A version of this story was originally published earlier this month.
A monthslong, public dispute between one of Maine’s largest health care providers and one of the country’s largest insurance companies has left tens of thousands of patients in limbo, with Northern Light’s contract with Anthem expiring at the end of the day Tuesday.
While there’s still a chance the two parties could reach an agreement to keep Northern Light services in Anthem’s network, there’s no guarantee despite the high stakes for both sides.
Here’s what you should know if you get health care from Northern Light and insurance coverage from Anthem.
Will Northern Light providers leave Anthem’s network?
Odds of the two parties reaching an agreement seemed low when Northern Light announced Aug. 15 that it was ending contract negotiations with Anthem.
But it’s still possible that the two companies could come to an agreement before Sept. 30, when their contract expires.
Northern Light announced Aug. 26 that it was making a “last-ditch effort” at an agreement by entering a mediation process with Anthem. Mediation allows companies and businesses to seek a neutral third party to oversee negotiations.
It’s not unheard of for hospitals and insurers to reach a deal at the eleventh hour of negotiations. In 2023, Anthem solved a dispute with a health care system in Missouri less than a day before patients would have lost coverage.
In another dispute with a Missouri health system earlier this year, Anthem let a contract expire after the two parties failed to reach an agreement, causing many patients to go for months without coverage.
When would my provider become out-of-network?
For patients with private or employer-based Anthem insurance, primary care providers and specialists would become out-of-network on Oct. 1. Hospital care would remain in network through the end of the year.
For patients with Anthem Medicare Advantage plans, both primary care and hospital services would remain covered through the end of the year.
Emergency room services will always be covered at the in-network cost, according to Northern Light. A federal law passed in 2022 protects patients from surprise bills and out-of-network cost sharing for most emergency services.
What if I have a serious health condition?
Some people getting longer-term care from Northern Light providers may be able to continue getting those services at in-network costs for a “limited period” through a process called “continuity of care,” if they are approved by Anthem, the insurer said.
Conditions that may qualify for this extension include pregnancy, serious illnesses like cancer, transplant candidates, terminal illness, certain major surgeries, and certain acute or chronic conditions, according to Northern Light.
The health care system is instructing patients who may fall into one of those categories to apply through Anthem’s continuity of care form.
Can I change my insurance?
Patients who want to stick with their Northern Light providers might want to consider other insurance options if their provider becomes out-of-network.
Maine’s insurance marketplace offers an open enrollment period from Nov. 1 to Jan. 15. For coverage starting Jan. 1, the deadline to enroll is Dec. 15.
Besides Anthem, there are three major medical plans approved in Maine that can be sold directly to individuals and families: Harvard Pilgrim Healthcare, Community Health Options and Taro Health.
Northern Light recently announced a new deal to lower costs with Community Health Options, which covers about 30,000 people in New England.
For Medicare Advantage patients, the open enrollment period runs from Oct. 15 to Dec. 7, according to Northern Light.
People who are insured through an employer, however, will likely need to find other solutions. Many major employers, including the state of Maine itself, provide Anthem insurance to employees.
Can I switch health care providers?
People who can’t switch to another insurance company or don’t want to will pay higher out-of-pocket costs at Northern Light providers if a contract is not reached.
Some of those patients may decide to find new providers outside of the Northern Light health system — which could be difficult, especially in northern Maine where fewer provider options are available. Some people may end up traveling longer distances for their medical care.
National primary care provider shortages are also making it harder for Mainers to find primary physicians, who often have long waitlists, the Lewiston Sun Journal reported last year. Parts of 13 of Maine’s 16 counties are categorized by the federal government’s Health Resources and Services Administration as health professional shortage areas.
Anthem has noted on its website that its insurance covers all non-Northern Light hospitals in Maine. The company also recently added ConvenientMD’s for-profit primary care office in Bangor to its network.
Clients can search for alternative in-network care options on Anthem’s website.
How did we get here?
The contract negotiations between Northern Light and Anthem stalled at the beginning of June, and the feud has grown messy and public over the last few months. Anthem wants Northern Light to lower proposed rate increases, the insurer has said. Northern Light, on the other hand, has argued that higher reimbursement rates are necessary for a fair contract.
The dispute is playing out as the health care system, one of the largest in Maine, 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.
These sorts of disputes are happening across the country, with trends like hospital consolidation, rising costs and threats to federal health care spending meaning disagreements between hospital systems and insurers could become more frequent, NPR reported.
What if I have more questions?
Northern Light is directing patients to email their questions to [email protected].
Anthem has said people should call the member services number on the back of their insurance card for help.
