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Louisville, Ky.-based Baptist Health has been out of network with UnitedHealthcare and Centene’s Wellcare Medicare Advantage plans since Jan. 1, citing insurers’ denials and delays in prior authorization requests and payments.
The same reasons were cited when Baptist Health went out of network with Humana’s Medicare Advantage and commercial health plans last fall.
Baptist said it has spent months working on a new contract with WellCare but has made little progress. According to the health system, the most important issues in discussions with Wellcare are protecting the patient/clinician relationship and preserving access to care.
While the annual enrollment period for Medicare Advantage ended Dec. 7, the health system said there is an additional change period that lasts until March 31 for people with individual MA plans. Patients can change to a different MA plan or switch to original Medicare (and enroll in a separate Medicare drug plan in the meantime) once.
What impact does it have
The change in network status affects all Baptist Health hospitals, outpatient clinics, home care and medical group practices, the health system said.
The system also noted that insurers are required by law to continue paying for treatment at in-network rates for patients with certain medical conditions through a program called the Continuum of Care. Situations that may qualify for continuum of care include pregnancy, chronic illness, and ongoing and active medical treatment, such as chemotherapy or dialysis or home health care services.
However, only Wellcare or UnitedHealthcare can determine whether a person is eligible – patients can find out by calling the number on the back of their insurance card.
Baptiste said it will continue to treat all emergency patients as well as plan-approved cases to ensure continuity of care coverage regardless of Medicare Advantage payer or plan type.
Without continuity of care benefits, a person’s ability to continue receiving Baptist Health will depend on the type of plan they have. Those with individual PPO plans can continue to access providers and services, but out-of-pocket costs may be higher. Those in a group PPO plan may have “mirror benefits,” although they can continue to access providers and services as if they were within the network.
If someone has an HMO plan, their out-of-pocket costs may be significantly higher due to plan type; Baptist said HMO plan members will not be scheduled to receive services on or after Jan. 1 and HMOs scheduled to receive services Patients will also be cancelled.
Business and Medicaid members are not affected by the change, Baptiste said.
An analysis of federal data by news station WDRB found that as of December, Humana, United Healthcare and WellCare collectively covered 271,328 people in counties across Kentucky and southern Indiana through their various MA plans.
Baptist posted a slight operating loss in the fiscal year ended Aug. 31, 2023, on revenue of $4.2 billion, according to WDRB. The system says going out of network on some MA plans is one of the strategies to improve its financial health.
Medicare Advantage is an alternative to traditional Medicare offered by private insurance companies. It often includes additional benefits such as prescription drug coverage, dental, vision and wellness plans, and often has a different cost-sharing structure than traditional Medicare.
Jeff Lagasse is the editor of Healthcare Financial News.
Email: [email protected]
Healthcare Financial News is a HIMSS media publication.