In Miami, private Medicare plans cover half or less of local hospitals, study finds

July 02--Private Medicare is big business in Miami-Dade, where nearly 278,000 people receive their healthcare benefits through an insurance company, such as Cigna, Humana or United Health.

But choosing a private Medicare plan by one of the most basic criteria -- whether that plan includes a preferred hospital -- can be frustrating if not impossible for consumers, potentially exposing them to higher costs from out-of-network providers, according to a new study by the nonprofit Kaiser Family Foundation, a health policy think tank.

Kaiser researchers found many private Medicare insurers, also known as Medicare Advantage, publish unreliable and outdated provider directories that are hundreds of pages long, and that on average the health plans covered only half or less of the hospitals in their home county, leaving their members vulnerable in case of unanticipated medical needs.

Open enrollment for Medicare is Oct. 15 through Dec. 7. Of the nearly 435,000 Medicare beneficiaries in Miami-Dade County in Dec. 2015, more than half -- about 272,000 -- enrolled in a private health plan, according to the Centers for Medicare and Medicaid Services.

"This is a very difficult system for seniors, particularly seniors with any sort of health conditions, to really try to wade their way through," said Gretchen Jacobson, a Medicare public policy analyst for Kaiser and co-author of the report. "Even if you sit down and compare the plans, you'll often find errors and outdated information."

Advocates for private Medicare say hospital networks are only one of several priorities that seniors should consider when selecting a health plan -- including premiums and other out-of-pocket costs -- and that consumers in Miami-Dade and elsewhere report "huge satisfaction" with their coverage.

Nearly 436,000 people in Miami-Dade have Medicare, the federal healthcare program for people 65 and older, and about 62 percent of them choose a private health plan to receive their benefits, according to the Centers for Medicare and Medicaid Services.

"The numbers of people who are enrolling in Miami-Dade specifically and across the country generally suggest that beneficiaries find great value," said Mark Hamelburg, senior vice president of federal programs for America's Health Insurance Plans, the nation's biggest health insurance lobby.

Hamelburg said Miami-Dade consumers have 36 private Medicare plans to choose from this year, and that 27 of those plans offer "zero dollar premiums," which means that beneficiaries pay little or nothing to be enrolled in those plans.

"There are choices for beneficiaries to be able to find the best plan that best meets their needs," Hamelburg said.

This is a very difficult system for seniors.

Gretchen Jacobson, Kaiser Family Foundation researcher

In their analysis of hospital networks among private Medicare plans in 20 counties across the country, Kaiser researchers found that Miami-Dade Medicare plans offer their members lots of "extra" benefits -- from free eyeglasses to cooking lessons and gym memberships -- but only a handful of plans provide broad coverage, meaning 70 percent or more, of the hospitals in the county.

Jacobson said it's difficult to know why private Medicare insurers don't contract with more hospitals in their home county. "Plans could be selecting providers that they feel are providing a higher quality of care," she said. "They also could be selecting providers that are less costly for the plan."

But she said she was surprised by the paucity of local plans with broad hospital networks because, historically, the federal government has paid private Medicare insurers in Miami-Dade among the highest rates in the nation, which could allow those plans to contract with more hospitals.

Medicare per capita spending in 2013 averaged $9,415 nationwide, according to Kaiser, from a low of about $6,000 in Josephine County, Oregon, to a high of more than $16,000 in Miami-Dade.

"We really didn't see any relationship between the average network size and the size of the Medicare payments," Jacobson said.

Among the 29 private Medicare plans sold in Miami-Dade in 2015, only two offered access to 70 percent or more of the 28 hospitals in the county, according to the Kaiser study. Most private Medicare plans in Miami-Dade offered access to a "medium-sized" network, or 30 to 69 percent of hospitals in the region.

Yet even plans that covered half or less of the hospitals in the county still offered their members access to a large share of hospital beds in Miami-Dade, according to the study.

48 Average rate of Miami-Dade hospitals included in Medicare Advantage networks

For instance, Leon Medical Centers Health Plans, a Cigna subsidiary with about 44,000 members in 2015, covered 46 percent of hospitals in Miami-Dade. But those hospitals owned about 70 percent of all the hospital beds in the county.

Albert Maury, president and CEO of Leon Medical Centers, said in a written statement that the insurer offers its members a "quality network of hospitals" and that Leon is "the only medical provider to have Hospital Service Centers at most of our network hospitals staffed by our own personnel, whose mission is to serve and advocate for our patients while they are in the hospital."

Building a hospital network for a private Medicare plan requires a balance that is financially beneficial for both the hospital and the health insurer, said Mike Stubee, executive director of managed care for University of Florida Health, which operates hospitals in Gainesville and Jacksonville.

Stubee said many hospitals are not willing to accept less than the standard Medicare payment for their medical services, especially when health plans have the ability to deny claims.

And even though a UF Health hospital can offer high quality care with fewer medical errors and readmissions, he said, it's still too costly for the health plans.

"More often than not," Stubee said, "that value I can give the plan is not enough. So what they do is exclude us from the network to save a little bit of money."

Stubee said that value proposition is changing, though, as more health insurers seek arrangements that reward hospitals for keeping patients healthy as opposed to paying them for every medical service provided.

"Maybe that's the common ground they're going to find," Stubee said of hospitals and private Medicare plans, "that there are some shared incentives to work together."

A previous version of this article provided the wrong title for Albert Maury.

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