Q&A with the OIC on Coordinated Care matter

Last week, when the news about the OIC’s ‘cease and desist‘ letter to Coordinated Care came out, I posed a few question to the OIC about the matter. They were very gracious in getting back to me in detail.  I’ve included that correspondence here for everyone’s review.  I thought their comments were technical and helpful to many readers, so I thought it best to post them in their entirety.


Q:  The OIC certified to the HBE on Sept 25th that Coordinated Care (CC) met the network adequacy standards.  The board materials for that meeting are here.  Was that certification incorrect?  If not, what material changes did Coordinated Care make to degrade their network between Sept 25 and Dec 12?

The OIC does not certify QHPs. The Exchange does. The OIC approves the rate, form and binder only after we have sufficient information to believe that a company has a plan to get network access in a timely manner for the plan year. Signing off on network access for plan year 2018 is about having adequate access starting Jan. 1, 2018. In August, the OIC was still getting information back from Coordinated Care regarding 2017. The OIC believed that Coordinated Care would  act responsibly to address the identified and developing concerns. When the network access group at the OIC got involved in September and started requesting more information, that’s when things started to change. In October, Coordinated Care provided information to the network access group that indicated a bigger problem. Unfortunately, Coordinated Care never did address the OIC’s concerns.


Q:  In my review of contracts submitted by CC to the OIC, it appears that not a single contract was reviewed and approved by the OIC staff.  Contracts are all either “deemed” or “review pending.”  Why have none of these contracts been fully reviewed and fully approved since 2013, or do I misunderstand things?  I can send PDFs of the site if needed.

First, the action “deemed” does not mean that a filing was not reviewed.  Deemed is technical action required by statute.  When a filing is made, the OIC has a certain amount of time to review it.  If the OIC does not meet that timeframe, the filing “deems” and the health carrier can move forward to use it. The OIC will still review the filing and take action.  For a filing that has met its statutory time requirement, it is deemed.

As for filings that are “review pending,” there are two reasons the filings are in this status.  First, the OIC has been working with Coordinated Care for an extended period of time to get these filings into compliance. These filings are also used by a related Coordinated Care entity to support its contract with Medicaid. The other entity has a different license and the OIC has been working with both Coordinated Care and the related entity as they develop contracts that can be approved for filing and use by both.

Second, several of the filings were submitted as part of the OIC’s call for contracts. These filings will be “acknowledged” because the carrier is not seeking approval for use. They are part of filing requirements by the OIC.

Lastly, some filings are simply part of a backlog due to ACA review.  We are working on those filings now.  Please note, the backlog is not specific to any one health carrier.


Q:  In the consent order from June, CC is fined $20k, of which $10k is suspended.  It’s clear the OIC knew that the network adequacy was in question in June.  Why did the OIC wait until December 12th to take action?  As in my first question, why did the OIC certify an adequate network for the Sept 2th meeting, but then change its mind by Dec 

This consent order was related to an OIC determination that Coordinated Care had not acted in a timely manner in resolving appeals to the company from enrollees. In contrast, the current enforcement is related to inadequate provider networks.  This was also at about the same time the OIC began gathering complaints (over 140 by December) from enrollees that were related to network concerns, but the OIC did not have sufficient information to take action based on the provider networks in June.


Q:  It appears that CC informed brokers at 12:16 pm on Dec 14th.  The OIC sent out its announcement at 4:49 pm on the 14th.  Why did it take two days following the Dec 12th action to inform the market?

We hoped that Coordinated Care would agree to resolve the concerns without having to resort to the cease and desist order. All of this could have been avoided had Coordinated Care taken appropriate action much earlier to resolve the issues noted.


Q:  As objectively as I can be, this looks something like a negotiation tactic to get CC to play ball with the OIC after months of apparently not correcting the issues related to the consent order.  Is that a fair assessment?

Again, all of the actions could have been avoided had Coordinated Care taken appropriate action much earlier to resolve the issues noted.


I asked a follow up question related to clarification on the approval of network adequacy and whether that was the purview of the OIC or the Exchange.  This is in response to the first question above

Q:  Page 8 of this document makes clear that, in the relationship between the Exchange and the OIC, that the OIC is responsible for determining a carrier meets network adequacy requirements as part of the QHP process.  I don’t want to quibble over final QHP certification – I understand that’s the HBE’s job.  But the OIC is responsible for the network review during that HBE/QHP process.  The statement that the OIC approves networks when it “believe(s) that a company has a plan to get network access in a timely manner” strikes me as odd.  The OIC is generally much more rigorous in its review process than basing approvals on a “belief” that things will get figured out.  Do you want to clarify that at all?

OIC looks at network access for active plans all year long.  Networks change constantly throughout the year, so we are in frequent communication with carriers about their networks.

The challenge when reviewing proposed networks for individual and small-group plans is that the proposed network doesn’t have to be in place until the plan start date (January 1 for individual market carriers), but the Exchange certification must occur prior to open enrollment with enough time for the Exchange to load plan data.

If OIC is reviewing a proposed network for Carrier A, and the coming plan year is Carrier A’s first year in the market, then it’s clear that the network doesn’t have to be in place until January 1.  So at the time of Exchange certification, the network would likely still be under construction.  In that scenario, when we review the Access Plan, we look for how the carrier intends to complete the network in a timely fashion, and make sure that the carrier knows what we may require if the network is not complete, such as an alternative access delivery request (AADR), and what the AADR might be.  The carrier has to demonstrate to us how the network will perform as of January 1.

Carriers often use the same network from year to year, so if Carrier B is using a network for 2017 and wants to use it for 2018, we look at what the network will be as on January 1, 2018 for the proposed plan, at the same time we are looking at what the network is during 2017 for active plans.

At the time of approving the 2018 health plans, we had concerns about Coordinated Care’s current and future network, but we did not have any reason to believe the company could not (and would not) resolve the issues for both 2017 and 2018.  We did not have documentation to support denying approval of the 2018 health plans based upon network access concerns at the time of the certification.  Our concerns grew in October/November, culminating in our action of December.