Skip Maine state header navigation
Skip All Navigation
|Home | Contact Us | Careers | Calendar|
Maine.gov > PFR Home > Insurance Regulation> Administrative & Enforcement Actions > Document 279 : INS 99-14 : Hearing Decision
STATE OF MAINE
TO: Associated Hospital Services of Maine
c/o Robert Frank, Esquire
Harvey and Frank
Two City Center
P. O. Box 126
Portland, Maine 04112-0126
Anthem Health Plan of Maine, Inc.
c/o James Zimpritch, Esquire
One Monument Square
Portland, Maine 04101-1110
Maine Medical Association hereby requests that you provide responses to the following inquiries and document requests. In producing the requested documents, the applicants are requested to furnish all documents regardless of whether they are in the possession of Associated Hospital Services, Anthem Health Plan of Maine, or any subsidiary, affiliate, or parent of either entity. If the Applicants refuse for any reason to provide any of the documents described below, the Applicants should identify in writing each such document and provide the reason for such refusal.
1. Please provide copies of the forms of provider agreements that Anthem has utilized in contracting with physician, hospital and other providers in the States of New Hampshire, Colorado, Nevada, Connecticut, Ohio, Kentucky and Indiana.
2. Please provide copies of any and all Anthem executive or management policies, procedures, standards, directives or other determinations concerning the provisions, terms and conditions of provider agreements to be entered into by Anthem or any Anthem subsidiaries or affiliates with physician, hospital or other providers.
3. Please advise whether, to what extent and for what period of time, Anthem will honor existing provider agreements with BCBSME and will continue to utilize the forms of such provider agreements without material change.
4. Please advise whether there are included in any Anthem provider agreements in any state any so-called "all products clause" or any "most favored customer" clause.
5. Please identify and describe the Anthem policies, programs or practices in any state for the payment of provider fees or charges, provider reimbursement or provider compensation.
6. Please identify and describe any downstream risk-sharing arrangements or programs, including capitation, included in any Anthem provider agreement in any state.
7. Please advise whether Anthem will utilize in Maine any forms of provider agreements for osteopathic physicians that are different from the forms of provider agreements for other physicians. Please advise whether Anthem shall seek to impose any special provisions, limitations or restrictions on the delivery of osteopathic manipulation services.
8. Please identify and describe in detail and with specificity the management information systems support made available by Anthem and delivered to providers sharing or assuming any "downstream" risk, including reports provided and data made available to providers. Please provide copies of report formats and schedules for the delivery of reports. Please identify and describe any provider rights to access, download and retain Anthem data or information relevant to a respective providers productivity, utilization or other performance or relevant to any risk pool in which a respective provider is a participant.
9. Please identify and describe and please provide copies of any policies, protocols, procedures or any documents that identify or describe the extent of discretion of a local Anthem provider agreement negotiator to modify or amend any provision of an Anthem form of provider agreement.
10 Please advise and describe with specificity the extent to which policies and standards for the terms and conditions of Anthem provider agreements are or will be made at the regional or national levels, rather than at the local, Maine level.
11. Please provide copies of any of the following to be used by Anthem Blue Cross-Blue Shield of Maine upon and after closing of this transaction:
12. Please identify the dollar amounts of Anthem capital resources that will be contributed to Anthem Blue Cross-Blue Shield of Maine by the time of closing of this transaction and that will be available and accessible to Anthem Blue Cross-Blue Shield during the three (12) years immediately following the closing of this transaction.
13. Please advise of any standards to be satisfied or any authorizations that will be required prior to any Anthem contribution, or additional contribution, to the capital of Anthem Blue Cross-Blue Shield of Maine.
14. Please provide any and all documents and information relevant to the design, planning, organization, startup and operations of the "East Region," including any documents and information concerning the date of commencement of operations of the East Region, and the scope, nature and extent of the administrative, management or other support to be provided by the "East Region" to Anthem Blue Cross-Blue Shield of Maine and Maine providers.
15. Please advise whether Anthem will include on its "national Board of Directors" any representative from the State of Maine, and please identify the criteria for and method of election/selection of any such person.
16. Please advise whether and to what extent provisions shall be made to include providers on the Board of Directors of Blue Cross-Blue Shield of Maine.
17. Will the Maine-based senior medical officer of Anthem Blue Cross-Blue Shield of Maine be a physician licensed to practice medicine in the State of Maine?
18. How will Anthem change the current BCBSME product line? Will the company continue to offer both managed care and indemnity products? Will Anthem maintain BCBSMEs position as the primary provider of individual coverage in the State of Maine?
19. How will Anthem structure its senior management in Maine? Will medical and administrative decisions continue to be made locally in the State of Maine?
20. Does Anthem plan any reduction in the staffing of BCBSME? If so, please identify positions to be reduced or eliminated and the job descriptions and functions of each such position.
21. How will Anthem administer prescription drug and behavioral health benefits in Maine? Will Maine providers be asked to take on or share any financial risks arising out of or related to pharmacy benefits?
22. How will Anthem involve Maine physicians in the development of medical policy; in coverage decisions, particularly the determination of medical necessity; in the establishment of credentialing standards; and in the quality management and utilization review activities?
23. Please describe in detail any and all Anthem policies, programs, directives or other determinations concerning community benefit programs, such as health screenings, free immunizations and other such community benefit programs, to be pursued in the State of Maine. Please provide a copy of any such policies, programs, directives or other determinations. Please explain whether and to what extent any such community benefit programs to be provided by Anthem in the State of Maine will differ in scope or quality from the community benefit programs that have been provided by BCBSME. Please advise of the amounts of funds that will be made available for any such community benefit programs annually during the first three years of operation of Anthem Blue Cross-Blue Shield of Maine.
24. Please provide information about Anthems relationship with Federally Qualified Health Centers (FQHCs) in each state in which it operates, including, but not limited to, all contracts it has in place with Federally Qualified Health Centers and/or their clinicians and copies of provider handbooks provided to enrollees in each state which show how FQHCs and/or their clinicians are identified. We are particularly interested in knowing if in all states Anthem contracts directly with the FQHC or if they only contract with their clinicians and Anthems practices on listing both the health center and their providers in provider handbooks.
25. Please provide information about any limitations or special conditions Anthem places on FQHCs, including whether it contracts with FQHCs for all services they provide and if it requires accreditation or licensing of these entities.
26. Please provide information that demonstrates Anthems reimbursement policies for nurse practitioners and physician assistants practicing in FQHC. We are particularly interested in determining whether Anthem provides a lower reimbursement for nurse practitioner and physician assistant services in FQHCs than they do for similar physician services in those settings.
27. Please provide documentation relative to the number of FQHCs in each state with whom Anthem directly contracts.
28. Please provide documentation that details Anthems future plans regarding indemnity coverage in Maine. Include documentation that details Anthems existing and five-year history regarding indemnity coverage in all other states in which Anthem is present..
29. Please provide documentation that Anthem accepts the Federal Tort Claims Act coverage in lieu of medical malpractice insurance in all states in which it provides coverage.
30. Please describe how Anthem will outline reproductive health services to its subscribers.
31. What will Anthem include as services for reproductive health care?
32. Will Anthem contract with family planning programs for all services each program provides, such as colposcopy, endometrial biopsies? Please explain your rationale for your answer.
33. Please provide documentation that details Anthems future plans regarding contracting with nurse practitioners.
34. Will Anthem allow subscribers to self-refer to reproductive health providers (including nurse practitioners) beyond the state mandated statute of one annual visit per year? Please explain your rationale for your answer.
Dated: February 4, 2000
CERTIFICATE OF SERVICE
The undersigned hereby certifies that on February 4, 2000 a copy of First Discovery Request of Maine Medical Association, for Itself as Intervenors, and on Behalf of the Provider Group of Intervenor was served via United States mail, first class postage prepaid, on each of the persons listed below.
Last Updated: January 21, 2014
|Copyright © 2006 All rights reserved.|