Children’s fights to ensure all Washington families have access to the health services they need

UPDATE: Seattle Children’s reached an agreement with Molina Healthcare of Washington and Children’s is an in-network provider on the plans Molina offers through the state’s Health Benefit Exchange.

National healthcare reform has dominated headlines with the recent government shutdown and the opening of Healthcare Exchanges across the country, offering health benefits to individuals, families and small businesses who are not currently insured.

Seattle Children’s Hospital is taking a stand on the issue, working hard to ensure that children in Washington have adequate access to the care they need, when they need it.

On Oct. 4, Children’s filed a lawsuit against the state’s Office of the Insurance Commissioner (OIC) citing the failure of the OIC to ensure adequate network coverage in several of Washington’s Health Benefit Exchange plans. The suit aims to make sure that children can access the health services they need through the insurance plans purchased via the state’s Exchange, a new marketplace where individuals and families can find, compare and buy insurance.

Today, Children’s is going a step further and filing an administrative appeal requesting the OIC to reverse its decision to approve the Exchange plans from Coordinated Care Corporation (aka Ambetter), Molina Healthcare of Washington, Premera Blue Cross (including LifeWise) and Regence (aka BridgeSpan) because they do not provide adequate network access for plan enrollees. The appeal also asks the OIC to reconsider how it approves Exchange plans so that only plans with adequate networks are approved.

Here, Dr. Sandy Melzer, senior vice president and chief strategy officer at Children’s, answers a few questions about the actions that Children’s is taking to encourage the state to guarantee adequate coverage for kids and families in Washington.

Why did Seattle Children’s file a suit against the OIC?

Sandy: When Washington’s Health Benefit Exchange opened on Oct. 1, it offered a range of insurance plans from seven companies, but only two of the companies – Group Health and Community Health Plan of Washington (aka Community HealthEssentials) – cover care at Children’s. Even though all these companies cover care at Children’s through other plans they offer outside of the Exchange, their Exchange plans exclude us.

We’re concerned that the plans that exclude us don’t provide adequate coverage for kids. That’s because many of the services we provide are unique – they’re simply not available anywhere else in the state.

Children’s is the only pediatric hospital in King County and the preeminent provider of many pediatric specialty services in the Northwest. Some of these specialized services not available elsewhere in our area or region include acute cancer care, inpatient pediatric rehabilitation, level IV neonatal intensive care and heart, liver and intestinal transplantation. We also take care of the very sickest and most complex children in the entire Pacific Northwest.

We’re suing the OIC because it’s the agency responsible for approving the plans offered on the Exchange. Our suit charges that the approval of these plans should be overturned because their provider networks are not adequate to meet the needs of patients, which the Affordable Care Act specifically requires.

If Children’s isn’t included on some of the Exchange plans, what does it mean for families?

Sandy: It means families of current patients who switch to certain Exchange plans could lose their trusted care teams and their child’s care could be disrupted. It also means that kids whose families have purchased plans that don’t include Children’s and who need our services in the future won’t have the option to get their care here.

Families who buy insurance on the Exchange may not know that their new plan doesn’t cover care at Children’s. And it’s easy to understand why: Families who purchased a Premera plan in the past, for instance, might assume that all Premera plans provide the same coverage. But that’s not the case. The Exchange plans are not the same as plans people may have purchased previously from the individual market or through an employer.

What outcome are you hoping for?

Sandy: We want to encourage the Insurance Commissioner to approve Exchange plans only if they provide adequate care networks for kids and families. Period.

Suing and filing the administrative appeal was not our first choice. We tried very hard to negotiate with the companies that excluded us – in fact, we’re still trying, and the door is open for further discussions. But, Jan. 1 is coming fast, and that’s when the Exchange plans take effect. We’re doing everything in our power to ensure adequate networks so children who need care here can get it.

What happens next with that suit?

Sandy: For technical legal reasons, the suit we filed on Oct. 4 names just two of the insurers that excluded us – Molina and Coordinated Care. The filing of the administrative appeal seeks to disapprove any plans on the Exchange from the four companies named because they don’t include adequate healthcare networks for enrollees. We want these companies to improve their provider networks before their plans can be approved again, so patients can get the services they need.

If we win the suit and/or the appeal, the companies will not automatically be required to include us in their networks. Rather, they’ll be required to make sure their care networks provide adequate “in-network” healthcare providers. We believe this means including Children’s.

What has been the response thus far to you sharing concerns about network inadequacy?

Sandy: We have been pleased with the response we’ve received from the OIC. They have acknowledged the issue of network inadequacy and are looking at ways to address it. As an example, we’ve been invited to submit suggestions for how to make networks more sufficient for Exchange plan enrollees. Children’s will be in Olympia today to provide our recommendations to the OIC.

Since filing the lawsuit in early October, we have heard from patient families and groups like the Bleeding Disorder Foundation of Washington and the Arthritis Foundation of the Northwest expressing their concerns about network inadequacy and interest in helping ensure Exchange insurance offerings provide sufficient networks for families. We are also continuing conversations with insurers.

What’s your advice for families who are planning to buy health insurance through the Exchange?

Sandy: Before signing up, it’s important families know what is going to be included in their plan if their child gets sick. As a parent myself, I believe that families want to know that they can access the care they need when they need it.

To help inform families, we’re mailing information to parents and current patients who live in Washington and who we believe bought insurance on the individual market in the past, because they are likely to be looking at plans on the Exchange. We’ve set up a Health Insurance Changes page where we’ll post up-to-date information as the situation evolves, and that’s a good place for families to go.

What else can be done to assist Children’s efforts to guarantee adequate coverage through Exchange plans?

Sandy: Seattle Children’s has set-up a webpage with instructions on how our community can help. Supporters can express their concern about inadequate networks and let the Insurance Commissioner and the Washington Health Benefit Exchange’s Board of Directors know how this issue has an impact on people’s lives. Here is the website that people can visit:

If you’d like to arrange an interview with Dr. Melzer, please contact Seattle Children’s PR team at 206-987-4500 or at [email protected].