- Associated Press - Sunday, February 23, 2014

AUGUSTA, Maine (AP) - When Roberta Lane went to her local hospital emergency room, where the doctors she’s seen for years practice, she was shocked to find out her insurance wouldn’t cover treatment.

The Auburn resident had bought a plan on the Affordable Care Act exchange through Anthem Blue Cross and Blue Shield, unaware that the hospital was one of the six excluded in the insurer’s “narrow network,” Lane wrote to lawmakers last month. Unable to immediately transfer to another hospital, she spent several days in Central Maine Medical Center worrying about how she’d pay for the mounting costs.

“I was quite irritated and angry and obviously had some anxiety because I was like, this is a $15,000 bill,” said Lane, who declined to say why she was receiving treatment. “To have to worry about that on top of dealing with a serious illness … that’s really the last thing I need to worry about.”

Lane said it appears that Anthem will cover the costs after all, thanks to a built-in grace period, but Maine lawmakers hope they can help others avoid that headache.

Two bills the Insurance and Financial Services Committee will examine again on Tuesday aim to bring more transparency to these narrow provider networks - both for the consumers and the hospitals that are being excluded.

Rep. Paul McGowan, a Democrat from York, wants to require insurers to clearly show in their marketing and informational materials what hospitals aren’t included in plans. He also wants insurers to explain publicly how their plans provide reasonable access to care for their members. Under another measure the committee is examining, introduced by Democratic Sen. Dawn Hill of Cape Neddick, insurers would have to disclose to providers why they weren’t included in the network.

Anthem, one of the two companies offering insurance in Maine on the federally-run exchange, contends that its narrow network enables it to offer premiums that cost 8 percent less than if they had crafted a network that stretches to more hospitals in the state.

“As health care spending in Maine continues to rise, we are working diligently to manage costs, including offering new products with new networks, rather than simply passing additional costs on to those we serve,” Rory Sheehan, a spokesman for Anthem, said in an email.

Among the hospitals excluded from Anthem’s network are York Hospital, Mercy Hospital in Portland and Parkview Adventist Medical Center in Brunswick.

The three others - Central Maine Medical Center in Lewiston, Bridgton Hospital and Rumford Hospital - are owned by Central Maine Healthcare, a vocal critic of Anthem, which claims that the insurer hasn’t explained why its hospitals weren’t allowed to participate in the network. Central Maine Healthcare says the narrow network is forcing patients to drive longer to receive care and destroying patient-doctor relationships.

Consumers do have the option to see out-of-network doctors, just at a steeper cost.

Anthem, which is pushing back against the proposals, says Maine’s Bureau of Insurance already has a process for reviewing whether a network adequately serves resident’s needs.

Lawmakers are at odds with how to best address the situation, or whether anything needs fixing at all.

Republican Sen. Rod Whittemore of Skowhegan said insurance companies aren’t trying to be secretive by not disclosing to providers why they weren’t included in a network - that information is proprietary. Furthermore, insurers already make it clear to consumers where they can seek care and where they can’t, he said.

“By attempting to fix something that isn’t broken you can create more costs and less choice for the consumer in the long run,” he said.

Maine isn’t the only state where insurers are getting criticism for narrow networks. In neighboring New Hampshire, 10 hospitals are excluded from Anthem’s provider network for individual plans on the exchange. But unlike in Maine, where the nonprofit cooperative Maine Community Health Options is also in the market, New Hampshire only has one insurer offering coverage on the exchange. MCHO is offering plans with networks that include all Maine hospitals.

Hill said she hopes the committee can find a way to move forward with the bills because providers and patients have a right to know why certain hospitals are being excluded from a provider network and others aren’t.

“Let’s be open and transparent. What’s wrong with that?” she said.


Follow Alanna Durkin on Twitter at https://www.twitter.com/aedurkin

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