SEATTLE -- Seattle Children’s Hospital continues to fight to ensure all Washington residents have access to the hospital’s services. After filing a lawsuit against the state’s insurance commissioner for failing to ensure adequate network coverage in several of Washington’s Health Benefit Exchange plans, one more insurance company has agreed to cover services at Seattle Children’s.
When Washington’s Health Benefit Exchange plans were first introduced, only two of the six plans – Community Health Plan of Washington and Group Health – included Children’s in its network of providers. The hospital responded with a lawsuit against the Insurance Commissioner on Oct. 4.
This week, Seattle Children’s went a step further by filing an administrative appeal requesting the commissioner reverse his decision to approve exchange plans that did not cover Seattle Children’s – Coordinated Care Corporation (aka Ambetter), Molina Healthcare of Washington, Premera Blue Cross (including LifeWise) and Regence (aka BridgeSpan).
“Our primary goal has always been to ensure that children who are covered under the exchange plans have adequate access to pediatric care,” said Dr. Sandy Melzer, senior vice president and chief strategy officer at Children’s.
Seattle Children’s has made some progress since then, coming to a verbal agreement Tuesday with Molina to include the hospital in the insurance company’s network of providers.
But, Melzer remains concerned half of the healthcare exchange plans still do not cover the hospital, which provides specialized services otherwise unavailable in Washington, including transplant services, in-patient rehabilitation for brain injury and level-4 neonatal intensive care. Seattle Children’s also currently performs three-quarters of the state’s open-heart surgeries for children.
“Any plan that excludes us is denying access to care for kids,” Melzer said. “We’re hearing from many families who are quite concerned about whether they can continue to bring their children here.”
Hemophilia is a rare bleeding disorder in which the only specialist in Western Washington is at Seattle Children’s.
Stephanie Simpson, Executive Director of the Bleeding Disorders Foundation of Washington, feels that children with hemophilia would suffer significantly if they could not be treated at the local hospital.
“Our families go to Children’s to get live saving medication intravenously,” she said. “We believe denying them access would impact their lifespan.”
Eric Earling, a media relations representative from Premera Blue Cross, said Premera did not include Seattle Children’s in its network of providers because it would have driven up premium costs.
“We’re concerned about affordability for our customers,” Earling said. “We set out to make sure we were establishing a network of high-quality care while trying to do so at an affordable price.”
But, Earling said Premera will cover unique services only available at Seattle Children’s at a network benefit level, including emergency care. Additionally, members seeking non-unique services at Children’s would have consumer protections already established in Premera’s commercial insurance plans to limit how much they can be billed.
Earling said consumers should check with Premera to determine which services are considered unique.
Regence has opted not to comment at this time and Coordinated Care Corporation has not responded to our inquiry at the time this story was published.
Steve Valandra with the Office of the Insurance Commissioner says the commissioner is concerned about patient’s access to care. While he said the exchange plans meet current legal requirements for network coverage, the commissioner has initiated a rule-making process that could change coverage requirements next year.
“Some insurance companies are not negotiating with providers who they’ve negotiated with in the past,” Valandra said. “They’re trying to keep their rates down, but price cannot be the sole factor.”
In the meantime, Melzer recommends families choose new health care plans carefully.
“Check very carefully to see if Seattle Children’s is included as a network provider in your plan.”