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Originally published October 4, 2013 at 8:18 PM | Page modified October 5, 2013 at 12:55 AM

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Left off many networks, Seattle Children’s sues

People buying insurance through the exchange may not realize that the pediatric hospital is not in the health plan’s network of providers, Children’s officials say.

Special to The Seattle Times

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Seattle Children’s filed suit Friday over the state Office of the Insurance Commissioner’s “failure to ensure adequate network coverage” in several health plans being sold through the state’s new online insurance marketplace, called Washington Healthplanfinder.

Most plans available through Healthplanfinder for coverage in 2014 do not include Children’s among their in-network providers, which hospital officials say could significantly disrupt and delay care for children in need of the hospital’s services.

In King County, seven insurers are offering plans through the exchange. Only two — Group Health Cooperative and Community Health Plan of Washington — include Seattle Children’s in their provider network.

The five that do not are Premera Blue Cross, LifeWise Health Plan of Washington, Bridgespan, Molina Healthcare and Coordinated Care. Families that enroll in those plans could face significantly higher cost-sharing amounts they have to pay if they seek care at Children’s rather than at in-network providers.

Children’s officials say they are worried that families may sign up for coverage without realizing that the pediatric specialty hospital is not in most of the plans’ networks.

Healthplanfinder opened for enrollment Tuesday, as did other health-insurance exchanges around the country established under the federal Affordable Care Act, also known as Obamacare.

The lawsuit underscores a concern that has emerged in Washington state and elsewhere that many health plans sold through the exchanges may have “narrow networks” of providers compared with those offered in commercial health-insurance products.

Children’s officials say the hospital’s exclusion from the exchange plans represents a significant change for the pediatric hospital, which has typically been included in most health plans in the state’s commercial market.

“The notion that a major insurance plan is going to exclude us from their network is truly precedent-setting and represents a new level of degradation in children’s access to care,” said Dr. Sandy Melzer, the hospital’s senior vice president and chief strategy officer.

Insurers say they are trying to balance the need to offer adequate networks of providers with market demand for affordable health insurance.

“Affordability is still the single most important concern,” said J. Mario Molina, president and CEO of Molina Healthcare, which is offering exchange health plans in several states, including Washington.

The Children’s suit specifically mentions Molina and one other insurer — Coordinated Care — and asks for a reversal of the insurance commissioner’s decision to approve those companies’ exchange plans.

Insurance Commissioner Mike Kreidler initially rejected Molina and Coordinated Care’s plans, citing the inadequacy of their provider networks among the reasons. But his office later reversed that decision.

Insurance Commissioner spokeswoman Stephanie Marquis said the office takes concerns about access to care seriously.

“We are reviewing Children’s petition to see what lies at the heart of their concerns and will see how it gets resolved through the legal process,” she said.

Amy Snow Landa is a Seattle freelance writer. This story was produced through a partnership with Kaiser Health News, an editorially independent part of the Kaiser Family Foundation.

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