LEWISTON — The Bureau of Insurance has granted Anthem’s request to partner with MaineHealth, the state’s largest health-care organization, to offer a new insurance plan for the upcoming Affordable Care Act insurance exchange.
The plan locks out Central Maine Medical Center, Bridgton Hospital, Rumford Hospital and their affiliated specialists, except in cases of patients seeking emergency care. Also locked out are Mercy Hospital in Portland, York Hospital in southern Maine and Parkview Adventist Medical Center in Brunswick.
That will force Central Maine Healthcare's patients who decide to enroll in the Anthem plan to find other health-care providers, according to CMHC, which administers CMMC, Rumford and Bridgton hospitals. And, employees of small businesses that enroll in the plan may also have to switch doctors, depending on where they live.
MaineHealth hospitals and their affiliated specialists, including Mid Coast in Brunswick, St. Mary’s Regional Medical Center in Lewiston, MaineGeneral in Waterville and Augusta, and Franklin Memorial in Farmington, are included in the Anthem plan.
Of the 38 hospitals in Maine, only six are excluded. Chuck Gill, vice president of marketing for Central Maine Healthcare, pointed out that all six are direct competitors of MaineHealth or one of its affiliates.
"You (patients) are going to end up changing your doctor or hospital if you’re caught up in the plan," he said, and will be forced to travel farther for health care.
That does not fit the state’s requirement of “reasonable access to health care,” he said, repeatedly calling the bureau's approval a backroom deal.
Gill acknowledged he was angry about the bureau's decision. "People who really should be angry are the people who will be directly affected by this, who wake up and are sick and could have gone directly to Lewiston" but may now have to drive elsewhere, he said.
The Anthem plan is actually two plans, geographically split into north and south, with a guided-access HMO — considered a narrow network plan — to be available in 10 southerly counties, including Androscoggin, Oxford and Franklin, and a guided-access POS — a broad network plan — available in Maine’s remaining counties to the north.
To date, Anthem's proposal is one of only two seeking state approval to be added to the new health insurance exchange mandated under the 2010 Patient Protection and Affordable Care Act, through which individuals and small groups can buy insurance and receive federal subsidies. The other is offered by Maine Community Health Options, a new nonprofit co-op insurance program based in Lewiston.
The Anthem plan was made public July 1, and Eric Cioppa, superintendent of the Bureau of Insurance, faced a July 31 deadline from the federal government to make his ruling.
Central Maine Healthcare has been highly critical of the approval process from the start, filing a lawsuit against the state in June for access to Anthem documents made confidential by the bureau and criticizing the plan for its strict limitations on doctors and hospitals for which the proposal will pay.
According to Gill, CMHC does not have an immediate plan to seek approval of its own insurance plan to join Maine's exchange.
In his review of the Anthem proposal, Cioppa determined some counties lack access to a limited number of specialists within the mandated 60-minute drive time and, under his order granting the plan, has required Anthem to contract with additional specialists to fill in some geographic holes.
For example, Franklin County has no practicing gastroenterologists and none of the six in Oxford County are included in the Anthem plan because they are affiliated with CMHC. So, as one of the conditions for plan approval, Cioppa has directed Anthem to either contract with at least one in-network gastroenterologist in Oxford County or to ensure that patients are able to obtain services from one of the out-of-network gastroenterologists at no greater cost than if the physician were in-network.
Cioppa has also determined that there is inadequate availability of nephrology and pulmonary care in far Western Maine, and has directed Anthem to contract with one specialist in nephrology and another in pulmonary medicine in Oxford County.
Cioppa also voiced concerns about the need for pediatric care exceeding availability of pediatricians in Anthem’s proposed HMO network in Sagadahoc County and, potentially, in Androscoggin County.
Sagadahoc County has nine pediatricians, but none are contracted with Anthem, which could force parents to take their children to Androscoggin, Cumberland, Kennebec or Lincoln counties for care. But since only seven of the 25 pediatricians in Androscoggin County are contracted with Anthem, that could overwhelm capacity, Cioppa said. He has directed Anthem to contract with at least three more pediatricians in Sagadahoc County to expand patient access there.
In addition to these directives, Anthem must satisfy nearly a dozen more for final approval.
None of the network restrictions contained in the Anthem plan apply to emergency services. According to Cioppa, patients suffering medical emergencies “can be treated at the nearest hospital, whether that hospital is part of Anthem’s network or not.”
But only three hospitals in Maine offer tertiary care, which is comprehensive care by specialists. They are Maine Medical Center in Portland, CMMC and Eastern Maine Medical Center in Bangor. During the approval process, CMMC and its affiliates argued that it was not reasonable to require patients living in Androscoggin, Franklin and Oxford counties, some of whom are chronically ill, to travel to Portland for care.
However, Cioppa determined that if all of northern Maine can rely on EMMC, it was not unreasonable to identify a single hospital to serve southern Maine, and Maine Med was named as that hospital.
Much of Cioppa's ruling is based on drive time for medical care.
Under federal requirements, primary care services shall be available within 30 minutes' travel time; specialty care and hospital services shall be available within 60 minutes.
According to Gill, Cioppa's ruling suggests that patients living in Fryeburg will drive only 30 minutes to reach primary care services in Norway, a distance of 32 miles. Even under optimal driving conditions, that trip takes closer to 45 minutes.
"That's counter to the idea of keeping care local," Gill said.
"What Anthem is trying to do is force people to travel out of (Androscoggin County)," Gill said. "Our idea of access to care is to keep care in the local community," he said.
And, "on the economic development side, we want to keep people in Lewiston and Auburn working, not force them to Portland" for employment, he said.
According to Doug Dunbar, spokesman for the Bureau of Insurance, the bureau’s decision can be appealed through the judicial process. Gill said CMHC is talking to its lawyers and would make a decision in the next week to 10 days on whether to appeal.
On Sept. 9, in a second phase of ACA requirements, the Bureau of Insurance has scheduled a public hearing as part of its process to determine whether the plan it just approved should be expanded to draw Anthem’s current 17,000 members into the MaineHealth plan, including the University of Maine System and Maine Education Association members and retirees.
Enrollment in marketplaces is expected to begin in October; insurance coverage would be effective Jan. 1.
MaineHealth did not return a call for comment.