fanny@wvgazette.com
The director of the state Public Employees Insurance Agency saidTuesday managed care doesn't work in rural areas, so starting July 1,PEIA will not offer managed care in 19 counties.
Tom Susman said Carelink has only 468 current policyholders out ofa total of 22,816 in the 19 counties.
Healthy people enrolled in Carelink and less healthy policyholdersopted for PEIA's indemnity insurance plan. 'They [Carelink] weren'tassuming enough of the risk,' Susman said.
That meant PEIA was paying more of the cost. For HMOs to work,Susman said, 'they have to pick up a greater share of the risk.'
The director said managed care works better in urban areas, and inthe Northern Panhandle, where the Health Plan of the Upper OhioValley as been in operation for many years.
'Managed care is a tough sale in rural West Virginia,' he said.
From the enrollee's side, if someone in the managed care plan losthis primary or family doctor and wanted back in the indemnity plan,Susman said, PEIA couldn't let him back until the year's enrollmentwas up. Only the primary doctor could refer a patient in managed careto another physician or a specialist.
'I'm sure there are some folks upset with us,' Susman said. Thedecision wasn't something that PEIA made 'nilly-willy,' he added.
In Logan County, for example, Susman said Carelink policyholderscould go to Logan General Hospital in an emergency situation, butthey couldn't make a follow-up visit to the hospital since it is nota Carelink provider.
Logan County had only 75 managed-care policyholders this year outof 1,841 residing in the county.
Additionally, Susman said, Carelink has jerked PEIA employeesaround with the benefits coverage.
Public employees in the 19 counties will have to join the PEIAindemnity plan, Susman said, but noted that appeals can be made tothe director.
'It's not PEIA's fault that managed care doesn't work in ruralareas,' he said.
In the PEIA 2004 plan year, Susman said, PEIA plans to offer anHMO look-alike as an option within PEIA.
'We've done that for non-state agencies,' he said, adding theagency is 'trying to build diversity.'
The PEIA look-alike will be an alternative to the PEIA indemnityplan.
Susman said North Carolina's state health agency did away withmanaged care options.
While Logan County has the highest number with managed care of the19 counties, Grant County doesn't currently have anyone in Carelinkout of 567 policyholders.
Nicholas County had the second highest number enrolled withCarelink, with 67 out of 1,332 policyholders in the county.
Pendleton County has only two Carelink policyholders out of 453 inthe county, Hardy County has three in Carelink out of 589, andHampshire County has four in managed care out of 1,050 policyholdersin the county.
Other counties affected and the number of policyholders were:
Braxton, 49 in managed care, 839 in the indemnity plan;Greenbrier, 48 in managed care, 1,951 in the indemnity plan;McDowell, 18 in managed care, 1,394 in the indemnity plan; Mercer, 12in managed care, 3,568 in the indemnity plan; Mingo, 7 in managedcare, 1,394 in the indemnity plan; Mineral, 11 in managed care, 1,302in the indemnity plan; Monroe, 18 in managed care, 624 in theindemnity plan; Pocahontas, 13 in managed care, 751 in the indemnityplan; Randolph, 36 in managed care, 1,911 in the indemnity plan;Summers, 33 in managed care, 938 in the indemnity plan; Tucker, 18 inmanaged care, 613 in the indemnity plan; Webster, 33 in managed care,545 in the indemnity plan; and Wyoming, 21 in managed care, 1,154 inthe indemnity plan.
To contact staff writer Fanny Seiler, use e-mail or call 348-5198.
