When Ascension Wisconsin left UnitedHealthcare’s network of hospitals and clinics on Oct. 1, older residents in southeastern Wisconsin were among the hardest hit.
Tens of thousands of them hold private health plans sold by UnitedHealthcare, called Medicare Advantage. Those plans are an alternative to traditional Medicare, the government health insurance program for people age 65 and older.
UnitedHealthcare is the dominant insurer selling Medicare Advantage plans in the area.In Milwaukee County, the health insurer had around two-thirds of the Medicare Advantage market share last year, according to a data analysis by KFF, a health policy research organization. A little over 100,000 Milwaukee County residents were enrolled in Medicare Advantage in 2024.
Now they are seeing a disruption to their plans’ network of doctors, after Ascension Wisconsin and UnitedHealthcare failed to agree to a new contract, and Ascension’s physicians and other providers left the network.
Here’s some answers to questions about the impact on people with Medicare or Medicare Advantage plans.
I have a Medicare Advantage plan through UnitedHealthcare. Am I affected?
Yes. Ascension Wisconsin hospitals, physicians and other providers are no longer in-network for people with a Medicare Advantage plan through UnitedHealthcare.
Depending on the type of Medicare Advantage plan you have, you may still be able to see your Ascension physician. However, you might have to pay more in out-of-pocket costs than you would for a physician in your plan’s network.
I have a Medicare Supplement plan through UnitedHealthcare. Am I affected?
No. If you have original Medicare and a supplemental plan, also known as Medigap, through UnitedHealthcare, you are not affected, according to the insurer.
People with original Medicare may see any doctor who takes Medicare and are not restricted to a network of doctors.
What about Medicare prescription drug plans through United? Are they affected?
No. There is no impact on Medicare prescription drug, or Part D, plans through UnitedHealthcare, according to the insurer.
Can I change Medicare Advantage plans before Oct. 15 when the open enrollment period begins?
Yes. You may be able to change Medicare Advantage plans or return to original Medicare immediately.
If there is a significant change in your plan’s provider network, you may qualify for a special enrollment period, when you are allowed to make changes to your plan outside of the open enrollment period.
Call 1-800-MEDICARE (1-800-633-4227) to say you think you qualify for a special enrollment period and would like to change plans.
You can say you qualify because of a significant disruption in your network, said Todd Catlin, partner at Transition Health Benefits, a Brookfield-based independent brokerage agency.
Separately, you may also switch plans outside of the open enrollment period if you are switching to a Medicare Advantage plan with a five-star rating from the federal Centers for Medicare and Medicaid Services, Catlin said.
The only such plan in southeastern Wisconsin is sold by Network Health, he said.
Which insurers offer Medicare Advantage plans that have Ascension Wisconsin in their network?
According to Catlin, these insurers sell Medicare Advantage plans in southeastern Wisconsin that include Ascension providers in the plan’s network:
Does it make a difference what kind of Medicare Advantage plan I have?
There are different types of Medicare Advantage plans:
In general, Medicare Advantage plans that are PPOs give enrolled members more flexibility to see providers outside of the network than HMOs do.
Generally, HMOs cover only services provided by hospitals, physicians and other providers in their networks.
HMO-POS plans cover only certain health care services from providers outside of the plan’s network, typically at a higher cost.
Meanwhile, PPOs cover services from virtually any provider, but typically have higher cost-sharing for providers not in the plan’s network.
“The insurance company is going to pay some portion but it’s usually less than what they’re going to pay in-network, and it’s going to make you responsible for more out-of-pocket costs,” Catlin said.
UnitedHealthcare says that people enrolled in its Medicare Advantage PPO and Group Retiree plans may receive care from an out-of-network provider that participates in Medicare and accepts the plan.
UnitedHealthcare recommends speaking with the provider to confirm they will provide care, regardless of their network status.
However, people with PPO plans risk having to pay more by seeing an out-of-network provider.
According to UnitedHealthcare, for people with a Group Retiree PPO plan, their share of the cost is typically the same as if the provider was part of the network.
The federal Centers for Medicare and Medicare Services recommends calling the plan before seeking services from an out-of-network provider to make sure they are covered.
What resources are available if I have questions about Medicare or related coverage?
The Medigap helpline, at 1-800-242-1060, provides guidance on Medicare and is run by the Wisconsin Board on Aging and Long-Term Care. You may also email BOALTCMedigap@wisconsin.gov to reach insurance counselors with the helpline.
Medicare.gov has helpful information for Medicare members. You may also call 1-800-MEDICARE (1-800-633-4227) with questions.
This article originally appeared on Milwaukee Journal Sentinel: Do you receive Medicare? What to know about the Ascension Wisconsin and UnitedHealthcare split
Reporting by Sarah Volpenhein, Milwaukee Journal Sentinel / Milwaukee Journal Sentinel
USA TODAY Network via Reuters Connect
