UnitedHealthcare Medicare Advantage Changes Affecting Virginia and West Virginia

UnitedHealthcare Medicare Advantage beneficiaries using Valley Health facilities will lose in-network benefits at these locations following the contract's expiration on September 30.

This shift, impacting approximately 8,000 individuals in Virginia and West Virginia, including around 1,900 from Winchester and Frederick County, stems from the inability of both organizations to secure a new agreement. Craig Connors, Vice President of Revenue Cycle and Payor Relations at Valley Health, shared that despite efforts to propose a resolution addressing reimbursement cuts and administrative challenges, UnitedHealthcare declined the proposal. As a result, both parties have ceased negotiations and are focusing on transitioning affected beneficiaries.

Understanding Medicare Advantage

Medicare Advantage, or Part C, allows private insurers to offer plans under federal authorization, targeting primarily older adults. These plans consolidate hospital and medical coverage, often including prescription drug benefits and other add-ons like dental or vision care. For those impacted, the shift to out-of-network status means changes in cost-sharing with Valley Health, effective October 1. However, emergency services will remain covered, as mandated by Medicare Advantage requirements.

Looking Ahead: Claim Processing and Options

For the current year, Valley Health will manage out-of-network claims with UnitedHealthcare, but starting in 2027, patients will be billed directly by Valley Health. They must submit their own claims for reimbursement. Valley Health is assisting impacted patients with guidance on coverage options. Possible pathways include continuity of care exceptions for active treatments, a special enrollment period contingent on CMS approval, and adjustments during the annual Medicare Open Enrollment period.

Medicare Advantage Impact Overview

• Affected Individuals: ~8,000 in Virginia and West Virginia
• Specific Local Impact: ~1,900 in Winchester and Frederick County
• Contract Expiration Date: September 30
• Start of Out-of-Network Cost-Sharing: October 1
• 2027 Onwards: Patients billed directly by Valley Health

Future Developments and Considerations

Valley Health and UnitedHealthcare are still discussing agreements concerning commercial health plans, with a September 30 deadline looming. Medicaid recipients and veterans in the Community Care Network will have consistent coverage as per existing terms. Impacted individuals are encouraged to explore all available options and stay informed, utilizing Valley Health's online resources or customer service channels for guidance.