Above photo: Kay Tillow, with Kentuckians for Single Payer Health Care, led a rally against Medicare Advantage plans Oct. 11, 2023 outside the Humana headquarters in Louisville. Deborah Yetter.
Baptist Health and a federal investigation cite plans’ denial of care and refusal to pay.
Louisville – With open enrollment underway, older Americans are getting barraged with television ads, mailings and online notices hawking a variety of Medicare Advantage plans for health coverage.
But many Kentuckians, including thousands of state retirees, are largely captive customers with such plans selected by their employer as part of health coverage promised for those 65 or older — an increasingly popular means to cover retirees.
And members of such plans may have fewer choices for care because of ongoing contract disputes between Baptist Health and three national companies that offer Medicare Advantage plans in Kentucky including Louisville-based Humana, which covers most state retirees.
Already, the dispute has limited access of Humana enrollees to Baptist Health physicians and could affect enrollees covered by UnitedHealthcare, which covers retired public school teachers, and Wellcare.
“They’re taking away the freedom of people to choose their physicians,” Kay Tillow, a long-time crusader for single-payer health care, said at a recent rally in Louisville protesting the proliferation of Medicare Advantage plans. “It is causing havoc.”
In Kentucky, about 53% of the about 950,000 Medicare enrollees are in Medicare Advantage plans, according to KFF, an independent health policy research organization.
Nationally, one in five Medicare enrollees are in a group plan offered by an employer or union, according to Medicare Advantage plans, touted as a way to make health plans more efficient and save costs, have grown rapidly over the past two decades and now account for just over half the 60 million people enrolled in Medicare, reports KFF.
Under such plans, the consumer pays Medicare premiums and the employers pays a private insurer a fixed amount per enrollee to provide health benefits. Medicare Advantage plans also promote additional benefits, such as prescription drug coverage or fitness programs.
Enrollees in traditional Medicare must pay premiums, purchase a Medicare D plan for drug coverage and often purchase a “Medigap” policy to cover extra health costs.
AHIP, an insurance industry organization, said on its website that Medicare Advantage plans deliver “better services, better access to care and better value,” describing it as a “prime example of the government and free market working together.”
But critics said the private plans have grown increasingly profitable at the expense of taxpayers and retirees, many of whom have no choice in the matter.
‘Follow the money’
“I follow the money,” said Kirk Gillenwaters, president of the Kentucky Alliance for Retired Americans, who joined Tillow and others at the Oct. 11 rally in downtown Louisville outside the Humana headquarters.
Gillenwaters pointed to the $959 million in profits Humana reported in August, up 38% from the same time a year ago, as well as the $17 million annual compensation of its CEO, Bruce Broussard.
“We know that’s coming off the backs of seniors who are in the Medicare system,” said Gillenwaters, a Ford retiree in Louisville. “That’s what the for-profit system is doing for us in this country.”
Pointing to Humana’s 26-story, award-winning pink granite skyscraper on West Main Street, he added, “All we’ve got to do is look at this shrine in front of us.”
A Humana spokesman did not directly address the criticisms of the protesters but said that Baptist Health and Humana were unable to reach an agreement after “several months of negotiations.”
“Humana will continue to have discussions with Baptist Health in the hope of ultimately reaching an agreement,” Mark Taylor, corporate communications director, said in an email.
Taylor described Medicare Advantage programs as being highly popular with seniors and individuals with disabilities, providing better health outcomes at reduced costs.
“Medicare Advantage organizations approach health care holistically,” he said in an email. “At Humana, we prioritize preventative care and offer expansive supplemental benefits to keep seniors healthy.”
Supplemental services include meal delivery, transportation and vision and dental benefits not covered by traditional Medicare, Taylor said.
‘Deny or delay’
A statement released by Baptist Health regarding the dispute cited ongoing problems with approval for care as well as reimbursement.
“It is our experience — and the experience of other health care providers across the country that many Medicare Advantage plans routinely deny or delay approval or payment for medical care recommended by a patient’s physician or provider,” the statement said. “We think the need for medical care should be determined by a patient and his or her doctor, not an insurance company.”
Baptist spokeswoman Rebecca Brown said more detailed information for patients is available on the Baptist Health website dealing with Medicare Advantage plans.
Last year, a federal investigation found that Medicare Advantage plans too often deny necessary medical care or decline to pay for it.
The report by the inspector general for the U.S. Department of Health and Human Services recommended Medicare increase oversight of the private plans and increase enforcement for violations, according to the New York Times
Humana and Baptist Health physicians cut ties Sept. 22, meaning that Baptist patients with Humana plans must find other doctors or face higher, out-of-network costs. The change doesn’t affect patient access to Baptist Health hospitals.
More recently, Baptist Health notified patients with UnitedHealthcare and Wellcare Medicare Advantage plans that all of its health services will be out-of-network for those two plans Jan. 1 unless the parties can reach agreements on new contracts.
Humana holds a contract with the Kentucky Public Pension Authority through 2025 to provide Medicare Advantage coverage for retirees from state and local government and state police. The contract includes options for renewals through 2029, according to a press release from the pension authority.
Unitedhealthcare covers about 38,000 retirees through the Teachers’ Retirement System.
‘Everybody is covered’
Tillow and about two dozen others who gathered outside the Humana building recently, said the problems with Medicare Advantage plans underscore their ongoing call for a single-payer system in which individuals are guaranteed care.
They represented several labor unions and groups such as Kentuckians for Single Payer Health Care and Physicians for a National Health Plan.
Harriette Seiler, 83, and a native of Canada, said Americans should look north of the border to that country’s government-run health plan as an example.
“Everybody is covered,” she said. “Nobody ever gets a bill in the mail.”
Meanwhile, advocates urge everyone to review their Medicare health plans carefully before making a selection, if possible for 2024. Some employee retirement plans offer members several options for insurance companies.
Any changes must be made by Dec. 7. More information is available at Medicare.gov.