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Two will pull out of the area, and others will curtail their service plans. Dropped plans affect nearly 17,000 people.
By KRIS HUNDLEY
© St. Petersburg Times, published September 18, 2001
If you are one of the nearly 150,000 Tampa Bay area residents enrolled in a Medicare HMO, be prepared for changes effective Jan. 1.
BlueCross BlueShield of Florida is dropping its Medicare HMO in Hillsborough and Pasco counties, as well as in parts of Pinellas County, affecting nearly 15,000 members.
AvMed Health Plan, a much smaller player with local enrollment of about 2,200, is also dropping out of the Medicare HMO business in the bay area for next year.
Humana Inc. and United Healthcare of Florida, the two largest Medicare HMOs locally, will continue to offer plans with no monthly premium. But benefits will be pared back, and Humana will put a limit on membership.
The fifth Medicare HMO company in the area, Well Care of Tampa, will still offer coverage in Hillsborough, Pinellas, Pasco and Hernando counties. But the premium cost and benefit levels will not be made public until mid October.
In announcements made Monday to comply with a federal deadline, health insurers repeated their familiar complaints about inadequate federal reimbursement as they revealed their Medicare HMO plans for the coming year.
It's the fourth consecutive year of major withdrawals from Medicare HMOs, which were supposed to be able to deliver quality health care with extra benefits for seniors, but at a lower cost for the government than traditional Medicare.
Medicare HMOs, which receive a set amount per member per month to cover all health care expenses, are slated to get at least a 2 percent increase in reimbursements in 2002.
That will increase the reimbursement to the HMOs for Pasco County retirees to $601.42 per member per month next year, up from $589.63. In Hillsborough County, reimbursement will be $553.04, up from $536.98. In Pinellas, Medicare HMOs will receive $559.97, compared with $548.99 this year. Hernando County plans will be reimbursed $570.15 next year, compared with $558.97.
"We cannot deliver affordable, quality care to our Tampa Bay area Medicare members within the current reimbursement structure of the federal government," said Robert C. Hudson, AvMed's president and CEO.
AvMed said the gap between health expenses and reimbursement has led to a loss for the first six months of the year of $500,000 in Hillsborough County and $550,000 in Pinellas. Those losses are expected to double by year end.
An executive with BlueCross BlueShield blamed low government reimbursement, a heavy administrative burden and rising prescription drug costs for its decision to exit much of the Tampa Bay market.
"We have stayed in this market way beyond other plans," said W. Charles Scott, vice president of the Jacksonville insurer's Over 65 market. "But the economics of it are not working out."
BlueCross BlueShield's decision will mean loss of coverage for 2,600 members in Pasco County, 3,800 in Hillsborough and 8,300 in Pinellas. Another 5,700 Pinellas residents belong to the Blues' Burgundy group, which is concentrated in the Largo area and treated primarily by doctors at the Diagnostic Clinic. The Burgundy plan will be continued, although the premium, now $63 per month, and level of benefits may change.
Scott said the Pinellas group will be open to new members who live in 45 specific ZIP codes in the middle of the county, though enrollment may be limited.
Open enrollment for 2002 for all Medicare HMOs will begin in November.
"We're able to stay in that part of Pinellas County primarily because of the practice patterns of those physicians in the market," Scott said. "We're primarily focusing around those physicians who are providing excellent quality care."
Though only 16 percent of the nation's 39-million Medicare beneficiaries have opted to join HMOs, such programs have been especially popular in the Tampa Bay area, with about one-third of all those eligible signing on. That number has been dwindling, however, as insurers exit markets or increase their premiums.
Last year, Cigna pulled out of the Tampa Bay market. Retirees in Hernando County were threatened with no HMO options until intense lobbying led two insurers to step forward. Citrus County has no Medicare HMOs.
This year, Medicare beneficiaries in Hillsborough, Pinellas, Pasco and Hernando counties still will have at least two HMO options, but the benefits will undoubtedly be slashed.
Well Care, which will continue to offer coverage in all four counties, declined to disclose on Monday what its premiums or benefits would be in the coming year.
United Healthcare, which has 42,304 members in the four counties, said it would continue to offer a zero premium plan. However, benefits will change.
Humana, the area's largest Medicare HMO, will cancel one existing plan, which has a $179 monthly premium, but will continue a zero premium plan in Hillsborough, Pasco and Pinellas counties. Under this plan, renamed Humana Gold Classic, members will pay $15 for visits to their primary care doctors and $30 to see specialists. Hospital visits will cost members $200 per day up to five days. Only generic drugs will be covered, with a $12 member copay.
"People should look at the benefits, cost and physician network" of competing Medicare HMOs, said Pam Gadinsky, Humana spokeswoman. "They need to look for a plan that best fits their needs, and it will take a little more homework now."
That's not news to Jim DeGray, who has helped his 85-year-old dad, Robert, navigate Medicare HMO upheavals for the past two years.
The senior DeGray had been a member of Prudential's HMO, which pulled out of the market last year. He then joined BlueCross BlueShield's plan, where his primary care doctor has changed twice in the past nine months as the insurer dropped physicians.
With the Blues dropping DeGray's coverage in Clearwater in 2002, his son is ready to search for a new plan and probably a new doctor. He's doubtful any of the options will begin to cover his dad's prescription costs.
"The only thing that's killing us is paying for his drugs," he said.
- Kris Hundley can be reached at hundley@sptimes.com or (727)892-2996.
Plans of Medicare HMOs in Tampa Bay area as of Jan. 1, 2002:
AvMed Health Plan
Withdrawing from the area
Current number of members: 2,189
BlueCross BlueShield of Florida
Withdrawing from Pasco, Hillsborough and parts of Pinellas counties
Current number of members: 20,400
Humana
Will offer one plan, instead of two, in Hillsborough, Pinellas and Pasco counties
Current number of members: 61,058
United Healthcare of Florida
Will continue to offer one plan in Hillsborough, Pinellas, Pasco and Hernando counties
Current number of members: 42,304
Well Care
Will still offer plans in Hillsborough, Pinellas, Pasco and Hernando
Current number of members: 18,000
Source: Company reports and Florida Hospital Association