Blue Cross Blue Shield Seeks Partners for New Exclusive Provider Networks

Hospitals, health systems and group practices (“Providers”) have a new opportunity to create localized, exclusive provider networks by partnering with Blue Cross Blue Shield of Michigan (“BCBS”) for its new insurance products.  With the looming implementation of the of Patient Protection and Affordable Care Act (“ACA”), BCBS believes that many individuals will be willing to trade broad network access for a quality local network and a lower-cost insurance premium.  As such, BCBS has developed new insurance products that will only cover treatment within an individual’s designed provider network.  With the exception of emergency services, individuals will pay for out-of-network care.

Currently, BCBS seeks Provider partners for two insurance products.  The first product involves an exclusive provider contract through BCBS that will cover Providers in Lenawee, Livingston, Macomb, Monroe, Oakland, Washtenaw, Wayne and St. Clair counties.  The second product involves a contract through Blue Care Network that will cover Providers in Livingston, Macomb, Monroe, Oakland, Washtenaw, Wayne and St. Clair counties.  Providers must respond to BCBS’s request for proposal by October 7, 2013.  BCBS anticipates that both products will be available for enrollment through both conventional channels and the health insurance exchange starting in October 2014.  Coverage under these plans will be effective in 2015.

The introduction of these products for Southeast Michigan follows a partnership forged between BCBS and Mercy Health on the west side of the state.  In June 2013, BCBS partnered with Mercy Health to create an exclusive provider network for Kent, Muskegon and Oceana counties.  BCBS plans to have this product available when the health insurance exchange/marketplace begins open enrollment on October 1, 2013.

BCBS’s exclusive provider network contracts play an important role in the restructuring of Provider payments and the evolution of integrated health care.  Under the ACA, Providers are tasked with improving patient outcomes while reducing the costs of expenditures.  By keeping patient care localized within a network, BCBS hopes to reduce costs by eliminating unnecessary treatments and tests and improve the quality of care by encouraging Providers within the network to work together.  To accomplish these goals, BCBS has included a number of requirements for the two pending Provider contracts, including:

  • BCBS is allowed to audit a Provider’s utilization, quality and health management programs;
  • The Provider will not request or accept payment for services denied by BCBS;
  • The Provider agrees to include all employed doctors in the exclusive provider network;
  • The Provider agrees to coordinate benefits;
  • The Provider must agree to allow referrals to other Providers in BCBS’s network when a services is not available through the Provider; and
  • The Provider must demonstrate sound financial stability for the last five years.

To find out more about Blue Cross Blue Shield of Michigan’s exclusive provider networks or the RFP process for BCBS’s two new insurance products, contact attorney Michael James at mjames@michaeljameslaw.com, 810-936-4040 or www.michaeljameslaw.com. Michael James provides representation and counseling related to all facets of business enterprise and health care matters.

© 2013 Michael P. James, J.D., M.B.A., CSSGB

Government Pushes Pause on Pay or Play Mandate

On July 2, 2013, the Obama Administration delayed the implementation of the employer shared responsibility requirements of the Affordable Care Act (“ACA”).  Commonly referred to as the “Pay or Play Mandate,” the ACA requires that large employers provide affordable and comprehensive health care coverage to their employees or pay penalties.  The Pay or Play Mandate was scheduled to take effect on January 1, 2014.  Now, the Pay or Play Mandate will not apply until 2015.

The Obama Administrative cited the complexity of the reporting requirements and the need for more time to implement them effectively as reasons for the 1 year delay.  As part of Pay or Play Mandate, applicable employers will be required to report information to the government related to the health coverage offered to their employees.  The government hopes to use the additional time to simplify the reporting requirements for applicable employers and adapt health coverage and reporting systems related to this process.

Although there has been a delay in the implementation of the Pay or Play Mandate, large employers should continue to develop and implement strategies related to health care reform for their businesses.  The additional time may allow some employers to consider options previously unavailable to them.  In addition, because the health insurance marketplaces/exchanges are still slated to begin open enrollment on October 1, 2013, large employers should consider the effect the individual and SHOP marketplaces will have on their ability to satisfy their human capital needs.

© 2013 Michael P. James, J.D., M.B.A., CSSGB

To find out more about the impact of health care reform on your business, contact attorney Michael James at mjames@michaeljameslaw.com, 810-936-4040 or www.michaeljameslaw.com. Michael James provides representation and counseling related to all facets of business enterprise and health care matters.