Medicare shift tightens doctor, clinic networks in Minnesota

Oct. 27--Big changes in the state's Medicare market highlight the need for shoppers to check which doctors and hospitals are part of the network when sizing up new health plan options.

More than 300,000 people in Minnesota are being pushed into new coverage for 2019, and they are finding a market with more Medicare Advantage plans that limit the number of doctors and hospitals providing care at lower in-network rates.

Insurers that sell Advantage plans argue that their networks come in a variety of sizes -- some very big, and others more narrow -- that provide good choices for patients. Even so, the limits seem to be one reason some shoppers are considering a return to original Medicare plus a Medigap supplementary policy, which brings more choice but generally with higher premiums.

"For 2019, what people are finding is that networks have changed -- they are smaller with many of the plans, and as a result people are finding they [might] need to look at other options if they want to stay with their doctor, clinic or hospital," said Kelli Jo Greiner, health policy analyst with the Minnesota Board on Aging. "A lot of people are looking at Medigap as an option, whereas previously they did not."

Open enrollment for people in Medicare started earlier this month with big changes in the lineup of Medicare health plans. Federal law is forcing health insurers next year to eliminate Medicare Cost plans across 66 counties in Minnesota, resulting in more than 300,000 people switching coverage all at once. Many are looking at Medicare Advantage and Medigap plans, as a result.

Nationwide, Medicare Advantage plans during the first half of 2018 saw premium revenue grow 10 percent year-over-year to $93.9 billion, according to Mark Farrah Associates. The Pennsylvania-based market data firm says insurers across the country saw premium revenue from Medicare supplement policies grow in 2017 to $29.9 billion.

A network is the list of doctors and hospitals that have agreed to participate with any given health insurance plan. Most Medicare Advantage plans in Minnesota let patients go outside the network for care, state officials said, but with higher cost-sharing requirements.

Insurers limit the network of doctors and hospitals to manage costs. Some health care providers trade discounts on their service costs for the chance at a higher volume of patients through the agreements. Plus, there's an argument that when care is focused on a subset of providers, those doctors and hospitals can better coordinate care for efficiency.

"The thing to keep in mind is: There can be substantially higher costs if you go to a doctor who is not in-network," said Lukus Zuker, a community outreach specialist with the state's Senior LinkAge Line, during an information session last week in Woodbury.

For more than a decade, the government has been pushing to end the Cost plans due to cost concerns. They will disappear next year in 66 counties across Minnesota including Hennepin, Ramsey and others in the Twin Cities metro, while remaining in 21 counties including the northeast corner of the state.

More variation

Whereas the Cost plan networks in Minnesota have been big and stable, there's more variation in the number of doctors and hospitals that participate in Medicare Advantage plans, said Joshua Haberman, owner of Alexander & Haberman, a Bloomington-based insurance agency.

Some Cost plan enrollees are being steered toward a Medicare Advantage plan from their existing health insurer that's comparable in terms of out-of-pocket costs, but doesn't necessarily provide in-network access to their doctors and hospitals. Subscribers have the choice to pick a different plan, so Cost plan enrollees should look closely at the network details.

At Bloomington-based HealthPartners, some Cost plan enrollees in the metro are being directed to a Medicare Advantage plan that doesn't provide in-network access to clinics and hospitals run by Allina Health System, Fairview Health Services or the Mayo Clinic.

HealthPartners said in a statement that it's keeping premiums low in the Medicare Advantage plan "by focusing care on a network of providers who deliver quality care at a lower cost." Subscribers who want access to those health systems can opt for the company's Medicare supplement products, the insurer said.

At Minnetonka-based Medica, Cost plan enrollees could find themselves steered toward a Medicare Advantage plan where the network doesn't include hospitals and clinics in the HealthPartners and Park Nicollet systems. The insurer said in a statement that it expects some Cost plan enrollees, but not all, will balk at the network restrictions.

"We believe these beneficiaries are more likely to purchase a Medicare supplement plan," Medica said in a statement. "Conversely, there are beneficiaries who are overwhelmed by their complex conditions, and welcome the more integrated provider support of a narrower network."

Less choice in some areas

Eagan-based Blue Cross and Blue Shield of Minnesota said it's steering some Cost plan enrollees toward a Medicare Advantage (MA) plan with a large network that's generally comparable to what consumers already have, particularly in the Twin Cities and western Minnesota. That's less true, however, across 16 counties in southeast Minnesota, where Allina notified patients this month that its hospitals and clinics would not be part of the Blue Cross network for Medicare Advantage plans.

Joel Stich, a senior director at Blue Cross, said Thursday that Blue Cross and Allina recently came to an agreement whereby Owatonna Hospital will be in-network, but Allina's New Ulm Medical Center is still out-of-network.

People losing their Cost plans who aren't being steered to a particular Advantage plan still need to watch for potential network issues, too, just like all Medicare beneficiaries considering 2019 options during the current open-enrollment period. Insurers in Medicare are continuing a trend of developing accountable care organization (ACO) health plans that steer patients to care from a relatively small group of doctors and hospitals.

Blue Cross is launching an ACO in the Twin Cities in conjunction with Minneapolis-based Fairview Health Services. Minneapolis-based UCare is launching an ACO-style health plan in the Twin Cities with Fairview and North Memorial, while expanding an ACO in the Duluth area with the Essentia Health network of hospitals and clinics.

The new Advantage plan from Allina-Aetna in the Twin Cities focuses on care provided at Allina Hospitals and clinics, although a spokeswoman said other providers are included.

Minnetonka-based UnitedHealthcare says its new Medicare Advantage options for Minnesota have broad provider networks, but a search of the company's website shows Mayo Clinic is not included. Kentucky-based Humana is expanding the number of products in Minnesota, but says it isn't selling here any ACO products.

"You can get very good care in a narrow network," said Haberman, the insurance agent. But he added: "They are funneling it. You get some nice things in exchange for that funnel in terms of premiums and other benefits, but you are giving up some access and some choice."

Hard to compare networks

There's no set definition for what constitutes a big network of health care providers vs. a small or narrow network. It can be difficult to compare exactly how big networks are at different health plans, Haberman said, because insurers don't always count providers the same way. The Medicare website lists how many total providers are in different plans, but Greiner of the Minnesota Board on Aging says they aren't a great way for individuals to shop.

"Those provider numbers are all types of Medicare providers ... it's not just doctors, clinics and hospitals," she said. "To really get a clear picture of the providers that participate, they need to go to the health plan website."

While Medicare supplements might look really good from a network perspective, the difference with some Advantage plans can be smaller than consumers might think, said Ghita Worcester, a senior vice president with UCare, which has been the largest seller of Medicare Advantage plans in Minnesota for several years. The insurer said that 96 percent of all provider locations in the state are included in the network for its most popular plans.

"We are selling on that," Worcester said. She added: "People have different goals, and if you look at the price for a Medicare Advantage plan vs. a Medigap plan, there can be significant differences."

Combined with the variation in premiums, out-of-pocket costs and pharmacy benefits, the network wrinkles have contributed to a tough open enrollment season for Medicare consumers, complete with plenty of frustration. There were hints of that unhappy mood during the information event last week in Woodbury, where roughly a dozen people were in attendance.

Over the course of an hour, Zuker of the Senior LinkAge Line pointed out that people leaving Cost plans have a particular reason this year to give Medigap policies a look, since they will have a special one-time "guaranteed issue" right to the coverage starting Nov. 2. At other times, people can be denied access to Medigap plans based on their health history.

At the conclusion of the presentation, June Rhoads, 69, of Woodbury summed up the choice facing Medicare consumers in Minnesota as "mind-boggling." She's sorry to be losing her Cost plan from Blue Cross, and isn't thrilled about the process of picking a new plan.

"This is hard," Rhoads said. "It really is a hard transition."

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