HJNO Jan/Feb 2025

MEDICARE ADVANTAGE DENIALS 40 JAN / FEB 2025 I  HEALTHCARE JOURNAL OF NEW ORLEANS  by Mike Thompson Healthcare Policy Analyst & Media Liaison Louisiana Hospital Association DISMANTLING RURAL ACCESS Medicare Advantage Plans terminate rural healthcare providers, force Louisiana patients to drive further for care, and then retain higher payments intended to support local access to healthcare As rural Medicare Advantage (MA) expansion grows, more insurers are termi- nating local providers from their networks and requiring rural seniors to travel much longer distances for care. Critics say these changes provide a hidden windfall for MA plans while weakening rural access in ways Congress never intended. National policy experts warn that MA plans have a financial incentive to enter rural areas and eliminate seniors’ conve- nient, local access to care. As this article will explore, rural low-volume providers receive enhanced payments under traditional Medi- care to help cover their fixed staffing costs. Complex rules for paying MA plans allow the insurers to keep these enhanced pay- ment rates after severing local patient- provider relationships. Federal officials exacerbated this problem by removing safeguards that protected rural MApatients’ access to local in-network providers. In Louisiana, Humana and People’s Health MAplans have fully or partially ter- minated contracted services with five criti- cal access hospitals (CAHs). “The majority of the primary care physicians in this par- ish are no longer in network” beginning Jan. 1, 2025, said St. James Parish Hospi- tal (SJPH) CEO MaryEllen Pratt, explain- ing that Human’s unilateral patient-steering decision impacts more than 20% of STPH’s revenue and could trigger a significant net loss in 2025. Pratt’s award-winning 1 CAH serves as the only hospital in the parish, which includes approximately 1,200 Humana MA enroll- ees. SJPH also serves patients who lack any hospital in nearby St. John the Baptist Parish, where MA plans include more than 74% of Medicare patients. During Medicare’s Open Enrollment Period, Pratt partnered with the Louisiana Department of Insurance to help inform local seniors of their options. She said people are frustrated by Humana’s changes and their potential out-of-network costs. Humana’s MAplans had covered local providers since 2010. SEVERING DOCTOR-PATIENT RELATIONSHIPS Recently, 79-year-old former Humana MA enrollee Susie Jacob said she and her 85-year-old husband like and want to keep their family practice physician of more than 20 years. “When we have testing done, he always calls us with our results. That gives