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Originally published Tuesday, October 22, 2013 at 8:25 PM

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Seattle Children’s files appeal over its omission from health plans

Seattle Children’s hospital has filed an administrative appeal requesting that the state insurance commissioner remove health plans from the state’s new online insurance exchange that do not include Children’s. The hospital previously filed a lawsuit against the commissioner’


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Seattle Children’s hospital is upping the ante in its challenge to state Insurance Commissioner Mike Kreidler’s approval of plans for Washington’s new online insurance exchange that do not include Children’s in their network of care providers.

The hospital filed an administrative appeal Tuesday requesting that the Office of the Insurance Commissioner (OIC) remove plans from the exchange, called Washington Healthplanfinder, that do not include Children’s.

The appeal was sent to an administrative-law judge at the OIC, according to an OIC spokesperson.

This latest action comes on top of a lawsuit Children’s filed Oct. 4 in King County Superior Court against the OIC, citing what it is calling the office’s “failure to ensure adequate network coverage” for plans offered through Healthplanfinder for 2014.

That lawsuit specifically mentioned two insurers that had not included Children’s in their networks — Coordinated Care Corporation and Molina Healthcare of Washington.

The two actions underscore a concern 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.

In the appeal filed Tuesday, Children’s said five of seven insurers offering plans in the exchange did not include Children’s as an in-network provider. Those five are Premera Blue Cross, LifeWise Health Plan of Washington (a Premera subsidiary) and BridgeSpan (an affiliate of Regence Blue Shield), in addition to Coordinated Care and Molina. (Two insurers, Group Health Cooperative and Community Health Plan of Washington, include Children’s.)

However, Children’s announced later Tuesday that it had reached an agreement with Molina under which the insurer will include Children’s in its network for plans offered through Healthplanfinder.

Molina officials confirmed the company had reached an agreement “in principle” with Children’s.

The two parties “are now in the process of finalizing the agreement,” said Bela Biro, president of Molina Healthcare of Washington.

Children’s currently is in negotiations with other insurers as well, said Dr. Sandy Melzer, the hospital’s senior vice president and chief strategy officer.

“We really hope that as we have more time to explore this with them, we will find ourselves able to reach similar agreements with some of the other payers before consumers start receiving care under those plans,” Melzer said.

Coverage under plans for sale through Healthplanfinder will start as early as Jan. 1, 2014, for consumers who enroll by Dec. 15 and make their first premium payment by the Dec. 23 deadline.

Since Healthplanfinder opened Oct. 1, more than 35,500 Washington residents have completed enrollment in the exchange. That includes more than 4,500 who have enrolled in the exchange’s qualified health plans and 31,000 enrolled in Medicaid coverage, according to the latest figures released Monday by the Washington Health Benefit Exchange, which operates Healthplanfinder.

Children’s hopes the OIC will resolve the provider-network issue to its satisfaction before the coverage goes into effect.

“Our argument has been that because we have such a unique set of services, denying patients access to this care creates a real danger of degrading the care of children who need the specialty services we provide,” Melzer said.

Premera spokesman Eric Earling said late Tuesday that company officials had not had a chance to review the administrative appeal. He said Premera and its subsidiary, LifeWise, built their provider networks for the individual and small-group markets in 2014 “to ensure our members have access to care at an affordable price.”

OIC spokeswoman Stephanie Marquis said the agency normally doesn’t comment on matters in the administrative appeals process.

“But we know there are network issues, and that many of the plans have created what we would call ‘skinnier’ networks,” Marquis said. “So that is something we are looking at, and we have already started working on setting new standards for what a network looks like.”

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



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