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Hospital crunch surprises many

State House Bureau

September 06. 2013 12:39AM

CONCORD — North Country residents may have to drive hundreds of miles for maternity services if Anthem Blue Cross Blue Shield does not expand its provider network for individual and small business policies offered on health insurance exchanges under the Affordable Care Act, said one executive whose hospital is not in the network.

"We had no contact. There were no negotiations," said Charlie White, executive officer of Upper Connecticut Valley Hospital in Colebrook. "We found out about our exclusion in a registered letter in the mail saying they choose not to contract with us."

Upper Connecticut Valley Hospital and nine other hospitals are not in Anthem's "narrower network" that will serve those who purchase individual insurance coverage in or outside the exchange, or small businesses who purchase insurance through the Small Business Health Options Program (SHOP) exchange. Anthem, the only insurer approved to offer policies on the health insurance exchange created under the Affordable Care Act, said in a statement it chose to offer a narrower network "to offset the premium increases that would otherwise be necessary."

Before the Health Care Reform Oversight Committee Wednesday, Anthem officials said 14 of the state's 26 hospitals would be in the new network called Pathway. Thursday, the company indicated in a statement that two hospitals had been added to the network, both in the North Country — Androscoggin in Berlin and Littleton Hospital.

Company officials say the narrower network will be 25 percent cheaper for consumers than a broader network.

The new, smaller network caught many by surprise.

Republicans blamed the ACA for rationing services and upending the current system, while they lashed out at state regulators and Gov. Maggie Hassan for hiding the information.

Democrats said Republicans have tried to sabotage the ACA by preventing state regulators from working with the federal officials and refusing federal grant money that would have educated residents about the new system and helped set it up.

Critics say the smaller network will limit access to both hospitals and the physician groups often owned by hospitals, including primary care doctors.

Concord Hospital, along with Portsmouth Regional Hospital and Frisbie Memorial Hospital in Rochester, are not in the Pathway network, nor are Southern New Hampshire Medical Center in Nashua, Monadnock Community Hospital in Peterborough and Alice Peck Day Hospital in Lebanon.

"Without an adequate network, selling the (insurance) product may be very misleading in rural areas where people may not realize they will have to drive great distances to receive care," White said. "The intention of the ACA is to improve access to heath care, but what's happening is we are reducing access."

White said his hospital and its physicians remain in Anthem's network for its customary insurance policies, that the change affects only those patients who purchase through the exchanges and individual markets.

One of the hospitals in the network, Wentworth-Douglass in Dover, had to agree to rates Anthem set in order to be in the network.

Noreen Biehl, vice president of community relations for Wentworth-Douglass, said: "It is my understanding we were asked by Anthem to be in the exchange or the marketplace. The payment rates are different than regular insurance and we had to accept the rate offered to be in it."

She said the rates are similar to what Medicaid pays and are lower than the hospital's regular contract rates with Anthem.

Oct. 1 and Jan. 1

The exchanges or marketplaces are to begin offering policies Oct. 1 that go into effect Jan. 1, when all individuals must have insurance coverage or pay a fine of about $100 annually to the Internal Revenue Service.

There are currently 40,000 with individual health policies in New Hampshire. About one-third will be exempt from the Pathway network because the policies were purchased before the ACA was enacted.

Others not having to use the Pathway network include seniors on Medicare and those who receive health insurance through their employers.

The remaining individual policy holders will have to use the Pathway network when their policies are renewed, as will anyone without insurance who buys it through the marketplace or elsewhere beginning Jan. 1.

Some expect the individual marketplace could cover as many as 150,000 individuals — including the 3,000 individuals currently in the state's high-risk pool because they were refused private insurance. The high-risk pool ends Dec. 31.

Small businesses purchasing through the SHOP exchange will also have to use the Pathway network, although few are expected to do that because small business mandates do not go into effect until January 2015.

Under the Anthem plan, emergency care in non-network hospitals will be covered. Patients with ongoing serious illness will continue to receive treatment in their current hospitals.

Anthem NH senior legal counsel Maria Proulx said Wednesday if specialty care is not available in the network, individuals can be referred to out-of-network providers in or out of state.

According to a statement released by Anthem Director of Public Relations Christopher R. Dugan, the Pathway network meets all New Hampshire network adequacy requirements.

The network will offset premium increases that could be as high as 30 to 40 percent, according to the statement. The rate concessions from the hospitals will allow much lower premiums for exchange members.

Lawmakers upset

The network plan is now before federal regulators and is expected to be approved within the next two weeks, according to Proulx. State regulators recommended Anthem's offering to the federal Center for Medicaid and Medicare Services in July.

However, Insurance Department legal counsel Jennifer Patterson told the oversight committee Wednesday she could not discuss details of Anthem's plan until Oct. 1, when it becomes public.

That upset some lawmakers, including Senate President Chuck Morse, R-Salem.

"It is troubling the executive branch knew about these impending reductions for over two months, saw fit to send them to the federal government for approval, and through it all said nothing to the people who will be directly affected by the changes — many of whom will lose access to the doctors they have known their entire lives," Morse said in a statement.

Marc Goldberg, Hassan's communications director, said state law forbids the Insurance Department from sharing what is considered proprietary information — including within state government.

"We have encouraged Anthem to quickly and clearly provide information to consumers, legislators and all stakeholders about the scope of their network, as well as how they intend to reduce costs and ensure the affordability of the insurance products they intend to offer," he said.

Patterson said traditionally the department has not released a company's rates or plan details until they go into effect. She said administrative rules governor that.

Goldberg blamed a law passed last year by the Republican-dominated legislature that prohibited the state from running its own exchange and limited state agency involvement with federal officials in setting up the exchange. The law has impeded state-level oversight and ceded control to Washington, he said.

An attempt to loosen the restrictions on state agencies this year was killed by the Senate.

The oversight committee, which has frequently deadlocked 3-3 down party lines this year over health care reform issues, meets again Oct. 2 — after the Anthem plans are approved by federal regulators and the exchange opens.

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