State order: Anthem must cover some WellStar services, but not all

Anthem corporate headquarters in Indianapolis. (PHOTO by AP/Michael Conroy)

Anthem corporate headquarters in Indianapolis. (PHOTO by AP/Michael Conroy)

The state Department of Insurance has accepted an agreement from Anthem to cover some WellStar Health System services again for the rest of 2019. But not all.

Early this year, the insurer previously known as Blue Cross Blue Shield stopped covering WellStar services for individual policyholders after those Georgians were already locked in to the health insurance plans they obtained through the state's Affordable Care Act exchange. WellStar is a giant health care system covering the northwest swath of metro Atlanta.

Anthem knew well before then that it would be cutting that coverage, having notified WellStar in August that it would not renew their contract for those customers. But the patients didn’t learn until this year, many of them not until they tried to make appointments with doctors and were told they couldn’t.

Nothing in the dispute affects group policyholders, such as those with employer-sponsored plans. Anthem left in place its group policyholders’ in-network coverage with WellStar.

The consent order signed this week will restore those individuals’ coverage for visits to WellStar primary care doctors and specialists. But they still won’t have coverage for hospital inpatient admissions or outpatient services such as X-rays.

The Anthem ACA product, Pathway, is an HMO, so out-of-network generally means no coverage at all.

”(The consent order is) a step in the right direction; it’s just not gone far enough,” said Jason Doss, a lawyer representing patients suing Anthem. “I’m disappointed about that.”

Doss said his clients would continue to fight in the courts. They want out of their Anthem contracts.

The Department of Insurance was hoping the Trump administration would open a special enrollment period to allow these ACA policyholders to change policies. So far, it has declined to do that.

Pricing for a medical service depends on the insurance company and the service provider — in this case, WellStar. A spokesman for the Insurance Department said that although it has no authority over WellStar, WellStar has told the state agency that it will agree to charge those patients the Anthem rate if the insurer treats the service as in-network.

In a statement, WellStar Chief Financial Officer Jim Budzinski said that Anthem’s action “continues to impact the individuals with Pathway products in the communities we serve throughout Greater Atlanta.”

“WellStar will work with our patients and Anthem to seamlessly restore the access to our physicians,” Budzinksi said.

He added that WellStar would continue to dispute Anthem’s right to terminate coverage of its hospitals’ services through the Pathway network.

Asked why it was leaving outpatient services out of the agreement, Anthem said in a written statement only that it “will continue to work to ensure our members receive high quality, affordable care through our network of participating providers and hospitals across Georgia.”

The consent order marks a retreat for the Insurance Department.

After The Atlanta Journal-Constitution first reported the news of Anthem's move this year, freshly elected state Insurance Commissioner Jim Beck responded with vigor, setting a new tone for the typically placid department.

Beck said there was reason to believe Anthem had violated the law. He issued a scathing demand to the insurance giant to appear at a hearing and explain itself.

Shortly afterward, federal prosecutors charged Beck in a 38-count indictment that alleges he stole more than $2 million from a former employer. Beck is now on suspension, and this week’s consent order was signed by F.A. “Drew” Lane, the agency’s chief deputy commissioner.

Under the agreement, the hearing Beck called for, scheduled for next week, has been canceled.