Insurance plans’ in-network rates for medical care are generally more affordable than out-of-network rates. Patients pay less out-of-pocket for services they get from a provider that’s considered in-network.
In recent months, Baptist has cited concerns about various Medicare Advantage plans routinely denying or delaying approvals of or payments for medical services recommended by patients’ doctors. And the health system said it has been trying to negotiate new contracts with several insurers.
Talks with Humana earlier this year did not result in a new contract, so Baptist Health Medical Group — which includes over 1,100 clinicians in Kentucky and Southern Indiana — went out-of-network with the insurers Medicare Advantage and commercial health plans in September.
This week, Baptist confirmed negotiations with two other insurers — UnitedHealthcare and Wellcare — also have not resulted in new agreements.
That means Baptist hospitals, outpatient clinics, home care and Baptist Health Medical Group practices all will be out-of-network with Medicare Advantage plans from UnitedHealthcare and Wellcare starting Jan. 1.
“We are notifying affected patients so they can consider their out-of-network benefits, choose a different health plan or make other arrangements for care,” Baptist spokesperson Kit Fullenlove Barry told LPM News in a statement.
“It remains our top priority to secure agreements with Medicare Advantage plans that protect our patients’ access to the medical care they need and allow medical care decisions to be made by the patient and their doctor, not an insurance company.”
UnitedHealthcare told LPM it still hopes to reach an agreement with Baptist.
“Our top priority is to renew our relationship with Baptist Health and ensure continued access to the health system for people enrolled in our Medicare Advantage plans,” the company said in a statement. “We are committed to continued good-faith negotiation and using the remaining time on our contract to reach a new agreement.”
Wellcare did not respond to a request for comment.
In letters to patients this week, Baptist said people may be affected differently depending on the specific Medicare Advantage plan they have through UnitedHealthcare or Wellcare.
For example, someone with an individual PPO plan may face higher out-of-pocket expenses if they stick with Baptist providers. But a patient with a group PPO plan may still be able to access Baptist services at in-network rates.
A person with an HMO plan could face “significantly higher” out-of-pocket costs starting next year, Baptist said in a letter to patients obtained by LPM.
“Baptist Health cannot, in good conscience, schedule HMO plan members for services on or after January 1, 2024, and HMO plan patients already scheduled for services on or after January 1 will be cancelled,” Baptist wrote, although it noted there are a couple of exceptions to that rule.
One such exception would be if a patient applies for “continuity of care” benefits. Through continuity of care, eligible patients’ Medicare Advantage plan temporarily would have to keep covering their care at Baptist with in-network rates.
Someone may qualify under a variety of circumstances, such as if they’re pregnant or are receiving chemotherapy or dialysis. People can call their insurer to find out if this is an option for them.
Other options for patients with affected Medicare Advantage plans
There are alternatives for people who see Baptist medical providers but will no longer be considered in-network through their Medicare Advantage plans next year.
One option is for affected patients to find new medical providers that are still considered in-network with their Medicare Advantage plan.
Another alternative is for them to change their insurance plan. They could choose a different Medicare Advantage plan under which Baptist will remain an in-network provider, or they could switch to Original Medicare.
Medicare is a public health insurance program that’s mainly provided to patients who are at least 65 years old. Original Medicare is managed by the U.S. government, but the privatized Medicare Advantage option has become increasingly popular.
“A Medicare Advantage plan is a private insurance company that is managing your Medicare benefits, essentially,” said Melanie Garland, who works for the Indiana State Health Insurance Assistance Program as the volunteer supervisor for the Southwest region. “They have to provide the same benefits that Medicare does, but they are managing them.”
“So that means … you have to make sure that your providers are in-network. And then also, instead of Medicare approving or denying your [medical] services, the Medicare Advantage plan is now approving or denying those services.”
With Original Medicare, Garland said patients won’t run into the in-network versus out-of-network issue. But there is no maximum limit on how much a patient may have to pay out-of-pocket each year.
Cost concerns are a key reason why many people choose a Medicare Advantage plan instead of Original Medicare.
Patients could get additional benefits or lower out-of-pocket expenses by choosing Medicare Advantage. However, a 2022 federal inspector general report said audits “have highlighted widespread and persistent problems related to inappropriate denials of services and payment” by Medicare Advantage plans.
An open enrollment period for Medicare is happening now and runs through Dec. 7, Garland said. Even if a patient already registered their choices during the current open enrollment period, they can make new changes until Dec. 7 and those will take effect instead.
There also is a second open enrollment period for people with Medicare Advantage plans that runs from Jan. 1 through March 31. Patients could switch to a different Medicare Advantage plan or choose the Original Medicare option during that three-month period as well.
“They don't have to jump ship right away,” Garland said. “They can kind of see what happens in January. … They don't have to make a decision in a week.”
People can review their Medicare choices by:
- Visiting medicare.gov, where people can search for available plans based on their zip code and other criteria.
- Calling 1-800-MEDICARE for guidance from a representative with the federal Medicare operation.
- Contact the Indiana SHIP or Kentucky SHIP offices, which offer free assistance with reviewing Medicare enrollment options.
