Oregon Health & Science University officials have issued notices to 30,000 patients with Aetna coverage that they may need to switch plans or providers to avoid unexpected costs.
Significantly, those affected include about 3,300 seniors who pay for Aetna Medicare Advantage plans and use OHSU providers. Open enrollment for Medicare opened on Oct. 15.
“Unfortunately, OHSU Health’s clinics and hospitals may no longer be participating providers in Aetna’s network, starting in 2024,” stated the letter, which began going out on Oct. 13. A final decision to cut ties has not yet been made.
Out-of-network charges can be incredibly costly, blindsiding patients. Medicare enrollment closes Dec. 7, meaning there is still time to switch. Oregon’s Senior Health Insurance Benefits Assistance program offers free independent advice to people seeking guidance.
Aetna’s website on Oct. 15 listed OHSU as part of its provider network, according to Jeff Conklin, OHSU’s senior vice president and chief payor strategy officer. At OHSU’s request, the insurer’s website no longer lists OHSU as in-network, but the insurer does not plan to alert members until next month, he added.
“We felt it was very important to be sure consumers had appropriate information,” the OHSU official said.
Contract negotiations spanned years
The notices stem from contract negotiations that have OHSU joining the ranks of hospitals and health systems pushing back on insurance reimbursement rates they say are unfair.
Conklin said the university has been negotiating with Aetna since January 2022. A recent discussion with the insurer showed promise, but there’s no resolution yet. “We are waiting to hear from them to see if they can take steps to close the gap,” Conklin said.
OHSU Health, which holds the contract with Aetna, includes Oregon Health & Science University Hospital, OHSU Doernbecher Children’s Hospital, Adventist Health Portland, Hillsboro Medical Center, plus affiliated clinics and nearly 3,000 physicians.
Aetna told The Lund Report in a statement, “We are hopeful that our active negotiations will result in a fair agreement that keeps OHSU Health in our network and serves the needs of Portland-area members and employers.”
Failure to reach deal would disproportionately affect seniors
If OHSU does not reach an agreement with Aetna, seniors could be forced to shift to other plans available under the privatized Medicare Advantage program or to traditional Medicare to ensure access to needed care. For some patients, changing plans could restrict benefits and add significant costs.
Medicare Advantage plans are available through private insurers, but traditional Medicare offered through the federal government can come with higher out-of-pocket payments. It covers only 80% of costs, requiring the patient to pay the rest. Medigap plans can cover the cost, but some patients face barriers to buying them, and sorting through the options is not easy.
For employees who obtain Aetna coverage through their job and want to keep OHSU as a provider, they should contact their employer and Aetna to figure out the potential ramifications, according to a university web page.
OHSU says Aetna alone among insurers to not renew
OHSU, a public corporation granted semi-independent status by the Legislature, has been enjoying a more profitable year than expected, while also facing increased costs such as a new labor contract it says makes its nurses the best-paid in the state.
During the pandemic, OHSU faced the same extraordinary cost hikes as other hospitals, Conklin said, but Aetna has paid the hospital and its providers the same rates negotiated before the pandemic.
“We need our payer partners to help us close the gap between their rates, which traditionally go up (in the) low single digits, and the costs we are incurring that are going up in the double digits,” he said.
He said about 10 other insurers have renewed their contracts without OHSU needing to send out a notice as it did with Aetna. “What we’re asking for from Aetna is not unusual or inconsistent with what we’re asking for from others, and others have stepped up.”
Aetna, once a Hartford-based insurer, was purchased by CVS, the pharmacy chain in 2018 as part of CVS’ plans to branch out into other areas of health care including retail services. It is now successfully competing with giants like Amazon, Walmart and United Healthcare in this sector.
Big Medicare Advantage insurers including Aetna are increasingly under fire for alleged improper billing practices, excessive denials of care, and deceptive marketing that sometimes overpromises to a vulnerable population. In 2021, a former Aetna employee’s lawsuit was unsealed. It claimed the insurer had falsely listed providers in its network in 13 states, including providers that were out-of-state, unavailable or dead.
Other changes in Oregon Medicare Advantage market underway
Other Medicare Advantage changes are afoot in Central Oregon, where St. Charles Health cut ties with three Medicare Advantage plans — Humana, Wellcare and Healthnet — affecting 6,000 seniors.
In Tillamook County, Moda Health and Regence Blue Cross are also halting Medicare Advantage coverage, according to the Newport New-Times. Moda is halting coverage in Lincoln County as well.