Concerns arise over doctors not taking CHA patients
The state's insurance agency wants to hear from people covered by Community Health Alliance insurance plans who are experiencing problems with hospitals or physicians accepting their coverage.
The call comes after anecdotes from around the state have raised concerns that some patients are being jilted because the insurer is set to close at year-end.
The Tennessee Department of Commerce and Insurance decided in October that CHA's rates for 2016 would not sustain its business and the Knoxville-based co-op agreed to shut down and no longer offer insurance plans after Dec. 31.
Now the agency is hearing that some patients are having trouble with providers and hospitals not accepting the plans over concerns about delinquent claim payments from the insurer.
“As with any professional field we regulate, the department expects all parties to honor their contracts,” TDCI Commissioner Julie Mix McPeak said in a statement. “It is unfair and unacceptable that CHA consumers would be denied access to services because the company is in runoff."
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A spokeswoman for Community Health Alliance did not immediately respond to an inquiry.
Community Health Alliance is expected to pay claims through the end of the year. McPeak told a U.S. House of Representatives committee this month that she expects the insurer to make the payments.
Liz Schrader, 60, found herself caught between CHA and her provider in September. Her doctor declined to see her because of concerns about CHA's payments, although the insurer told her the policies were in good standing until the end of the year.
Schrader said at the time she called other providers in the Murfreesboro area and ran into trouble finding someone who would take her as a patient.
Ultimately her existing doctor's office agreed to keep seeing her as long as she said she would pay the bill if CHA did not, she said.
"They agreed to keep seeing me because they identified with my plight. I was an existing patient, not a new patient,” Schrader said.
State Sen. Richard Briggs, R-Knoxville, said he heard from a woman who had an elective surgery canceled by a Knoxville-area hospital because it had concerns about delinquent payments from CHA.
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"We want to get our arms around how big this issue is,” said Kevin Walters, a spokesman for the TDCI. "We are exploring our next steps. Right now we are in the information gathering stage.”
Briggs, a physician, is concerned that patients are going to get left "holding the bag" in disputes between CHA and medical providers.
"If they waited and went with another (insurance) company after the first of the year, they’d be starting all over,” Briggs said about patients who may have met their deductible and be faced with canceled surgeries.
CHA, one of about half of the 23 co-ops established by the Affordable Care Act to fail, faced setbacks from the outset, including a growth spurt from the first to second year on the exchange.
The insurer projected it would enroll 12,000 to 15,000 in its first year on the exchange and then 20,000 in the second year. Its plans, though, were among the higher-priced options on the exchange in the first year, but it enrolled only a fraction of what it projected: It had 2,287 members, with 186 on individual plans at the end of 2014.
Then, in the second year, it redesigned and repriced its plans, coming in as one of the least-expensive options, and enrolled 35,761 by mid-January. Its sudden growth concerned state officials, and the insurer was frozen from open enrollment.
Co-ops faced funding challenges as well, which were magnified by the high volume of medical claims accrued by members.
"I think if the patient paid the premium, they played by the rules, then I don’t think the patient should be penalized,” Briggs said.
McPeak is concerned that patients are spending time trying to get their existing plans honored rather than looking for new plans for the next year. Open enrollment began Nov. 1 and runs through the end of January. Tennesseans with CHA insurance will need to find a new insurer on the exchange for 2016.
"CHA consumers should be shopping for 2016 insurance coverage, not fighting with health-care providers about their coverage,” McPeak said.
Reach Holly Fletcher at 615-259-8287 and on Twitter @hollyfletcher.
Patients needing help
Are you a patient with an issue with a doctor or hospital accepting your Community Health Alliance plan?
Reach out to the Tennessee Department of Commerce and Insurance at 1-800-342-4029 or 615-741-2218.
Providers needing help
Are you a provider with an issue with Community Health Alliance?
Insurance Commissioner Julie Mix McPeak said to contact the insurer as disputes arise. The insurer is obligated to pay claims through the end of 2015.
Tell us your story
Email health care reporter Holly Fletcher with your CHA experience at hfletcher@tennessean.com with the subject line "CHA."