More than 139,000 low-income Arkansans who are covered by Arkansas Blue Cross and Blue Shield plans under Arkansas Works won't have coverage when they see out-of-state health care providers, except under limited circumstances, starting Jan. 1.
Currently, customers have full coverage when they visit a provider in the network of insurers belonging to the Blue Cross and Blue Shield Association -- allowing customers to see providers nationwide.
That will change next month for those enrolled in the company's two Arkansas Works plans, known as Silver Plan AW1 and Silver Plan AWM1.
Starting next month, those customers will have coverage outside of Arkansas Blue Cross and Blue Shield's state-based network only during an emergency or when a service isn't offered by a network provider, company spokesman Max Greenwood said.
The network includes providers in Arkansas as well as some in counties bordering the state. The association's rules prohibit the Arkansas company from contracting directly with other out-of-state providers, Greenwood said.
The move is designed to hold down premiums and keep the cost of Arkansas Works below a limit established in a federal waiver authorizing the program, Greenwood said.
Because the company negotiates reimbursement rates with providers in its network, those rates are often below what providers in other states charge, she said.
Arkansas Works enrollees had twice the out-of-state costs in 2016 as the average Arkansas Blue Cross and Blue Shield customer who was an Arkansas resident, she said.
Restricting Arkansas Works enrollees to in-state providers, she said,"will result in substantial savings, because there is a big difference" in what Arkansas providers charge compared with their counterparts in other states.
"Obviously, this program is for Arkansans and Arkansas residents, and we are also wanting to keep as much care as possible in the state for the providers in this state," Greenwood said.
Gov. Asa Hutchinson noted in a statement that Arkansas Works enrollees will have out-of-state coverage for emergencies and for providers in counties bordering Arkansas.
"The Arkansas Works program is a partnership between the state and private health insurance plans," Hutchinson said. "The participating plans are free to make changes to their policies, within the limits of state and federal law."
Marla Barina, 56, of Bella Vista said she didn't learn about the change until late last month.
A few weeks earlier, she had surgery in Dallas, where her mother and brother live, to fuse a pair of vertebrae in her neck.
Now, she said, she's worried about whether she'll have coverage for what she expects to be several months of follow-up visits, including one scheduled for Jan. 2.
This week, her surgeon submitted written requests for extension of coverage through the end of March and for an exception to the network restriction.
The possibility of having to switch to another surgeon is "a huge concern," she said.
The Dallas surgeon "worked with me," she said. "He's the one that did it. He knows why he did it the way he did it."
A 1997 state law, the Arkansas Health Care Consumer Act, requires insurers to continue coverage when a provider is dropped from a network for 90 days "or until treatment for an acute condition is completed," whichever comes first.
In a provider newsletter, Arkansas Blue Cross and Blue Shield said it will provide such extensions in the case of women who are more than six months pregnant; "high risk," newly diagnosed or relapsed cancer patients undergoing "chemotherapy, radiation therapy or reconstruction," transplant patients; and "serious acute care conditions in active treatment such as heart attacks or strokes."
To qualify for an extension, patients must submit a request by Friday.
Such requests will be evaluated "on a case-by-case basis" and may be granted for follow-up visits after surgery, Greenwood said.
She said the company sent a letter in October about the new restriction to about 3,000 customers who had visited an out-of-state provider within the previous year. The change also is included in the details of the plans' coverage policy for 2018.
"Outside of that, we did not want to broadcast this change to all members enrolled in these plans since it applied to a small number of members, and we wanted to avoid confusion from the vast majority of our members that have not ever used out-of-state providers," Greenwood said.
Arkansas Insurance Department spokesman Ryan James said companies are required to notify customers about changes in benefits, but not about changes to networks, which are considered "service" changes.
Barina, whose first visit with the surgeon was in September, said her first clue about the change came in a letter, dated Oct. 27, that noted the insurer "added prior approval requirements to services received from out-of-area providers" as well as for other types of services.
Marquita Little, health policy director for Arkansas Advocates for Children and Families, said she's concerned about how the change will affect Arkansas Works enrollees who want to see a specialist in another state.
She also noted that some enrollees have a residence in Arkansas but attend college outside the state.
"It just creates new access barriers, but it also creates a considerable amount of confusion," especially coming during other recent and planned changes to Arkansas Works, Little said.
Greenwood said her company has "the ability to put in place an approval process that will prevent any delay in coverage" for college students.
"If we're alerted a member is a student, our team will take the necessary steps to ensure the appropriate services are provided," she said.
Arkansas Blue Cross and Blue Shield customers accounted for more than half the 251,262 people enrolled in Arkansas Works as of July 27.
The program covers adults who became eligible for Medicaid under the expansion of the program in 2014. The expansion extended eligibility to adults with incomes of up to 138 percent of the poverty level: $16,643 for an individual, for instance, or $33,948 for a family of four.
Concerned about the eventual cost of the program, Hutchinson has requested federal approval to move about 60,000 people off it by limiting eligibility to people with incomes up to the poverty level and to impose a work requirement on many of those remaining.
A decision on his request hadn't been announced as of Friday.
Silver Plan AWM1 is one of three plans Arkansas Blue Cross and Blue Shield offers as part of the Multi-State Plan Program, which is administered by the federal Office of Personnel Management.
Despite its name, that program does not require plans to have provider networks in more than one state. Silver Plan AWM1 has the same network as Silver Plan AW1, Greenwood said.
Although most people who are enrolled in Silver Plan AW1 and Silver Plan AWM1 are Arkansas Works participants, the plans are also available through healthcare.gov to people who don't qualify for Medicaid.
Representatives of St. Louis-based Centene and Little Rock-based QualChoice Health Insurance, which also offer Arkansas Works plans, didn't respond Friday to inquiries from the Arkansas Democrat-Gazette about their plans' out-of-state coverage.
The traditional fee-for-service Medicaid program, which covers poor people who are elderly or disabled and children from low-income families, pays for care from Arkansas providers, those who are within 50 miles of the state, and other out-of-state providers who enroll with the program, Department of Human Services spokesman Amy Webb said in an email.
She said requests for out-of-state care "are reviewed to ensure the service can't be provided in state." Most such cases are for transplants and have provider agreements negotiated on a case-by-case basis, she said.
A Section on 12/09/2017