News

Contact: Mary Roberts

North Platte, Neb., November 17, 2023 –A large community employer is changing its healthcare plan for retirees to the United Healthcare Medicare Advantage Group plan.

The information below is specific for Great Plains Health patients who have the option of health benefits through the Group Iron Road Medicare Advantage plan. If you see any clinic or provider outside of Great Plains Health, please call that provider directly to discuss your coverage.

• Great Plains Health is out of network for this plan.
• However, GPHealth primary care providers and specialists will continue to see patients who are under this plan.
• GPHealth patients can continue care as normal.
• At this time, our understanding from Iron Road officials is that being out-of-network will have limited impact on out of pocket costs for GPHealth patients.
• Based on the information we requested from Iron Road, our understanding is that prior authorization is not required for out-of-network care, which is good for patients of Great Plains Health. However, those documents also indicate there may still be some prior authorization requirements for in-network providers.

Here are some excerpts from their plan guide to illustrate this:

• • Some of the network benefits listed may require your provider to obtain prior authorization. You never need approval in advance for plan covered services from out-of-network providers. Please refer to the Evidence of Coverage for a complete list of services that may require prior authorization.

Until we begin to process claims under this plan, we do not know how this will impact patients. Our experiences indicate that prior authorization can delay care.

• We encourage all patients to consider thoughtfully their own health needs and history as they make any decision about their healthcare coverage.
• As you weigh options for coverage, we encourage you to talk to someone you trust.
• For an objective consultation, call the State Health Insurance Assistance Program (SHIP) at 1.800.234.7119 or visit https://doi.nebraska.gov/consumer/senior-health.
• Helpful questions to ask a benefits manager are:
  • What will be my maximum out of pocket?
  • Is my local primary care provider in network or out of network?
  • Are my specialists in network or out of network?
  • What home health services are in network and which are out of network?
  • What skilled nursing facilities are in network and which are out of network?
  • Which services require preauthorization if I am in network?
  • Which services require preauthorization if I am out of network?

Q&As

What is the difference between an Individual Medicare Advantage plan and Group Iron Road Medicare Advantage plan?

Based on the information we currently have, there are differences between the Group Iron Road Medicare Advantage plan and individual Medicare Advantage plans. Our understanding is that the Group Iron Road Medicare Advantage plan will pay in-network or out-of-network providers and will have no cost share for the beneficiaries. There may be additional differences that are referenced in your plan documents.

Will my out of pocket costs change if I switch to the Group Iron Road Medicare Advantage plan?

Based on our understanding of information we requested about the Group Iron Road Medicare Advantage plan, there will be no out of pocket expense to the patients. The information indicates that additional charges may be covered by the plan. We have been advised that the Group Iron Road Medicare Advantage plan will allow patients to see any providers that accept traditional Medicare.

What is preauthorization (or prior authorization) and how does that work through this plan?

Prior authorization is a process where the provider/facility has to contact the insurance and get authorization to bereimbursed for ordering/performing certain services for patients. Through this process, the insurance determines if theservice is covered by the plan, if the service is medically necessary, and if the service requested fits within the specificpolicy of the insurance.

From what we have been told, prior authorization will not be required for out of network providers; however, it does appear in the plan documents that there are prior authorization requirements for in network providers. There is still much that we do not know about this plan.

If I switch to the Group Iron Road Medicare Advantage plan, and want to return to a traditional plan, what does that process look like?

To elect to return to a traditional Medicare plan, you will be required to wait until open enrollment season, held annually in October, November and December, and there may be additional requirements if you are also seeking a supplemental insurance to traditional Medicare. Supplemental insurance companies may rerate you and it may cost more for supplemental coverage depending on pre-existing conditions.

What should my next steps be as I consider my options?

Each individual must consider their personal situation based on health history, healthcare needs and ongoing care. Review plan documents carefully and ask questions. You can reach out to the State Health Insurance Assistance Program (SHIP) at 1.800.234.7119 or go to https://doi.nebraska.gov/consumer/senior-health. You can also learn about Medicare health plan options by calling 1.800.MEDICARE.

Why is Great Plains Health out of network for Medicare Advantage plans?

Great Plains Health has elected to remain an out of network provider for a number of complex reason, largely surrounding the negative impact that individual Medicare Advantage plans have on Great Plains Health, its providers, critical access hospitals and the greater healthcare community.