WELLFLEET — As the Dec. 7 deadline to change Medicare Advantage plans approaches, over 500 patients of Outer Cape Health Services (OCHS) must decide whether to choose a new plan now that Blue Cross Blue Shield of Massachusetts has dropped the Outer Cape’s only health center from its provider network.
Some are choosing to stick with their current plan and pay out-of-network rates for care at OCHS. “I don’t want to change my primary care,” said Keith Scott of Wellfleet. “I have been going to Outer Cape since they opened.”
Medicare recipients in a Blue Cross Blue Shield Preferred Provider Organization (PPO) plan can continue to see out-of-network providers with an added co-payment. According to Medicare’s website, an out-of-network primary care visit would trigger a $25 co-pay, while a visit to a specialist could cost up to $95.
Betty Eipper, who is a counselor with SHINE (Serving the Health Insurance Needs of Everyone), a state service that coordinates volunteer counseling for Medicare recipients, said that co-pays could be cost-prohibitive for many patients. About a quarter of the Medicare recipients Eipper has helped receive state or federal financial support for their insurance, she said.
Eric Mays and Roger Blethen told the Independent they were sticking with their BCBS plans but that it had been difficult to understand their options and get accurate information.
“Outer Cape’s letter didn’t get into the fact that people could still go there for primary care,” said Mays. He said the letter was framed as a binary choice: “Either you had to go back to traditional Medicare or you had to find another Medicare Advantage plan.”
“OCHS wouldn’t say definitively that you can still receive care with a higher co-pay,” Blethen said. “I think the center needs to be put on the spot and confirm that. There are a lot of people who like the BCBS Medicare Advantage plan and think that they can’t continue with it.”
According to OCHS’s Oct. 15 letter, while the open enrollment period ends on Dec. 7, patients already enrolled in Medicare can switch plans between Jan. 1 and March 31.
‘Strict Regulations’ Cited
OCHS CEO Damian Archer would not comment on whether the health center can provide out-of-network care for those with a Blue Cross Blue Shield PPO plan.
According to Archer, that is because health-care providers are limited in how much they can help patients due to “strict” regulations created by the federal Centers for Medicare and Medicaid Services (CMS), which administer the public insurance programs.
“We are not allowed to influence a patient’s decision on what insurance plan they choose,” said Archer. “We are only able to say to a patient, please see a SHINE counselor or call BCBS for further instructions about what to do.”
He added that OCHS has done “the maximum of what is compliant with the regulations,” which is limited to “assertive and aggressive outreach” about the change in coverage.
But according to the rules in the Code of Federal Regulations about Medicare Advantage communication requirements, providers are permitted to give patients the names of Medicare Advantage organizations in which they participate as well as “answering questions or discussing the merits of a Medicare Advantage plan or plans, including cost sharing and benefits information.”
In a follow-up statement, Archer said that OCHS follows only certain communication guidelines in the established regulations, including providing CMS educational information materials and referring patients to other resources. “It is important to prevent even the perception of providing undue influence on a patient’s choice of insurance plan,” Archer said.
The health-care access specialists at OCHS whose job it is to help patients navigate the health insurance marketplace are certified only to assist with MassHealth and Connector Care Health Plans, the state’s public health insurance programs, Archer said.
Meanwhile, appointments with SHINE counselors have been filling up. According to Wellfleet’s Director of Community Services Suzanne Grout Thomas, all appointments with counselors at the adult community center have been booked, as have appointments at other councils on aging on the Outer Cape, she said.
SHINE appointments through Barnstable County’s Dept. of Human Services are also full, according to a voice recording at the department’s phone number.
Staff in state Sen. Julian Cyr’s office said they have asked the state’s Executive Office of Elder Affairs to provide more SHINE counselors to help with the demand.
“This state-level support has been helping manage affected patients since the local SHINE counselors are quite busy,” said Cyr’s legislative director, Meg Ribera.
Ribera said she could not confirm details of that support, including whether any SHINE appointments are currently available.
Cyr told the Independent that he has been meeting weekly with the government affairs team at Blue Cross Blue Shield and with community health centers the company dropped from its network to “ensure progress and coordinate a warm hand-off for each patient.”
“We will not allow anyone to be denied the care they need,” Cyr said without provide details of how that would be done. “I will continue to push, fight, and hold BCBS accountable until every affected patient has access to the health care they deserve.”
‘Favorable Selection’
The Independent reported on Nov. 14 that when Blue Cross Blue Shield terminated its Medicare Advantage contract with the Community Care Cooperative, which includes 23 federally qualified health centers across the state, it cited the five-star rating system the federal government uses to score insurance plans.
Those “star ratings” are based on both clinical quality metrics and consumer surveys, and they affect the overall profitability of an insurance plan because lower ratings dissuade customers, while higher ratings trigger “quality” bonus payments from the federal government.
BCBS told the Community Care Cooperative in June that a decline in its star rating could be traced to the quality of care at the community health centers. But federal CMS data reviewed by the Independent showed that the company’s lowest ratings are not in clinical quality but come from low marks on “member experience” surveys.
The insurer’s decision reflects a documented tactic called “favorable selection,” in which private insurance companies boost their star ratings by targeting healthier, higher-income communities, leaving behind those they deem a risk to their ratings. A report by Physicians for a National Health Program found that the practice results in overpayments from the federal government to insurance companies of around $50 billion per year.
Meanwhile, rural hospitals and health systems across the country are also ending their contracts with Medicare Advantage plans because of administrative and financial challenges, including high rates of coverage denial and slow payments from insurers. A report from the Dept. of Health and Human Services found that in 2019 the 15 top Medicare Advantage plans denied reimbursement for 13 percent of claims that had met Medicare criteria.
The rate of reimbursement from private companies is significantly lower than federal Medicare and Medicaid reimbursements, said OCHS CEO Archer.
“Health centers tend to lose money on each of those visits through commercial plans, including Medicare Advantage plans,” Archer said. “The larger the plan, the less interested they are in paying a rate that is adequate.”
Archer said that outright denials of claims “add insult to injury.”
The effect of this lowballing by insurance companies is felt across the country. Almost 200 rural hospitals have closed since 2005, and more than 600 more are at risk of closure from financial stress due to low payments from private insurers, according to a report from the Center for Healthcare Quality and Payment Reform.
“We are being radically underpaid for our services,” Archer said.
