New Hampshire’s ‘Multistate’ Insurance Plans Sow Confusion

Elaine Shamos, the former director of the Dartmouth-Hitchcock Women's Resource Center in Lebanon, N.H., pictured on July 22, 2014, is taking on the providers of the insurance policy she bought on the Health Insurance Marketplace. (Valley News - Ariana van den Akker)

Elaine Shamos, the former director of the Dartmouth-Hitchcock Women's Resource Center in Lebanon, N.H., pictured on July 22, 2014, is taking on the providers of the insurance policy she bought on the Health Insurance Marketplace. (Valley News - Ariana van den Akker) Purchase photo reprints »

Hanover — As consumer alerts go, the New Hampshire Insurance Department’s July 17 “clarification on ‘multistate’ plans” was a bit dry.

The alert concerned a pair of so-called multistate insurance plans sold on the federally operated Health Insurance Marketplace. It was issued after a consumer had complained that she was paying premiums for a policy that didn’t cover out-of-state medical care as she had been promised.

The unhappy consumer was a Hanover retiree named Elaine Shamos. Anthem Blue Cross Blue Shield had refused to cover, and apply against her $1,500 deductible, several hundred dollars of physical therapy costs incurred during an extended stay in Maine, where she was caring for her mother.

Shamos had been mistaken to think that a multistate plan would provide that coverage. As the regulators noted: “The term ‘multistate,’ as used here, does not imply that residents may access non-emergency health care coverage beyond New Hampshire.”

Shamos knows she can’t re-create the unrecorded telephone conversations or retrieve the discarded brochures that might document how she came to expect her multistate plan to offer her care in multiple states. But despite the lack of evidence to make a case against those she believes gave her confusing or misleading advice, Shamos has doggedly continued knocking on doors and arguing that more needs to be done to clear up the confusion about multistate plans.

“I’ve always been a consumer advocate,” she said.

Shamos’ experiences illustrate the perils and confusions that may lie in wait as New Hampshire residents shop for coverage through the insurance marketplace. They also serve as a reminder that if a New Hampshire resident faces the question of how to pay for non-emergency medical care while living, studying or traveling out of state, a multistate plan is not necessarily the answer.

In addition, Shamos’ plight highlights differences in the insurance choices available to consumers using the Twin States’ respective insurance exchanges. Vermont residents who want policies that cover routine care in other states can find it on Health Connect, the state-run marketplace, said spokeswoman Emily Yahr.

Health Connect policies sold by Vermont Blue Cross Blue Shield offer access to the full Blue Cross and Blue Shield network in Vermont and across the country, said spokesman Kevin Goddard.

But in 2014, all of the policies — multistate or otherwise — sold to New Hampshire residents through the insurance marketplace came from Anthem, the state’s largest health insurer. The Anthem policies covered care from providers included in its newly created Pathway network. That network includes only New Hampshire providers and the Lahey Clinic in Burlington, Mass., according to Chris Dugan, an Anthem spokesman.

Pathway is a “very narrow network,” said Danielle Barrick, communications director for the New Hampshire Insurance Department. And that doomed to failure any New Hampshire resident’s search for a marketplace policy that covered care in other states: “Because of Anthem’s Pathway network … a consumer couldn’t have found a policy with non-emergency care in other states.”

Consumers could have shopped outside the marketplace for individual policies offering such coverage, she noted. But consumers with low incomes that made them eligible for premium subsidies in the form of tax credits would have forfeited those subsidies on policies bought outside the marketplace, Barrick said.

Federal law requires hospitals to provide emergency care without regard to a patient’s ability to pay. The Affordable Care Act prohibits insurers from offering new policies that impose higher copayments or charges when consumers get emergency care from an out-of-network hospital.

No Health Care Novice

But in late 2013, as Shamos prepared for a year with extended caregiving stays in southern Maine and travel to northern California, she wanted to be able to be covered for some routine medical care in those areas. She began searching on the Health Insurance Marketplace for a policy that would cover physical therapy and other services from providers there.

Shamos, 59, was no novice when it came to navigating the complexities of the health care system. She has a master’s degree in public health. Until she took up Dartmouth-Hitchcock’s 2010 offer of early retirement, Shamos ran its Women’s Health Resource Center in Lebanon, where she wrote a consumer newsletter and, she said, “my whole job was to make hard-to-understand health information understandable.”

After she retired, Shamos continued to be covered by Dartmouth-Hitchcock’s group policy for employees. That policy routinely covered Shamos’ health care, including out-of-network care from Alice Peck Day Memorial Hospital and other providers.

But after three years, Shamos’ entitlement to pay the same premiums as employees was about to expire. That threatened to boost the monthly premium on her existing policy from about $350 to $800.

With a premium increase looming, Shamos began shopping for a new policy through the Health Insurance Marketplace operated by the federal Centers for Medicare and Medicaid Services. New Hampshire residents shop in the marketplace because the state decided not to set up its own exchange.

Shamos was a hard-working shopper. She logged on to the marketplace web site. After her computer froze, she called the marketplace help line. She also called navigators working for Covering New Hampshire, the state-affiliated help line for insurance shoppers.

What Shamos learned, she said, is that a multistate plan would cover routine medical care in Maine or California or other locations far from New Hampshire.

Shamos said she repeatedly asked whether the multistate plan she was considering — something called an Anthem Blue Cross Blue Shield Silver Direct Access policy — would cover services from out-of-state providers who were part of various Blue Cross Blue Shield networks. Each time, she said, she was assured it would. “If you’re traveling, then multistate’s the right plan for you,” she recalled being told.

When she finished shopping, Shamos seemed a satisfied customer. She had found a policy with a $550 premium. And after applying the subsidies to which she was entitled due to her low retirement income, she would have to pay only $135 a month. It was identified as a multistate plan and, said Shamos, “It looked great.”

The Meaning of ‘Multistate’

Multistate plans were little-noticed products of the prolonged and highly politicized orgy of sausage-making that produced the 2010 Affordable Care Act, widely known as Obamacare. They were created as federally approved alternatives to the state-approved insurance plans sold on the insurance exchanges created by the ACA.

For a period during the debate prior to passage of the new health care law, some reform advocates supported a so-called “public option” — a government-run insurance program that consumers could choose instead of policies underwritten by private insurance companies. A low-cost, government-run public option would provide healthy competition to private offerings, supporters said.

But eventually it became clear that the public option had no chance of making it into whatever legislation might pass. Instead, the law that passed contained less controversial provisions “to increase competition and choice in local” markets, including the multistate plans, according to Timothy Jostt, a law professor at Washington and Lee University in Lexington, Va., and a blogger for Healt h Affairs magazine.

Details of what defines a multistate plan seem designed to numb the mind of anyone but a wonkish health care industry insider or advocate. Essentially, multistate plans are policies reviewed and authorized for sale by the federal government. With that authorization, an insurance company can sell that plan in any state in which it is already licensed to operate.

In a July 17 news release, New Hampshire Insurance Commissioner Roger Sevigny described what a multistate plan was not. “A resident who purchases a health insurance plan labeled ‘multistate’ through should understand that the term does not refer to coverage in other states but rather to the contractual arrangement between the U.S. Office of Personnel Management … and a health insurance company that offers a plan or plans in more than one state.”

Got that?

Nationwide, about 300,000 consumers have signed up for one of the more than 150 multistate plans offered in 30 states and the District of Columbia. All come from insurance companies that are members of the Blue Cross Blue Shield Association.

One such member is Anthem Blue Cross Blue Shield, which is owned by WellPoint Inc., an Indianapolis-based company with annual revenue of $71 billion. WellPoint owns the Blue Cross licensees in 13 states in addition to New Hampshire.

A spokesman for the federal Office of Personnel Management said the agency had not tallied the number of consumers covered by multistate plans in each state. However, Barrick, of the New Hampshire Insurance Department, said the feds had told state regulators that 7,769 New Hampshire consumers chose a multistate plan. Dugan, the Anthem spokesman, said the company generally doesn’t disclose plan membership figures, but its multistate plan membership numbers were “considerably lower” than the figure cited by Barrick.

Shamos’ multistate plan coverage took effect on Jan. 1, 2014, according to a timeline compiled by Anthem. In March, when shoulder pain prompted her to seek treatment, a physical therapist in Portland, Maine, readily accepted her Anthem card. Shamos assumed that the cost of the care she received would be applied toward the $1,500 deductible in her policy.

But when Shamos received an explanation of benefits following her physical therapy, she found that Anthem had rejected the claim filed by her caregiver. “You are only covered with in-network people in New Hampshire,” she said she was told when she called Anthem’s customer service center.

While Shamos misunderstood the nature of a multistate plan, she was in good company in viewing multistate plans as a way to get coverage in more than one state. “That, I think, was one of the thoughts behind the multistate plans,” Jostt said.

In an Oct. 1 blog post, Jostt wrote that multistate plans might “solve the problems of some Americans, however, who have family members in states other than their exchange home state, or who reside in several states over the course of the year.”

In April 2012, two members of the faculty at George Washington University in Washington, D.C., wrote that a multistate plan “could offer continuity of coverage and assure a family that all its members could be covered in one plan, regardless of their state of residence.”

And while the plan that Shamos signed up for offered care only from a network of providers in New Hampshire, it seems plausible that not all of the advisers and navigators she turned to for guidance had gotten that memo. Said Jostt: “There was unfortunately a lot of misinformation that people got at various times from various people” including navigators, call center operators and insurance brokers.

Rattling the Chains Of Command

Without the insurance coverage she had been counting on, Shamos went into action. She called her way up and down the chains of command at Anthem and the New Hampshire Insurance Department and got through to representatives of two federal agencies — the Office of Personnel Management, which authorized Anthem to sell the multistate plan, and the Centers for Medicare and Medicaid Services, which operated the Health Insurance Marketplace where Shamos bought it.

When Shamos’ dialing finger tired, she wrote up a formal complaint against “NH Anthem Blue Cross Blue Shield and state of NH” and on June 12 sent it to state insurance regulators.

Anthem won’t say much about Shamos’ complaints. “We are aware of the grievance filed by Ms. Shamos with the NHID and have filed our responses as required,” Dugan said in an email.

But Anthem has acknowledged that on at least two occasions Shamos got misinformation from company service representatives. In a July 9 letter to New Hampshire regulators, Anthem grievance and appeals analyst Lisa Stavropoulos said Shamos was told on March 21 that she did not have vision benefits when she did. In addition, according to Stavropoulos, on June 12, when Shamos asked for the name of an in-network internal medicine doctor near Santa Rosa, Calif., an Anthem representative “incorrectly provided the name of a provider to Ms. Shamos … in Santa Rosa, California, and indicated that the provider was in network.”

Asked to comment on Stavropoulos’ letter, Dugan responded with an email: “We recognize that navigating the ACA can be confusing at times and we continue to work with our members and their families on a daily basis to inform and educate them on the law and how it impacts them,” he wrote. “At the same time, we continue to provide ongoing education and training to our customer service representatives to ensure that we provide clear and accurate information to those we serve.”

Barrick said that, in addition to Shamos’ complaint, the Insurance Department had received “one inquiry from an insurance broker on behalf of a consumer who had purchased a multistate plan and was switching to another plan.” And, Barrick said, even prior to the receipt of Shamos’ complaint, the department had had “some internal discussion of the potential for confusion about multistate plans.” In preparation for the upcoming open enrollment period that begins Nov. 15, New Hampshire regulators had begun talking with representatives of the federal Office of Personnel Management and marketplace operators about ways to eliminate consumer confusion about the use of the term “multistate,” Barrick added.

Shamos said she thinks it likely that other consumers misunderstood the nature of a multistate plan in the same way she did. So she still wants Anthem to notify its multistate policyholders, reimburse them for costs incurred when they thought they were covered for out-of-state services, and make sure its customer services representatives understand the policies’ limits.

For her part, Shamos said Anthem has shifted her out of her multistate plan and into another plan offered through the marketplace, although she is still awaiting arrival of her new card. And she still supports the need for reform of the health insurance system, and is sympathetic to the Obama administration’s efforts to deliver change through the Affordable Care Act.

Within the context of those broader goals, it might be argued that the woes of a single consumer who ended up without the coverage she needed (and thought she had) might be offset by the benefits from enhancing market competition — what experts view as the underlying rationale for creating multistate plans.

Except in this case, according to state regulators, it hasn’t. Said Barrick, the state Insurance Department spokeswoman, “Because they are offered by the same carrier and use the same network as Anthem’s other marketplace plans, the multistate plans have not had an impact on the state’s insurance market.”

Shamos had mixed feelings about her encounter with a multistate plan. If she had realized that the only options available to her through the marketplace covered care only from local providers, she said, “I could have taken the risk of not getting any health insurance.” But, she added, to the extent that her efforts have helped make a portion of the health insurance more transparent, “this experience has been a positive one.”

Rick Jurgens can be reached at or 603-727-3229.