CONCORD, New Hampshire — The New Hampshire Insurance Department on Tuesday denied a Rochester woman's request to include her doctor and others affiliated with Frisbie Memorial Hospital in the new provider network for individuals under the federal Affordable Care Act.
The decision comes more than three months after a hearing at which Margaret McCarthy argued that she was harmed by the department's approval of Anthem Blue Cross and Blue Shield's Pathway network, which excludes 10 of the state's 26 hospitals. The narrow network has been a frequent target for critics of the health care overhaul law.
In his ruling, Commissioner Roger Sevigny did not address the issue of injury, saying doing so was unnecessary because McCarthy had not shown that the network was inadequate.
"Quite simply, the petitioner's case consisted only of speculation," he said. "The petitioner has not put forth any evidence that indicates that the department failed in its review of the Pathway Network or that Anthem was required to submit any additional or different data as part of its submission for review of its marketplace plans."
McCarthy did not immediately return a call seeking comment Tuesday. Her attorney, Jeremy Eggleton, said the decision was disappointing but not unexpected given prior rulings in the case. But he said he was pleased that McCarthy's challenge raised important questions about how the state approves networks. Partly because of the outcry over Anthem's narrow network, the insurance department is in the midst of an in-depth review of its adequacy standards.
"No matter what the ruling was, I still think it was an oversight to not scrutinize Anthem's narrow network more," he said. "The fact that there's a broad effort to figure out what network adequacy standards are and to make sure this doesn't happen again, that's a good result of this."
At the hearing in May, lawyers for both Anthem and the Insurance Department argued that the network meets or exceeds all state adequacy standards, including the maximum distance allowed between patients and providers. But Eggleton argued the department approved the network based on incomplete information. For example, he said, the Insurance Department should have asked Anthem to assess the average wait times for doctor appointments. Anthem argued, and the state agreed, that it was not required to provide information that it didn't have since the network didn't yet exist.
In defending the network, company officials have said including all hospitals would have driven up premiums because network hospitals agreed to reimbursement rate concessions in exchange for the promise of a certain volume of patients.
Anthem and insurance department attorneys also argued that McCarthy wasn't harmed because she could have renewed her plan early last fall and extended it until 2015, or could have purchased a plan from a much smaller insurance company whose network included Frisbie. They said the state also can't require an insurance company to negotiate with a particular provider, let alone contract with one.
"So long as these networks meet state standards, they are lawful even if, as a result, a longstanding and trusted medical provider is no longer included in that network," Sevigny said.
Anthem was the only company that offered health plans through the new marketplace during the first enrollment period that ended March 31. Four others are expected to begin offering plans for next year, and every hospital will be included in at least three networks.
"As has been the case from the outset, we strongly feel that our Pathway network is adequate and offers those who choose us insurance rates that are far more affordable than they would otherwise be, and we are pleased that the department came to that conclusion with regard to the adequacy of the network," Anthem spokesman Chris Dugan said Tuesday.
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