New Medicaid enrollees and those previously not assigned to a managed care plan under Apple Health, Washington’s Medicaid program, are now covered by an insurer called Amerigroup.
Notices regarding this change, which went into effect Jan. 1, were mailed out by the Washington Health Care Authority (HCA) on Dec. 19, according to Preston Cody, division director for health care services for the HCA.
According to Cody, all of Klickitat County’s “fee-for-service” patients, or those previously not assigned to a managed care plan, were assigned to Amerigroup because the HCA determined the company to have an “adequate provider network” for the area.
“Ultimately we want to make sure clients receive the services they need. Through this model they will have better services they simply do not get through fee-for-service,” Cody said.
The change to Amerigroup impacts more than 3,000 Klickitat County residents who were either previously listed as fee-for-service patients or who are new Medicaid enrollees, according to Cody.
Lynnette Grubb, of Glenwood, and her daughter are two such patients. Grubb said she had made numerous doctors’ appointments for her daughter prior to Jan. 1 and has since opted out of Amerigroup and switched back to the fee-for-service status.
She said if she hadn’t, none of the doctors’ appointments she made for her daughter would have been covered by Amerigroup, including the neurologist or primary care physician she usually sees. The CT scans she usually gets at Providence Hood River Memorial Hospital, which does not contract with Amerigroup, would have also not been covered.
Grubb said in all it took her 18 hours on the phone to figure out what was going on and opt out of Amerigroup’s coverage.
“I wanted to beat my head on a brick wall. I thought it would be easier,” Grubb said.
Since the change, Cindy Robertson, administrator at NorthShore Medical Group in White Salmon, said the phones at her business office have been ringing non-stop. NorthShore does not contract with Amerigroup, meaning Medicaid patients assigned to Amerigroup can no longer go there for checkups or other health care needs.
According to Amerigroup’s on-line network catalogue, the closest covered primary care provider to White Salmon for Medicaid patients is in The Dalles, the next closest being in Goldendale. Hospitals covered include Skyline Hospital in White Salmon, Mid-Columbia Medical Center in The Dalles, and Klickitat Valley Health in Goldendale.
“Our phones have gone crazy. We’ve gotten tons of calls from people. A lot of folks are really anxious and upset, understandably,” Robertson said.
In addition to numerous patients being sent elsewhere, Robertson notes that specialty care for Medicaid patients under Amerigroup is now farther away.
For example, Amerigroup’s online network catalog lists the closest covered orthopedist to White Salmon as being in Prosser. Those needing a cardiologist or sleep specialist covered by Amerigroup will have to drive to Yakima. The nearest doctor specializing in pulmonary diseases covered by Amerigroup is listed in Ellensburg.
Other specialists can still be accessed here, like Skyline Hospital’s neurologist or general surgeons. Endocrinologists and dermatologists covered by Amerigroup can be found in The Dalles.
“These are Medicaid patients, so by definition they’re the people who have the least resources in society and the least ability. A lot of these folks don’t even have reliable transportation,” Robertson said.
The change to Medicaid patients being covered by Amerigroup also represents an issue for those who are expecting. Usually, NorthShore Medical Group’s doctors send pregnant patients to Providence Hood River Memorial Hospital for delivery because they have admitting privileges there.
According to Robertson, even if NorthShore were to contract with Amerigroup, its doctors could not send pregnant patients to Mid-Columbia Medical Center in The Dalles because they do not have admitting privileges there.
Overall, Robertson does not believe the HCA made the right decision pertaining to changing fee-for-service patients and all new Medicaid enrollees over to Amerigroup’s coverage and she is in total disagreement with the entity maintaining that the insurer’s network is “adequate.”
For now, Robertson said there is no plan for NorthShore to contract with Amerigroup.
“That is a question we get sometimes, ‘why don’t you guys just sign up with them?’ We might be able to; I don’t know if we could or couldn’t. Sometimes insurance companies will contract with you sometimes they won’t, but even if we could we do not sign up with insurance companies that don’t have an adequate network for us to send our patients,” she said.
Cody added that when considering plans to be awarded to assignment of enrollees in a given area, the plan must demonstrate their network can serve at least 80 percent of the Medicaid eligible population. A definition of an “adequate network” provided by Amy Blondin, chief communications officer with the HCA, states “this is calculated not only by number of providers within the service area, but also by proximity of the providers to the possible enrollee.”
“Ultimately we want to get better service to our clients at a better cost to the state while maintaining quality,” Cody said.
Cody said there are a few methods of opting out of Amerigroup’s coverage, the preferred method being online at www.waproviderone.org. If for any reason that method doesn’t work, patients can also call the HCA directly at (800) 562-3022.
Opting out of Amerigroup coverage goes into effect as of the first of the following month, so those who opt out this month will be back as a fee-for-service patient as of Feb. 1.
That said, Cody acknowledges that opting out over the phone might take longer.
“We have more calls coming in than staff to answer those calls, so it does take some time on the phone,” he said.