Connie Kousman’s Medicare plan with Anthem has gotten her through open heart surgery, breast cancer surgery and many stage four cancer scans without any out-of-pocket expenses.
But with two months remaining for Northern Light Health to reach an agreement with Anthem insurance before their contract expires, she fears what could happen to her health care options if the system moves out of network.
“Sixty days and potentially it will be an all new, unplanned for, unacceptable ball game,” said Kousman, who lives in Hancock.
The uncertainty has left patients scrambling as they wonder if their health care providers will be covered in October. Meanwhile, both organizations have released opposing statements saying they’re doing everything they can to keep Northern Light in network for Anthem customers and accusing the other of spreading misleading information.
About 30,000 of Northern Light’s established primary care patients are covered by Anthem or Anthem Medicare Advantage, according to the health care system’s spokesperson, Suzanne Spruce. That figure doesn’t include patients who use Northern Light’s emergency services or specialists.
In a July 22 email to clients, Northern Light said that negotiations had been unsuccessful thus far. Talks between the two organizations stalled at the beginning of June, when Northern Light announced the contract would expire if Anthem didn’t agree to raise reimbursement rates.
For people who have employer-sponsored or individual health plans, all non-hospital Northern Light providers — including primary care and specialists — would leave Anthem’s network Sept. 30 if no agreement is reached, while Northern Light hospitals would leave the network Dec. 30, according to Anthem.
Customers with Medicare Advantage plans would have until Dec. 31 before any Northern Light facility becomes out of network.
If the two parties fail to reach an agreement before those deadlines, Northern Light patients covered by Anthem may be forced to find new insurance, pay more out of pocket or find new providers, which could include traveling farther for care.
For example, if Northern Light’s Eastern Maine Medical Center became out of network for Anthem, the nearest in-network hospital providing cancer care is an hour and a half away at the MaineHealth hospital in Rockport, according to a provider search on Anthem’s website.
Anthem wants Northern Light to lower the proposed rate increases before moving forward with an agreement, the insurer has said.
“Anthem has offered reasonable payment rate increases that are higher than the inflation rate and would align with other Maine health systems, along with millions in quality incentives,” spokesperson Matt Wheeler said.
The company has also said Northern Light could have earned more in previous years but has not met the “agreed-upon quality standards” required for additional payments under their contract.
Northern Light, on the other hand, has argued that higher reimbursement rates are necessary for a fair contract. The health care system is encouraging patients to call Anthem and urge the insurer to keep Northern Light in its network.
The dispute is playing out as the health care system tries to recover from a $156 million loss last year and an array of recent setbacks, including hospital closures and downgrades in its credit rating.
Northern Light’s budget for the current fiscal year aims to reduce losses by $140 million.
