St. Luke's splits from Humana plan over money

A change in the local coverage network could affect thousands.

adutton@idahostatesman.comNovember 13, 2013 

  • THE MANY FACETS OF MEDICARE

    Medicare coverage falls into several categories.

    • Original Medicare (Part A and Part B): Part A covers hospital inpatient care, skilled nursing care, hospice and some in-home health care. For most people 65 or older, Part A is funded by the federal government. But some people, such as those who aren't eligible for Social Security, can be charged more than $400 per month for Part A coverage.

    Part B covers doctor services, outpatient medical care, preventive care and medical supplies. For most people 65 or older, Part B requires a monthly premium of about $105.

    • Medicare Advantage (Part C): These optional plans, run by private insurance companies, are similar to HMO or PPO plans. They offer the benefits in Original Medicare (Part A and Part B) and might offer lower costs or more services than original Medicare. These plans usually offer the same prescription drug benefits as Medicare Part D.

    • Medicare Part D: These plans, also run by private companies, cover prescription drugs. Part D is voluntary. People who do not have Medicare Advantage and need prescription drug coverage must buy Part D plans.

    • Medicare Supplement or Medigap: These private plans pay the out-of-pocket costs from Original Medicare (Part A and Part B). Medicare Advantage members cannot use or buy supplemental policies.

Treasure Valley residents who have private plans from Humana to complement their bare-bones Medicare coverage might have to change where they get medical care.

St. Luke's Health System will no longer be part of Humana's Medicare Advantage network starting Jan. 1. That means St. Luke's patients with Medicare Advantage plans from the Kentucky-based insurer will need to find new providers or pay more out-of-pocket costs to stick with St. Luke's.

Humana canceled the contract in August because of a disagreement over payments, said St. Luke's spokesman Ken Dey. Humana wanted to change its contract to pay St. Luke's less than Medicare does, Dey said.

"We tried to renegotiate and proposed a shared savings arrangement that is similar to what we have with other (insurers), but Humana declined," Dey said in an email. He was referring to arrangements wherein St. Luke's may keep some of the premiums that are left over if it provides efficient health care.

"The discussion we had with Humana about shared savings didn't progress very much, because Humana insisted that it wouldn't waver on its request to reduce our contract," Dey said. "Without any willingness on Humana's part to negotiate, we couldn't move forward with any discussions about shared savings."

Humana spokesman Ross McLerran said, "Humana is acting in the best interests of its health plan members with the goal of offering the most affordable, highest-quality and accessible health care possible. We'll work with our Medicare members to ensure a smooth transition of care and ensure that they have timely information on alternative providers."

The change comes as seniors are making decisions about whether to keep or change their Medicare Advantage health insurance plans. Open enrollment began in October and ends Dec. 7.

The Boise-based health system said about 2,800 patients with Humana insurance plans have gone to St. Luke's providers so far this year. St. Luke's said that total might include some Humana members with Medicare Supplement insurance who are unaffected by the contract cancellation.

More than 50,000 people in counties around St. Luke's hospitals are enrolled in Medicare Advantage plans, federal records show. About 5,870 are with Humana, up slightly from about 5,820 five years ago.

Patients who have certain Humana Medicare Advantage plans might see no difference in out-of-pocket costs for visits to St. Luke's doctors. One example would be a patient covered by Humana under a specially created government benefits package.

Dey said St. Luke's "preference would have been for Humana to renew its contract. We also want to stress that patients have the option to enroll in another plan and can maintain their St. Luke's physician."

McLerran gave the Statesman a list of hospitals and physicians who will be in Humana's Treasure Valley network next year:

• Saint Alphonsus Health System hospitals.

• More than 270 Saint Alphonsus-affiliated doctors.

• West Valley Medical Center in Caldwell.

• Walter Knox Hospital in Emmett.

• About 300 non-St. Luke's providers.

Humana has been setting up St. Luke's patients with other doctors, according to a letter provided to the Statesman by a local patient who was assigned to a Saint Alphonsus doctor.

Dey said the change is unrelated to the rollout this year of a new Medicare Advantage plan St. Luke's helped bring to the Idaho market. That plan is offered by SelectHealth, a Utah-based company that has become a partner with St. Luke's on a number of initiatives.

SelectHealth had 865 customers on its Medicare Advantage plan as of October, according to federal records.

For most St. Luke's patients, nothing will change. People who have the following Medicare Advantage plans are unaffected:

• Blue Cross of Idaho's True Blue and Secure Blue plans.

• PacificSource Medicare Essentials/Medicare Explorer.

• Regence BlueShield of Idaho MedAdvantage.

• SelectHealth Advantage.

• United Healthcare's AARP Medicare Complete Choice.

Audrey Dutton: 377-6448, Twitter: @IDS_Audrey

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