Almost two weeks after their contract originally lapsed, WakeMed and insurance giant Humana have yet to reach a deal, leaving many Medicare patients without coverage.
Several Medicare Advantage Plan contracts with Humana lapsed on Oct. 31 after weeks of tense conflict. For patients covered by these plans, WakeMed could remain out-of-network “well into 2024,” the health system wrote on its website.
“Good faith” negotiations had failed due to Humana’s high rate of health claim denials and refusal to set up systems that allow providers to resolve disputes about necessary care, a WakeMed spokesperson wrote to The News & Observer when asked about posting on Monday.
WakeMed did not ask Humana to pay more for its services in the new contract, the spokesman said.
“Meanwhile, Humana is demanding a rate cut because ‘2024 will be a challenging year financially’ for them,” the statement read.
Humana declined to comment on details about the negotiations.
Here’s what you need to know.
Who is impacted?
Humana MAP HMO Members: Because this plan does not have any out-of-network benefits, patients would be fully responsible for the cost of their care at WakeMed facilities, including hospitals, outpatient clinics and physician practices.
Humana MAP PPO Members: This plan has some out-of-network benefits, which allows patients on this plan to continue seeing WakeMed doctors for non-emergency care. However, this care may now have higher out-of-pocket costs and stricter prior authorization requirements.
State Health Plan’s Medicare Advantage plan: For now, services will not change for members of this plan. Benefits are the same regardless of whether members see an in or out of network provider. WakeMed has agreed to continue scheduling elective services for SHP retirees while negotiations continue.
Even if WakeMed is now considered out-of-network for your plan, you can seek immediate care at WakeMed’s emergency rooms. North Carolina law prevents patients from paying more for emergency services from an out-of-network provider than from an in-network provider.
What can people losing WakeMed coverage do?
It’s unclear when, or if, the health system and insurance company will resolve their dispute.
Last year, WakeMed and UnitedHealthcare allowed their contract to lapse for about five months during a similar contract conflict, before finally reaching an agreement on a three year deal.
One option is to switch Medicare Advantage plans. The Medicare open enrollment period, during which you can choose from dozens of plan options, runs until Dec. 7. WakeMed is still in-network with a number of other Medicare Advantage plans administered by companies like Aetna and Cigna.
WakeMed has encouraged its patients to choose this path, arguing that Humana is “not a safe choice if access to WakeMed is your priority.”
Another option, which Humana has lobbied for in a letter to patients, is to switch health providers to people and clinics within its approved provider lists.
Teddy Rosenbluth covers science and health care for The News & Observer in a position funded by Duke Health and the Burroughs Wellcome Fund. The N&O maintains full editorial control of the work.