Anthem insurance plan with MaineHealth wins key approval

Posted July 25, 2013, at 1:27 p.m.
Last modified July 25, 2013, at 5 p.m.

AUGUSTA, Maine — A state regulator has greenlighted a key component of a new health insurance product that would be sold next year under a controversial deal between insurer Anthem and MaineHealth.

The Maine Bureau of Insurance issued a decision Thursday that largely approved one piece of the health plans, the proposed network of doctors and hospitals that would serve consumers who buy the policies. The plans would be sold next year on Maine’s health insurance exchange under the Affordable Care Act.

The network was the subject of a public hearing in late June at which health providers excluded from the network raised concerns that patients may have to travel farther for care and find new doctors.

The bureau approved the provider network but listed 14 conditions, including that Anthem submit more information about how the plans would affect access to health care based on where consumers live, contract with additional specialists in some areas, and report on consumers’ future experience with the plans.

The plans need more approvals before they can be sold on Maine’s insurance exchange. The state insurance bureau will issue a broader report by the end of July detailing whether the plans comply with the federal health reform law. That report also will include one other carrier that plans to offer health insurance on Maine’s exchange, the nonprofit Maine Community Health Options.

The next report also will shed light on how much the plans will cost and what benefits they’ll include.

The federal government will have the final say about whether plans meet standards to be sold on the exchange.

The insurance exchanges are a key component of the health reform law, the federal Affordable Care Act, which aims to widen health coverage to 30 million people.The exchanges will operate as online markets where consumers and small businesses can shop for coverage beginning in October 2013. The plans would take effect in January 2014.

Plans sold on the exchanges will be available to individuals who buy their own insurance, small businesses and the uninsured. Most workers who have health insurance through a large employer aren’t eligible to shop for plans on the exchange and wouldn’t be affected by the Anthem-MaineHealth deal.

About 257,000 Mainers are expected to be eligible to shop for insurance on Maine’s exchange, which will be run by the federal government.

The Anthem-MaineHealth plans include 32 of Maine’s 38 hospitals, but exclude Central Maine Healthcare, which operates Central Maine Medical Center in Lewiston, Bridgton Hospital and Rumford Hospital, as well as Parkview Adventist Medical Center in Brunswick, York Hospital, and Portland’s Mercy Hospital.

Central Maine Healthcare officials have denounced the plan as a “backroom deal” that allows MaineHealth to undercut hospitals that compete with its health system, undermining the intent of the reform law to improve access to affordable health care.

Chuck Gill, a spokesman for Central Maine Healthcare, said Thursday afternoon that the system was still reviewing the 61-page decision but planned to confer with its attorneys about an appeal.

He expressed disappointment with the finding that the proposed network, which would require some western Maine patients to travel up to an hour to see a primary doctor, met the state requirement for providing “reasonable access to care.”

“Evidently it’s a relatively low bar, reasonable access to health care, and Anthem got under that bar,” he said.

Anthem has proposed two plans for Maine’s insurance exchange, a “point of service” plan for northern Maine that includes all hospitals in the region and an HMO plan for southern Maine that excludes the six providers.

The bureau’s 14 conditions that Anthem must meet include attempting to contract with additional pediatricians, dermatologists and other specialists to serve patients in southern and western counties.

“This is a classic case of buyer beware,” Gill said.

Anthem and MaineHealth contend that their collaboration will lead to lower health insurance premiums for consumers while allowing policyholders plenty of choice in who they see for care.

Patients still could visit any hospital for emergency care.

The hospitals included in the network agreed to significantly reduced payments from Anthem in exchange for having more patients funneled to their facilities. Anthem has said those rate reductions are critical in offsetting extra costs associated with the Affordable Care Act, which requires insurers to offer a wider scope of benefits and prohibits them from denying customers with pre-existing medical conditions.

Anthem spokesman Chris Dugan said in a statement Thursday that the insurer was pleased with the bureau’s decision.

“Simply passing along increasing costs in the form of higher premiums is not acceptable,” Dugan said. “That’s why Anthem collaborated with MaineHealth and selected providers across the state to develop a comprehensive provider network that could be paired with the new products to slow the rate of premium increases.”

In the decision, Maine Bureau of Insurance Superintendent Eric Cioppa noted that insurers aren’t required to contract with every hospital and commonly form networks, “the product of intentional business decisions made by carriers and providers.” The practice naturally excludes some hospitals and doctors, but is allowed by Maine law as long as the networks satisfy a number of consumer protections, he wrote.

While Thursday’s decision will affect future Anthem customers, it did not address the fate of Anthem’s existing policyholders in Maine. Cioppa scheduled a Sept. 9 hearing on whether Anthem can move forward with plans to move many customers, who now have access to a broader network of providers, into the new policies.

“Simply because I am permitting Anthem to offer these narrow-network plans for sale in Maine does not necessarily mean I will also permit Anthem to move its current customer base into these plans,” Cioppa wrote.

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