Skip Maine state header navigation
Skip All Navigation
|Home | Contact Us | Careers | Calendar|
Maine.gov > PFR Home > Insurance Regulation> Administrative & Enforcement Actions > Document 503 : INS 99-14 : Hearing Decision
STATE OF MAINE
Maine Medical Association ("MMA") hereby submits this statement pursuant to the Superintendents Order of February 23, 2000 requiring the parties to designate issues to be considered by the Superintendent. Each of the issues MMA identifies below bear on whether the proposed transaction is unfair, prejudicial, or inequitable to policyholders or enrollees or would adversely affect, in any manner, the services to be rendered to subscribers, 24-A M.R.S.A.
§ 222(7)(A)(4); 24 M.R.S.A. § 2301(9-D)(E)(1) and (9-D)(L), or prejudicial to the interests of creditors. 24-A M.R.S.A. § 3484(2):
1. Access to capital. Whether Anthem will provide sufficient working capital to enable Anthem BCBSME to adequately provide services and coverage to present and new policyholders and to cover obligations to providers. To date, Anthem has provided no confirmation that such capital would be made available. Without such assurances, enrollees are at risk of Anthem BCBSMEs failing and leaving enrollees without coverage.
2. Administrative expense. Whether Anthem will maintain or lower administrative costs, or other expense components of the proposed premium rates. In the absence of such plans, enrollees would be at risk for higher premiums or company failure.
3. Commercial insurance market. Whether applicants have failed to demonstrate that BCBSME could not financially recover and operate successfully now that Tufts Health Plan of New England (TNE) is in liquidation and Harvard-Pilgrim Health Plan is in receivership. Given the shrinking number of competitors, BCBSME can "grow" out of its financial difficulties without selling, and a sale of assets is not required to enable the continued operations of BCBSME.
4. Anthem East. Whether Anthem had failed to meet its burden to describe the integration of its current operations with those of BCBSME. At present, "Anthem East," or the "East Region" does not exist in practice and Anthem has not provided sufficient information describing how the operations of the several participants in the East Region would be integrated without creating the integration problems experienced by other health plans that have expanded substantially through acquisitions.
5. Provider Agreements. Whether, based upon the review of Anthem provider contracts in Kentucky, Connecticut, Ohio, and Indiana, providers would face contract terms that are unfair, onerous and discriminatory, leading to potential de-enrollment which would jeopardize the health of enrollees and be unfair and inequitable to enrollees.
The health of enrollees could be impacted by physician disenrollment, as enrollees may be
forced to travel some distance for care, or worse, be unable to access in-network care.
Among the contract provisions utilized by Anthem in other states are clauses requiring
physicians to participate in additional products if they participate in one (similar to an all-
products law). Other onerous provisions include "hold harmless" clauses, unilateral rights
to amend and restrictions on referrals.
6. Lack of Data Management Systems. Whether Anthem has failed to demonstrate that it has adequate information systems or data management systems to provide data to physicians to allow them to properly manage risk. Failure to provide adequate data to manage "downstream" risk would jeopardize the financial security of medical practices, putting physicians at risk of losing their practice, further jeopardizing plan enrollees.
7. Purchase Price. Whether the asset purchase agreement is fair, given that it provides for no increase in the purchase price if the number of enrollees increases prior to closing or if other changes occur in the marketplace, increasing the value of the company, but does provide for a decrease in the purchase price if the number of enrollees decreases.
8. Integration. Whether Applicants have provided sufficient evidence to meet their burden of proof to demonstrate that integration of Blue Cross plans in Connecticut, New Hampshire and Maine would lead to administrative efficiencies or superior operations. Given the difficulties experienced by other plans in attempting to integrate purchased plans (Harvard-Pilgrim, for instance), the lack of specificity on this point is an issue.
9. Payments to providers. Whether any sale of the assets of BCBSME should be conditioned upon an agreement to pay providers under the terms of existing or new provider agreements so long as obligations exist under said agreements. In other words, if the contracts should be terminated by Anthem, the Company should pay for covered services provided to enrollees during the notice period preceding termination and should be required as a condition of the purchase to provide sufficient security to cover said obligations, to the extent that guarantees of the parent company are insufficient.
10. Transfer of capital. Whether, given the precarious state of the health care delivery and financing system in Maine, provisions should be included in the sale ensuring that capital earned Maine not be transferred out of state to cover plan losses in other Anthem states. Such transfers would be unfair to enrollees and in violation of the Maine Insurance Code and Bureau rules.
11. Anthems performance elsewhere. Whether, given the documents that have recently been produced in response to discovery requests, Anthems actual performance since 1993 in Indiana, Kentucky, Ohio, Connecticut, Colorado, Nevada and New Hampshire makes it an eligible purchaser. The number of complaints by enrollees filed against the plan, as well as the resolution of said complaints, is an issue.
12. Local decision-making. Whether evidence demonstrates that medical policy and decision-making in Anthem plans is made on a local, statewide (as opposed to regional or central) basis. Responses to discovery requests contend that this is so, but actual past practice in states where the plan now operates is not conclusive.
Dated: March 3, 2000
Gordon H. Smith
Maine Medical Association
30 Association Drive
P.O. box 190
Manchester, Maine 04351
Michel A. LaFond
CERTIFICATE OF SERVICE
The undersigned hereby certifies that on March 3, 2000 a copy of Maine Medical Associations Designation of Issues was served via United States mail, first class postage prepaid, on each of the persons listed below.
Robert S. Frank, Esq. Michele M. Garvin, Esquire
Harvey & Frank Ropes & Gray
Two City Center One International Place
P.O. Box 126 Boston, Massachusetts 02110-2624
Portland, Maine 04112 e-mail: Mgarvin@Ropesgray.com
e_mail: email@example.com (Central Maine Healthcare Corporation;
(Blue Cross/Blue Shield of Maine) Central Maine Partners Health Plan)
Judith Chamberlain, Esq. Robert I. Goldman
State of Maine Maine Counsel of Senior Citizens
Department of the Attorney General 27 Bowery Beach Road
6 State House Station Cape Elizabeth, Maine 04107
Augusta, Maine 04333_0006 e-mail: Rgoldma1@maine.rr.com
e_mail: firstname.lastname@example.org (Maine Council of Senior Citizens)
(Bureau of Insurance)
William H. Laubenstein, Esq. Executive Director of the Maine Ambulatory
State of Maine Care Coalition
Department of the Attorney General P. O. Box 390
6 State House Station Manchester, Maine 04351
Augusta, Maine 04333_0006 e-mail: email@example.com
e_mail: firstname.lastname@example.org (Sacopee Valley Health Center, Regional
(Office of the Attorney General) Medical Center at Lubec, Eastport Health
Care, Inc., and the Maine Ambulatory
Gregory A. Brodek, Esq. Care Coalition)
Duane, Morris & Heckscher, LLP
15 Columbia Street, 4th Floor John Dieffenbacher-Krall
Bangor, Maine 04401_6355 Executive Director
e_mail: email@example.com Maine Peoples Alliance
(Maine Health Alliance) 192 State Street
Portland, Maine 04101
(Maine Peoples Alliance)
Joseph P. Ditre, Esq. Kellie P. Miller, M.S.
Consumer Health Law Program Executive Director
One Weston Court, Level One Maine Osteopathic Association
P.O. Box 2490 693 Western Avenue
e_mail: firstname.lastname@example.org Manchester, Maine 04351
(Consumers for Affordable Health Care
Donald E. Quigley, Esquire Edward Miller
General Counsel Executive Director
465 Congress Street, Suite 600 mailto:Mgarvin@Ropesgray.commailto:Rgoldma1@maine.rr.commailto:email@example.com:MPA@gwi.netmailto:firstname.lastname@example.orgAmerican Lung Association of Maine
Portland Maine 04101_3537 122 State Street
e_mail: email@example.com Augusta, Maine 04330
(Maine Medical Center) e-mail: firstname.lastname@example.org
Sandra L. Parker, Esq.
Attorney for MHA, Inc.
150 Capitol Street
Augusta, Maine 04330
James B. Zimpritch, Esquire
Jeffrey M. White, Esquire
Catherine R. Connors, Esquire
Pierce Atwood mailto:email@example.com
One Monument Squaremailto:firstname.lastname@example.org:email@example.comPortland, Maine 04101
(Anthem Insurance Companies, Inc.)
Gordon H. Smith
Maine Medical Association
30 Association Drive
P.O. Box 190
Manchester, Maine 04351
Last Updated: January 21, 2014
|Copyright © 2006 All rights reserved.|