A nurse practitioner at the India Street Public Health Clinic in Portland examines a patient.
Anthem Blue Cross and Blue Shield won a key approval Thursday from the state Bureau of Insurance for the insurer's plan to partner with MaineHealth on the new health insurance exchange.
The decision by the bureau to approve the Anthem-MaineHealth network is a blow to Central Maine HealthCare, which is not included in the plan. Central Maine HealthCare had argued that Anthem's proposal was a "backroom deal" that failed to include providers in central and western Maine and could require patients to change doctors to get care.
The proposed Anthem-MaineHealth pact would include 32 of the state's 38 hospitals, and would exclude the three hospitals owned by Central Maine Healthcare of Lewiston, as well as Parkview Adventist in Brunswick, York Hospital in York and Mercy Hospital in Portland.
Despite objections from excluded hospitals, the insurance bureau approved the proposed network, with some conditions. It instructed Anthem to contract with additional specialists in certain areas.
"Overall, I find Anthem's network – with the modifications and conditions imposed herein – to be capable of providing 'reasonable access to health services,'" Superintendent of Insurance Eric Cioppa said in the order.
Anthem, the state's largest health insurer, and MaineHealth, the state's largest network of hospitals and care providers including Maine Medical Center in Portland, want to offer the insurance network on the state's new health exchange being created under the federal Affordable Care Act.
The proposal, however, appears to run counter to President Obama's pledge that people will be able to keep their doctors and health plans, critics said.
The bureau did not address the issue of product pricing. That remains subject to approval later this month.
The bureau called for a hearing on Sept. 9 to address whether Anthem could move its current customer base into the proposed network.
"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 said.
Central Maine HealthCare had slammed the proposed Anthem-MaineHealth network as discriminating against insurance subscribers in central and western Maine, who would have to travel farther to reach doctors participating in the plan. In hearings last month, Anthem said the network was designed so that every subscriber could reach a primary care physician within 30 minutes driving time and a specialist within an hour.
"If the access provided is reasonable, it is irrelevant that the network could be bigger or better," Cioppa said in the order.
Still, critics have said the plan runs counter to Obama's vision for the Affordable Care Act.
In an address to the American Medical Association in July 2009, Obama said: "No matter how we reform health care, we will keep this promise: If you like your doctor, you will be able to keep your doctor. Period. If you like your health care plan, you will be able to keep your health care plan. Period. No one will take it away, no matter what."
Anthem had previously said that customers who bought their plans before March 23, 2010, would be allowed to keep their coverage, which includes access to all hospitals in the state.
Chuck Gill, a spokesman for Central Maine Healthcare, said Thursday that Central Maine officials are "disappointed" in most of the insurance bureau's decision. Central Maine will decide in the next few weeks whether to appeal, he said.
Under the Affordable Care Act, people can purchase health insurance starting Oct. 1 on the exchanges for coverage that begins in January. Those earning 100 percent to 400 percent of the federal poverty line will be eligible for subsidies on the exchanges. The health insurance exchange will target the roughly 260,000 Mainers who have individual or small-group insurance plans and those who are now uninsured.
Only the Anthem and Maine Community Health Options, a nonprofit co-op insurance plan, have applied to compete on the exchange in Maine. The plans offered by Maine Community Health Options would cover the entire state.
Central Maine HealthCare maintained Thursday that the Anthem network would fail to provide reasonable access to care for its subscribers.
"We don't believe driving an hour to receive primary care is reasonable service," Gill said, describing potential situations when Anthem HMO customers in western Maine would have to drive to Portland to see their doctor. "We don't believe that's reasonable access to care."
Gill said while it's true that many individuals living in western Maine who purchase insurance on the exchanges would instead choose Maine Community Health Options, some may not have that choice.
"What if I live in Rumford and my employer in Lewiston chooses the Anthem plan?" Gill asked.
Anthem and MaineHealth previously said that the proposed network, which excludes certain providers, would help cut costs. MaineHealth, for example, agreed to take lower reimbursement rates in exchange for more customers being directed to its network of hospitals and caregivers.
"Anthem Blue Cross and Blue Shield in Maine is pleased that our proposed network has been approved by the Maine Bureau of Insurance subject to conditions, which we are taking the necessary steps to meet," Anthem spokesman Chris Dugan said in a statement.
The new network will be available for customers who choose to purchase Anthem's individual or small group plans for 2014.
"Simply passing along increasing costs in the form of higher premiums is not acceptable. 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," Dugan said.
The proposed plans from Anthem-MaineHealth and Maine Community Health Options are subject to federal approval.
-- Staff Writer Joe Lawlor contributed to this story.
Staff Writer Jessica Hall can be contacted at 791-6316 or at: