Insurance Coverage Changes at South Shore Health
Possible terminations are coming, but it really varies by insurance provider and the services patients need. Starting January 1, about 3,900 patients enrolled in United Medicare Advantage plans will find South Shore Hospital and South Shore VNA out of their network. Additionally, physicians and healthcare workers there will no longer be in-network beginning in May, with urgent care services at the Health Express Clinic following suit in mid-October.
On the same day, another 2,200 patients with Tufts Health Direct insurance received notifications that their access to hospital and physician services might also change. Emergency medical services are set to be taken out of network in September.
In communication directed at Tufts patients, South Shore Health indicated that any scheduled treatments after December 31, 2025, would be canceled. This includes surgeries, lab tests, physical exams, and radiology services. It’s a bit concerning, really.
Some patients, however, might still get treatment depending on their insurer’s guidelines. Access could be maintained for serious and complex conditions for up to 90 days, continuing care for those currently hospitalized, and treatment for terminal illnesses and women up to six weeks postpartum.
Negotiations are ongoing. It seems unlikely that an agreement will be reached with United Medicare Advantage, but the health system has managed to extend its contract with United Healthcare for employer-sponsored plans until February. They’re still attempting to hammer out new terms for those members.
United Healthcare did not respond to inquiries regarding the situation.
South Shore Health is also in discussions with Point32Health, which oversees both Tufts Health Plan and Harvard Pilgrim Health Plan. A spokesperson from Point32Health mentioned that affected members have been informed about the potential changes and given guidance on selecting new primary care providers or specialists if necessary. They emphasized prioritizing members to minimize disruptions.
This ongoing conflict stems from larger issues, like the recent disputes involving Blue Cross Blue Shield of Massachusetts and Massachusetts State University Mass Memorial Health. That situation nearly impacted around 200,000 patients, shedding light on the volatility in contract negotiations lately.
Experts suggest that such disputes are likely to persist. Healthcare providers are under increasing pressure due to shifts in federal Medicaid and NIH funding, all while trying to manage rising healthcare costs for their employees. Meanwhile, insurers are grappling with higher healthcare utilization and escalating drug and provider costs.
In this climate, health systems are pushing for hefty increases during contract discussions with insurance companies, while the insurers themselves are hesitant, facing significant financial losses.
Sara Iselin, CEO of Blue Cross Blue Shield of Massachusetts, noted recently that, during her tenure, nearly every negotiation began with hospital systems asking for increases between 10 to 15 percent. It certainly highlights the tension that will likely be felt in the upcoming years as stakeholders try to strike a balance between what consumers can afford and the actual costs of running healthcare facilities.
