After Northern Light/Humana Break, Maine Delegation Presses CMS for Special Enrollment for Medicare

U.S. Senators Susan Collins and Angus King and U.S. Representatives Chellie Pingree and Jared Golden, in response to Northern Light Health terminating its contract with Humana, have written a letter urging the Centers for Medicare and Medicaid Services (CMS) to create a special enrollment period for Humana Medicare Advantage beneficiaries impacted by this decision.

On September 30, 2024 Northern Light Health terminated its contract with Humana, citing administrative issues. It has been estimated somewhere between 2,000 and 4,000 patients will be impacted by this decision. Given the rural nature of the region served by Northern Light Health, the inability to receive treatment at the facility could result in Maine people having to travel long distances to receive care, or forgo care completely.

Special enrollment periods (SEPs) are provided by CMS for certain life changing scenarios like moving or emergencies. In the letter, the Delegation writes that given the significant strain this decision puts on a large number of constituents who seek care at Northern Light Heath, a special enrollment period is necessary. If CMS grants the special enrollment period, new plans to bridge care access issues could become effective as early as November 1, 2024 - limiting further disruptions in care by providing an additional 60 days of coverage before any new coverage might begin January 1, 2025 as a result of beneficiaries selecting new plans during open enrollment that begins on October 15, 2024.

"We write today to share our concerns about the significant changes to the Medicare Advantage (MA) network for thousands of our constituents currently covered through Humana. Effective September 30, 2024, Northern Light Health (NLH) terminated its MA contract with Humana. As a result, many of our constituents now have inadequate or reduced network coverage through the end of this year. To bridge that coverage gap for current Humana customers, we request that CMS create a qualifying Special Enrollment Period (SEP) for all affected beneficiaries," began the Delegation.

"An SEP would help those affected patients continue to seek treatment from their current doctors with minimal disruption in coverage. It is our understanding that Humana has shared recommendations for alternative in-network hospital sites of care with NLH patients, but such alternatives pose additional challenges. For example, of the seventeen facilities to which our constituents are being directed, only two are a mile or less away from the current NLH facility. The vast majority of suggested alternative in-network facilities are at least 20 miles away, with some as far as 50 miles and one nearly 100 miles away. Furthermore, these alternative facilities may not have the capacity to take additional patients. Maine is a large rural state, and access to emergency, acute, or in-patient care can be challenging," continued the Delegation.

The full text of the letter can be found here or below.

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Dear Administrator Brooks-LaSure:

We write today to share our concerns about the significant changes to the Medicare Advantage (MA) network for thousands of our constituents currently covered through Humana. Effective September 30, 2024, Northern Light Health (NLH) terminated its MA contract with Humana. As a result, many of our constituents now have inadequate or reduced network coverage through the end of this year. To bridge that coverage gap for current Humana customers, we request that CMS create a qualifying Special Enrollment Period (SEP) for all affected beneficiaries.

The scope of Northern Light Health's service area is considerable. The system is comprised of ten hospitals and more than 120 locations and provides services throughout seven of Maine's 16 counties. Its locations span from Maine's southernmost York County, to the northernmost County of Aroostook, with a number of rural communities in between. Nearly 4,000 Mainers are expected to be affected by this contract termination. Our constituents have told us that that they are anticipating serious challenges, ranging from worries about substantial changes to cost-sharing rates to concerns about maintaining care with current providers, including for complex services like oncology. We understand that Humana has pledged a 90-day window of continuity of care, though we have serious concerns around issues of timely access to care and substandard access to care for affected constituents.

An SEP would help those affected patients continue to seek treatment from their current doctors with minimal disruption in coverage. It is our understanding that Humana has shared recommendations for alternative in-network hospital sites of care with NLH patients, but such alternatives pose additional challenges. For example, of the seventeen facilities to which our constituents are being directed, only two are a mile or less away from the current NLH facility. The vast majority of suggested alternative in-network facilities are at least 20 miles away, with some as far as 50 miles and one nearly 100 miles away. Furthermore, these alternative facilities may not have the capacity to take additional patients. Maine is a large rural state, and access to emergency, acute, or in-patient care can be challenging.

The timing of the Humana-NLH contract termination has also posed unique challenges that are not adequately addressed by the upcoming MA open enrollment period. Although all beneficiaries will have an opportunity to make changes to their coverage between October 15 and December 7, those new plans will not take effect until January 1, 2025. Having to navigate new care options for the remainder of the year, while also selecting coverage for 2025, is confusing and risks leaving many patients with inadequate coverage or care, or even unaware of these sudden changes. Approving an SEP for all affected Humana-NLH beneficiaries would minimize these challenges during the remaining three months of 2024, while easing the transition to new coverage or a new provider in 2025.

Special enrollment periods for MA have been approved by CMS to help beneficiaries maintain access to MA plans when their circumstances change, including when individuals are affected by a significant change in a plan provider network or when other certain exceptional conditions are met. CMS has also approved SEPs to help address changing circumstances that beneficiaries face so that that they have access to the best plans when possible. For example, the Contract Year 2021 notice of Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, and Medicare Cost Plan Program made some of the most notable recent changes, with CMS announcing the addition of more than 20 new SEP categories that qualifying MA beneficiaries could use. Additionally, beneficiaries enrolled in MA have the option to use an SEP at any time to enroll in an MA plan offered by an MA organization with a Star Rating of 5 stars. Unfortunately, Maine currently does not have any 5-star plans and thus our affected constituents enrolled in MA cannot use that pathway. MA SEP regulations related to significant changes in plan provider networks could arguably apply to our affected constituents.

The Humana-NLH contract termination represents a significant change to the plan provider network, affecting thousands of Mainers. We urge CMS to use its existing authority to authorize an SEP for all Maine MA beneficiaries affected by this change. Thank you for your attention to this matter.

Sincerely,

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