Document 68 : Docket No. 99-14 : Hearing Decision : Bureau of Insurance

STATE OF MAINE
DEPARTMENT OF PROFESSIONAL & FINANCIAL REGULATION
BUREAU OF INSURANCE

In re: Application of Associated	)
Hospital Service of Maine, d/b/a	)
Blue Cross and Blue Shield of	)
Maine, to Convert to a Stock	)
Insurer and Voluntarily Liquidate	)
and Dissolve	)
	)
and	)	Maine Medical Association’s Motion to
	)
In re: Application of Anthem Health	)	Amend the HMO Certificate of Authority
Plan of Maine, Inc., to Acquire the	)
Assets of Associated Hospital Service	)	Standard of Review in Paragraph III(26)
of Maine, d/b/a Blue Cross and Blue	)
Shield of Maine, and Related	)	of the Notice of Hearing
Transactions	)
	)
Docket No. INS 99-14	)
	)
	)

NOW COMES the Maine Medical Association ("MMA"), through counsel, pursuant to the Superintendent’s letter dated November 15, 1999 regarding Paragraph III(26) of the Notice of Hearing and Bureau of Insurance Rule Chapter 350(7), and moves that the Superintendent amend Paragraph III(26), or take other appropriate steps, to ensure consideration of the issues contained therein based upon the following:

1. Paragraph III(26) of the Notice of Hearing states one of the standards of review in this matter as follows:

(26) whether the proposed acquisition of control of BCBSME and its HMO Maine line of business by Anthem requires compliance with the filing and approval requirements of the Maine Insurance Code with respect to the issuance of a certificate of authority to a health maintenance organization (24-A M.R.S.A. §§ 4203 - 4204).

2. In his letter of November 15, 1999, the Superintendent directs any party who believes Paragraph III(26) means that "Anthem is required to make the filings required by 24-A M.R.S.A. §§ 4203 - 4204" to file a written brief supporting its contention (emphasis supplied).

3. Upon information and belief, HMO Maine or BCBSME have provided managed health care services continuously under a HMO Certificate of Authority since 1985. The Maine HMO Act has required BCBSME to update periodically the documents filed in support of its HMO Maine Certificate of Authority.

4. The BCBSME/Anthem transaction envisions a transfer of the HMO Maine line of business as an intact "book of business" from BCBSME to Anthem along with the other BCBSME indemnity and managed care product lines.

5. The MMA takes no position on requiring Anthem "to make the filings" required by §§ 4203 - 4204 because of the intact transfer of HMO Maine. Moreover, the MMA acknowledges that Anthem and BCBSME may incur additional costs in carrying out a purely administrative process of re-filing materials previously filed on behalf of HMO Maine by BCBSME and that the value of such an exercise for the Superintendent and all parties may be outweighed by the additional cost.

6. The MMA does, however, submit that the Superintendent and all parties must have the authority to inquire about Anthem’s ability to, and plans to, meet the requirements of the Maine HMO Act, including §§ 4203 - 4204, if the proposed transaction is approved. Specifically, the MMA may wish to inquire about and/or raise issues concerning the following subsections of 24-A M.R.S.A. §§ 4230 - 4204:

A. enrollees’ evidence of coverage (24-A M.R.S.A. § 4203(F));

B. group contracts or evidence of coverage (24-A M.R.S.A. § 4203(G));

C. quality assurance program (24-A M.R.S.A. § 4203(M));

D. list of network providers (24-A M.R.S.A. § 4203(S));

E. quality assurance program (24-A M.R.S.A. § 4204(2-A)(B));

F. statutory definition of health maintenance organization (24-A M.R.S.A. § 4204(2-A)(C));

G. providers and services necessary to meet patient demand (24-A M.R.S.A. § 4204(2-A)(K);

H. provider network adequacy (24-A M.R.S.A. § 4204(2-A)(L); and

I. services for rural and underserved populations and relationships with essential community providers (24-A M.R.S.A. § 4204(2-A)(M).

7. Amending Paragraph III(26) of the Notice of Hearing to follow the form of Paragraph III(1) of that document may ensure the Superintendent’s and the parties’ right to address Anthem’s compliance with the provisions of the Maine HMO Act. Paragraph III(26) might be replaced with the following:

(26) whether, after the proposed change of control, Anthem Health Plan could satisfy the requirements for the issuance of a certificate of authority under the Maine HMO Act (24-A M.R.S.A. §§ 4203 - 4204).

8. Should the Superintendent find that he cannot adequately protect his interests and those of the parties to consider issues of Anthem’s compliance with the Maine HMO Act, particularly 24-A M.R.S.A. §§ 4203 - 4204, as suggested herein, then the MMA submits that 24-A M.R.S.A. § 4203(1) provides ample authority for the Superintendent to require Anthem to complete the filing and approval requirements of the Maine HMO Act as an element of this proceeding.

WHEREFORE, the Maine Medical Association respectfully requests that the Superintendent amend Paragraph III(26) as proposed herein or in similar fashion, or that he take such other steps as appropriate to ensure the Superintendent’s and the parties’ right to raise issues of Anthem’s compliance with the Maine HMO Act in this proceeding in the most efficient and cost-effective manner.

Dated at Manchester, Maine, November 23, 1999.

_________________________________________

Gordon H. Smith

_________________________________________

Andrew B. MacLean

Attorneys for the Maine Medical Association

Maine Medical Association

30 Association Drive, P.O. Box 190

Manchester, Maine 04351

207-622-3374

207-622-3332 (Fax)