- Louisville, Kentucky-based health system Baptist Health and its hospitals, outpatient facilities and medical group are out of network with UnitedHealthcare and Centene’s WellCare Medicare Advantage plans.
- Baptist Health, which serves patients in Kentucky and Southern Indiana, went out of network with UnitedHealthcare and Cenetne’s WellCare MA plans as of Jan. 1 after failing to come to new contract agreements.
- In a statement, the health system cited concerns about plan denials and coverage delays. “The concerns that we face with Medicare Advantage plans are similar to the concerns expressed by many providers across the country and echoed by hospital associations that represent them: coverage criteria applied by the plans result in denials and delays of medically necessary care to our patients,” the system said.
The news comes after Baptist Health Medical Group, a network of over 1,100 physicians and advance practice clinicans in the health system, went out of network with Humana’s commercial and MA plans in September. Baptist is in active discussions with Humana, a system spokesperson said.
In letters to affected patients, Baptist Health, which operates nine hospitals, urged members enrolled in individual MA plans to switch to a different MA plan, or traditional Medicare, during the additional change period between Jan. 1 and March 31.
A UnitedHealth spokesperson said that Baptist Health is no longer in the payer’s network due to “repeated demands” for changes to its contract.
“While we remain open to continued discussions, our focus now is ensuring the people we serve have access to the care they need through either continuity of care or a smooth transition to one of more than 90 hospitals or 14,000 physicians and practitioners remaining in our Medicare Advantage network in Kentucky,” the spokesperson said.
UnitedHealthcare employer-sponsored, individual and Medicaid plans types are not affected and will remain in-network, according to a spokesperson.
MA plans, where private insurers are paid by the federal government to administer plans for seniors, have grown over the past decade, with more than half of eligible Medicare beneficiaries enrolled in the plans last year.
But the plans have garnered scrutiny from regulators and lawmakers over prior authorization denials, overpayments and access.
Regulators have said they intent to increase oversight into MA plans and federal agencies have said they intend to claw back billions of dollars in overpayments. Regulators alleged insurers of inflating patient sickness to generate higher payments to plans.
The CMS finalized a 2024 rule last year requiring MA plans to comply with coverage rules in traditional Medicare and attempted to crack down on misleading marketing in the plans.
But hospital groups like the American Hospital Association have said they’re concerned that MA plans are still applying coverage criteria that are more restrictive than traditional Medicare, resulting in coverage disparities between the programs.
The CMS recently mandated that two Centene WellCare plans in Arizona and North Carolina suspend enrollment due to persistent low quality metrics. Centene completed its acquisition of Wellcare in 2020.
Wellcare did not respond to a request for comment by press time.