Friday, June 20, 2008

BCBSNC Gets Shielded by Professional Organizations: no parity for BCBSNC PPO 'State Plan'

BCBSNC Gets Shielded by Professional Organizations : no parity for BCBSNC PPO ‘State Plan’



I would like to know why, when people talk about this vague ‘State Health Plan PPO’ (see below, Cameron statement), they do not mention the fact that we are talking about basically the only game in town in terms of group plans for families and individuals who are not members of group plans (read: they have no employer sponsored health insurance).

State Health Plan PPO = BCBSNC PPO Plan.

They are avoiding stating that it is associated w/ BCBSNC, that’s why.

It is unbelievable that BCBSNC is supposedly overseen by NC State Legislature. When you call a state legislator’s office, they advise you to call the BCBSNC ‘Government Affairs’ employees.

These ‘Government Affairs’ employees are hired by BCBSNC to keep a lid on complaints while the state legislators apparently look the other way.

My 3 member family has BCBSNC PPO. We pay over $650 month for this PPO. There are over 2 million PPO BCBSNC members in NC.

BCBSNC PPO plans will not pay for clinic based screening colonoscopies (see referenced information at:

There are NO gastroenterologists in western NC who will do an ‘office based’ screening colonoscopy except for one practice in Boone, NC, fully 2-3 hours away from the most populated part of western NC, specifically, Buncombe county, the location of Asheville.

Now you’re telling me that BCBSNC somehow got out of having to adhere to mental health parity (H973) which was signed into law.

Moreover, NC Psychological Association is stating, as per Sally Cameron, Executive Director:

“…The parity law does not cover the State Health Plan PPO plans…. a strategic decision because the PPO plans have a broader benefit and includes parity for substance abuse…..”

Physicians are able to bill BCBSNC at an 80/20 formula with the patient or other carrier picking up the 20% while mental health providers are stuck at the 60/40 level as associated with mental health coverage.

Furthermore, in terms of ‘implementation problems’ how are state funded clients as managed by the LME’s included----(OR NOT)-----as mental health parity ‘supposedly’ created this (as per Cameron):

“HB 973 provides that nine (9) diagnoses are covered at full parity with physical illness “ bipolar disorder, major depressive disorder, obsessive compulsive disorder, paranoid and other psychotic disorder, schizoaffective disorder, schizophrenia, PTSD, anorexia nervosa and bulimia. The means there can be no durational limits set in insurance/managed care plans for these nine diagnoses. Insurance/managed care plans can use utilization review criteria to manage a mental health benefit.”

Western NC has 2 LME’s which cover 25% of NC 100 counties. They manage state funded mental health clients, the 'working poor' who have no health insurance.

Governor Easley, and assumably subsequent governors are advocating that these LME’s also manage Medicaid. This means that their ability to impact psychologists is going to INCREASE not decrease.

Western Highlands Network LME has stated that only Personality Disorders will receive more than 8 sessions of therapy and then only if Dialectical Group Therapy is included.

I would like to know how H973 applies to this matter.

Smoky Mountain Center LME has stated that no Basic Level Services are available for state funded clients. All therapy is subsumed under Community Support Services which is being rapidly defunded; is scrutinized under post payment reviews; and requires people who utilize it to undergo 20 hours of unpaid training.

I would like to know how H973 applies to this matter.

You asked, Sally, that NCPA members give you some feedback re: this implementation matter:

“Please note the FOLLOW-UP section and let us hear from you about an implementation issue. “

This is my statement about this implementation: BCBSNC is being shielded by professional mental health organizations in this state.

Monday, June 16, 2008

CO PASSES 'COLORADO COLORECTAL SCREENING GUARANTEE': no more than 10% of the cost of the procedure is passed to those insured

House Bill 1410, the Colorado Colorectal Screening Guarantee, by Representative Andy Kerr, the Colorectal Cancer Screening Health Insurance Mandate Bill. The bill would require small group and individual plans regulated by the state to include coverage for the range of screenings as recommended by the U.S. Preventive Services Task Force. Additionally, it provides guaranteed coverage for folks younger than 50 who have a family history or exhibit other chronic conditions. While policy deductibles no longer apply to colon cancer screenings, co-payments and co-insurance will continue to. HMO’s are limited to a fee of no more than 10% of the cost of the procedure. ACS supported this bill.

Medicare offers colonoscopy at any age re: colorectal cancer screening : HOW BCBSNC SKIRTS THE ISSUE OF PROVIDING FOR COLORECTAL CANCER SCREENING

The following information was gathered from: GAO-04-713 Colorectal Cancer Screening Test Coverage : : Government Accounting Office: GAO

What is the purpose of screening for colon cancer?:

"...Surviving colorectal cancer is greatly enhanced when the disease is detected and treated early; however, only 38 percent of colorectal cancer cases are diagnosed at an early stage, according to ACS...."

How preventable is colon cancer when utilizing screening?:

"Colorectal cancer is one of the most preventable cancers. Screening tests can help prevent colorectal cancer by finding pre-cancerous polyps so they can be removed before they turn into cancer. "

How do you screen for colon cancer?:

".....To facilitate early diagnosis, ACS recommends regular colorectal cancer screening for certain individuals using at least one of four key tests: FOBT, flexible sigmoidoscopy, DCBE, and colonoscopy. These tests are used to find potential signs of colorectal cancer, including polyps—abnormal growths in a person’s colon—or blood in a person’s stool. FOBT is a laboratory test used to detect blood (that is otherwise not visible) in stool samples that are collected by patients at home. Using a flexible sigmoidoscopy, a physician can find and take samples of polyps in a patient’s lower colon and rectum. DCBE detects polyps by providing x-ray images of a patient’s entire rectum and colon. Finally, a colonoscopy allows a physician to find and take samples of polyps in a patient’s rectum and entire colon as well as remove most polyps found during the test."

What is the recommended frequency of screening?:

"....ACS guidelines recommend that, beginning at age 50, all average-risk individuals be screened annually using an FOBT; every 5 years using a flexible sigmoidoscopy or DCBE; or every 10 years using a colonoscopy...."

Why does American Cancer Society (ACS) recommend that screening start at age 50?

"Risk increases as we age. The risk of developing colorectal cancer increases with age. In fact, most cases (92%) occur in people 50 and older.'

Does Medicare cover colorectal screening?: YES

"Medicare helps pay for colorectal cancer screening tests. People with Medicare Part B coverage who are age 50 or older are eligible for colorectal cancer screenings. However, in the case of colonoscopy, there is no age limit. Several different screening tests can be used to test for polyps or colorectal cancer. Each can be used alone. Sometimes they are used in combination with each other. The following screening tests are covered by Medicare."

Is there colorectal screening utilizing colonoscopies for those insured with BCBSNC PPO? Not as associated with clinic based screening.

How many states, by law, cover preventive care re: colon cancer? (as of 2004):

"Twenty states had laws requiring private health insurance plans to cover colorectal cancer screening tests as of May 2004. In 19 of these states, the laws generally applied to group or individual health plans, and required coverage of all four tests—FOBT, flexible sigmoidoscopy, DCBE, and colonoscopy—typically consistent with ACS guidelines.

Was NC one of the states stated by the GAO to 'require by law private insurance coverage of colorectal cancer?: YES

Table 1: State Laws Requiring Private Insurance Coverage of Colorectal Cancer Screening Tests : Scope of state laws States Number of states

Apply to fully insured group or California, Connecticut, Delaware,
individual plans and screening test coverage according to ACS guidelines District of Columbia, Georgia, Illinois, Indiana, Maryland, Minnesota, Missouri, New Jersey, Nevada, North Carolina, Oklahoma, Rhode Island, Tennessee, Texas, Virginia, West Virginia

Table 5: State Colorectal Cancer Screening Laws for Private Health Insurance
p. 18:

State Law generally applies to group/individual Law generally requires coverage consistent
w/ ACS guidelines

North Carolina (2002) Yes Yes

So, how does BCBSNC get away with not providing colorectal cancer screening in NC?
ACS Comments : The GAO report states itself, as associated with criticisms of its report: "(we) did not independently verify the responses of the insurers and employers we contacted. "


BCBSNC offers no colorectal screening in western NC except in Boone, NC---ONE gastroenterology practice. And that is an office based procedure, not clinic based.

How big is western NC?

Western North Carolina generally consists of 23 counties. NC has 100 counties.

Tuesday, June 10, 2008

274-6151 INFO:JUNE 13, 6 pm,N. Bunc. Middle Sch: Amer. Cancer Society 'Fight Back Tour': PLEASE LOBBY BCBSNC FOR SCREENING COLONOSCOPIES IN WESTERN NC

Thanks for your note American Cancer Society!

There are no screening colonoscopies for BCBSNC PPO insured.

There are over 2 million BCBSNC insured in NC.

You indicated that the Fight Back Tour bus will be coming to the North Buncombe Middle School baseball field. The relay for life event starts at 6 pm.

Address: 51 N Buncombe School RdAsheville, NC 28801(828) 645-7944: near Exit 8, Home Depot exit, Asheville, NC

Come early and enjoy music, food and lots of fun and games. The American Cancer Society Advocacy Bus will be there to distribute information on how you can be an advocate for family and friends dealing with the many types of cancer. All proceeds benefit the American Cancer Society. Call 274-6151 for more information.

"American Cancer Society Cancer Action Network (ACS CAN) 2008 Fight Back Express
National Tour

May I suggest that you lobby BCBSNC to create for citizens of NC screening colonoscopies.

I pay over $600/ month for BCBSNC PPO.

There are no colonoscopies available for NC citizens within 2.5 hrs of Asheville, NC, a city of 100,000 people.

BCBSNC attempts to understate the problem by creating mumbo-jumbo working associated with 'policy talk.'

This does not hide the fact that unless I pay $1200.00, I cannot obtain a screening colonoscopy by ANY gastroenterologist in western NC.

The $1200.00 does not include any matters like biopsies or tests that might be associated with such an preventive medical exam-----which is recommended by the American Cancer Society and gastroenterologists. .

marsha hammond, phd