Frequently Asked Questions:
Medicare Advantage Changes
Background information:
St. Charles Health System has been providing health care in Central Oregon for more than 100 years. As we look to stabilize our core health care services and ensure our ability to continue providing quality care for the next 100 years, we are reevaluating our participation in all Medicare Advantage plans.
Open enrollment for Medicare is Oct. 15 to Dec. 7 and we want to provide information to seniors and other residents to help make informed decisions.
What is the difference between traditional Medicare and Medicare Advantage?
Original or traditional Medicare is health care operated and funded by the federal government. Medicare Advantage plans are operated by private insurance companies.
Why is St. Charles reevaluating its participation in Medicare Advantage plans?
We have found that patients on Medicare Advantage plans tend to have longer hospital stays than necessary, are more difficult to place in skilled nursing facilities and can experience high rates of denial for health care services their physicians believe are necessary.
By bringing attention to these issues, St. Charles is looking to reduce administrative challenges for health care providers which can lead to high rates of burnout, while also strengthening the core services we provide to patients.
What plans are being affected now?
Beginning in 2024, St. Charles Health System will no longer be an in-network provider for Medicare Advantage plans offered through Humana, HealthNet and WellCare. As a result, patients who are currently on these plans may need to choose another insurance plan to avoid changes in insurance coverage or payment responsibilities.
When will St. Charles’ in-network status change for Humana, HealthNet and WellCare?
Humana changes as of Dec. 31, 2023.
HealthNet and WellCare coverage changes as of Feb. 1, 2024.
What about PacificSource?
St. Charles Health System announced recently that it has reached an agreement with PacificSource that promotes excellence in cancer care, reduces administrative burdens and keeps St. Charles hospitals and clinics in-network for PacificSource Medicare Advantage plans in Central Oregon through 2024. The agreement includes PacificSource’s Oregon Health Plan and commercial insurance plans. Learn more about the agreement.
What plans does St. Charles currently accept?
St. Charles accepts traditional Medicare.
While the health system is currently reevaluating its ongoing participation with all Medicare Advantage plans, it will begin the year accepting the following plans: PacificSource, Providence, Moda and Regence Blue Cross Blue Shield.
Visit our Insurance Information page for more information.
Can patients on Humana, HealthNet or WellCare Medicare Advantage plans switch to another Medicare Advantage plan?
St. Charles will continue to reevaluate its ongoing participation with all Medicare Advantage plans for the foreseeable future. This means if you switch to another Medicare Advantage plan, St. Charles cannot guarantee its participation as an in-network provider with those insurance plans in the future. St. Charles will continue to participate as an in-network provider with traditional Medicare and all Medicare Supplemental plans.
If you wish to explore your insurance options, we suggest contacting:
Oregon Senior Health Insurance Benefits Assistance (SHIBA) at 800-722-4134, option 2,
800-MEDICARE (800-633-4227),
Council on Aging of Central Oregon at 541-678-5483,
or an insurance broker of your choosing.
What does out of network vs in network mean?
Out-of-network refers to a health care provider who does not have a contract with a particular health insurance plan. If patients use an out-of-network provider, health care services could cost more since the provider doesn't have a pre-negotiated rate with the health plan.
Is it unusual for a health system to move away from accepting Medicare Advantage plans with insurance companies?
No. In fact, in recent years, it is becoming more common for hospitals and health systems to move away from accepting Medicare Advantage insurance plans (“Hospitals are dropping Medicare Advantage left and right”).
What about patients actively undergoing treatment for cancer care, outpatient rehab, wound care, or dialysis care?
People undergoing an active treatment plan, for these covered and approved services, will continue to receive treatment from St. Charles. This continuation of care includes patients receiving post-operative care, those with urgent/emergency medical conditions, those mid-treatment for serious medical conditions, those on high-risk medications that require monitoring, those requiring regular infusions and those on chronic controlled substances. To determine any changes in insurance coverage or payment obligations, we recommend contacting Humana, HealthNet and WellCare directly by calling the phone number on your insurance card to determine specific coverage and payment responsibilities.
Can patients on Humana, HealthNet and WellCare Medicare Advantage plans continue to be treated by St. Charles’ hospitals and physicians for other services?
Except for the above-mentioned services and Emergency Room and Urgent Care and lab services, St. Charles will not schedule or allow walk-in appointments for outpatient and elective services on or after the contract ends for patients on the affected Medicare Advantage plans (Dec. 31 for Humana and Feb. 1, 2024 for WellCare and HealthNet). We recommend contacting your health insurance provider directly by calling the phone number on your insurance card to determine specific coverage and payment responsibilities.
How do patients continue to see St. Charles physicians or St. Charles hospitals as an “in-network” provider?
To be treated by a St. Charles physician as an “in-network” provider, patients would need to change their insurance plan to an “in-network” plan like traditional Medicare.
If you wish to explore your insurance options, we suggest contacting:
Oregon Senior Health Insurance Benefits Assistance (SHIBA) at 800-722-4134, option 2,
800-MEDICARE (800-633-4227),
Council on Aging of Central Oregon at 541-678-5483,
or an insurance broker of your choosing.
Which insurance plan does St. Charles recommend?
That is a decision that each patient needs to make based upon their personal needs. You can find a list of all insurance plans that are in-network for St. Charles on our Insurance options webpage.
If you wish to explore your insurance options, we suggest contacting:
Oregon Senior Health Insurance Benefits Assistance (SHIBA) at 800-722-4134, option 2,
800-MEDICARE (800-633-4227),
Council on Aging of Central Oregon at 541-678-5783,
or an insurance broker of your choosing.
What is the deadline to make a change?
Changes should be made during the annual benefits open enrollment period, which is Oct. 15 – Dec. 7.
How can I learn more?
Individuals should contact their insurance companies to learn more about their coverage.
Our St. Charles team is available to answer questions on our call line at 541-612-8378.
Individuals wishing to explore insurance options can contact:
Oregon Senior Health Insurance Benefits Assistance (SHIBA) at 800-722-4134, option 2,
800-MEDICARE (800-633-4227),
Council on Aging of Central Oregon at 541-678-5783,
or an insurance broker of your choosing.
