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By Deborah Yetter

Kentucky Lantern

A stalemate between one of Kentucky’s largest health care providers and three major health insurers is affecting thousands of Kentucky retirees enrolled in Medicare Advantage plans.

Baptist Health last fall ended its contract agreement with Humana for physician services covered by Medicare Advantage, the Kentucky Lantern reported in October. That means doctors’ visits are considered “out of network” and patients would have to pay more for services.

And effective Jan. 1, Baptist also ended agreements with United HealthCare and Wellcare for Medicare Advantage coverage for services including physician and hospital care — meaning all such care is considered out of network.

Baptist has cited denials of care and delays in payment which the Medicare Advantage companies dispute.

The changes affect around 102,000 retired public employees enrolled in such plans in which a private company manages health coverage for those 65 or older enrolled in Medicare.

Louisville-based Humana, one of the nation’s largest providers of Medicare Advantage plans, covers some 64,000 state and local government retirees who get health coverage through the Kentucky Public Pension Authority.

Another 38,000 retired teachers have Medicare Advantage plans with United through the Kentucky Teacher’s Retirement System though under terms of their plan they won’t pay more to see Baptist providers.

Kay Tillow, a longtime crusader for single-payer health coverage, said the result of the contract dispute is a loss of access to physicians and other services retirees depend on. She also said the increased privatization of Medicare is damaging the federal government plan she and other advocates see as a model for public, single-payer health coverage.

“The profit motive is destroying patient care,” she said in an email.

Medicare Advantage customers may be eligible for special enrollment period

Other Kentucky retirees have Medicare Advantage plans assigned to them by their unions or former employees such as United Auto Workers union members who may choose either Humana or United, Tillow said.

Together, Humana and United account for nearly half of all Medicare Advantage coverage in the nation, according to KFF, an independent health news site.

Medicare Advantage plans, which now cover more than half of enrollees in the government health plan, tout their role as one of providing more efficient care at lower costs.

“Medicare Advantage organizations approach health care holistically,” a Humana spokesman said last year. “At Humana, we prioritize preventative care and offer expansive supplemental benefits to keep seniors healthy.”

A United spokesman cited “Baptist Health’s repeated demands for changes to our contract” as the reason for the end of its affiliation with the health system.

“While we remain open to continued discussions, our focus now is ensuring the people we serve have access to the care they need through either continuity of care or a smooth transition to one of more than 90 hospitals or 14,000 physicians and practitioners remaining in our Medicare Advantage network in Kentucky,” spokesman Spencer Leuning said in an email.

Wellcare did not immediately respond to a request for comment.

Baptist has cited delays in payments and denial of care by such private insurers as the source of dispute with Medicare Advantage plans.

“The concerns we face with Medicare Advantage plans are similar to the concerns expressed by many providers across the country and echoed by hospital associations that represent them: coverage criteria applied by the plans result in denials and delays of medically necessary care to our patients,” Baptist spokeswoman Kit Fullenlove Barry said in an email statement Monday.

The practice costs time and money and leaves patients “caught in the middle,” she said.

However, Barry, public relations director for Baptist Health, said Baptist is in “active discussions” with Humana about a new contract.

Overall, about 53% of the 950,000 Kentuckians covered by Medicare are insured through Medicare Advantage plans.

Many are, in effect, captive customers since the state or private retirement system selects the Medicare Advantage company and provides it as part of retiree benefits. The retiree pays Medicare premiums to the government and the employer pays the private insurer’s charge.

For those seeking to change Medicare plans, the government’s open enrollment period ended Dec. 7.

However,  Medicare Advantage enrollees who would like to make a change to another plan may be eligible for the “special enrollment” period open to those because of a change in circumstances.

Information about that is available on the Medicare.gov website.