Disputes between health care providers (the hospital or clinic where you go to get care) and insurers (such as Humana) have become increasingly common, often triggered by disagreements during year-end contract renewals. 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 those providers will be out-of-network.
Can I See an Out-of-Network Provider?
The good news for ELCA Medicare-Primary members is your plan is a preferred provider organization (PPO) plan. PPO plans give you the freedom to get care in- or out-of-network. Your benefit plan coverage remains the same for health services, even if you receive care from an out-of-network provider. A health care provider who is eligible to participate in Medicare and agrees to bill Humana can treat and receive payment according to the Original Medicare fee schedule less any member plan responsibility. In contrast, prescription drug coverage must be in-network for your benefit coverage. Portico members can see the ELCA Health Plan Summary Plan Description for additional terms and coverage information.
What Happens If My Provider No Longer Accepts My Medicare Advantage Plan?
If your provider accepts Medicare and agrees to bill Humana, you will not be impacted. Humana will not agree to bill every provider that accepts Medicare. It’s important that you check with Humana to help you determine if your provider falls into this category and to help you find an alternative provider if needed.
What Can ELCA Health Plan Members Do?
Stay informed. In most cases, you will receive communication from both your health care provider and Humana. Ultimately, if an agreement is not reached, and your health care provider no longer accepts Medicare Advantage plan members, remember that your Medicare Advantage PPO plan is structured to include both in-network and out-of-network benefits for services other than prescription drug benefits. Portico members can see additional plan terms and coverage information in the ELCA Health Plan Summary Plan Description.
This Humana flyer explains the relationship between out-of-network providers and PPO members.
The ELCA Health Plan’s Medicare Advantage plan is unique and offers different benefits than other Medicare Advantage plans you can buy. Call Humana at 888.445.4788 to understand the potential impact a contract dispute or non-renewal has on you.
Portico is Here to Help
Portico is neither a health care provider nor an insurer. As the ELCA Health Plan administrator, we work on behalf of our plan members to maintain consistency in benefits and find solutions that minimize disruption. We know it’s important for members to maintain long-term relationships with their trusted health care professionals.
If this summary is found to be inconsistent with the ELCA Health Plan document, the plan document is considered the controlling document.