Anthem insurance contract dispute may imperil access to Mount Sinai Health System for some

About 90,000 New Yorkers with Anthem insurance plans, including more than 20,000 patients on Long Island, will no longer be covered in the Mount Sinai Health System starting Sunday, unless both sides can reach a deal before the March 1 deadline.

A contract between Anthem and Mount Sinai expired Jan. 1, leaving patients without access to more than 9,000 Mount Sinai doctors under the insurance plan. If an agreement is not reached by Sunday, Anthem inpatients would have only limited access to Mount Sinai hospitals. 

The contract included a 90-day continuity of care clause that allows some patients, including those being treated for more complex conditions such as cancer, access to their doctors, said Brent Estes, lead negotiator for Mount Sinai and senior vice president and chief managed care officer.

But that 90-day window runs out for most patients March 31, Mount Sinai and Anthem said. Patients must find in-network doctors if an agreement is not reached or pay out of pocket.

"We are still preparing for being out of network as of Sunday," Estes told Newsday, referring to Mount Sinai hospitals. "Our physicians have been out of network since Jan. 1, and we have been working aggressively for the last few months. We hope to reach an agreement by Sunday."

The contract dispute has left some Long Island Anthem policyholders with potentially much higher bills since Jan. 1 if they see a Mount Sinai doctor at an outpatient location, because the visit would be considered out-of-network. There are 17 Mount Sinai medical offices on Long Island.

As of Sunday, a hospital visit or stay at a Mount Sinai hospital — including Mount Sinai South Nassau in Oceanside — also would be considered out-of-network for Anthem policyholders, unless the two sides come to an agreement.

"If there is no agreement in place by March 1, patients with Anthem or other Blue Cross Blue Shield plans will be left with a much smaller, lower-quality, and more expensive network," Mount Sinai said on its website.

Among the issues being negotiated are resolving old accounts and $450 million in unpaid claims Mount Sinai has said it is owed by Anthem.

Anthem officials said Mount Sinai has been seeking price increases exceeding the rate of inflation, while Mount Sinai officials said they are seeking a rate comparable or lower to other regional health providers. 

"We are engaged in constructive, good-faith discussions with Mount Sinai to reach an agreement that keeps their doctors and hospitals in our network at affordable prices for patients and employers," Anthem said in a statement.

Patients undergoing treatment for serious, complex and terminal conditions and who have pre-scheduled nonelective surgeries, patients already hospitalized and pregnant women have been able to continue treatment at in-network costs for 90 days since the expiration of the contract, according to the state attorney general and Anthem. Women receiving postpartum care can continue in-network treatment beyond the 90 days.

Mount Sinai officials said among the patients affected are a Port Jefferson Station teen, Jizelle Andrade, who received a rare intestinal transplant a decade ago, followed by post-transplant lymphoma, which developed into a brain tumor.

Andrade, now 17, has undergone multiple surgeries, including removing a piece of her skull, and missed school for six years before returning to school, where she is in 10th grade at Comsewogue High School. In November, she developed a kidney disease.

Her family said access to her team of transplant doctors and specialists are vital to monitoring her care.

"It’s a little scary. She needs her doctors," her mother Tonicha Andrade said at her home Wednesday.

"Honestly I think families shouldn’t even have to think about this. They should come to an agreement and be fair to everybody," Andrade said.