Bert Krion, 95, and his wife Barbara faced a difficult choice in January. This year, a couple from upstate New York learned they could continue with either their private Medicare Advantage insurance plan or their doctors at Saratoga Hospital.
The Albany Medical Center system, which includes their hospital, will be withdrawn from Clione’s Humana plan — or vice versa, depending on which side is talking. The breakup threatened to cut off the couple’s lifeline to deal with a serious chronic health condition.
Krion refused to choose the lesser of two bad options without a fight.
He contacted Humana, Saratoga Hospital and the health system. The couple’s physicians were “an extraordinary group of caregivers who have enabled us to live active and productive lives,” he said in a letter to the hospital’s CEO. He called his wife’s former employer. This employer requires retirees to enroll in a Humana Medicare Advantage plan to receive company health insurance. he also New York Statewide Senior Action CouncilOne of the nation’s state health insurance subsidy programs Providing free and impartial advice about Medicare.
Kryon said they all said the same thing. “Please continue with your doctor or insurance.”
andrare exceptionAdvantage members are locked into their plan for the rest of the year, but their provider can opt out at any time.
When a dispute arises between an insurance company and a healthcare provider, an entire hospital system can suddenly go off plan. Insurers must follow extensive regulations from the Centers for Medicare and Medicaid Services, including little-known protections for beneficiaries if a doctor or hospital leaves the network. But the news of their breakup may come as a surprise.
According to CMS, in the nearly 30 years since Congress created a private-sector program to replace the original government-run Medicare, the plan has provided a record 52% of the 66 million people who are elderly or disabled with Medicare. He has joined the.But at the same time as getting additional benefits Although it’s not offered in original Medicare, Advantage beneficiaries have found a drawback. One common complaint is the requirement to receive care only from a designated network of providers.
Many hospitals are also becoming disillusioned with the program.
“Every day, we hear from hospitals and health systems across the country about the challenges they are experiencing with their Medicare Advantage plans,” said Scott, senior associate director of health insurance and insurance policy at the American Hospital Association, which represents approximately 5,000 hospitals. Michelle Millerik says. . Hurdles include prior authorization limitations, late or low payments, and “improper denial of medically necessary covered services,” she said.
“Some of these issues reach a boiling point and a decision is made not to participate in the network,” she said.
escape hatch
CMS provides most Advantage members with two opportunities to change their plan: during the fall annual general enrollment period and from January through March 31st.
But a few years ago, CMS expanded and created an escape hatch. Special enrollment period, or SEP. “Exceptional circumstances” are permitted. Eligible beneficiaries can request SEP to change plans or return to Original Medicare.
According to CMS regulations, there is a SEP that patients can use if they have trouble getting or continuing treatment and their health is at risk. This could include situations in which a health care provider leaves a plan’s network, said David Lipshutz, an associate director at the agency. Medicare Advocacy Center.
Beneficiaries who experience “material” changes to their networks will have access to another SEP, but CMS officials declined to explain what constitutes material. However, in 2014, CMS provided this SEP It was offered to UnitedHealthcare Advantage members after the insurer ended contracts with providers in 10 states.
Meena Seshamani, CMS deputy administrator and director of the Federal Center for Medicare, said in a statement that CMS will ensure that plans maintain “adequate access to needed services” even when a provider retires. Ta.
Hospitals say insurance companies are locking them out, but insurers blame hospitals for the Medicare Advantage Network disruption.
“Hospitals are using their dominant market position to demand unprecedented double-digit rate hikes and threaten to terminate contracts if insurers don’t agree.” said Ashley Buck, a spokeswoman for Regence Blue Shield, which offers the Advantage plan. ,State of Washington.
The patient is caught in the middle.
“It feels like the powers that be are playing a game of chicken,” said Mary Kay Taylor, 69, who lives near Tacoma, Washington. Regence Blue Shield has been in a dispute for weeks with MultiCare, one of the state’s largest health systems and where she receives treatment.
“For those of us who need this kind of care and coverage, it really doesn’t matter,” she says. “We are left at a loss and in uncertainty.”
Other dissolutions this year include Baton Rouge General Hospital in Louisiana leaving Aetna’s Medicare Advantage plan and Baptist Health in Kentucky leaving UnitedHealthcare and WellCare Advantage plans. In San Diego, Scripps Health has left nearly all Advantage plans in the area.
In North Carolina, UNC Health and UnitedHealthcare renewed their contracts just three days before their contracts expired and just two days before the deadline for Advantage members to switch plans.And in New York City, Etna I told Advantage members This year, the company is preparing to lose access to 18 hospitals and other care facilities in the NewYork-Presbyterian Weill Cornell Medical Center health system before a deal was reached last week.
limited choices
Taylor didn’t want to lose his doctor or his Regence Advantage plan. Although she is recovering from surgery, she said it was “really scary” waiting to see how the drama would end.
So last month, she enrolled in another plan with the help of Tim Smolen, director of Washington State’s SHIP (Statewide Health Insurance Benefits Advisor Program). Shortly thereafter, Regence and Multicare agreed to a new agreement. However, Taylor is only allowed one change until March 31 and will not be able to return to the Regence this year, Smolen said.
Finding a backup plan can be like winning at bingo. Some patients will see multiple doctors, all of whom should be easy to contact and covered by the new plan. To avoid high out-of-network bills, you need to find a plan that also covers prescription drugs and includes your preferred pharmacy.
“A lot of times, they go through the provider network and find out that this is OK, but then they end up with drugs,” said Kelly Jo Greiner, state director of Minnesota SHIP, LinkAge Senior Line. Stated. Since Jan. 1, counselors there have helped more than 900 people switch to new Advantage plans after Health Partners, a large Bloomington-based health system, left Humana’s Medicare Advantage plans. .
Options are even more limited for low-income beneficiaries who receive drug subsidies or monthly premiums. Only some plans are acceptedsaid Greiner.
For about 6 million peopleformer employer Choose a Medicare Advantage Plan Participation is required in order to receive retiree medical benefits. If a beneficiary wishes to remain with a provider who leaves the plan, that beneficiary must often be stripped of all employer-subsidized health benefits, including coverage for family members.
Fear of losing provider coverage is one reason some New York City retirees sued Mayor Eric Adams to halt an effort to force 250,000 people to enroll in Aetna Advantage plans. That’s because New York City President Marianne Pizzitola said. Civil servant retirement organization, filed a lawsuit. The retiree has been elected three times, and city officials are appealing again.
CMS requires Advantage plans to notify members 45 days before an attending physician leaves the plan and 30 days before a specialist leaves the plan. But counselors who advise Medicare beneficiaries say this notice doesn’t always work.
“A lot of people are experiencing interruptions in care,” said Sophie Exdell, San Diego program manager for California’s SHIP (Health Insurance Counseling and Advocacy Program). She said about 32,000 people in San Diego lost access to Scripps Health providers when the system eliminated most of its Regional Advantage plans. Many people either didn’t receive the notification, or even if they did, they “didn’t have the ability to reach out to someone to get help making the change,” she said.
CMS also requires plans to comply with network adequacy rules that limit the distance and time members must travel to primary care physicians, specialists, hospitals, and other providers. The Agency will check compliance every three years, or more frequently if necessary.
In the end, Bart Krion said he and his wife had no choice but to stick with Humana because they couldn’t afford to give up their retiree health benefits. This year, I was able to find a doctor who was willing to accept new patients.
But he wonders, “What will happen in 2025?”
KFF Health News is a national newsroom that produces in-depth journalism on health issues and is one of KFF’s core operating programs and an independent source of health policy research, polling and journalism.Click here for details KFF.
