for the provider to provide services for a larger number of patients, the provider must contract with insurance plan. • Many Insurance plans (especially HMOs and EPPs) routinely deny health providers applications to join their plan, or restrict the contracts for only a few providers in a given geographical area.

8. Any Willing Provider • Thus, it is in the best interest of the patients, and the healthcare providers who care for them for the states to enact any willing provider legislation for all licensed healthcare providers. • The insurance company shall be required to allow any healthcare provider who agrees to the terms and conditions of their plans to provide services for the patients, and be reimbursed at the agreed upon rates for those plans.

9. Any Willing Provider • Pharmacy Only • Alabama • Arkansas • Connecticut • Delaware • Florida • Kansas • Louisianna • Mississippi • New Hampshire • New Jersey • North Carolina • North Dakota • South Carolina • South Dakota • West Virginia • Wisconsin • Non-Physician Licensed Provider • Minnesota • All Licensed Provider • Idaho • Indiana • Kentucky • Utah • Virginia • Washington • Wyoming • Physicians & Chiropractors only • Illinois

10. How this law benefits patients • Ensure patients greater choices and ensures continuity of care • Improves quality of care • Reduces the travel distance for subscribers in smaller communities • It allows patients to choose providers who, in their judgment, provide better care

11. How this law benefits providers • Protects smaller providers and sole provider physician offices by allowing them to participate in networks • Providers increasingly depend on managed health plans as a source of income

12. How this law benefits providers (cont.) • Levels the playing field” so that all providers have the opportunity to participate in managed care networks • Lower prices for providers • Practice whole spectrum of optometry

13. Sources • http://www.ama-assn.org/amednews/2008/02/18/prsa0218.htm • http://www.ftc.gov/ogc/healthcarehearings/docs/030610morrisey.pdf • ArkansasBusiness.com • AANA Journal/August 2003/Vol. 71, No.4 • Health Affairs, Volume 14, Number 4 1995 • Johnson, Victoria; Morrisey, Michael: “The Spread Of State Any Willing Provider Laws” Health Services Research. • http://www.ncsl.org/statefed/health/AWP.htm • http://www.managedcaremag.com/archives/0305/0305.regulation.html • http://www.gilweber.com/gw_pro49.htm • http://www.hcfo.net/topic0503.htm • http://www.braytonlaw.com/news/legalnews/041103_hmo_kentucky.htmhttp://www.abanet.org/statelocal/lawnews/spring03/supremecourt.html • http://www.ftc.gov/be/healthcare/wp/17_vita_any-willing-provider.pdf • http://www.insurancejournal.com/pdf/InsuranceTimes_20030415_39111.pdf • Ohsfeldt, Robert L. “The spread of state any willing provider laws-Examining the role of regulation ina an evolving healthcare marketplace” Health Services Research 12. 1998

14. Sources (cont.) • Managing Care. Online NewsHour. http://www.pbs.org/newshour/bb/hour/health/jan-june03/managing_care_1-14.html. 1/14/03. accessed 2/22/08 • 2004 Sprint Employee Benefits Enrollment guide and detailed fact sheet for Ryan Losh. • http://www.nncc.us/policy/programspolicy.html