“Any Willing Provider Legislation”

1. “Any Willing Provider Legislation” State Governments should enact any willing provider (AWP) legislation

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

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—That is, the patient’s choices are “Yes I want the plan” or “No I don’t want the 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 entire fees 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. • Patients, in turn have insurance plans. • Therefore, in order for the provider to have access to most patients, the provider must have agreement with insurance plan. • Many Insurance plans (especially HMOs and EPPs) routinely deny health providers access to their plan.

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. References • 2004 Sprint Employee Benefits Enrollment guide. • http://www.nncc.us/policy/programspolicy.html