People with this Medicare plan could soon go out-of-network at UHealth hospitals

South Floridians enrolled in certain Medicare Advantage plans could soon find themselves locked out of in-network care with the University of Miami Health System.

UHealth patients insured through a Medicare Advantage plan that is part of Florida’s Preferred Care Network, a UnitedHealthcare-owned company, are on notice: If UHealth and United don’t make a new contract soon, their primary and specialty doctors at UHealth could be out-of-network with the insurer as early as September.

Patients with Medicare Advantage plans through the Preferred Care Network have told the Miami Herald they’ve begun to receive letters from United warning them about the potential coverage change.

United, the largest health insurer in the nation, confirmed to the Herald this week that the warning comes as it continues to negotiate “in good faith” to try and strike a deal with the private health system. And the deadline to make a deal is nearing, both for Preferred Care Network members and for members enrolled in commercial and Medicaid plans.

The heated negotiations are over reimbursement rates. UHealth is accusing United of not paying it enough for care. United is accusing UHealth of wanting too much money. It’s similar to the still ongoing and stalled contract disputes between Broward’s public health systems and Florida Blue, one of the largest insurers in the state.

Here are the key things to know.

If UHealth and United don’t make a deal, the hospital system — including the renowned Sylvester Comprehensive Cancer Center and Bascom Palmer Eye Institute — would be out-of-network within the next two months for thousands of people across South Florida enrolled in United-managed plans.

If a deal is not made, members insured through United’s Preferred Care Network Medicare Advantage plans would be out-of-network with UHealth starting Sept. 1. UHealth is already out-of-network for all other United Healthcare Medicare Advantage plans.

For all other United members, if no agreement is reached, UHealth would be out-of-network even earlier, starting Aug. 1. That includes people with employer-sponsored commercial plans, Medicaid (UnitedHealthcare Community Plan of Florida) and Individual Family Plans, which are health insurance plans a person purchases on their own, usually through the Affordable Care Act marketplace.

UnitedHealthcare says it has a “large network of providers” across South Florida, including Baptist Health Medical Group, HCA Florida Mercy Hospital, Nicklaus Children’s Hospital and Mount Sinai Medical Center.

South Florida’s three public hospital systems — Jackson Health System in Miami-Dade County and Broward Health and Memorial Healthcare System in Broward County — all accept some United health insurance plans, according to their websites.

The fastest way to find a doctor near you is to use United’s online doctor search. Patients should always call to double-check that the provider will accept your insurance.

United’s Preferred Care Network Medicare Advantage plans provide health maintenance organization (HMO) plans with prescription drug coverage across Miami-Dade and Broward counties. Some plans may also offer additional benefits, including vision, dental, rides to appointments, over-the-counter medications and a fitness program.

Over 41,000 people across Miami-Dade and Broward counties are enrolled in plans through Preferred Care Network, according to the National Committee for Quality Assurance (NCQA), an organization that measures and accredits health plans.

Patients with HMO plans are required to choose a primary care provider as their main doctor and must get care with doctors and other providers who are in the plan’s network and service area. United Healthcare describes HMO plans as an insurance that usually offers lower premiums, deductibles and cost-shares. However, there’s also no out-of-network coverage with an HMO plan.

“If you get care from any out-of-network provider (like a doctor, surgeon or lab for bloodwork), you’ll be required to pay the full cost of that service,” reads United Healthcare’s website. “The only time an HMO plan will cover out-of-network services is if it’s emergency care.”

READ MORE: Should you get original Medicare or an Advantage plan? Here’s what to know

If no deal is made, people with the aforementioned health insurance plans through United will no longer be able to get in-network care with UHealth doctors and other providers across UHealth’s South Florida facilities. That means you’ll either have to change doctors or pay out-of-pocket for treatment. And that can be costly.

It’s worth noting that if UHealth were to go out-of-network, patients who are undergoing treatment for serious or complex conditions, such as people who are pregnant or undergoing active cancer treatment, would be eligible to continue receiving in-network care with UHealth for 90 days due to a federal law that requires insurers to provide continuity of care.

“UnitedHealthcare members must apply and be approved for continuity of care. People can apply at any time from now through 30 days after a provider has left our network,” UnitedHealthcare wrote on a webpage about the ongoing negotiations. “They should call the number on their health plan ID card if they need assistance or have questions.”

The good news is that UnitedHealthcare, like most health insurers, is required by law to cover emergency care at UHealth and other ERs at in-network rates, even if the emergency room is out-of-network.

It doesn’t matter if the patient is hospitalized or goes home the same day. If it’s an emergency, health insurance will cover it at in-network rates, according to Patricia Kelmar, senior director of healthcare campaigns at PIRG, a nonprofit that advocates for consumer protections, public health and environmental sustainability.

But beware: ER doctors decide the necessary treatment, but it’s the health insurer that ultimately determines whether the provided services fall under emergency care for in-network rates, Kelmar previously told the Herald.

TIP: ERs are meant for life-threatening or potentially life-threatening symptoms and conditions, such as if you’re struggling to breathe or have chest pain or numbness on one side of the body. Urgent care is the place to start for everything else, like a cough, sore throat, runny nose or diarrhea. Urgent care visits are also cheaper.

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