St. Charles Health System, the largest provider of health care services in Central Oregon, has announced that it is considering dropping its participation in all Medicare Advantage plans due to concerns over patient care, access and affordability. The hospital system is advising local seniors to switch to traditional Medicare plans during the upcoming open enrollment period.
What are Medicare Advantage plans?
Medicare Advantage plans are alternative options to the original Medicare program, which is funded and operated by the federal government. Medicare Advantage plans are offered by private insurance companies that receive payments from the government to provide Medicare benefits to enrollees.
Medicare Advantage plans may offer some additional benefits, such as dental, vision and prescription drug coverage, that are not covered by original Medicare. However, they also have some drawbacks, such as:
- Restrictive networks of doctors and hospitals that may limit the choice and availability of care for patients.
- Prior authorization requirements that may delay or deny access to medically necessary services and treatments.
- Higher out-of-pocket costs for copayments, deductibles and coinsurance that may affect the affordability of care for patients.
Why is St. Charles evaluating its participation in Medicare Advantage plans?
St. Charles Health System has expressed its frustration with the Medicare Advantage plans that it contracts with, namely Humana, PacificSource, HealthNet and WellCare. According to the hospital system, these plans have caused numerous and prolonged difficulties for patients and providers, such as:
- Difficulty finding post-acute care facilities that accept Medicare Advantage plans for patients who need skilled nursing or rehabilitation services after being discharged from the hospital.
- Denials of physician-recommended treatments that are deemed medically necessary by the hospital’s clinical staff, such as surgeries, imaging tests and therapies.
- Extra work and burden for hospital staff who have to deal with administrative paperwork, appeals and disputes with Medicare Advantage plans.
St. Charles Health System is not alone in its concerns about Medicare Advantage plans. The American Hospital Association has also raised issues about certain Medicare Advantage plan policies that restrict or delay patient access to care, which add cost and burden to the health care system. Some Medicare Advantage plans are also under investigation for fraud and delays and denials in coverage.
What is St. Charles recommending to its patients?
St. Charles Health System is publicizing its concerns about Medicare Advantage plans now because the Medicare open enrollment period is coming up from October 15 to December 7. During this time, seniors who are eligible for Medicare can enroll in or change their health insurance plans.
St. Charles is urging its patients who are currently enrolled in Medicare Advantage plans to switch to original Medicare plans during the open enrollment period. The hospital system believes that original Medicare plans offer more options, flexibility and quality of care for patients under all circumstances.
Dr. Mark Hallett, chief clinical officer for St. Charles Health System, said: “Medicare fee for service open enrollment is coming up. That would be our message to our patients so that they can preserve their options under all circumstances. The medicare fee for service, traditional medicare, would be what I recommend.”
St. Charles Health System will continue to accept original Medicare plans, which cover about 80% of the cost of health care services. Patients who choose original Medicare plans may also purchase supplemental insurance policies, such as Medigap or Part D plans, to cover the remaining 20% of the cost.
