NMHS terminates UHC Medicare Advantage agreements
For those on one of these two United Healthcare Advantage plans, NMHS providers and facilities are now out of network.
NMHS will remain in network for UHC commercial- and employer-sponsored plans. This change does not affect a vast majority of independent providers. For example, Cardiology Associates of North Mississippi is independent.
It is crucial for those on these plans to know if their plan is a PPO (Preferred Provider Organization) or an HMO (Health Maintenance Organization) — it makes a difference. If your UHC Medicare Advantage plan is a PPO, that means the plan offers out-of-network benefits, and NMHS can continuing offering its services. But if your UHC Medicare Advantage plan is an HMO, no benefits include out-of-network benefits.
If you are not certain if your UHC Medicare Advantage plan is an HMO or a PPO, your card has the information. Look carefully — it's there.
Each fall there is an annual enrollment period for making changes to Medicare. However, from January through March, seniors who purchased an Advantage plan but may not have been clear on its benefits, may return to traditional Medicare, if they desire.
This with dual eligibility, having both Medicare and Medicaid, can make changes every month and are not locked into an entire calendar year.
"Advantage plans are not a bad thing," said Wally Davis, vice president of NMHS Payor Strategy & Partnerships. "But people just need to understand the benefits of what they are choosing."
For those who have serious illnesses, such as cancer, diabetes, kidney dialysis, who need and want consistent ongoing care without interruption due to having to choose a new in-network facility or physician may seek approval from United Healthcare.
"This is true for members with both HMO and PPO plans," Davis said. "And each request is considered on a member-by-member basis. Continuity of care may be for 90 days or until the end of specific treatment."
NMHS's termination of the agreement with UHC was based on the fact patients on their Advantage plans were experiencing delays or denials of care.
"We notified UHC Medicare Advantage leadership about this concern in February 2024," Davis said. "Plans denied, on average, 25 to 30% of inpatient claims with North Mississippi Medical Center-Tupelo each month. Despite following the labor-intensive appeals process and achieving an overturn rate of 80 to 85%, we never received from UHC a definitive answer on why this was happening."
For more information about Medicare coverage options, call 1-800-MEDICARE, visit medicare.gov or speak with a local insurance agent or broker. To research plans that NMHS remains contracted with, visit nmhs.net/insurance.
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