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.

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