GUILDERLAND — A former Guilderland supervisor and recipient of retiree benefits from the town claims the municipality’s choice to change health-care providers has left her looking for a new doctor. 

The town disputes the claim, and says the switching of providers is actually a good thing for retirees and saves the town money. 

At issue is the town’s decision to change providers from Capital District Physicians’ Health Plan to Humana, which Anne Tucker Rose, Guilderland’s supervisor for a period in 1990s, said no longer allows her to see her pulmonologist of 30 years. 

Local medical group Community Care Physicians (CCP) in November sent a letter to patients informing them that the practice would “discontinue our participation in Humana effective March 13, 2024.”

The decision was made by CCP because the “requirements imposed by Humana have become increasingly cumbersome,” a November letter to patients said. “We need insurance partners who understand our patient and provider needs, allow for independent provider decision-making, and don’t have burdensome processes that delay care.”

CCP conceded the move “may be concerning,” but sought to allay patient fears by letting them know: “we are not discharging you from our practice and will continue to see you.”

Rose, a former nurse, acknowledged that, as an established patient, she wouldn’t be “abandoned” by CCP doctors, “because you can’t abandon a patient”; however, she went on, “They said nothing about what the cost would be.”

“In other words, they said where they’d see us, but they didn’t say whether they had another list of charges for Humana patients who had to pay out of pocket,” Rose said. 

She continued, “There were no details.”

Rose said her fear was, when her pulmonologist said he would no longer accept Humana, other doctors would do the same.

Alexis Musto, CCP’s senior vice president for marketing, communications, and strategy, explained that patients who have insurance through a provider that CCP no longer contracts with are treated as self-pay patients. 

“Since we are no longer contracted with Humana and these patients are unable to find an alternative insurance plan, they are responsible for the full cost of their visit at the time of service,” Musto said. 

The process for Humana recipients would be as follows: The patient would come in for an appointment, at which time they would be expected to make a full payment. Following the visit, as a courtesy, CCP files a claim with Humana on the patient’s behalf, Musto said. Then, if Humana does make a payment for the service provided, it would be in the form of a direct reimbursement to the patient. 

“We follow this process because a non-participating insurance carrier is not obligated to pay us for our services,” Musto said. So, “any reimbursement from Humana will be given to the patient at Humana's discretion.”

Musto advised patients who cannot select an alternative insurance plan, like insurance recipients covered by an employer-sponsored plan, to contact CCP before their appointment to receive an out-of-pocket estimated cost, and noted the medical group offers self-pay discounts and payment plans.

But she cautioned that the estimate is only an estimate,  the actual amount owed would be determined by the services performed on the day of the visit.

Humana did not respond to Enterprise requests for comment. 

But town comptroller Darci Efaw said Rose needn’t worry. 

She said retirees with CCP doctors “will see absolutely no difference after March when this happens.”

Efaw said, “There’s no change.”

Efaw said she thought there’d “just [been] a big misunderstanding,” which was “because of the way the letter was presented from CCP, saying that they’re discontinuing their participation with Humana.”

The move just makes CCP an out-of-network participant, Efaw said. 

Networks

With health insurance, providers are either in-network, meaning they have a contract with a health-insurance company, or out-of-network, meaning they don’t have a contract with the insurer.

Whether a health-care provider is in-network or out-of-network depends on the type of health plan being provided: a Health Maintenance Organization (HMO) or a Preferred Provider Organization (PPO). 

An HMO, according to the federal government, is a “type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won’t cover out-of-network care except in an emergency ….”

A PPO is a “type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost,” according to the Department of Health & Human Services.

Efaw said Guilderland “has such good, robust coverage because it’s an employer-sponsored PPO. We have the same in- and out-of-network benefits for our retirees, and therefore the co-pays will be exactly the same.”

The switch will also save the town money.

Efaw said under CDPHP’s Medicare Advantage, Guilderland’s cost was $278 per person per month. “And when we switched to Humana, it went down to $167 a month,” she said. 

Co-pays will be the only thing retirees are on the hook for, Efaw said, since the town covers everything else. She added that the co-pays were set up to mirror the town’s previous HMO co-pays. 

Efaw said providing retirees with both in- and out-of-network options is why the town made the switch to Humana. “It’s been such a benefit to so many of our retirees because, if they do choose to move to Florida in their retirement, they can and they still are covered down there,” which, she said, is something the town’s retirees didn’t have with CDPHP.