You may have read a news story, heard from a friend, or even received a letter from your doctor about a dispute between a health care provider (the hospital or clinic where you go to get care) and an insurer (such as Humana). These disputes, and in some cases non-renewal of the contract, have become increasingly common across the country.
At Portico, we’ve also noticed a significant increase in these disputes. As the ELCA Health Plan administrator this is concerning, because we value your health, and we know that consistency in the care you receive is very important.
When and Why Do These Disagreements Happen?
These contract disagreements usually happen in the fall because this is when these contracts come up for renewal.
These disagreements arise as providers push for higher reimbursement rates to cover rising operational costs, while insurers aim to control expenses.
If an agreement is reached, the provider will continue to be in-network. If an agreement is not reached, the contract will not be renewed, and that provider will be out-of-network. Due to your unique Medicare Advantage PPO plan, in many cases even if a contract is not renewed you can continue to see your current provider.
How is My Medicare Advantage Plan Different?
The good news for ELCA Medicare-Primary members is your plan is a passive preferred provider organization (PPO) plan. Passive PPO plans give you the freedom to get care in- or out-of-network, and your benefit plan coverage remains the same for health services.
Can I See an Out-of-Network Provider?
Because your plan is a passive PPO plan, you can receive care from an out-of-network provider as long as the provider accepts Medicare and agrees to bill Humana. An out-of-network provider can treat you and receive payment according to the Original Medicare fee schedule less any member plan responsibility.
To date, most of the providers in this situation do agree to bill Humana. This means the vast majority of our ELCA Medicare-Primary members can still see their current provider with no disruption in care.
What Can I Give My Out-of-Network Provider That Explains My PPO Coverage?
Be sure to show your ID card with the Portico name and logo and say that you have a Group Medicare PPO plan. You can also give your provider this Humana flyer, which explains the relationship between out-of-network providers and PPO members.
The ELCA Health Plan’s Medicare Advantage plan is unique. It offers different benefits than other Medicare Advantage plans you can buy. If you’re worried about getting care, or unsure about the status of your provider’s contract with Humana, you can speak with a member of Humana’s customer care team at 888.445.4788.
What if My Provider Does Not Agree to Bill Humana?
In rare cases a provider will not renew their contract with Humana and will not agree to bill Humana for services. Humana’s care team will reach out to you in this case to help you understand your options for finding the care you need.
What About My Prescription Drug Coverage?
If you are enrolled in one of our three ELCA Medicare-Primary plan options: Premium, Standard, or Economy, you have Part D prescription drug coverage. While the PPO plan allows you to use out-of-network providers, your prescription drug coverage must be in-network for your benefit coverage. If you want more detailed information about your plan, sign in to myPortico to see the ELCA Health Plan Summary Plan Description for additional terms and coverage information.
Portico is Here to Help
As the ELCA Health Plan administrator we at Portico are committed to the health and well-being of our plan members. We know that your long-term relationship with your trusted health care professional is important and is a big part of your care. This is why we work on your behalf to maintain consistency in benefits and to find solutions that minimize disruption. We are always seeking to provide the ELCA community with the best possible value and care. We’re here for you.