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RE: BCBSNC policy which does not cover screening colonoscopies as they are not available in western NC
December 12, 2008
Dear Ms. Thornton (Becky P. Thornton, AIRC, ACS, HIA, MHP
Life and Health Supervisor Consumer Services Division: "Becky Thornton"
Healthcare Review Program (919) 807-6863 Lrmuntz@ncdoi.net), of the NC Department of Insurance:
Thank you for your e mail letters regarding my concern about the lack of BCBSNC PPO coverage in western NC as per screening colonoscopies. (I enclose a copy of that below under 'item 1').
I am not asking the NC Department of Insurance to demand that BCBSNC exceed the terms of the agreement in place as per my family's coverage. I am asking that the NC Department of Insurance attend to the law which you sited which states that there be adequate network avaibility. And there is NOT network availability for screening colonoscopies which are covered, by law. There are no screening colonoscopies that are reimbursed by BCBSNC PPO within two hours of Asheville, NC, a major metropolis.
I would like to know if the NC Department of Insurance is going to attend to the law which requires BCBSNC---- as associated with NCGS 58-3-179 in terms of 'providing coverage for colorectal cancer examinations which is at least equal to the coverage required by NCGS 58-3-17', which is associated with the notion, Network Adequacy---to provide coverage for policy-holders.
You indicated that there is nothing in the law that attends to WHERE the procedure is to be obtained. However, the law does specify that speciality services must be covered in a manner 'at least equal' to other coverage.
And so as pertaining to the matter of 'as apply to other services covered under the plan', I might speculate that if I had to travel over 2 hours to go to my son's pedicatrician, that would be not in keeping w/ the plan, would it? Or if I had to go to a gynecologist over two hours away, that would not be in keeping w/ the plan, would it? And so, in keeping w/ other services which do not require a two hour trip, I believe that the answer is that BCBSNC must have a provider who can make available the screening colonoscopy service.
My understanding is that the law has to attend to the 'network availability' and there are no screening colonoscopies to be had in western NC except in Boone, NC, where there is an 'office based' screening colonscopy-----which is all that BCBSNC PPO will pay for. (see Item 2 below).
I noted this at the law's site, the number which you indicated to me in your e mail, specifically:
1 NORTH CAROLINA’S SMALL EMPLOYER GROUP BASIC AND STANDARD HMO ...
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THE COVERAGE REQUIRED BY NCGS 58-3-179. EVERY STANDARD HEALTH BENEFIT PLAN THAT IS DELIVERED, ISSUED. FOR DELIVERY, OR RENEWED ON OR AFTER JANUARY 1, ...
www.ncdoi.com/LH/News/Documents/HMOBasicAndStandardPlans_MentalHealthUpdate.pdf - Similar pages -
NORTH CAROLINA’S SMALL EMPLOYER GROUP BASIC AND STANDARD HMO HEALTH BENEFIT PLANS BENEFITS AND EXCLUSIONS
"EVERY STANDARD HEALTH BENEFIT PLAN THAT IS DELIVERED, ISSUED FOR DELIVERY, OR RENEWED ON OR AFTER JANUARY 1, 2002 SHALL PROVIDE COVERAGE FOR COLORECTAL CANCER EXAMINATIONS AND LABORATORY TESTS. THIS COVERAGE SHALL BE AT LEAST EQUAL TO THE COVERAGE REQUIRED BY NCGS 58-3-179."
I would like to hear from you or someone at the NC Department of Insurance about this matter which surely impacts thousands of NC citizens.
In accord w/ Ms. Rudd-Muntz's suggestion, I have filed a complaint. I would like to know what happens to those complaints. Thank you for letting me know. Please feel free to pass this e mail to any pertinent party.
Marsha V. Hammond, PhD
Item 1: your letter re: my letter to you as pertaining to this matter:
I have been reviewing the information you were previously given by Ms. Edwine with other Divisions within our Department to ensure proper information was relayed to you regarding your concerns with BCBS. The information you have been given was correct and I hope this further explanation helps.
NCGS 58-3-179 requires a health plan to provide coverage for colorectal cancer screening with the same deductibles, coinsurance and limitations as apply to other services covered under the plan. There is nothing in the law that addresses where the colorectal screening must take place in order to be covered under a health plan.
The NC Department of Insurance is limited to ensuring the company complies with the provisions of its policy contracts as well as complies with relevant insurance statutes and regulations that have been enacted by our Legislature. We do not have the authority to require BCBS provide benefits above and beyond that which is stated in the contract.
Thank you for the opportunity to respond further to you.
Becky P. Thornton, AIRC, ACS, HIA, MHP
Life and Health Supervisor
Consumer Services Division
From: Luann Rudd-Muntz
Sent: Thursday, December 11, 2008 8:21 AM
Cc: Becky Thornton; Doris Edwine
Subject: RE: Possibly spam: req to investigate BCBSNC no screening colonoscopies available in west ern NC
The Healthcare Review Program assists consumers who have been denied payment of medically necessary benefits by their insurers.
The Consumer Services Division can best address your concern, and investigate your complaint. I have forwarded your e-mail to them. Consumer Services can be reached at 800-546-5664 .
You may also complete a consumer complaint on the web-site at www.ncdoi.com. by selecting the first bullet in the center column, you will be taken to the information you'll need to complete the complaint.
Clinical Review Analyst
Healthcare Review Program
C 24 ONSUMER ROTECTIONS
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There are special consumer protections built into the laws governing small-group ...... [N.C.G.S. §§ 58-3-179, 58-50-155]. Contraceptives ...
www.nciom.org/hlthinspgms/C24.pdf - Similar pages -
Insurers that operate network-based plans (like HMOs or PPOs) must have systems to ensure the adequacy of the network. Insurers must set their own access standards and monitor how well the network meets these internal standards. The health plan’s access standards should include information about how long enrolees must travel to obtain primary care, specialty care, hospital-based services and other facilities."