UnitedHealthcare Medicare Advantage patients to lose in-network benefits at Valley Health

Patients insured through UnitedHealthcare Medicare Advantage will soon lose in-network benefits at Valley Health facilities, including Winchester Medical Center.

Roughly 8,000 patients in Virginia and West Virginia — including about 1,900 in Winchester and Frederick County — are affected, officials with the Winchester-based regional healthcare system estimate.

A contract between the two parties will expire Sept. 30. Recent negotiations toward a new pact enabling Valley Health to remain in network with the insurer for Medicare Advantage failed.

"We gave United a proposal we considered fair and would partially offset the reimbursement reductions created by excessive denials and administrative challenges," said Craig Connors, Valley Health's vice president of revenue cycle and payor relations

"United rejected our proposal without a counterproposal," Connors continued. "So both parties agreed to stop any further negotiations and to work together on transition planning."

Valley Health announced the impasse in a letter dated Aug. 18 and sent to its UnitedHealthcare patients with Medicare Advantage coverage.

Medicare Advantage, also known as Part C, is an alternative to Original Medicare. It's offered by private insurance companies approved by the federal health insurance program, which mostly serves older adults.

Advantage plans bundle hospital and regular medical coverage. Also, they frequently include Part D prescription drug benefits, plus extras such as dental or vision benefits.

Both individual and group Medicare Advantage plans will become out-of-network at Valley Health facilities effective Oct. 1. As a result, patients covered by the plans may pay higher out-of-pocket costs or see their coverage for services received from Valley Health reduced, according to Connors.

However, "emergency care will continue to be covered regardless of network status," Connors said.

"Medicare Advantage plans are required to cover emergency and urgently-needed services, including those received out of network," he emphasized.

To help patients with the transition, Valley Health will file out-of-network claims with UnitedHealthcare through Dec. 31. Those insured will owe any out-of-network cost shares, the letter to patients states.

At the start of 2027, though, Valley Health will directly bill patients who use out-of-network benefits. Patients will be expected to pay Valley Health the Medicare rates for services they receive. They will then have to submit their own reimbursement claims to UnitedHealthcare, using forms on the company's website, according to the letter.

"Impacted patients need to check their benefits plans carefully," Connors said, "to understand whether they have out-of-network benefits and how their financial responsibilities change when accessing care at out-of-network providers."

The letter to UnitedHealthcare Medicare Advantage patients outlined the following coverage options they may want to consider:

Continuity of Care protections for those with scheduled surgeries or undergoing care for serious or complex medical conditions.

If approved by the company, the protections let patients continue seeing Valley Health care providers at in-network benefit levels. Patients can call UnitedHealthcare at the number listed on their identification cards.

A special enrollment period during which those insured can change their Medicare Advantage plans or switch to Original Medicare.

The period must be approved by the Centers for Medicare and Medicaid Services. Patients can call 1-800-MEDICARE (or 1-800-633-4227) to ask about the option.

Changing their plans during the annual Medicare Open Enrollment Period from Oct. 15 through Dec. 7. Changes made during the period will become effective Jan. 1.

Patients can go online to valleyhealthlink.com/United or call 1-888-472-0045 for more information.

Valley Health and UnitedHealthcare are continuing negotiations pertaining to commercial health insurance plans obtained through employers or the insurance marketplace. Yet those could become out-of-network, too, if an agreement is not reached by Sept. 30, Valley Health officials said.

UnitedHealthcare has agreed to terms that will continue coverage for Medicaid patients, as well as armed forces veterans receiving Community Care Network benefits, they said.