Open enrollment is just a few weeks away for Oregon’s 130,000 state employees and their dependents, who can choose a brand new health insurance option for the first time -- Moda Health, which is very close to having a statewide network of physicians and hospitals. It’s quickly becoming the major competitor to Providence Health Plan which has had the bulk of PEBB’s membership up until now – covering 108,679 employees and dependents, while Kaiser insured 21,367 lives. Enrollment begins Oct. 1 for the 2015 calendar year.
But Moda isn’t finding an easy road ahead. Many physicians from Salem and other communities contacted The Lund Report and are outraged about Moda’s decision to post their names on its website -- saying they are participating providers when – they haven’t signed the contract to participate with PEBB and are reluctant to do so because of the risk arrangement required by the health plan.
Several physicians also sent The Lund Report excerpts from the contract that Moda Health asked them to sign, which contains several onerous requirements, among them:
- "Requires an enrollee to use a specified network or networks of providers managed, owned, under contract with or employed by the insurer in order to receive benefits under the plan, except for emergency or other specified limited service; or
- In addition to the requirements of paragraph (a) of this subsection, offers a point-of-service provision that allows an enrollee to use providers outside of the specified network or networks at the option of the enrollee and receive a reduced level of benefits."
And,
"Preferred provider organization insurance" means any health benefit plan that:
- Specifies a preferred network of providers managed, owned or under contract with or employed by an insurer;
- Does not require an enrollee to use the preferred network of providers in order to receive benefits under the plan; and
- Creates financial incentives for an enrollee to use the preferred network of providers by providing an increased level of benefits.
‘Preferred provider organization insurance’ does not mean a health benefit plan that has as its sole financial incentive a hold harmless provision under which providers in the preferred network agree to accept as payment in full the maximum allowable amounts that are specified in the medical services contracts.”
The physicians aren’t alone in raising shackles – two hospitals in the areas served by Moda -- Silverton Hospital and Santiam Hospital – haven’t received contracts.
In an earlier version of this story, the medical community told The Lund Report that it was convinced Salem Health was running the show and, and only wants its physicians and Salem Clinic, which has more than 60 physicians to be part of the action.
However, after our article appeared, Salem Health denied having any role in choosing the physician panels for Moda or dictating any terms.
In fact, a memo -- obtained by The Lund Report -- said that Salem Health has not yet received a proposed contract from Moda, and will not be offering its Synergy product to its employees because :"we do not know how the product will work and have received no contract to negotiate."
Apparently Moda has a different opinion of what's occurring. During a meeting on September 5 with providers and Moda to discuss how this Synergy product would work, Moda officials said that Salem Health had, in fact, signed a contract and "agreed to favorable rates and risk arrangements," according to this memo.
Salem Health does have current contracts with the Medicare Advantage plan and the commercial PPO, known as the ODS Plus Panel.
Meanwhile, When asked whether the Oregon Insurance was looking into how Moda Health may be giving inaccurate information about its physician panel, Lisa Morawski, senior policy advisor of communications, told The Lund Report, “We are looking into your question regarding Moda, but we don’t have any information to share yet. In general, one of the ways we protect the insurance-buying public is to ensure that carriers provide accurate and timely information about their benefits.
The Public Employees Benefit Board was also contacted, and its deputy administrator, Kathy Loretz, said, “PEBB contracts are built to ensure each health plan has an adequate network. As part of those contracts, our partners contract with providers in their regions. We met with Moda as recently as this morning and are confident they will have adequate providers for the start of the 2015 plan year.”
Moda also weighed in, acknowledging that not all the providers listed on its website had an existing ODS plus contract. “Not all providers have signed or returned an addendum to participate in certain financial aspects of the Summit and Synergy network, in those circumstances the terms and conditions of the ODS Plus contracts remain in place for participation in the Summit and Synergy networks,” said Katie Paullin, director of marketing.
For the PEBB contract, Moda’s Synergy network includes Oregon Health & Science University, Salem Health, Salem Clinic, Adventist Health, Legacy Health and PeaceHealth and covers Benton, Clackamas, Clark, Clatsop, Lane, Linn, Marion, Multnomah, Polk, Tillamook, Wasco, Washington and Yamhill counties.
This year, PEBB”s budget has been capped at 4.4 percent inflation this year and 3.4 percent starting next year -- but with Providence, inflation had already shrunk to zero.
“The rate in January will be a flat increase. We've never had that before in the history of PEBB,” former PEBB administrator Joan Kapowich told The Lund Report before she left her longtime post in the middle of the contract process. Publicly, she voluntarily retired, but insider sources, speaking on condition of anonymity, said she resisted Kitzhaber’s wish to move PEBB into the CCOs, and was shown the door. Since leaving state government, Kapowich has become a health promotion benefit design consultant.
Diane can be reached at [email protected].
