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What is happening between Mission Health and Blue Cross and Blue Shield of North Carolina (BCBSNC)?

Mission Health is currently negotiating with BCBSNC for new contracts that cover the services we provide to its members. On July 5, 2017, we issued BCBSNC a formal notice of intent to terminate our existing contracts. We did this because BCBSNC is not even considering baseline inflationary increases, which will not allow us to keep up with the rapidly rising medical supply and pharmaceutical costs, let alone providing wage increases for our valued team members. To help offset even inflation-based increases, we have offered repeatedly to explore transformational care models (including virtual care, admit to home, discharge to home, bundled payments, care management networks and more) without success. BCBSNC’s proposal is simply unsustainable and would place the health system at significant risk.

Mission Health is and will always be fully committed to continuing negotiations with BCBSNC.  But to do so, BCBSNC must be willing to engage in meaningful conversations. Currently, BCBSNC has quoted their “corporate policy” to not negotiate with any entity that has provided a notice of termination. If BCBSNC maintains its position of refusing to negotiate, then Mission Health will indeed be forced out of BCBSNC’s network. We continue to urge BCBSNC to fully reengage in negotiations. We are available – 24-hours a day, 7 days per week – to meet with BCBSNC should they be willing to do so.

Are these negotiations necessary?

Negotiations with health plans are important for a variety of reasons, but most importantly, to ensure the financial sustainability of our health system which enables us to serve our community. Our contract with BCBSNC is by far our most significant agreement. As the region’s only safety net provider, we serve a higher population of patients insured by Medicare or Medicaid that reimburse us below costs, and we also serve a higher volume of uninsured patients than most health systems. Our commercial insurance contracts cover only a small portion of our population but represent our only ability to keep up with cost inflation that is out of our control.

Costs for medical supplies and pharmaceuticals continue to rise, and recruiting and retaining top talent, keeping our technology up to date, and advancing treatment plans for our patients all represent significant costs. We are already taking aggressive cost-cutting measures to reduce our expenses by more than $240 million between 2014-2018. We simply cannot continue to cut our costs and take payment rate reductions from BCBSNC; it’s not sustainable.

Are negotiations with BCBSNC still ongoing or is the contract officially terminated?

Mission didn’t “terminate the contract.” Instead, we provided a notice of intent to terminate if an agreement isn’t reached by October 4, 2017. Effectively, we told them we need to renegotiate the agreement.

Mission Health is and always will be fully committed to continuing negotiations with BCBSNC. But to do so, BCBSNC also must be willing to engage in meaningful conversations. Currently, BCBSNC has quoted their “corporate policy” to not negotiate with any entity that has provided a notice of termination, which of course, was specifically forced by their forever-zero evergreen contract that automatically renews in the absence of a notice of termination with a zero rate increase in perpetuity. If BCBSNC maintains its position of refusing to negotiate which on its face is nonsensical, then Mission Health will indeed be forced out of BCBSNC’s network.

That said, there have been some communications between us and we remain forever hopeful that they will reengage in negotiations. We remain available – twenty four hours per day, seven days per week – to meet with them should they be willing. However, even if BCBSNC does force Mission out of network, its members will continue to have access to Mission Health and all of its providers. Importantly, access to our Emergency Departments would continue as in-network for all BCBSNC members. Being out of network doesn’t necessarily mean our healthcare services will be “higher priced.” Each BCBSNC product is specific to each patient, which means the out-of-network benefit may vary, as will the out-of-pocket cost.

When do the contracts with BCBSNC end?

We are negotiating as a health system, on behalf of our facilities and physicians, and the contracts are set to expire at midnight on October 4, 2017. That’s why we began our contract discussions with BCBSNC nearly six months ago, to allow both organizations plenty of time to reach a new agreement. To our disappointment, BCBSNC pushed us off for months, wasting time we could have used to work in collaboration and make meaningful progress toward a new agreement. After engaging, they have offered nothing close to our input cost inflation rate and have not budged on their proposal.

If BCBSNC does force Mission out of network on October 5, 2017, its members will continue to have access to Mission Health and all our providers. Importantly, access to our Emergency Departments would continue as in network for all BCBSNC members. Being out of network doesn’t necessarily mean our healthcare services will be “higher priced.” Each BCBSNC product is specific to each patient, which means the out-of-network benefit may vary, as will the out-of-pocket cost.

What other health insurance plans does Mission Health accept?

We have relationships with several of the other major health insurance networks. We will be in network with the following health plans in 2018:

Commercial (employer-sponsored and Health Insurance Exchange)

  • Aetna
  • BMS TPA
  • Cigna
  • Coventry
  • CWI Benefits
  • Crescent TPA
  • Humana (CareChoice)
  • Healthgram TPA
  • Key Benefits Administrators TPA
  • MedCost
  • MedCost Ultra
  • MultiPlan PHCS
  • UnitedHealthcare
  • WellPath
  • Western North Carolina Healthcare Coalition

Medicare Advantage

  • First Carolinacare Insurance – First Medicare Direct Healthy State
  • Gateway
  • Humana
  • UnitedHealthcare
  • WellCare

Are BCBSNC Medicare Supplemental health plans impacted?

No, BCBSNC Medicare Supplemental plans (also known as MediGap health plans) are not impacted. Even if we are out of network with BCBSNC, you will still have in-network access to all Mission providers.

Which Mission facilities are affected by the negotiations?

Our current negotiations with BCBSNC affect the following hospitals and associated providers:

  • Mission Hospital
  • Angel Medical Center
  • Blue Ridge Regional Hospital
  • CarePartners
  • Highlands-Cashiers Hospital
  • McDowell Hospital
  • Transylvania Regional Hospital

It’s important to know that Asheville Specialty Hospital is not impacted.

Additionally, CarePartners Outpatient Rehabilitation Centers are not out of network until March 3, 2018.

Are physicians impacted by the negotiations?

Yes. Mission’s employed and contracted physicians are impacted by our negotiations with BCBSNC. There is one exception, however, which is our anesthesiologists who are not impacted. You can view a complete list of impacted hospitals and physician practices here.

The initial information on Blue Cross’ site was incorrect and stated that Mission physicians would not be out of network until March, if we did not reach agreement. This is only the case for physical, occupational, and speech therapy through CarePartners’ at seven locations, which doesn’t take effect until March 3, 2018, if we do not reach agreement on new contracts.

Which BCBSNC health insurance plans are affected by these negotiations?

We are currently negotiating with BCBSNC to renew our commercial and Medicare Advantage contracts. This includes employer-sponsored health plans, including the State Employees Health Plan, and health plans purchased on the Health Insurance Exchange.

It’s important to know that BCBSNC Medicare Supplemental plans (also known as MediGap health plans) are not impacted, as they are not contracted with our health system.

How are patients who have Blue Cross coverage from another state or federal plan affected?

In some cases, out of state and federal Blue Cross coverage are part of the BCBSNC agreement. Those patients should contact Blue Cross to understand how their costs may change if our contractual relationship ends.

Mission Health is no longer listed as in network on Blue Cross’ online provider listing. Is Mission Health already out of network?

Effective immediately, BCBSNC has removed all Mission Health providers from its online directory, with the exclusion of Medicare Advantage. This overt and senseless action has created unnecessary confusion for BCBSNC members. All Mission Health providers are in network with BCBSNC until midnight on October 4, 2017. We recommend that our patients with BCBSNC do not cancel their appointments or procedures if they’re occurring on or before October 4, 2017.

What does this mean for BCBSNC members?

There are no immediate changes for BCBSNC members. BCBSNC patients may continue to receive care at our facilities and with our physicians the same way they always have. BCBSNC members’ in-network access will only change if we are unable to reach a new agreement with BCBSNC by midnight on October 4, 2017.

If Blue Cross does force us out of network, all BCBSNC members will continue to have access to Mission hospitals and providers.  Being out of network doesn’t necessarily mean Mission’s healthcare services will be “higher priced,” particularly given the fact that Mission’s prices are 23% less than our peer group hospitals, 7% less than local hospitals and 36% less than the highest priced hospitals in the state.

Each BCBSNC health plan is unique and members may have access to out-of-network benefits.  Whether those benefits are more expensive or not is a function of the actual plan between their employer and BCBSNC. Further, Mission Health has a generous charity care policy that applies to co-pays and deductibles in addition to serving patients without any insurance at all.  Given that, it’s quite possible that an individual may experience a very similar cost to access Mission even if we are forced out of network.

Regardless of our contract status with BCBSNC, access to our Emergency Departments always continues on an in-network basis for all Blue Cross members.  For additional information, patients can call our dedicated information line at (828) 417-0480 to speak with one of our representatives.

What if a patient is hospitalized, pregnant or receiving treatment for a special condition after October 4, 2017?

Certain patients, including those hospitalized, in their second or third trimester of pregnancy, or undergoing a course of treatment, may be able to receive care for a limited time as part of the Continuity of Care transitional period. The length of the transitional period depends on the specific health plan. Patients should call the phone number on the back of their BCBSNC insurance card to find out if they are eligible and apply. When calling BCBSNC, please record the reference ID number you are provided and the name of the representative you speak with. This will help us if we need to make additional follow up with BCBSNC on your behalf.

Patients must apply for Continuity of Care benefits no later than Sunday, November 19 (45 days from October 5). Applications sent after that date will be denied by BCBSNC. 

What if a patient has an emergency after October 4, 2017, and Mission Health is out of network?

Patients will always have access to our emergency rooms, regardless of our contract status with BCBSNC. If a patient experiences a medical emergency, they should always visit the nearest emergency room. Patients are entitled to in-network emergency care at any hospital until they are stabilized, and then any needed admission would require BCBSNC’s authorization.

What is Continuity of Care, and how do I know if I qualify from BCBSNC?

Continuity of Care is a process that allows current BCBSNC members to continue receiving care from an out-of-network provider for ongoing special conditions.

If your primary care physician or specialist is out of network with BCBSNC and they are currently treating you for an ongoing special condition that meets BCBSNC Continuity of Care criteria, BCBSNC will notify you 30 days before the contract end date (October 5, 2017). If you do receive a letter from BCBSNC advising you of the termination and their Continuity of Care policy, it’s important to respond to BCBSNC within the timeframe noted in the letter.

To be eligible for Continuity of Care, the patient must be seen by a participating provider (this includes hospital services) prior to the termination taking effect. The patient must be actively being seen by the out-of-network provider for an ongoing special condition and the provider must agree to abide by the BCBSNC requirements for Continuity of Care.

An ongoing special condition means:

  • In the case of an acute illness, a condition that is serious enough to require medical care or treatment to avoid a reasonable possibility of death or permanent harm;
  • In the case of a chronic illness or condition, a disease or condition that is life-threatening, degenerative, or disabling, and requires medical care or treatment over a prolonged period of time;
  • In the case of pregnancy, the second and third trimesters of pregnancy;
  • In the case of a terminal illness, an individual has a medical prognosis that the member’s life expectancy is six months or less.

The allowed transitional period extends up to 90 days, except in the cases of:

  • Scheduled surgery, organ transplantation, or in-patient care, which shall extend through the date of discharge and post-discharge follow-up care or other inpatient care occurring within 90 days of the date of discharge;
  • Second trimester pregnancy which shall extend through the provision of postpartum care; and
  • Terminal illness which shall extend through the remainder of the individual’s life with respect to care directly related to the treatment of the terminal illness.

If available, patients should speak to their employer to see if there are Continuity of Care exceptions that may be available. Otherwise, patients should call the phone number on the back of their BCBSNC insurance card to find out if they are eligible and apply for Continuity of Care. When calling BCBSNC, please record the reference ID number you are provided and the name of the representative you speak with. This will help us if we need to make additional follow up with BCBSNC on your behalf.

Patients must apply for Continuity of Care benefits no later than Sunday, November 19 (45 days from October 5). Applications sent after that date will be denied by BCBSNC. 

How many patients are affected by the negotiations?

There are nearly 130,000 Blue Cross patients who have visited Mission Health System hospitals, associated facilities and contracted physicians over the last 12 months. This includes patients who have Blue Cross employer-sponsored coverage, State Health Plan, Health Insurance Exchange plan, Medicare Advantage or Blue Cross as a secondary health plan.

How will I know if the negotiations are progressing?

We encourage you to continue to visit this website often to ensure that you have the latest information. If you have additional questions, or want to speak with one of our representatives, we encourage you to call our dedicated information line at 828-417-0480.

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How substantial are the cost increases for accessing Mission facilities at out-of-network rates?

Each health plan is unique to that particular member based upon the specifics of the insurance plan, so we encourage all Blue Cross patients to call the customer service number on the back of their insurance card for more details.

How often does Mission negotiate the contract with BCBSNC?

Each negotiation with a health plan is different. Typically, contracts are renegotiated anywhere from one to five years. Mission Health is currently negotiating (or seeking to negotiate) with Blue Cross for a multi-year agreement. Specifics, at this point are proprietary.

Is Mission Health more expensive than other healthcare providers in the state?

BCBSNC’s assertion that Mission Hospital is expensive is in direct conflict with the North Carolina Department of Health and Human Services’ independently maintained data that explicitly shows Mission Hospital’s charges are 23% below its peer group average, 36% below the most expensive peer group hospitals, and 7% below the average of the other local hospitals in western North Carolina. Further, BCBSNC has refused to share its data with Mission. BCBSNC alone has access to its data, prepares and formats the data and has been unwilling to reconcile the data. In our attempts to do so, we have found no correlation between their data and our actual experience of reimbursement from BCBSNC.

Finally, we have no idea what locations and therefore prices they are using given that prices do vary by site of care. As such, we had no other choice but to obtain third-party, independently verified data to show BCBSNC is not constrained by the truth, nor willing to be transparent with its own data.

Mission Health has its own health plan, Healthy State. What exactly is it and what is it meant to do?

Healthy State is an innovative employee health benefits provider designed to offer competitive options to employers and comprehensive, low-cost health benefits options to their employees. The current cost of providing attractive employee health benefits is reaching unprecedented levels and creating a crisis for many of today’s employers. Healthy State is designed to allow employers to save costs and build a healthier, stronger and more productive workforce.

Healthy State was formed one year ago as a wholly owned subsidiary.  It was created to help support Mission’s population health strategy. Mission has long believed that high quality, cost effective care with an excellent patient experience is the core of its mission. Healthy State extends these same values as it offers health benefit solutions to our community.

Healthy State provides health benefit products and services to self-insured employers utilizing the MHP network of about 1,100 physicians, 8 hospitals – a collaborative of Mission, community hospitals and independent doctors.

Healthy State is not a competitor in the individual or small group insured market and we don’t’ intend to be. This is a space that is really limited to insurance companies with really large amounts of capital and the wherewithal to enter into the federally-controlled ACA markets.  We appreciate the role that BCBS plays in the marketplace and we have no interest in being their competitor.  We believe and sincerely hope that Mission and BCBS come together to serve our region.

Learn more at http://healthystate.us/.