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The following article appeared in various formats in the Helena Independent Record and the Billings Gazette.

Dispute centers upon definiton of 'good faith'

By ERICA CURLESS
IR State Bureau

Montana insurance companies are worried recent controversies over the state's new managed-care rules may block many Montanans from accessing affordable health coverage.

Chuck Butler, Blue Cross Blue Shield's vice president of government and public relations, said Montana hospitals are trying to prevent managed-care plans from offering competitive insurance coverage in many communities. And this blockage goes against the Managed Care Adequacy and Quality Control Act passed by the 1997 Legislature, Butler said.

"It was to make sure good managed-care plans were available to Montanans," Butler said, adding that won't happen if lawmakers make changes in the new rules recently adopted by the state Department of Public Health and Human Services.

An interim legislative committee voted last week to stall a provision that gives managed-care companies the ability to compete in communities that refuse to negotiate with health networks. It remains unclear what authority the Children, Families, Health and Human Services Committee will have when it reconsiders the rule at its Nov. 19 meeting.

At issue is the definition of a "good faith" effort. The rule, which would have taken effect Friday, allows the department to determine whether a health network has made a "good faith" effort to negotiate a contract with local providers, such as a hospital or pharmacy in a particular community. That means it's possible a managed-care company could still offer its plan to consumers even if no local providers are participating.

Some protesters argue there is no clear definition of "good faith" so it's impossible for the state to determine if a managed-care network has made an adequate effort. State Auditor Mark O'Keefe, who is also the state insurance commissioner, called the rule a loophole and said it may force Montanans to drive farther for health services or allow managed-care companies to reimburse patients for a smaller amount of their bill.

But Butler argued the rule isn't a loophole and removing it would result in a lock out -- preventing even more Montanans from accessing affordable health insurance. About 20 percent of Montanans are uninsured, one of the highest averages in the nation, he said.
Butler used the Montana Care network, which partners with Blue Cross Blue Shield of Montana, as an example. This company offers its insurance plan to people in Helena even though St. Peter's Hospital doesn't participate. But Montana Care members can still get treated at the hospital because the company has agreed to pay the bills.

Butler said this proves the company is offering adequate health coverage to its customers even without the hospital's participation.

If the legislative committee removes the "good faith" rule, Butler said Montana Care may not have the ability to continue serving Helena consumers because it has no contract with St. Peter's Hospital.

"Consumers of that community should not be frozen out," Butler said.

Denzel Davis, state Quality Assurance Division administrator, is working to clarify the "good faith" definition. He added that it's not automatic that the department would grant a waiver to a health care network that has negotiated with providers in good faith.

Davis said the rule states that the department "may" grant a waiver to a health network.
"It's not the case that a (Health Maintenance Organization) fails to negotiate a deal in 60 days so we have to grant the exemption," Davis said. "In some cases we may not be able to grant it because there is no adequate network."

But M. Susan Good, Allied Citizens for Healthcare Equity, said defining "good faith" isn't so easy. She said lawmakers intended the managed-care rules to protect consumers, not health networks.

"Good faith is like good art or good taste," Good said. "It's in the eye of the beholder."

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