Baptist Health abandoning Medicare Advantage plans from UnitedHealthcare, Centene
The health system cited denials and delayed prior authorization requests in making the move, as well as its financial position.
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Since January 1, Baptist Health, based in Louisville, Kentucky, has been out-of-network with UnitedHealthcare and Centene's Wellcare Medicare Advantage plans, citing denied and delayed prior authorization requests and payments from the insurers.
It was the same reason cited by Baptist Health when it went out-of-network with Humana's Medicare Advantage and commercial health plans last fall.
Baptist said it had been working for several months to secure a new contract with WellCare, but made little progress. The most important issue in the discussions with Wellcare, according to the health system, was to protect the patient/clinician relationship and preserve care access.
While the Annual Enrollment Period for Medicare Advantage ended on December 7, the health system said that for people with individual MA plans, there's an additional change period that lasts until March 31. Patients can change to a different MA plan or switch to original Medicare (and join a separate Medicare drug plan) once during that time.
WHAT'S THE IMPACT?
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 pointed out that insurance companies are required by law to continue paying for treatment at in-network rates for patients with certain medical conditions through a program called "Continuity of Care." Examples of situations that may qualify for Continuity of Care include pregnancy, chronic medical conditions, and ongoing and active medical treatment, such as chemotherapy, dialysis or home healthcare services.
However, only Wellcare or UnitedHealthcare can determine if a person qualifies – which a patient can find out by calling the number on the back of their insurance card.
Baptist said it would continue to treat all emergency patients – and plan-approved cases for continuity of care coverage – regardless of Medicare Advantage payer or plan type.
Without continuity of care benefits, a person's ability to continue to access Baptist Health would depend on the type of plan they have. Those with individual PPO plans can continue to access providers and services, though there may be higher out-of-pocket costs. Those in group PPO plans likely have "mirror benefits," though which they can continue to access providers and services as if they were in-network.
If someone has an HMO plan, their out-of-pocket costs could be significantly higher because of the plan type; Baptist said it would not schedule HMO plan members for services on or after January 1, and HMO patients scheduled for services will be canceled.
Commercial and Medicaid plan members are not affected by the change, said Baptist.
THE LARGER TREND
In an analysis of federal data, news station WDRB found that as of December, Humana, United Healthcare and WellCare collectively covered 271,328 people in Kentucky and southern Indiana counties through their various MA plans.
Baptist posted a slight operating loss on $4.2 billion in revenue during the fiscal year ending August 31, 2023, according to WDRB. The system said going out-of-network on certain MA plans was among the strategies being employed to improve its finances.
Medicare Advantage is an alternative to traditional Medicare offered by private insurance companies. It typically includes additional benefits such as prescription drug coverage, dental, vision and wellness programs, often with different cost-sharing structures compared to traditional Medicare.
Jeff Lagasse is editor of Healthcare Finance News.
Email: jlagasse@himss.org
Healthcare Finance News is a HIMSS Media publication.
