Patients looking at options after Stillwater Medical Center terminates Medicare Advantage plans
Oct. 15—By Chris Peters
Potentially thousands of Humana Medicare Advantage plan members in north central Oklahoma will be taking a hard look at their options during this year's Medicare open enrollment period that begins today.
On Oct. 4, Stillwater Medical Center notified Humana Medicare Advantage members that the regional hospital will no longer be a preferred in-network provider as of Jan. 1, 2023. SMC will still provide high-quality care for patients if they choose to keep their Humana Advantage Plan but will be responsible for paying more for some services.
Stacia Smith helps her parents manage their health care needs and was shocked when she read the notice that her parents' health care costs could rise significantly under their Humana Advantage Plan.
"The difference is significant." Smith said. "Just max out-of-pocket is over $3,000 higher and a 40% coinsurance cost can get steep quickly for any procedure, lab services, or X-rays."
For Humana Advantage Plan members, an inpatient stay at SMC will go up by $50 for each of the first eight days, from $275 to $325. But not every service will increase in cost. Co-pay for primary doctors visits will go down from $10 to $5 and co-pay to visit specialists will stay the same — even out-of-network — at $50.
"Where people are concerned is the outpatient surgery," Charles Himes, of Himes Insurance said. "There's not a co-pay like inpatient, but if it's an outpatient surgery, they will have to pay 40% of the surgical bill and nobody really knows what the surgical bill's gonna be."
Himes's customers have asked if they can go to another in-network hospital for outpatient surgery. He tells them there are many in-network options, but they must be prepared to travel.
"You can go to Hillcrest Hospital in Cushing, you can go to Edmond, there's the new Integris and Mercy Hospitals, or you could use all the major hospitals in OKC or Hillcrest in Tulsa," Himes said.
Blue Cross and Blue Shield of Oklahoma were also recently notified by SMC of the termination of their Medicare Advantage HMO and PPO plans.
"Medicare Advantage plans are popular as they offer benefits beyond traditional Medicare and lower out-of-pocket expenses," Tricia Ament, a communications manager with BCBSOK said. "BCBSOK is willing to work with Stillwater Medical Center in finding solutions that will allow Payne County residents continued local access to Medicare Advantage providers."
Humana has not responded to contact from the News Press as of this writing.
Currently, there are no zero premium Medicare Advantage Plans that are in-network at SMC for 2023. A decision that SMC said they needed to make financially.
"This was a very tough financial decision for the Stillwater Medical leadership team. Our cost to operate has increased 26% over the past 2 years," Tamie Young, Vice President of Revenue Cycle at SMC said. "Financial challenges are increased by a 22% denial of service rate from Medicare Advantage plans. This is in comparison to a less than 1% denial rate from Traditional Medicare."
Young shared that Traditional Medicare has identified very few procedures that require prior authorization before services can be provided. Medicare Advantage plans like Humana require approval and assign a physician advisor that often does not approve the procedure, she said. The financial inequity imposed on the care provider is usually hidden from the patient.
"Traditional Medicare has compliance and regulatory requirements that are validated through educational reviews and audits. MA plans do not have to follow these same Medicare requirements," Young said. "This forces health systems to follow multiple sets of rules that are often contradictory and cause added cost and less reimbursement."
During this open enrollment period for Medicare, people are encouraged to reach out to a local medicare agent that can help walk them through the best options for their health needs.
"Every individual is a little bit different," Himes said. "What we do is drill down into it (current health needs and medications) and found out what they can afford, what their comfort level is and what company they wanna do business with."
People can also get their Medicare questions answered for free by contacting the Oklahoma Insurance Department. Call 405-521-2828 or go to oid.ok.gov.
