Use Case 21: healthcare.gov + NPPES + HPOES provider health plan network status

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Requirements

Use case summary

Description: Need ability to clearly (and in real-time) identify if/when a provider accepts a health plan.


Value: More efficient comparison of "narrow network" plan options in the marketplace. Metric of how frequently a provider adds/drops accepted plans. Metric of how frequently a health plan expands/contracts their network. Metric of comparison of covered service options.


Challenge(s): Getting commercial networks to submit real-time network status of providers. Granularity of acceptance for specific services.

Customer

  • Billian's HealthDATA

Specifications

Desired fields

  • national provider id (NPI-NPPES)
  • national plan id (NPI-HPOES) /currently NOT open/
  • date added to plan
  • date removed from plan
  • (optional) full or partial coverage of provider's services (boolean)
  • (optional) CPT code or ICD-9/10 procedure code(s) covered

Desired frequency:


  • real-time API


Solution

  • The information to determine whether a provider accepts a health plan can be derived from 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
    • Timeframe information: There is no specific timing information for when a provider started or stopped accepting a plan in the MR-PUF. It's possible that this information could be interpolated over time using the "last updated" field or tracking over time when a provider is no longer listed.
    • 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.


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