Blue Cross NC Contract With Carteret Health Care to End February 1, 2016

As you may already be aware, Carteret Health Care (formerly known as Carteret General Hospital) will be out of network for many Blue Cross and Blue Shield of North Carolina (Blue Cross NC) customers effective February 1, 2016. The organizations tried to negotiate a new contract but were unsuccessful.

As a result, our contract with Carteret Health Care’s hospital will end, which means the hospital will no longer be considered in network for commercial Blue Cross NC customers, including State Health Plan and Federal Employee Program members, as of February 1, 2016. Blue Medicare HMO^SM and Blue Medicare PPO^SM plans will not be affected.

We understand this termination will have an impact on participating provider practices and Blue Cross NC patients in the Morehead City area, especially if you only have admitting privileges at Carteret Health Care. Our members in the Carteret County area will receive a letter from us to explain the situation in early November, and we want to share key messages with you as well:

• Carteret Health Care will continue to be an in-network hospital in Blue Cross NC’s commercial networks until 11:59 p.m. January 31, 2016. Nothing has to change for our customers until February 1, 2016. Members covered by our Blue Medicare HMO or Blue Medicare PPO plans will not be affected.
• After this date, in-network hospital benefits at Carteret Health Care will be available only for emergency care, for care not reasonably available at other area hospitals, or for specific situations approved for eligible members requesting continuity of care from Blue Cross NC.
• We will honor any authorizations made before February 1, 2016, for approved, in-network services at Carteret Health Care.
• Any other referrals to Carteret Health Care for services on or after February 1, 2016, will result in related hospital charges being subject to the member’s out-of-network benefit level (if member’s plan includes out-of-network benefits). In order to protect the financial interests of your Blue Cross NC patients, as well as to comply with your Blue Cross NC contractual obligation to refer to in-network providers, you should:
  • Refer to or provide services at Carteret Health Care only for care not reasonably available at other hospitals.
  • When your Blue Cross NC patients request you to refer them to Carteret Health Care, you should document evidence to show you offered an in-network choice, the patient chose to go to an out-of-network facility, and the patient understood the additional out-of-pocket costs they will incur by going out of network.
• Carteret Medical Group physician services will remain in network. However, any referred services at Carteret Health Care on or after the termination date will be covered at the member’s out-of-network benefit level (if member’s plan includes out-of-network benefits).
• We have in-network commercial contracts in place with all other hospitals in the surrounding counties.

Continuity of Care Guidelines

It is the policy of Blue Cross NC to provide continuity of care at the in-network benefit level to members who qualify for special ongoing conditions. For members to be eligible, one of the following conditions must apply:

• The member is in her second or third trimester of pregnancy or completing postpartum care. For members in their second or third trimester of pregnancy, the continuity of care period may last through the postpartum period.
• The member has an acute illness, which is a condition serious enough to require medical care or treatment to avoid a reasonable possibility of death or permanent harm. For members who have an acute illness or condition as described in this policy, the continuity of care period may extend up to 90 days.
• The member has a chronic illness or condition, which is a disease or condition that is life-threatening, degenerative, or disabling, and requires medical care or treatment over a prolonged period of time. For members who have a chronic illness or condition as described in this policy, the continuity of care period may extend up to 90 days.
• The member is terminally ill, which means the medical prognosis is that the individual's life expectancy is six months or less. For members who are terminally ill, continuity of care shall be in place for the remainder of the member’s life.
• Continuity of care is only granted for 90 days or the end of the course of active treatment, whichever is less, unless noted above in the conditions.

If any of these ongoing special conditions apply to your Blue Cross NC patients, and they have procedures scheduled at Carteret Health Care on or after February 1, 2016, please direct them to call Blue Cross NC Customer Service to request a “Continuity of Care” form. After the patient completes and returns the request form to Blue Cross NC, it will be reviewed by a nurse, and the patient will be contacted regarding their specific situation. Please note this is not a guarantee of coverage at in-network rates.

If you have any questions about our continuity of care guidelines, please contact the Provider Blue Line^SM at 1.800.214.4844. For more information about the situation with Carteret Health Care, please visit us online at www.bluecrossnc.com/carteret.