Week 5:

Provider Contracting, Negotiating Rates and Managing Networks

  1. Explain who is responsible for administration of the health care provider networks that are offered to covered members under your managed care plan? Identify the number of staff and proportion of health plan administration expenses devoted to contracting with health care providers, negotiating rates of reimbursement and managing the day-to-day needs of providers in networks.

  1. Identify the number of staff and proportion of health plan administration expenses devoted to the administration of health care provider networks.
  2. Explain the separate staff, resources and expenses that may be associated with offering products in the following markets
    1. Medicare/Medicaid;
    2. Individual/small employer (50 or fewer eligible employees) insured plans;
    3. Large employer (over 50 eligible employees) insured plans; and
    4. Administration of self-funded plans.

Managing Health Care Provider Systems (5 Minutes)

  1. Over the past five years, what is the average percentage of your annual expenses (not including claims paid) that are devoted to each of the following health plan administration activities:

    1. Maintaining quality assurance and education systems;
    2. Maintaining credentialing programs;
    3. Developing educational materials for contracting health care providers;
    4. Responding to questions raised by health care providers.
  2. During the 2008 calendar year, how many mailings did your health plan make to your contracting providers or potential contracting providers? If your health plan communicates with contracting providers via e-mail or other electronic means, how many such electronic messages did your health plan send to contracting providers?

  3. Highlight what your company has done over the past five years to change your day-to-day activities and explain for each of these changes how it has improved service and/or reduced your health plan administrative expenses.

  4. Explain how your company allocates the above-noted expenses among each of its product lines, identifying whether the health plan administrative costs are allocated for premium development purposes among each of the four noted types of products (e.g., are certain health plan administrative expenses pooled and allocated across all types of products or are some tied directly to the products that apply to the expenses).

  5. How does your health plan make health care providers contracting health care providers aware of changes to your web-based information?

  6. Does your health plan issue a periodic newsletter for contracting providers? During the 2008 calendar year, how often did you produce the newsletter and how did you distribute it to contracting providers? Describe the normal content included within the newsletter and the reasons that your health plan continues to provide this to your contracting providers.

  7. For calendar years 2006, 2007 and 2008, how many phone calls did your health plan receive from contracting providers about their health plan? How many staff are dedicated to responding to phone calls from contracting providers?

    1. Categorize the reasons for the calls and identify the proportion of calls that required your health plan's staff to respond to complaints about your health plan.
    2. Identify the proportion of calls that are associated with contracting providers in the following markets:
      1. Medicare/Medicaid;
      2. Individual/small employer (50 or fewer eligible employees) insured plans;
      3. Large employer (over 50 eligible employees) insured plans; and
      4. Administration of self-funded plans.
    3. Explain the process that your company uses to identify trends in complaints and ways that your health plan uses this information to address issues in your health plan.
  8. During calendar years 2006, 2007 and 2008, how many letters and e-mails did your health plan receive from contracting health care providers? How many staff are dedicated to responding to letters and e-mails from contracting providers?

    1. Categorize the reasons for the letters and e-mails and identify the proportion of letters and e mails that required your health plan's staff to respond to complaints about your plan.
    2. Identify the proportion of letters and e-mails that are associated with contracting providers in the following markets:
      1. Medicare/Medicaid;
      2. Individual/small employer (50 or fewer eligible employees) insured plans;
      3. Large employer (over 50 eligible employees) insured plans; and
      4. Administration of self-funded plans.
    3. Explain the process that your company uses to identify trends in complaints and ways that your health plan uses this information to address issues in your health plan.
  9. Explain how expenses to manage the day-to-day operation of your provider network may differ among the products that you offer, identifying the different provider network expenses for the following types of products:

    1. Medicare/Medicaid;
    2. Individual/small employer (50 or fewer eligible employees) insured plans;
    3. Large employer (over 50 eligible employees) insured plans; and
    4. Administration of self-funded plans.
  10. Identify how your company measures provider satisfaction with the way that your company administers its health plan. If your company surveys contracting providers, explain the frequency of the surveys, present any results and explain the ways that your company uses the results and what your company has done over the past five years to change your health plan administrative activities and explain for each of these changes how it has improved service and/or reduced your health plan administrative expenses.

Provider Contracting (10 minutes)

  1. Explain how many health care providers or groupings of health care providers were newly enrolled with your plan during calendar year 2008? How many groups/providers were disenrolled during calendar year 2008? How many groups/providers renewed their contracts during calendar year 2008? What proportion of contracts are up for renegotiation in any one year? Do you stagger contracts so that they renew at different times? Provide the response for each of the following:

    1. Hospitals
      1. Acute
      2. Mental health
    2. Rehabilitation
    3. Ambulatory surgery centers, community health centers, urgent care centers or other freestanding facilities
    4. Primary Care Physicians
    5. Specialty Physicians
    6. Non-Physician Providers
    7. Pharmacies and Medical /DME Suppliers
  2. What proportion of your health plan's health care providers have been continuously contracted with your company for less than 1 year? Between 1 and 3 years? Between 3 and 10 years? Over 10 years?

  3. What are the most frequent reasons that a health care provider may terminate his/her contract with a health plan and/or cease to be a provider in the health plan's network?

  4. Over the past five years, what is the number of staff and the average percentage of your annual expenses (not including claims paid) devoted to each of the following health network administration activities:

    1. Establishing initial contracts with health care providers;
    2. Credentialing health care providers; and
    3. Developing new provider networks.
  5. Identify the proportion of health care providers accepted and denied form your health plan's network(s) (provide statistics for each provider network if you have more than one) for each of the following health care providers and identify the most common reasons that your health plan has denied providers from being included in your network

    1. Hospitals
      1. Acute
      2. Mental health
    2. Rehabilitation
    3. Ambulatory surgery centers, community health centers, urgent care centers or other freestanding facilities
    4. Primary Care Physicians
    5. Specialty Physicians
    6. Non-Physician Providers
    7. Pharmacies and Medical /DME Suppliers
  6. Explain whether your health plan contracts directly with each of the following health care provider types or whether your health plan contracts with a network manager who separately contracts with individual health care providers:

    1. Hospitals
      1. Acute
      2. Mental health
    2. Rehabilitation
    3. Ambulatory surgery centers, community health centers, urgent care centers or other freestanding facilities
    4. Primary Care Physicians
    5. Specialty Physicians
    6. Non-Physician Providers
    7. Pharmacies and Medical /DME Suppliers
  7. Does your health plan use boilerplate provider contracts for all health care providers? If not, identify the types of providers that may require customized contract language:

    1. Hospitals
      1. Acute
      2. Mental health
    2. Rehabilitation
    3. Ambulatory surgery centers, community health centers, urgent care centers or other freestanding facilities
    4. Primary Care Physicians
    5. Specialty Physicians
    6. Non-Physician Providers
    7. Pharmacies and Medical /DME Suppliers
  8. Identify any contractual standards that you expect health care providers to adhere to in order to obtain and maintain their contracts with your health plan in the following areas:

    1. Risk-sharing;
    2. Collection of copayments and other cost-sharing;
    3. Reporting of data;
    4. Use of health plan referral and prior authorization processes;
    5. Quality of care;
    6. Participation in educational forums;
    7. Use of claims payment systems; and
    8. Communications with covered members.
  9. Are there particular times during the year that a non-contracting provider is required to request to be added to your health plan network or will your health plan accept applications on a rolling basis?

  10. How has your health plan define "adequate access to care" when determining whether it has a network of health care providers who present adequate access to comprehensive health care services?

    1. Identify whether your plan uses membership ratios, driving distances or other criteria when identifying "adequate access" to care.
    2. When your health plan has decided that it has satisfied "adequate access to care," does your health plan stop contracting with additional providers? If not, please explain the reasons that your health plan has contracted with providers beyond a network that provides "adequate access to care."
  11. Explain how your provider contracting expenses may differ among the products that you offer, identifying the different provider contracting and network management costs for the following types of products:

    1. Medicare/Medicaid;
    2. Individual/small employer (50 or fewer eligible employees) insured plans;
    3. Large employer (over 50 eligible employees) insured plans; and
    4. Administration of self-funded plans.
  12. Highlight what your company has done over the past five years to change your provider contracting and network management activities and explain for each of these changes how it has improved service and/or reduced your provider contract and network management expenses.

  13. Explain how your company allocates the above-noted expenses among each of its product lines, identifying whether the health plan administrative costs are allocated for premium development purposes among each of the four noted types of products (e.g., are certain health plan administrative expenses pooled and allocated across all types of products or are some tied directly to the products that apply to the expenses).

  14. Explain the process that your health plan goes through to determine whether to develop a second health care provider network and the amount of time you may estimate that it would take to develop such a network, including:

    1. How the opportunity was identified;
    2. The network types that were considered to meet the market need;
    3. The non-cost criteria used when considering new networks;
    4. The reasons that a new network product was either rejected or decided upon;
    5. The upfront cost in staff and other resources to implement a new network;
    6. The additional cost or savings of implementing the new network; and
    7. Whether targets are set that must be met in order to consider the new network successful and to continue to market the product.
  15. Explain whether your company needs to develop special provider contracts when offering non-Medicare products with "benefit tiers" or lower cost-sharing for benefits when the covered person receives care from those identified by the health plan as being in its "top tier" of providers.

Negotiating Rates of Health Care Provider Reimbursement (30 minutes)

  1. Explain the process for negotiating rates of reimbursement with each of the types of health care providers:

    1. Hospitals
      1. Acute
      2. Mental health
    2. Rehabilitation
    3. Ambulatory surgery centers, community health centers, urgent care centers or other freestanding facilities
    4. Primary Care Physicians
    5. Specialty Physicians
    6. Non-Physician Providers
    7. Pharmacies and Medical /DME Suppliers
  2. Present your company's timetable to initiate the negotiation process, obtain initial quotes from health care providers, secure commitments from a health care provider to be in the health plan's provider network and agree to provide services to the health plan's members at the negotiated rate. Identify the information that you use to evaluate what your plan believes to be a fair and appropriate rate of reimbursement.

  3. Explain whether your health plan negotiates different rates of reimbursement for coverage offered in each of the following markets and the reasons that you have different rates of reimbursement for any of these markets:

    1. Medicare/Medicaid;
    2. Individual/small employer (50 or fewer eligible employees) insured plans;
    3. Large employer (over 50 eligible employees) insured plans; and
    4. Administration of self-funded plans.
  4. Over the past five years, what are the number of staff and the average percentage of your annual network administration activities that are devoted to rate negotiations?

  5. Identify the persons who are involved in the process of negotiating rates of reimbursement from each of the following types of health care providers:

    1. Hospitals
      1. Acute
      2. Mental health
    2. Rehabilitation
    3. Ambulatory surgery centers, community health centers, urgent care centers or other freestanding facilities
    4. Primary Care Physicians
    5. Specialty Physicians
    6. Non-Physician Providers
    7. Pharmacies and Medical /DME Suppliers
  6. Identify for each of the following types of health care providers whether your health plan contracts only with individual facilities or health care providers or whether you also contract with multi-provider networks of facilities or providers (and if you contract with multi-provider networks, identify the multi-provider networks):

    1. Hospitals
      1. Acute
      2. Mental health
    2. Rehabilitation
    3. Ambulatory surgery centers, community health centers, urgent care centers or other freestanding facilities
    4. Primary Care Physicians
    5. Specialty Physicians
    6. Non-Physician Providers
    7. Pharmacies and Medical /DME Suppliers
  7. Has your health plan ever encountered a situation where another party - other than the health care providers or their appointed representatives - has attempted to intervene in the contract negotiation, for example, on behalf of any health care providers' inclusion in a health care network or about the level of reimbursement to be paid to the health care provider? Explain what, if any, influence these parties may have on the negotiating process.

  8. Do you have contracts with provider networks that have the exclusive right to contract on behalf of their constituent entities? If yes, are those rates negotiated through provider networks higher or lower than rates negotiated for providers who are not part of provider networks?

  9. Identify the minimum level of detail regarding actual and projected costs that your health plan requires from each of the following types of providers as the basis for their requested reimbursement and the ways that your plan uses this information in its negotiations:

    1. Hospitals
      1. Acute
      2. Mental health
    2. Rehabilitation
    3. Ambulatory surgery centers, community health centers, urgent care centers or other freestanding facilities
    4. Primary Care Physicians
    5. Specialty Physicians
    6. Non-Physician Providers
    7. Pharmacies and Medical /DME Suppliers
  10. Provide any information you have regarding all of the underlying costs of each provider system that you reimburse for health care services. In particular, for each provider group, please provide a breakdown of actual costs and trends in those costs over the past five years, including, but not limited to, the following costs: medical malpractice insurance, health information technology, hospital executive compensation, labor rates for hospital staff, physician compensation, construction, and medical supplies.

  11. Explain whether your health plan evaluates providers on the basis of quality and if so, explain (1) the factors you use, (2) how your plan ranks the outcomes of these quality evaluations and (3) whether there a relationship between the quality rankings and the level of payments made to a particular provider. If there are other factors or use of quality evaluations, explain the factors and why your health plan uses them.

  12. For the following types of health care providers, over the past five years, identify the proportion of contracts in which the providers accept the health plan's initial offer; the proportion of contracts in which the health plan accepts the provider's initial offer; and the proportion of contracts in which the ultimate negotiated rate of reimbursement is somewhere between the health plan's and the health care provider's initial offer:

    1. Hospitals
      1. Acute
      2. Mental health
    2. Rehabilitation
    3. Ambulatory surgery centers, community health centers, urgent care centers or other freestanding facilities
    4. Primary Care Physicians
    5. Specialty Physicians
    6. Non-Physician Providers
    7. Pharmacies and Medical /DME Suppliers
  13. . Are there any health care providers who are the only providers in a geographic area who have identified that they will only continue contracts with your plan if you reimburse them at the level they believe to be appropriate? If these providers were no longer in your system, explain the impact this would have on your service delivery system and your ability to provide adequate access to care. Are there providers in a certain geographic area or certain provider types that will either not enter into a contract to be part of a network or that will not accept a discount from their standard changes, and if so, identify these types of providers?

  14. Has your health plan ever refused to contract with any health care provider because of the level of increase requested by the provider? Why? Why Not?

  15. If a health care provider notifies your health plan it is seeking an increase of 10-15% increase in payments for the same services, explain the process your company does undertake to identify and evaluate the reasons for the increase. How do you look at any particular costs the provider is trying to pass on, including capital costs, interest on debt, R&D costs, executive salaries, etc. Have you ever informed provider that they will have to do a better job of controlling costs or that your health plan will not be able to contract with them in the future?

  16. When identifying your health plan's initially offered contract rate, do you impose limits on increases from one year-to-the-next based on any index (e.g., CPI) or any fixed level of increase? Identify all other factors or reimbursement limitations that you apply when negotiating what your company will allow for year-to-year reimbursement changes?

  17. For the following types of health care providers, identify the proportion of contracts in which you reimburse providers primarily on (1) a fee-for-service or discounted fee for service basis, (2) DRG basis or (3) other basis (where other, please identify the method of reimbursement):

    1. Hospitals
      1. Acute
      2. Mental health
    2. Rehabilitation
    3. Ambulatory surgery centers, community health centers, urgent care centers or other freestanding facilities
  18. For the following types of health care providers, identify the proportion of contracts in which you reimburse providers primarily on (1) a fee-for-service or discounted fee for service basis or (2) other basis (where other, please identify the method of reimbursement):

    1. Primary Care Physicians
    2. Specialty Physicians
    3. Non-Physician Providers
    4. Pharmacies and Medical /DME Suppliers
  19. For each of the following types of health care providers, identify all types of "global payment" arrangements that you have negotiated, the proportion of providers who may take advantage of the global payments, and if not all providers of a certain type are eligible for global payments, the method that your health plan has used to determine which health providers to offer "global payments:"

    1. Hospitals
      1. Acute
      2. Mental health
    2. Rehabilitation
    3. Ambulatory surgery centers, community health centers, urgent care centers or other freestanding facilities
    4. Primary Care Physicians
    5. Specialty Physicians
    6. Non-Physician Providers
    7. Pharmacies and Medical /DME Suppliers
  20. If your plan does offer "global payments" to all health care providers, identify the reasons that certain providers have not agreed to accept "global payments" for covered services.

  21. For each of the following types of health care providers, identify (1) all types of supplemental reimbursement (e.g., signing bonuses, infrastructure payments, bad debt payments, etc.) that your health plan makes to any health care provider that is not tied directly to the delivery of care, (2) the range of different supplemental reimbursements made to any providers in a type of provider during the 2008 calendar year, (3) the proportion of providers who are offered such supplemental reimbursements, and (4) if not all providers of a certain type are eligible, the method that your health plan has used to determine which health providers receive such supplemental reimbursements:

    1. Hospitals
      1. Acute
      2. Mental health
    2. Rehabilitation
    3. Ambulatory surgery centers, community health centers, urgent care centers or other freestanding facilities
    4. Primary Care Physicians
    5. Specialty Physicians
    6. Non-Physician Providers
    7. Pharmacies and Medical /DME Suppliers
  22. For each of the following types of health care providers, identify (1) all types of pay-for-performance or quality-based reimbursement that your health plan makes to any health care provider, (2) the range of different pay-for-performance incentives to any providers during the 2008 calendar year, (3) the proportion of providers who are offered such pay-for-performance or quality-based reimbursements, (4) and if not all providers of a certain type are eligible, the method that your health plan has used to determine which health providers receive such pay-for-performance supplemental reimbursements:

    1. Hospitals
      1. Acute
      2. Mental health
    2. Rehabilitation
    3. Ambulatory surgery centers, community health centers, urgent care centers or other freestanding facilities
    4. Primary Care Physicians
    5. Specialty Physicians
    6. Non-Physician Providers
    7. Pharmacies and Medical /DME Suppliers
  23. For the following types of health care facilities , identify whether you can choose to contract for only some of the services provided in the facility or whether some facilities will only contract with your health plan if the contract is for all the services provided in the facility (an "all or nothing" approach):

    1. Hospitals
      1. Acute
      2. Mental health
    2. Rehabilitation
    3. Ambulatory surgery centers, community health centers, urgent care centers or other freestanding facilities
    Identify any facility with whom you can only contract on an "all or nothing" basis.
  24. For multi-provider networks, identify whether you can choose to contract for only some of the services provided through the providers in the multi-provider network or whether any multi-provider network will only contract with your health plan if the contract is for all the services provided through the multi-provider network (an "all or nothing" basis). Identify any multi-provider network with whom you can only contract on an "all or nothing" basis.

  25. Explain what occurs if an existing health care provider contract is set to expire on a particular date including when your plan or the provider contacts the other party about renewing the contract. Explain what occurs when your health plan has not been able to reach an agreement with a health care provider about the level of reimbursement. Do you have contractual terms or processing requiring that your health plan have a signed commitment a certain number of days prior to the expiration of a contract? Does your plan have any provisions to extend an existing contract beyond the expiration date in order to continue negotiations with any company?

  26. Explain what your health plan does when it is not able to come to an agreement with a health care provider and needs to notify covered members that a health care provider is no longer part of your health plan network. Explain the length of time needed to properly notify affected members,

  27. Explain the length of time necessary to have your provider contracts finalized and the network fixed prior to marketing that provider network to accounts. Please provide an example of the rate negotiating timeline assuming that your health plan is marketing a health product with an effective date of January 1 so that there are not any interruptions in covered persons obtaining covered health services.

  28. In preparation for these hearings, the Division of Insurance forwarded scanned screen prints from the Health Care Quality and Cost Council website which illustrate the risk-adjusted aggregate payments for services that health plans for particular services - along with measures of quality - at facilities within 20 miles of the following geographic areas: Boston, Lowell, Bridgewater, Worcester and Springfield for claims paid through 2007. The presented information illustrates a wide range in the payments made to one facility versus another.

    1. Identify whether your health plan also has wide ranges in the levels of payments that are made to facilities in the noted geographic areas and whether this persists in other parts of the state.
    2. Identify the reasons that your health plan continues to pay certain facilities at higher rates of reimbursement instead of providing for services only from lower cost facilities.
    3. Would your health plan continue to provide adequate access to a comprehensive care delivery system if it did not include high-cost health care providers in its system? If not, list for each of the following types of providers, the services provided by the high-cost providers may need to be available in order to offer adequate access to a comprehensive care delivery system:
    4. Hospitals
      1. Acute
      2. Mental health
    5. Rehabilitation
    6. Ambulatory surgery centers, community health centers, urgent care centers or other freestanding facilities
  29. Since your health plan does not pay all providers the same amount of money for identical procedures (e.g., MRIs, x-rays or other scans), what factors determine why some providers could be paid 2, 3 or sometimes more than others for the same procedures?

  30. Identify any provisions within written contracts with health care providers that impact your health plan or any health care provider's negotiations or contracts with other plans or providers, including provisions that require or permit the following:

    1. The health plan has the contractual right to negotiate, adjust or renegotiate rates or terms of reimbursement agreed to with the health care provider based upon the rates or terms of reimbursements that the health care provider has agreed to with another health plan or payor;
    2. The health care provider has the contractual right to negotiate, adjust or renegotiate rates or the terms of reimbursement agreed to with a health plan based upon the rates or terms of reimbursement that the health plan has agreed to with another health care provider;
    3. The health plan has the right to know the rates or terms of reimbursement that the health care provider has agreed to accept from any other health plan;
    4. The health care provider has the right to know the rates or terms of reimbursement that the health plan has agreed to with any other health care provider;
    5. The health care provider may not negotiate reimbursement rates with any other health plan that are lower than the ones in your health plan's contract;
    6. The health care provider may not contract with any other health plan or is restricted to have your health plan's approval before contracting with any other health plan;
    7. The health care provider has some special right or consideration to be included in a health plan's limited network product or to be within certain benefit tiers within a health plan's tiered benefit product;
    8. The health care provider has some special right or consideration to be included in the network of any product offered by an associated company (e.g., an insurance company affiliated with your Health Maintenance Organization) or other companies (e.g., through national account networks);
    9. The health care provider has some special right or consideration to be included in the same networks offered to insured and self-funded business;
    10. The health care provider has the ability to withdraw from the health plan's network if the health plan contracts with other specified health care providers;
    11. The health care provider has the ability to withdraw from the health plan's network if the health plan establishes other provider networks that do not include the health care provider;
    12. The health care provider has the ability to withdraw from the health plan's network if the health care provider is not listed in the most advantageous "tier" for a product with a "tiered" benefit product;
    13. The health care provider has the ability to withdraw from the health plan's network if the health plan offers any new product design that was not part of the original contract;
    14. The health care provider may withdraw from any contract before giving a specified number of days of notice to the health plan; or
    15. The health care provider may "opt out" of any new products and/or variations on existing products.
    If you do include any of the noted provisions in any of your contractual relationships, explain whether these provisions are in all provider agreements, or if not, identify the providers or multi-provider networks in which your health plan has included these clauses. In addition, explain how any of the noted provisions affect your ability to create new lower cost products.

  31. Identify any provisions within written contracts with health care providers that limit, restrict or identify a cap to the number of physicians or other providers who can be compensated under the contract's negotiated rate of reimbursement. Identify the providers or multi-provider networks with which your health plan has such agreements or understandings and if these limits, restrictions or growth caps differ from one provider to another, identify the different arrangements that apply to the different providers. In addition, explain how any of the noted provisions affect your ability to create new lower cost products.

  32. Explain whether you have ever entered into a contract or agreement -- verbal or written - with a provider on the condition that the provider would not pay any other carrier an amount of money lower than what the provider had agreed to pay you. If yes, provide details of the contract or agreement.

  33. Identify any agreements or understandings outside written contracts with health care providers that impact your health plan or any health care provider's negotiations or contracts with other plans or providers, including agreements or understandings that require or permit the following:

    1. The health plan has the contractual right to negotiate, adjust or renegotiate rates or terms of reimbursement agreed to with the health care provider based upon the rates or terms of reimbursements that the health care provider has agreed to with another health plan or payor;
    2. The health care provider has the contractual right to negotiate, adjust or renegotiate rates or the terms of reimbursement agreed to with a health plan based upon the rates or terms of reimbursement that the health plan has agreed to with another health care provider;
    3. The health plan has the right to know the rates or terms of reimbursement that the health care provider has agreed to accept from any other health plan;
    4. The health care provider has the right to know the rates or terms of reimbursement that the health plan has agreed to with any other health care provider;
    5. The health care provider may not negotiate reimbursement rates with any other health plan that are lower than the ones in your health plan's contract;
    6. The health care provider may not contract with any other health plan or is restricted to have your health plan's approval before contracting with any other health plan;
    7. The health care provider has some special right or consideration to be included in a health plan's limited network product or to be within certain benefit tiers within a health plan's tiered benefit product;
    8. The health care provider has some special right or consideration to be included in the same networks offered to insured and to self-funded business;
    9. The health care provider has some special right or consideration to be included in the same networks offered to insured and to self-funded business;
    10. The health care provider has the ability to withdraw from the health plan's network if the health plan contracts with other specified health care providers;
    11. The health care provider has the ability to withdraw from the health plan's network if the health plan establishes other provider networks that do not include the health care provider;
    12. The health care provider has the ability to withdraw from the health plan's network if the health care provider is not listed in the most advantageous "tier" for a product with a "tiered" benefit product;
    13. The health care provider has the ability to withdraw from the health plan's network if the health plan offers any new product design that was not part of the original contract;
    14. The health care provider may withdraw from any contract before giving a specified number of days of notice to the health plan; or
    15. The health care provider may "opt out" of any new products and/or variations on existing products.
    If you do have any agreements or understandings regarding any of the above-noted provisions, please explain whether these provisions apply to all providers, or if not, identify the providers or multi-provider networks in which your health plan would honor these agreements or understandings. In addition, explain how any of the noted provisions affect your ability to create new lower cost products.

  34. Identify any agreements or understandings with health care providers that limit, restrict or identify a cap to the number of physicians or other providers who can be compensated under any contract's negotiated rate of reimbursement. Identify the providers or multi-provider networks with which your health plan has such agreements or understandings and if these limits, restrictions or growth caps differ from one provider to another, identify the different arrangements that apply to the different providers. In addition, explain how any of these agreements or understandings affects your ability to create new lower cost products.