CHARLESTON, W.Va. -- Sen. Jay Rockefeller, D-W.Va., sent letters to top officials at Humana Inc. and Charleston Area Medical Center on Oct. 31, asking them to resume contract negotiations and reach an agreement to cover patients before Medicare's "open enrollment period" ends Dec. 7.CAMC plans to leave Humana's network next year. In September, talks between Humana and the hospital system broke down. People eligible for Medicare benefits can choose a private insurance company, such as Humana, to manage their benefits under Medicare Advantage Health Plans. Humana and other private companies typically receive the annual money set aside for Medicare beneficiaries, plus an additional 17 percent, to help them pay their health-care bills."We are again facing a situation where access to health services for West Virginia seniors may be seriously curtailed because of business decisions that seemingly put profits before patients," Rockefeller wrote.
When hospitals are "outside" the network of a company like Humana, Medicare patients covered by Medicare Advantage plans must pay the bills themselves for care received at those hospitals.Jeff Blunt, a spokesman for Humana, which is based in Louisville, Ky., said Monday there is no "breaking news" to report."We are still in communication with CAMC and we are still hopeful that a compromise can be reached. But beyond that, there is nothing new," he said.Elizabeth Pellegrin, CAMC's chief marketing officer, also said Wednesday that there are no new developments, but that 12,000 Public Employees Insurance Agency Humana members would remain in CAMC's network. West Virginia's Public Employees Insurance Agency provides retirement pay and health benefits to retired state workers.But there are no current negotiations between CAMC and Humana about covering Humana's other Medicare Advantage beneficiaries, Pellegrin said."They will be with us until Dec. 31," she said. "Then they will be treated as being outside the network."This is an open enrollment period. This is the time for people to choose a Medicare Advantage plan. If they want to change insurance plans, they can."Or they can use straight Medicare as well," Pellegrin added. "Some physicians don't take Medicare. Most hospitals do."In his letter to Humana CEO Michael McCallister, Rockefeller wrote, "I request that you immediately inform your current Medicare Advantage enrollees and those seeking more information about Medicare in West Virginia that CAMC is not currently planning to participate in Humana's network for 2013."Recently, CAMC ran newspaper advertisements listing other Medicare Advantage plans that still include CAMC, including: Aetna Medicare, Health Plan of the Upper Ohio Valley, HealthSpring Medicare and Highmark Blue Cross Blue Shield Medicare.
"When you are selecting your health insurance plan for 2013, be sure to check that your preferred physicians and hospitals are available through your plan," the CAMC advertisement stated.Stephen P. Dexter, CEO of the Thomas Health System that includes Thomas Memorial and Saint Francis hospitals, said, "this is not good news for senior citizens in the Kanawha Valley."We have really worked well with Humana. The program helps people move back home, get home health care, go to nursing homes and keep in contact with their families.""The federal government puts 17 percent more into [private] Medicare Advantage plans than into its own plans. It covers eyeglasses, hearing aids, a variety of different benefits," Dexter said.In January, Humana reversed a decision it made in late 2011 to remove Thomas Memorial and Saint Francis from its network of preferred providers.Dexter also stressed the advantages of long-term physician-patient relationships, which can be broken up if a Medicare Advantage program excludes certain hospitals and physicians from its network.
"If a physician has been practicing for 25 years, he knows what you want," he said.Carolyn Lewis, now 70, lives with her husband on Charleston's West Side. Lewis, who worked in the medical field for 40 years before she retired, was upset when Humana excluded Thomas from its program in late 2011."If a person of my age doesn't have the choice of what hospital to go to, it is sad," she said last January.Last week, Lewis contacted Rockefeller's office about the current problems with Humana and CAMC."If I had my preference, I would rather go to Saint Francis or Thomas. But what happens if my husband is on heart medication or if he needs surgery? CAMC monopolizes heart surgery for this area."If he needs surgery, we could go to Cabell Huntington Hospital or St. Mary's Hospital in Huntington," Lewis said of getting care within Humana's network."We could still go to CAMC if there is a problem. But Humana will only pay 30 percent of the costs," she added."We would also be subject to a very large deductible, probably about $7,000, since CAMC is out of the [Humana] network. If we stay in network, we have zero co-pay in the policy I am on."In his letter to Humana President and CEO David Ramsey, Rockefeller wrote, "As you know, this is the second time in less than a year that a contract dispute between a private Medicare Advantage plan and our state's hospitals has jeopardized coverage for seniors." He was referring to last year's dispute between Humana and Thomas."The recent announcement that negotiations have ended between Humana and CAMC again puts seniors in the middle of your dispute. Fortunately, the parties involved were able to reach a resolution in January, and I am hopeful that, by working together, you can do so again."It is unacceptable for seniors to be put in the middle of your ongoing dispute and continually left in limbo," Rockefeller added.John Givson<co >, a senior citizen in Sutton, said Wednesday that for people having a difficult time in life, the dispute is unfair to patients. "You spend two or three or four days in the hospital and you could be out $4,000 or $5,000," he said. "I don't understand how Medicare, our governor and the people of West Virginia can put up with this. There are a lot of people who have depended on CAMC hospitals for 10 years or more."Reach Paul J. Nyden at firstname.lastname@example.org or 304-348-5164.