Getting answers: Following up on Medicare rules for out-of-network provider coverage

(WSAW) - The Centers for Medicare and Medicaid Services is answering questions still facing some patients in central Wisconsin.

Following coverage of confusion as Aspirus sent letters to patients and negotiated or declined contracts with various insurance companies in the fall, some patients of a once popular insurance plan still have questions. 7 Investigates has been working to answer those questions and has received responses from CMS. Those being:

1. Can a Medicare participating provider ask patients insured by an out-of-network Medicare Advantage plan with out-of-network coverage to pay the full cost of care upfront, and then direct patients to seek reimbursement from their insurance provider?

2. Does a Medicare participating provider have to accept a patient insured by an out-of-network Medicare Advantage plan that has out-of-network coverage as part of the plan?

First, here is some background. For many years a popular Medicare Advantage plan covered several patients in central Wisconsin. The plan was through Network Health, an insurance company based in Wisconsin and affiliated with Ascension. The plan allowed patients to be covered at the same rate whether they sought care at in- or out-of-network Medicare participating providers.

Aspirus was never in-network with Network Health except for a period of time last year as it completed its acquisition of Ascension facilities in central Wisconsin, in particular in Stevens Point. Aspirus noted it wanted to make sure patients had a smooth transition and would be covered as the transition was completed mid-year.

Sid Sczygelski, Aspirus’ Senior Vice President of Finance and Chief Financial Officer, told 7 Investigates in October that while Aspirus had offered to “acquire the lives” -- or essentially transfer the insurance members from Network Health to its Medicare Advantage plan, the Aspirus Health Plan -- Aspirus had no interest in contracting with Network Health. Aspirus does not have to, either.

Some patients received letters saying that Aspirus would not be scheduling appointments with patients whose primary insurance coverage is with an out-of-network company. Sczygelski said they wanted to ensure patients would not be surprised by balance bills -- the amount difference between what the insurance provider covers and what the provider charges for services. However, CMS told 7 Investigates that Medicare participating providers cannot balance bill patients with Medicare Advantage plans; they have to accept the Medicare rate for services as payment in full.

That caused many patients to be confused and conflicted, as they loved their insurance coverage and the relationships they had built with their doctors. Many patients 7 Investigates followed up with over the fall and into the new year told us they had either kept their insurance and switched doctors, or they kept their doctors and switched their insurance. However, some have decided to try to keep both.

Those patients who spoke with 7 Investigates and their local Aging and Disabilities Resource Center said they asked Aspirus what would happen if they, as Network Health enrollees with that out-of-network provider coverage, scheduled an appointment with Aspirus in 2023. They explained that they were told by Aspirus that they would have to pay for the full service upfront and seek any reimbursement necessary from their insurance plan themselves. When those patients sought to get that protocol in writing they were, effectively, told that was not going to happen.

7 Investigates reached out to Aspirus for about a month to explain this protocol and why patients were being told this, but they did not provide a response. 7 Investigates asked CMS about that scenario to clarify whether a Medicare participating provider could do that and received a response from a spokesperson.

Q: Can a Medicare participating provider ask patients insured by an out-of-network Medicare Advantage plan with out-of-network coverage to pay the full cost of care upfront, and then direct patients to seek reimbursement from their insurance provider?

A: “Presuming that these are Medicare Part A or Part B services that are covered by the MA plan out of network, a provider that participates in Medicare should only collect the cost sharing that is owed by the MA enrollee and bill the MA plan for the remaining amount.”

“With respect to the Medicare Advantage (MA) program, per section 422.214(a)(2) of Title 42 of the Code of Federal Regulations (CFR), out-of-network providers must follow original Medicare statutory requirements related to payment. Responsibilities of assigned providers are codified at 42 CFR 424.55(b). In short, the requirement specifies that a provider may only bill a Medicare enrollee for deductible and applicable coinsurance amounts. Similarly, with the exception of those who have complied with Medicare’s opt-out procedures, when a physician or supplier furnishes a service that is covered by Medicare, the physician or supplier is subject to the mandatory claim submission provisions of section 1848(g)(4) of the Act.”

“When enrollees obtain plan-covered services in a Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), or Reginal Preferred Provider Organization (RPPO) from an out-of-network provider who participates in Medicare, they may not be charged or held liable for more than plan-allowed cost-sharing. Medicare non-participating providers permitted to ‘balance bill’ must obtain the amount in excess of the enrollee’s cost sharing (the balance) for services, directly from the MA plan and not from the enrollee. See section 170 of chapter 4 of the Medicare Managed Care Manual.”

So, in short, the answer is no except for any payments laid out in the patient’s plan like copays and deductibles and the patient cannot be placed in the middle between the provider and insurance company. This moves us to the next question and answer from a CMS spokesperson:

Q: Does a Medicare participating provider have to accept a patient insured by an out-of-network Medicare Advantage plan that has out-of-network coverage as part of the plan?

A: “Outside of emergency and urgent care, out-of-network providers are not obligated to see Medicare Advantage enrollees even if they are Medicare participating providers.”

So, Aspirus does not have to take on patients with Medicare Advantage plans for their regular care.

January through March is the Medicare Advantage Open Enrollment period. This gives people who are already members of a Medicare Advantage plan the opportunity to switch to another Medicare Advantage plan -- with or without prescription drug coverage -- or drop their coverage and switch to original Medicare. This open enrollment period is less flexible than the general Medicare open enrollment period in the fall.

A spokesperson for Security Health Plan explained those with original Medicare coverage cannot enroll in a Medicare Advantage plan or drug plan during this time.

“A member can make one change only during the open enrollment period, and it goes into effect the first of the month after the plan gets the change request,” the spokesperson said.

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