HMO plans to expand into North Bay

NORTH BAY -- Sacramento-based HMO Western Health Advantage has filed for an expansion into Marin and Sonoma counties, where it hopes to partner with the Marin-Sonoma IPA and much of the region's hospitals in offering a new health plan for employers and individuals.

In June, the health maintenance organization filed plans with the state Department of Managed Health Care, which must approve of any move into new territory for any commercial health plan. Currently, Western Health Advantage operates in Solano, Yolo, Sacramento, Placer and El Dorado counties and serves some 92,000 members.

If approved, Western Health Advantage could represent the most significant commercial health plan to enter the region since the bankruptcy of Health Plan of the Redwoods in 2002, which created a void that was filled quickly by Kaiser Permanente. Kaiser's San Rafael Medical Center, which includes Petaluma, has 120,258 insured members, while it's Santa Rosa Medical Center has 141,338 members. The next largest HMOs serving the North Bay are Blue Shield with 15,000 members, Health Net with 12,000 and United Healthcare with about 4,200.

It's not yet clear when Western Health Advantage will receive final approval, but Rick Heron, a spokesman for the HMO, said he expected it to be soon. Details of how the new plan would work are still being ironed out, and Mr. Heron said he could not comment on specifics while final negotiations take place with potential providers.

"We have filed to potentially move and expand our geographic area to include Marin and Sonoma," Mr. Heron said. "We are still at a point of negotiations and cannot confirm anything beyond anticipation of an expansion."  

The HMO must demonstrate a "network of adequacy -- i.e., do they have enough providers in their network for the expanded service area to meet requirements of the law," said Marta Bortner Green of the Department of Managed Health Care.

According to the state filing, Western Health Advantage hopes to begin enrolling members in January 2013. It also intends to contract with the following hospitals: Marin General, Sonoma Valley, Palm Drive, Healdsburg District and Petaluma Valley and Santa Rosa Memorial, which are operated by St. Joseph Health.

The plan includes tertiary agreements to include UCSF Medical Center for transplant and neo-natal intensive care patients, as well as for specialized care that would be out of network. UC Davis Medical Center would be the in-network option. Santa Rosa Memorial would be the in-network trauma hospital.

The plan calls for having 93 primary care physicians across Marin and Sonoma counties, and the nearly 600-member Marin-Sonoma IPA would be the sole provider of both primary care and specialty physicians, according to the filing, which was obtained by the Business Journal through a public records request.  The filing also says that nearly 400 physicians practicing a wide range of specialties are on a list of contracting physicians. Western Health also notes that the Marin-Sonoma IPA "continues to recruit new physicians, which will result in even greater access."

Additionally, Western Health Advantage will include behavioral health services, chiropractic and acupuncture, and optional eye and dental services through "plan-to-plan" contracts.

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