As the contract between Anthem and Northern Light is rapidly approaching expiration, it appears increasingly less likely that the two will be able to reach an agreement in time.
The current contract between the two organizations is set to expire on Tuesday, September 30, at which point services will begin to be phased out-of-network through the end of the year for certain groups of patients if an eleventh-hour agreement is not reached.
Over the past several months, the two companies have publicly traded strongly worded statements, each offering updates on the negotiation process from their own perspective.
While Northern Light has accused Anthem of undercutting them financially, the insurance provider intimated that the health care system’s demands would cause millions of dollars in cost increases for other Anthem members over the life of Northern Light’s proposed three-year agreement.
In their most recent set of updates, Northern Light indicated that Anthem has refused to “requests for contract language that protects Northern Light Health and the patients we serve,” but the insurance provider has accused the health care system of refusing to make adequate compromises.
After announcing in August that they were at an impasse, with neither side appearing willing to budge, things seemed to take a positive turn when both parties expressed an openness to continuing negotiations with a mediator as the deadline approached.
This progress, however, appeared to soon stall, with the parties once again sharing updates that indicated an inability to reach a suitable agreement with each other.
So what exactly will happen to Mainers receiving care through Northern Light who are insured by Anthem if the contract does elapse?
Changes will be rolled out gradually over the next few months, with all services being considered out-of-network for patients insured by Anthem, either commercially or through Medicare Advantage.
Although Northern Light patients insured by Anthem will not necessarily be forced to go elsewhere for care, any services rendered would be treated as out of network, meaning that out-of-pocket costs would likely rise.
Beginning on October 1, Northern Light Health physicians — including primary care providers and specialists — will be considered out-of-network for Mainers insured by Anthem commercial plans, including individual and employer-sponsored plans.
Inpatient care and other hospital-based services will continue to be considered in-network until December 31 for those with commercial plans.
This timeline will look a bit different for Medicare Advantage patients, as all Northern Light services would be considered out-of-network beginning on January 1, 2026. Until then, service will remain uninterrupted for these patients.
Medicare Advantage patients will have the ability to choose a new plan or return to original Medicare during the open enrollment period, which will be taking place between October 15 and December 7.
Those who have original Medicare and are enrolled in a Medicare Supplement Plan — also known as a Medigap Plan — through Anthem will not be impacted, as these types of plans do not have network requirements in Maine.
Anthem Pharmacy plans will also not be affected by these changes. It is also important to note that emergency care at Northern Light will continue to be covered despite these contracts lapsing.
Patients receiving care at Northern Light for certain ongoing conditions may be eligible to continue receiving in-network care through Anthem’s Continuity of Care benefits even if the health system goes out of network.
Examples of qualifying situations may include pregnancy, ongoing treatments for “serious or complex conditions,” recent or upcoming non-elective surgeries, and acute conditions “needing specialized medical intervention to prevent severe harm,” among other things.
A longer, but still not all-encompassing, list of circumstances has been shared by Northern Light on their website: https://northernlighthealth.org/Anthem.
Northern Light has encouraged patients who believe they may qualify for such an exception to call the phone number located on the back of their insurance card.
Final eligibility determinations for continuity of care extensions will be made by Anthem.
More information about what these changes may mean for you can be found on Northern Light‘s and Anthem‘s respective websites.
As of this article’s publication, neither Northern Light nor Anthem have officially announced if their contract has been allowed to lapse or if a deal was ultimately reached at the eleventh hour.
