Aultman Hospital no longer 'in network' for Humana Medicare Advantage

• Aultman and Humana had been negotiating since the start of the year.
• The change affects Humana's Medicare Advantage patients.
• Hospitals nationwide have been reporting similar problems with Medicare Advantage insurers.

Thousands of patients insured through Humana's Medicare Advantage plans are no longer "in network" at Aultman hospitals.

Adam Luntz, senior vice president of finance at Aultman, said the contract between the nonprofit health system and private insurance provider ended July 1. Aultman mailed notices to about 7,000 patients who used Humana in recent years at facilities throughout Stark, Tuscarawas, Carroll, Holmes and Wayne counties.

"This termination affects the Medicare Advantage patients, and that’s the bulk of the enrollment in our market," Luntz said.

Humana also has some commercial insurance plans and a Medicaid plan, he said, but Aultman was not part of those networks. Aultman and Humana had been negotiating two key issues since the start of the year.

“They are not paying us as a Medicare plan should but secondarily, it’s just all the administrative burden and delays,” Luntz said.

Humana provided The Canton Repository with a prepared statement:

"Aultman terminated its Humana agreement, effective July 1. Humana maintains a strong network of providers in Stark County, and we are working with our Medicare Advantage members to help them select new in-network providers to ensure their care is not interrupted. We understand that changing health care providers can be difficult and we encourage our members to call the Humana Customer Care phone number on the back of their membership card if they need personal assistance."

Aultman also encouraged any patients with questions to call 330-363-0475.

Uncertain future with Humana

Luntz said it's the first time in his 21-year career with Aultman that the health system was unable to resolve issues with an insurance provider during negotiations. Aultman would like to work with Humana on a new contract to return to the network but, Luntz said, "the ball is in Humana's court."

He doesn't anticipate future issues with other existing insurance providers but said hospitals nationwide have been reporting similar problems with Medicare Advantage insurers.

“We’re seeing more and more of this happen across our industry, across the country," Luntz said. "We are just kind of the unfortunate local example.”

Medicare v. Medicare Advantage

The original, publicly-funded Medicare plan consists of two parts ― hospital insurance, Part A, and medical insurance, Part B. It covers hospital stays, preventative services and medical tests. It doesn't cover long-term care, eye exams or dental care, among other services, but people can add supplemental insurance, known as Medigap, from private insurance companies.

There's also an alternative to the original plan ― Medicare Advantage. That consists of health plans offered by private insurance companies, such as Humana, that contract with Medicare and receive federal funding. Aultman also has its own Medicare Advantage plans under the PrimeTime Health Plan.

Luntz said Aultman will continue to serve Medicare Advantage patients who are in the midst of ongoing treatment, such as chemotherapy or radiation for cancer, until that care is completed. Emergency services are provided regardless of a patient's insurance status.

Patients with traditional Medicare and the Humana supplement plan are not affected. Other patients could continue to use Aultman with their out-of-network benefits, which might result in additional costs.

"We’re here for the community," Luntz said. "This is kind of a business negotiation, and we don’t want to put the patients in the middle of that but, unfortunately, in some situations they are.”

Patients in the middle of Humana vs. Aultman

Dan Fonte, a Canton resident and board member with the Ohio Alliance for Retired Americans, is insured through the Plumbers and Pipefitters Local 94 union welfare plan, which is managed by six trustees. It covers active and retired members and their spouses.

The plan used original Medicare until 2023, when the trustees switched to Medicare Advantage in an attempt to save money, Fonte said. More than 220 union members ranging in age from 65 to 100 and some spouses were affected by Aultman's termination of Humana.

“This particular situation, it’s affected a lot of people," Fonte said.

Fonte was able to submit a Humana Continuity of Care form to temporarily extend his coverage through December because of medical issues related to his heart. He has not had a good experience with Humana's Medicare Advantage plan, though, and said every recent medical test required pre-authorization that delayed care by weeks.

He never had that issue with traditional Medicare. Fonte said he should be able to return to that but supplement plans are not as good as they once were because of a nationwide shift toward private plans.

"Medicare Advantage has been a total disaster since it was invented in 2003 under the Medicare Modernization Act," he said. "And my opinion is, and I think I'm right, this was designed to privatize Medicare and get it out of the hands of the government."

Kevin Davis, 68, of Kimbolton in Guernsey County, was born at Aultman Hospital and most of his medical care has been in the Canton area. He said he hopes to stay healthy until he can change his insurance rather than doctors.

"I was just more familiar with the Canton area," he said. "I was from Stark County most of my life."

Davis said he's now in a health care "desert" without a major hospital system nearby. He mentioned fewer locally based options as major hospital systems have acquired regional ones, such as the Cleveland Clinic Mercy Hospital, and questioned whether Aultman offering both health care and insurance didn't also monopolize the market.

"You're really getting funneled into some of these hospital chains whether you like it or not," Davis said.

Reach Kelly at 330-580-8323 or kelly.byer@cantonrep.com