Popular individual health insurance plan adds local doctors at the last minute, but Sanford’s only hospital remains left out

By Gordon Anderson

Back in November, while shopping for an individual health insurance plan for 2020, Linda Diesfeld of Sanford noticed something distressing. Almost no Lee County doctors were a part of the plan she usually purchased through Blue Cross Blue Shield of North Carolina.

That meant very, very little covered care would be available anywhere close to Sanford. Instead, she’d have to drive to Pittsboro or Chapel Hill or Holly Springs or Cary. Most notably missing from the list of in-network providers was Central Carolina Hospital.

“We got a letter from Blue Cross explaining our options, and then we called my husband’s doctor,” said Diesfeld, who herself is on Medicare but was shopping plans for her husband and son. “We were told that if (the BCBSNC plan) was going to be UNC affiliated, they would not be participating.”

Blue Cross Blue Shield partnered with UNC Health Alliance as the sole network for individual purchasers in the Triangle through its “Blue Home with UNC Health Alliance” plan that became effective on Jan. 1, removing dozens of providers and hospitals in the area from the network Diesfeld and others relied on.

An estimated 2,000 people in Lee County are facing the same dilemma as Diesfeld — either stick with BCBSNC and get a plan that is compliant with the Affordable Care Act but does not include CCH and many others in Sanford, or opt for a plan through Ambetter that costs more and covers less.

With the change, BCBSNC estimates the individual ACA rates in Lee County have gone down by a pre-subsidy average of more than 26 percent — saving those members roughly $1,900 a year. But members like Diesfeld had to decide whether that savings offsets the prospects of travelling outside Sanford for care.

BCBSNC has changed course from its initial plan since late 2019, presumably in response to concerns from customers and those in the insurance industry. More than a dozen Lee County doctors ranging from primary care providers to specialists were added to the plan in December, bringing the total number of Lee County doctors in the UNC network to 18. But one rather significant issue remains for the thousands of locals who purchase individual ACA plans: Lee County’s only hospital will remain out of network.

“For more tertiary events, you’re going to see more and more people being shipped off to UNC Hospital and other places for care, which is not good for Central Carolina Hospital,” explained Tom Snell, a benefits advisor with OneDigital in Sanford.

Central Carolina Hospital is owned by Duke Lifepoint and is not a part of the UNC Health Alliance. According to CCH CEO Spencer Thomas, the hospital became aware that it wouldn’t be in network for BCBSNC plans at the same time as the general public:

“Despite our best efforts, we are not considered ‘in-network’ with the Blue Cross Blue Shield health insurance exchange plan for 2020,” Thomas said in a statement provided to The Rant. “Blue Cross Blue Shield of North Carolina made a unilateral decision to eliminate CCH from the network without proactively engaging and notifying patients or providers of this significant change. We were not given advanced notice of this decision — and like the public — became aware that CCH would be ‘out-of-network’ with this plan in late October.”

Of course, while non-emergency care at CCH will cost BCBSNC individual customers significantly more, both the hospital and BCBSNC say emergency care at the hospital will still be covered as in-network by the ACA plan.

But that distinction is confusing to some, including Diesfeld, and even CCH referred questions about what constitutes an emergency — does a baby arriving earlier than expected, for example, count? — back to BCBSNC. The hospital even went so far as to recommend patients who still had the option to enroll sign up for the competing Ambetter plan.

“I’m worried about the hospital,” Diesfeld said. “UNC is a ways off. What if you’re in a bad accident? Are you going to have out of network charges? That would kill you.”

The nearest UNC Health Alliance hospitals to Sanford are Chatham Hospital in Siler City or UNC Hospitals in Chapel Hill. And while 2,000 may not sound like that large a number, in a county of just over 61,000 people, that represents almost three and a half percent of the population.

Still, BCBSNC stresses the savings its customers will see under the new plan.

“For years, our customers who bought insurance through the federal exchanges saw significant rate increases,” said Laura Eberhard, a spokesperson for BCBSNC. “This made coverage unaffordable for many families. Blue Cross NC’s goal is always to offer our customers the best possible coverage at the lowest possible price.”

Eberhard added that BCBSNC “engaged Duke, WakeMed, and UNC in a competitive process to see who could offer customers the lowest possible costs while continuing to offer them access to the highest quality care.” UNC delivered the deepest cost savings, Eberhard said.

Shannon Suggs, who owns Suggs Insurance in Sanford, said the situation is better than it was before, but she still worries about customers she knows who have to see doctors multiple times each month.

“I have a customer who can’t drive, and she has to see the doctor every couple of weeks,” she said. “And now she has to go to Chapel Hill for care.”

Snell said his understanding was that the BCBSNC approach was based on geography — “they’ll use, say, a 20- to 30-mile radius to determine whether there’s an adequate network for Lee County,” he explained — but he also understands those who felt that having almost no in county options for health care was itself inadequate.

“I had several conversations with Blue Cross and told them their plan had kind of thrown Lee County under the bus,” he said. “But they told me and they told others that they would get the UNC network engaged to get us some local options. So it’s a step in the right direction. They did what they needed to do from a primary care standpoint.”

Snell said the initial lack of in county options during most of the open enrollment period for 2020 only added to what’s already a cumbersome and bureaucratic process.

“I have a person in my office doing the meetings on open enrollment, and things were taking three times as long as they usually do,” he said. “People are frustrated.”

Like Snell, Suggs said the addition of local doctors was a good thing, but she fears the problem could repeat itself year after year.

“We did have nothing, so it’s definitely better than it was,” she said. “The problem is, are you going to have to change your doctor every year when the plan changes again?”

That’s a fear Diesfeld, who eventually ended up purchasing BCBSNC individual plans for her husband and son on the marketplace before the local doctors were added, also shares.

“You feel comfortable with your doctor, and you have a rapport with him,” she said. “Then all the sudden, you have to go far away and see somebody you don’t know. We might still have the same problem a year from now.”

Still, Snell said people should look on the bright side, explaining that it’s uncommon for an insurance carrier like BCBSNC to move so quickly in response to consumer concerns.

“Their ambition is excellent, but I know a lot of people feel like they just weren’t fair to Lee County,” he said. “Still, they’ve made an effort to rapidly expand their network, and that’s not something carriers do very often.”

Statement from Central Carolina Hospital CEO Spencer Thomas

“Central Carolina Hospital (CCH) is committed to providing comprehensive, quality healthcare to serve the needs of our community. We believe that our community deserves to have access to affordable, quality care close to home.”

“CCH makes every effort to establish suitable contracts with our payors; however, despite our best efforts, we are not considered “in-network” with the Blue Cross Blue Shield health insurance exchange (HIX) plan for 2020. Blue Cross Blue Shield (BCBS) of North Carolina made a unilateral decision to eliminate CCH from the network without proactively engaging and notifying patients or providers of this significant change. We were not given advanced notice of this decision – and like the public – became aware that CCH would be ‘out-of-network’ with this plan in late October.”

“CCH continues to treat any and all patients in need of emergency care through our Emergency Department. Individuals covered by this BCBS plan who wish to receive non-emergency care at our hospital will have significantly reduced benefits and have to pay additional out-of-pocket costs for services. Specific questions about coverage and costs should be referred to the plan administrator BCBS. Though the open enrollment period is now closed, we recommend that patients, who may still have the option to enroll, sign up for the Ambetter (Centene) plan.”

“Individuals with BCBS insurance through their employer or those with Medicare Advantage plans will not be impacted.”

“We regret any inconvenience this causes our community members as we want everyone to have easy and affordable access to the healthcare provider of their choice.”

Blue Home with UNC Health Alliance providers

UNC Health Alliance is continually building its network, therefore there may be some lag time before they show up in the provider directory on our Find a Doctor tool. Here is the list of Blue Home with UNC Health Alliance providers in Lee County as of December:

• Mid Carolina Radiology Associates
• Carolina Womens Health Center, PA
• Firsthealth Convenient Care
• Firsthlth Convenient Care Lee Campus
• Central Carolina Sandhills Family Care
• Central Carolina Community Family Care
• Paul M. Heimbecker Md, PA
• Brick City Primary Care PLLC
• Surinder Dhawan, M.D.
• Mid Carolina Primary Care, PA
• Dr Alfred Sidney B. Bunao
• Sanford Pediatrics
• Firsthealth Primary Care
• Central Carolina Internal Medicine
• Doctors Vital Care & Screening PLLC
• Ajay K. Ajmani, M.D.
• Central Carolina Internal Medicine Assocs.
• Kinetic Institute Physical Therapy
• Performance Rehabilitation Corp.
• Central Carolina EMS
• Benjamin K. Merritt, M.D.
• Mohan C. Deochand, M.D.
• John S. Shin, M.D.
• First Feet PLLC
• Food Lion LLC
• Central Carolina Urology
• Laurie M. Conaty, L.C.S.W.
• Firsthealth Back & Neck Pain Center
• Elizabeth M. Martin, Ph.D.
• Sanford Nephrology Clinic, PA
• Firsthealth Cardio Pulmonary Rehab
• Laureen B. Thomas, L.C.S.W.
• Pine Ridge Urgent Care & Occupation
• Katie M. Thomas, L.C.S.W.
• Jacobs Counseling, Inc.
• Dymond Speech & Rehab, PA
• Janet A. Cheek
• Linda A. Smith, L.C.S.W.
• Julie A. Brown, L.P.C.