WakeMed is Out-of-Network with Humana Medicare Advantage

WakeMed has been working diligently for an extended period of time to reach a reasonable new contract with Humana regarding their Medicare Advantage plans. Unfortunately, an agreement has not been reached and the contract terminated as of 12:01 am, October 31, 2023.

As a result, WakeMed hospitals, outpatient facilities, physician practices, freestanding ASCs and 210 PET, LLC, are no longer considered part of the Humana Medicare Advantage (MAP) network.

Much of the discussion to date has been around Humana’s high rate of denials on hospital care after that care has been provided, and the resolution process for disputes when these denials occur. Additionally, WakeMed has asked for contract language that would ensure Humana will abide by new Centers for Medicare & Medicaid Services (CMS) guidelines that take effect January 1, 2024.

When Humana denies claims for care that has already been provided, our patients may have significantly higher out-of-pocket costs. We believe your need for medical care should be determined by you and your doctor, not an insurance company. The decisions our physicians make about your care are based on best practices and evidenced-based medicine. Humana has a demonstrated history of making decisions that are often in conflict with these best practices.

As a not-for-profit, safety net health care system, fair and equitable contracts with health insurance companies is vital to our mission to improve the health and well-being of our community. For more than 60 years, we have been committed to caring for each member of our community – and we understand how important it is to have access to high-quality care, close to home.

Impacts to Your Care

WakeMed is committed to caring for our community and we recognize how difficult this situation is for the patients we serve. We are committed to communicating with our existing Humana MAP patients to ensure they understand the impact that this contract termination will have on them and their financial responsibility for care received.

A summary of impacts to the various Humana Medicare Advantage plans is below:

• NC Retiree/State Health Plan Members: While we have not signed a written agreement with Humana, we have agreed to continue scheduling elective services for NC Retiree members while negotiations are ongoing. In general, we will continue to schedule these patients if the State requires Humana apply the same administrative rules currently in place for this plan, as their benefits coverage will not change. The State’s benefit coverage does not change when a member receives treatment from an out-of-network provider, unlike Humana’s non-NC Retiree/State Health Plan members.
• Humana MAP PPO Members: Humana PPO plans offer some out-of-network benefits. Patients with these plans can continue to seek non-emergency care from a WakeMed facility, outpatient clinic or at a specialty WakeMed Physician Practice; however, patients may see an increase in out-of-pocket costs for out-of-network care for which you will be responsible. A deposit will be required in most instances. In addition, for many services, pre-authorization will be required and that must be obtained prior to care delivery.
• Humana MAP HMO Members: The Humana HMO plans do not have any out-of-network benefits. As a result, these patients will be fully responsible for the cost of their care. WakeMed understands these patients may seek care with Humana participating providers to be covered.

Continuity of Care

Humana Medicare Advantage members (HMO and PPO) who are currently in an ongoing treatment program at WakeMed may qualify for a Continuity of Care exception. These individuals should contact Humana to initiate this process. Our WakeMed providers and staff are available to assist with completion of any required documents. Humana is required to offer Continuity of Care coverage when appropriate to ensure their patients have uninterrupted access to the care they need. Members should contact Humana with any questions or concerns about navigating this process.

Any patient who needs immediate care, regardless of their insurance status, may still seek treatment at any of WakeMed’s seven Emergency Departments.

We recognize how difficult this situation is for the patients we serve. Patients are the heart of everything we do, and we continue working to come to a fair and equitable agreement with Humana. Should we reach an agreement, we will let our patients know as soon as possible.