Mainers on a new Anthem Blue Cross and Blue Shield insurance plan won't be able to go to Rumford or Bridgton hospitals for anything short of an emergency.
They won't be able to see most doctors employed by Central Maine Medical Center. And if they prefer Parkview Adventist Medical Center to Mid Coast Hospital in the battle of the Brunswick hospitals, they'll be out of luck.
That "narrow network" health insurance plan — strictly limiting which doctors and hospitals a patient can use in an effort to cut health-care costs — is controversial right now in Maine. But that kind of plan isn't new. And it isn't uncommon.
At least in the rest of the country.
"It's not unique at all. These are emerging and have been," said Alywn Cassil, director of public affairs at the Center for Studying Health System Change, a nonpartisan, Washington, D.C.,-based health policy research group.
Anthem first proposed its narrow network plan for the upcoming Affordable Care Act health insurance marketplace, also known as an exchange. Individuals and small groups can buy insurance from that exchange beginning Oct. 1. Individuals who make up to 400 percent of the federal poverty level can receive a federal subsidy in the form of a tax credit. The federal poverty level is $11,490 a year for one person, $25,550 a year for a family of four.
Anthem's plan represents a partnership between the largest health insurance company in the state and MaineHealth, the largest health-care organization in the state. All MaineHealth hospitals and affiliates are in the plan. Six Maine hospitals and their affiliates, all in some way competitors with MaineHealth or its affiliates, are out.
In central Maine, St. Mary's Regional Medical Center in Lewiston, Franklin Memorial Hospital in Farmington, Mid Coast Hospital in Brunswick and Stephens Memorial Hospital in Norway are in. Central Maine Medical Center in Lewiston, Bridgton Hospital, Rumford Hospital and Parkview Adventist Medical Center in Brunswick are out.
The Maine Bureau of Insurance last week OK'd the plan but added more than a dozen conditions. Among those conditions: Anthem must contract with additional specialists to fill in some geographic holes. If Anthem doesn't, it must allow patients to see an out-of-network doctor and pay the same as an in-network visit.
The conditions don't substantially change the plan's overall network. The plan must still win approval from the federal Centers for Medicare and Medicaid Services. However, the federal government is expected to accept the state's judgment on Anthem's network.
Anthem also wants to sell a narrow network plan off the exchange and move most of its current individual policyholders into it. The bureau has not yet ruled on that proposal.
The most vocal opponent to Anthem's narrow network: Central Maine Healthcare, which owns three of the hospitals not in the network and has a relationship with a fourth.
CMHC stands to lose business. Officials there have also said the plan will hurt patients by limiting their choices, forcing them to change doctors and making Rumford and Bridgton residents drive far out of town for care.
"What Anthem is trying to do is force people to travel out of (Androscoggin County)," CMHC spokesman Chuck Gill said last week after the state had announced it approved Anthem's plan for the exchange. "Our idea of access to care is to keep care in the local community."
Such narrow networks are reminiscent of HMO plans from the 1990s and, in fact, Anthem calls this plan an HMO. Those plans were popular for a time because they were often low-cost, but that popularity fizzled more than a decade ago, in part because consumers wanted more freedom when it came to their health care. Insurance plans in Maine now typically allow patients to use any doctor or hospital.
As patients and businesses struggle with increasing health-care costs, those narrow network plans have started to make a comeback across the country.
"Everything old is new again in health care," Cassil said.
She's seen growth in both narrow networks and tiered networks, which encourage patients to use particular doctors or hospitals by lowering the cost of those visits. Of the two, she said, narrow networks are the more common.
America's Health Insurance Plans, the trade association for the health insurance industry, has also noticed growth in narrow networks, particularly since the passage of the Affordable Care Act in 2010.
"Plans want to be able to keep coverage as affordable as possible given all of these changes, and one way to do that is to keep the networks focused on high-quality, efficient providers," said Robert Zirkelbach, vice president for strategic communications.
In addition to price, it's that focus on quality and efficiency that makes the general idea of narrow networks attractive to some.
"If the network was limited to the best-performing hospitals and doctors in terms of quality and efficiency, with an opportunity for other providers to be included when they meet that same high bar, I think that would be the best thing possible for both patients and our economy," said Nancy Morris, director of communications for the Maine Health Management Coalition, a Portland-based nonprofit group of insurers, employers, hospitals and doctors.
But others aren't sure Anthem's network will provide quality and efficiency.
Central Maine Healthcare officials have pointed out that an Onpoint Health Data analysis recently named Rumford and Bridgton hospitals among the lowest-cost hospitals in the state and CMMC the lowest cost of the state's three tertiary-care hospitals, including MaineHealth's Portland affiliate, Maine Medical Center, which will be included in Anthem's network.
Consumer Reports on Thursday gave CMMC the second-highest score of the six Maine hospitals it rated for patient safety related to surgery. St. Mary's Regional Medical Center received the highest score; Maine Medical Center received the lowest. St. Mary's and Maine Med are both in Anthem's network. CMMC is not.
Others have a different concern about the network: Too few doctors for too many patients.
"What is the capacity of those narrower networks?" said Joe Ditre, executive director of the Augusta-based Consumers for Affordable Health Care. "They've got a lot more work to do."
The bureau will hold public comment sessions on Anthem's proposal to move a large number of current individual policyholders into the narrow network plan. Those sessions will be offered before each of the four Affordable Care Act informational sessions it has scheduled throughout Maine in August. Central Maine's meeting will be held Thursday, Aug. 29, at Central Maine Community College, with public comment on Anthem's proposal at 5 p.m. and an information session on the Affordable Care Act at 6 p.m.
The bureau also will hold a hearing on Anthem's proposal on Monday, Sept. 9, at the Burton M. Cross State Office Building in Augusta. Presentations by parties to the proceeding will begin at 9 a.m.
CMHC is still considering whether to appeal the Bureau of Insurance's approval of Anthem's plan for the exchange.