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Clarity & Care: Understanding Medicare Changes
The headlines are loud, the mailers are confusing and the clock is ticking. We’re making one thing simple: Centra will leave the Humana Medicare Advantage network on January 1, 2026, and you can protect your care by choosing the right plan during open enrollment.
With our Chief Revenue Officer, Robert Boos, we walk through exactly who’s affected, how this differs from traditional “red, white, and blue” Medicare and why TRICARE members are not impacted. We break down the real-world impact of Medicare Advantage: prior authorization delays that stall MRIs and CT scans, high first-pass denial rates on emergency claims and why those practices can lead to surprise “late” bills months after a visit. You’ll learn why many health systems nationwide are rethinking Medicare Advantage contracts and how payment shortfalls and administrative hurdles make it harder to deliver timely care.
Most importantly, we focus on action. If you’re on Humana Medicare Advantage and want to keep your Centra doctors, you don’t need a new clinician you need a new plan. Use open enrollment (Oct 15–Dec 7) to switch to a Centra-participating Medicare Advantage plan like Anthem, Aetna, or UnitedHealthcare, or return to traditional Medicare with a Part D prescription plan. We share tips for confirming drug coverage, avoiding gaps on January 1, and keeping existing appointments on track. Emergencies remain covered by law, but routine care depends on your plan choice, so make the move now.
Ready to take the next step? Visit centrahealth.com/humana for FAQs and resources, and call our customer service at 434.200.3777 if you have billing questions or need help understanding your claim. If this conversation helped, subscribe, share with a friend who’s choosing a plan, and leave a review to help others find clear guidance.
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Hi, and welcome to Anne So Much More. I am here with Robert Boos. Thank you so much for joining us.
Bob Boos:You're welcome.
Cami Smith:You are our chief revenue officer, which I am sure comes with a wealth of responsibilities. Right now, living in the world of the biggest change that we're seeing in a while related to Medicare Advantage and Humana specifically. And so Medicare can be tricky to navigate on its own, aside from big drastic changes that impact your healthcare. And so what we want to talk about today is the most recent change that was announced that Effective in 2026, January 1, Center has chosen to not move forward with Humana, Humana Medicare Advantage. And so we just want to talk about what that means for those of you who are Medicare Advantage members. And also like the finite things that you need to consider. Like, what do I do if I have an appointment after January and I have this coverage? How does that impact me? How do I get the right care in place? There's a lot to consider. And so we're going to make this just as clean cut as we can for you. And so, first of all, thank you. Thank you for coming on. Tell us a little bit about you and your role here at Central.
Speaker 1:Well, you mentioned the fancy sounding title, Chief Revenue Officer. It's kind of a fancy way to say I'm responsible for the patient accounting, the patient finance side of the center world, which is quite large. I imagine it's quite a lot of responsibility. I'm thankful to have such a wonderful group of caregivers that work on that side of it for us, that every day try to keep the patient as the focus to assist in getting the maximum reimbursement we can from health insurances and payers. So the patient's burden financially is as less as possible. So it's a lot of words to say, you know, that's what we're responsible for, but it's a pretty serious responsibility.
Cami Smith:It is, it is. So we want to dig in here and you know, just to be as clear-cut as possible, we have chosen to not continue this relationship with Humana at factor January 1. So right off the bat, does this affect all Humana plans or only this Medicare Advantage subset in addition to those who have, you know, standard Medicare?
Speaker 1:I mean, to go from the top, Cammy, I mean, it has been a this is not something that we came about and discussion that we decided quickly.
Bob Boos:Yeah.
Speaker 1:This has been planning for quite a while. Um, we wanted to make sure that we kept the needs of our patient forefront at all times, that that when we're thinking about you know leaving the Humana Medicare Advantage network, that we see that from the patient's perspective. That we had a very diverse team of areas with inside center from community relations to folks that work with the you know underserved areas of our community to get their opinion. You know, what should we do? How should we message this? How should we reach our patients? Because it's a big decision. It's a very big decision. And you know, we understand that, and that's why we set up the way that we've discussed it, the way we're talking about it, with that firmly in mind.
Bob Boos:Yeah.
Speaker 1:Um, so this is primarily for Humana Medicare advantage for those patients that have opted to not have traditional fee-for-service Medicare. You're gonna hear that term, fee-for-service Medicare. That's your regular, what we call red, white, and blue Medicare. You get the red, white, and blue card. You know, you worked your entire life to retire to be eligible for Medicare, you're now eligible for Medicare, or you've become disabled and eligible for Medicare. You've given that coverage up to go to a Medicare Advantage plan. So that's the portion that we're talking about. We are planning to leave the Medicare Advantage side.
Bob Boos:Okay.
Speaker 1:This does not impact, and I've seen a lot of questions about this. Humana um administers the military plan.
Bob Boos:Okay.
Speaker 1:So there's a lot of confusion initially. Oh no, you know, there's going to be, you know, Centra's not going to take the military plan, Champ VA, Champ Us. That is not true. We are going to continue to deal with Humana on the TRI-Care, you know, you know, that portion that does not impact that. This is the Medicare advantage side of it.
Cami Smith:Okay. That is really key information. There's so there's so like language that is so similar that I think um really confuses and muddies the waters here. Um, and so when it comes to maybe it's important to talk about really quickly, and and this is not on here, so I apologize, but what is the difference between a Medicare plan and a Medicare Advantage plan?
Speaker 1:That's a great question, Cammy. Is that the traditional Medicare? So go back to that word traditional Medicare, also called fee-for-service Medicare, also called red, white, and blue Medicare, because the cards still to this day I have a red, white, and blue banner on them.
Cami Smith:Yeah.
Speaker 1:And you get issued that card. That is the coverage that you get. Part A, which covers inpatient services and hospital services, your part B that covers your doctor's bills and your outpatient services, your part C, which is your prescription, your part D, which is your prescription areas there. That is the coverage that you get. Part A is paid for. Part B, you pay for as a Medicare beneficiary. When you become eligible, you sign up, you're a Medicare patient. You get that as part of part of your life. You then have the opportunity to opt out of traditional Medicare, fee-for-service Medicare, red, white, and blue Medicare, to select one of these many Medicare advantage plans. Then you're into a network, you have left your traditional Medicare coverage, you now have the Humanas, the Anthems of the World, the United's of the world, the Aetna Health Keepers of the World, all these different plans that you can elect in place of your Medicare coverage. So be very careful. You cannot have traditional Medicare and Humana Medicare at the same time. If you have Humana Medicare, you have given up your traditional Medicare coverage to have that advantage plan in place of it. So I think that's very important. And there's often confusion out there, particularly with some of our senior population, you know, that get a Humana card in the mail and then walk into a doctor's office or a hospital and present a Medicare card. Now, thankfully, you know, we electronically verify coverage and say, no, I'm I'm sorry, Cam, you don't have Medicare, you have Humana Medicare. And we get that fixed most of the time. But you're right, it's it's confusing, it's intimidating at folks, particularly those that are that are either new to the coverage or are older and generally have help from family members or friends that are helping them guide this. But it's very important you know that distinction between Medicare and Medicare Advantage.
Cami Smith:So this change specifically, we've talked a little bit about how it's affecting the Advantage Plan versus regular Medicare. How is it going to affect, like you mentioned prescription? How is it going to affect like the drug plans that people have in place?
Speaker 1:If you have traditional Medicare and then you have a Humana supplemental drug plan, there really is no impact here. But if your Humana Medicare Advantage is covering your drug plan, when you change your plan, and we are we're going to talk about changing your plan to a different Medicare Advantage plan that Centra is going to be in network in as of January 1st, or opting back to traditional Medicare as of January 1st. If you're on the Humana-specific drug plan as part of your Medicare Advantage plan, you may not have coverage there. That's you need to be very careful with that, that there's confusion there. But if you change from a Humana to a different Medicare Advantage plan, make sure you have the prescription coverage with that plan. Talk about this with broker, with calling the different plans, some of the resources that Cammy's going to share with you on our webpage. Ask those questions to make sure you are certain that when that calendar turns to January 1st, 2026, that you have the coverage in place that you need.
Cami Smith:Yes. So we are in the middle of in this open enrollment period. It opened October 15th through, I think we said December the 7th. December the 7th. And so, as you mentioned, there are other plans that you can opt into in place of this Humana situation. What are those plans that Centra is a part of?
Speaker 1:Let me circle back just a little bit, Cammy, because I think it's important to mention. I talked about when we started having these discussions about we are not going to, we're not going to renew our agreement, we're going to terminate our agreement with Humana in January. We were very careful to notify Humana within actually earlier than we were required to. But more importantly, get this message out to our patients and that have coverage with us or that are center patients and you know want to make sure everything is appropriate, that we timed it to be during this open enrollment period. So we're saying as of January 1st, 2026, we will no longer participate in the Humana network. You have from October 15th, which is a which is a couple of weeks ago, up through December 7th to opt out of Humana and select one of the other plans that we have. Please go to our webpage. They're listed there. I'm not going to give you an exhaustive list because I'm going to forget one of them, but the Anthem, Aetna Better Health is out there, United Healthcare is out there. We fully participate with those plans. You can opt to one of those, and then your coverage will be enforced from 1126 going forward. You can also opt back to traditional Medicare, the red, white, and blue, the unrestricted, as I would call it, Medicare coverage, and you would be covered at center. We are a fully Medicare participating provider.
Bob Boos:Okay.
Speaker 1:So those are the important things to think about, and why it was very important to open this discussion when patients have the free chance to move for the next 30 to 40 days. No pre-existing checks, no paperwork to fill out. You simply go and opt out to change plans. It is meant to, again, the government's involved, so it might be a little sticky on some of it, but generally it's a very easy process to say, I want to opt out of Humana. I want to go to plan A, B, or C, or I want to go back to traditional Medicare as of this date. Okay. And you have that open period to do it.
Bob Boos:Okay.
Speaker 1:I think there's a lot of concern out there, Cami, with, oh, you know, I have Humana and I see a centra doctor, I'm going to have to change doctors. No one said that. That is not true. If you stay, if you're with a centra physician, you through centra medical group, if you're seen at a center location, an emergency room, an outpatient center. We, if you go to a plan that we participate with, you don't have to change your doctor. Your doctor that participated with Humana is going to, through Centra, is going to participate with the other plans that we accept. So please don't get caught up on that because that is not an issue.
Cami Smith:Yes. So you need to change your plan, not your doctor.
Speaker 1:Absolutely.
Cami Smith:So what does it mean for some of our patients, knowing that you need to change your plan and not your doctor during this open enrollment period? Let's say they already have an appointment scheduled January 1, after January 1, how does that impact their care at that time?
Speaker 1:The difficulty there, Cammy, is that if they do not change their plan after January 1, we will be out of network with the Humana Medicare Advantage Plan. That means that, and this is separate from emergency services, and we can talk about that in a bit, that you may not be covered for the service that you seek. You may be covered at a lower rate. You might be hit with out-of-network payments, where it will increase your copay or your deductible, depending on your plan. So be very aware of that. You will always be covered for emergency services. Medicare requires even out-of-network to cover emergent services, the emergency room, inpatient hospital services related to an emergency situation, the doctor bills that are included with that emergency physician bills are all required by the law to be paid and to be covered. So that's not an issue. The issue is for non-emergent care, for routine care, for services that you need to see your primary doctor. You know, that's where it is going to be a little bit of a path to navigate if we are not participating in Humana going forward. That's why it's important to not have Humana if you're going to continue to be seen et cetera.
Cami Smith:Okay. So we've kind of zigzagged through the questions here and have landed at the, you know, what do we need to reiterate? But before we get there, is there anything I haven't asked you specifically that you think is really important to know about this?
Speaker 1:I I think it's important, Cammy, to mention this is not a decision that Sentrum made in a silo. This is, you know, as as I mentioned, you know, the patient perspective has been forefront the entire time. And uh what else has been, you know, very telling is that this is a national discussion. This through our associations and work that we do and and and other through the news media as well, that we see health systems, physician groups leaving Medicare Advantage plans in droves. I've been doing this, Cami, for 30 plus years. I have never seen it at this rate. I mean, folks are always changing.
Bob Boos:Yeah.
Speaker 1:You know, looking to do different rates, want to get out of a certain line of business. You see that a lot. I mean, it happens. It has not happened in this area in a long time. But nationally, I've never seen it at the pace it is right now that we see lists of hundreds of health systems, physicians, physician groups across the country that are terminating agreements with Humana and some of these other plans. But we see a lot of Humana. So it doesn't influence us. I'm not saying that's part of the decision, but you know, we made our decision independently. However, we were very interested to see that we are not alone in saying and drawing a line and saying, you know, enough is enough here with the practices that they have and the financial detriments and and the barrier to care for our patients that we can talk about as well.
Cami Smith:Yeah. Um, so I want to reiterate again, open enrollment is open now. Those of you who have gone to the website, because it's been up um for I want to say about two months. Um, there is a wealth of information, and that is at centerhealth.com forward slash humana. Um, there is a frequently asked questions if you just need to know what you want, what you need to know. How are you impacted right now? Um, so I encourage you to go and check that out. We will also put the link down in the description. That is how you can learn more. Um, you also mentioned calling a broker. Um, for those who are, I mean, I would assume those who are involved in this are probably familiar with that, but just in case, how would they go about finding a broker that is going to direct them in the the way that's going to suit them best?
Speaker 1:There is a numerous number of insurance brokers out there that their function is to help patients find plans that best suit them, best suit what they need, what kind of coverage they need, and you know, to guide them to is a Medicare Advantage plan your best choice? Is traditional Medicare a choice? And there's different costs to go back to traditional Medicare, for example, but there is less restrictions when you're on traditional Medicare. And I think if you don't mind, Cammy, talk, let's talk about that just for a minute.
Bob Boos:Yeah.
Speaker 1:Um, part of the reason mentioned some of the reasons that we we are going away from Humana Medicare plan is the significant amount of prior authorization they require for any patient that needs services. They are requiring for certain services over 90% of the time that a prior authorization is obtained. For a majority of those services, Medicare does not require authorization. They rely on the documentation and the health system to decide what is appropriate per Medicare guidelines. Medicare Advantage plans have us jump through a lot of hoops, have patients jump through a lot of hoops to get an MRI that you need, to get a CT scan that you need, and to delay it three days, seven days, 14 days while they review documentation, deny the claim, we have to resubmit, we have to go back and we have to get, we have to take a ask one of our providers, a physician, a PA, you know, to come off the line of treating patients to talk to an insurance plan why it's important that I get a CT scan. Where with Medicare, traditional Medicare, you don't have that. The documentation of there, that's not done. That's put a tremendous barrier out there. You know, it's an administrative burden for the health system, absolutely. And we employ people that what they do is chase Medicare Advantage plans all day to get authorization for the hundreds of folks that are coming in every day for outpatient testing and services. What it's also doing is driving a wedge for the patient, getting tests rescheduled. Your doctor saying to you, you know, Bob, I'd like you to have an MRI, and but we have to wait for Humana Medicare to authorize it. It could take seven to 14 days. You're saying, I need to get this done, I want to get this done. You're anxious about it, and we're trying to help you get it done. But we, along with you, have to jump these hoops, go over these hurdles to get this done. Traditional Medicare, we could see you, we could schedule it. If we had an opening this afternoon, we could get you in that schedule. If we had an opening tomorrow morning, we could have your test done tomorrow morning if you have traditional Medicare. If you have a Medicare Advantage plan, particularly Humana, who's very aggressive with required authorizations, we're not going to be able to do it for probably a week or more, potentially two or three weeks based on their schedule.
Cami Smith:And being that this is a national problem, that's not let me go somewhere else and get it done faster. That is the current situation across the board.
Speaker 1:Absolutely. And you know, we have not even talked about that burden to the patients. And some of the reasons that that we looked to end this agreement was the difficulties that we have of getting reimbursed fairly. Yes. For what we're seeing. I mean, we Medicare many years ago, and and prior to even me being in the business, which was a long time ago, they set up Medicare is a cost-based service. And we're going to go a little deep here, Cammy.
Cami Smith:I'm going to try to keep it fairly level.
Speaker 1:But Medicare setup is cost-based. That health systems doctors are when they have a Medicare beneficiary, you're billing and getting paid what your costs are. We're not supposed to make any money. We're not supposed to lose any money. We're supposed to break even. You'll hear the term break-even on Medicare. So it's a it's a pretty good setup. You know, if we every at the end of every year, we file reports to say, you know, we've we've lost money because of expenses here, or we've made too much, and we adjust our payments to get into that break-even, it actually works pretty well. You know, it's a pretty good system. Medicare Advantage came along and said, well, we're not going to do that cost report, or we're not going to do that cost or price shifting. We're just going to pay you 102% of Medicare. Boy, when you first hear that, you're like, okay, if Medicare is break-even, we're going to get 2% more than break-even, we've got a little bit of room there. You know, we can we can make this work. Now, we know we've got more burdens here. We know we have to do prior authorization, and that's expensive. We have to employ folks that do that work. We have administrative burdens. We get more denial, and I'll talk about that, getting more denials of care going forward. So you would think, okay, you're getting 102% of Medicare. Long story short, at the end of the day, when we reconcile prior years with Humana in particular, we found that we're getting 93% of Medicare. So we are 7% underwater with Humana, with every patient that we see. So it's not sustainable. We cannot continue to have the services that we have, losing 7% on every on every patient that we see. It's just not sustainable. And it's it's systematic of how they force a long time and a lot of work to get authorizations. They deny, and I think this is one of the most surprising and headline comments, Cammy, is that they deny over 60% of our emergency claims. 60%, six out of every 10 claims they send back to us and say we're not paying that bill the way it's coded. We code, again, another long story, but let me let me bring it to basics. We code based on a national standard agreed to from a lot of health systems, the American College of Emergency Physicians. We've got written guidelines that say if this kind of work is done, it's a level one, if this kind of work, it's a level two. All hospitals use it pretty much. We submit the claim. Humanity comes up with their own criteria and denies 60% of our claims.
Bob Boos:Wow.
Speaker 1:So we have to manually resubmit six out of every 10 claims. Claims go electronically, but now we have paper. We've got to send paper, we have to send copies of the medical records, we have to pay a nurse to look at it and write an appeal and why we did it. We have to pay a certified coder to look at it, maybe, and decide this is appropriate, we did it. They're appropriate the majority of the time. You know, the majority of the time. We're appealing them all. But here's a hidden little pitfall. While we're appealing these, you know, thousands of claims per month, we are not sending the patient their final bill. Patients have a co-payment, a percentage, a deductible. And until we finalize the insurance benefits, we don't release the patient bill.
Bob Boos:Wow.
Speaker 1:This process takes months and up to a year or more sometimes, and we're going back and forth trying to get paid. When Humana or others pay these claims late, and Humana is a significant volume of these, we are not billing that patient, and then we do. So you might have been seen in the emergency room in January. By the time we get Humana to pay, it's October.
Bob Boos:Wow.
Speaker 1:And then we're gonna send you a bill in the mail because you owe a $50 co-payment on the ED that you know we were not able to collect when you were when you were at the hospital. And the instant reaction, and we see it and we get a lot of phone calls on it, is centra's delayed, you know, they can't get their billing straight. I got I had this service in January.
Cami Smith:And meanwhile, you're fighting for them.
Speaker 1:We're fighting for them the entire time, silently, yeah, because we don't send out bills, we don't say, hey, we're fighting Humana, you know, or other payers. It's not just Humana, but Humana is certainly at the forefront. We're doing all this work, you know. So we have our customer service center, they do a brilliant job out there. Please call them at 200-3777 if you if you have any of those questions. Um, because we'll walk you through that. If you're getting a late bill, we'll explain to you why you haven't seen that claim. We want your help to go back to not only Himana, to all of these payers, and say, why are you taking so long to pay this claim? I'm ready to blame Centra and say Centra's billing is delayed or there's issues with Centra billing when we're trying to get the maximum amount we can from your coverage that you have paid for, earned, and deserved. We want to get the most, we don't want to bill you for it. We want your payer to pay it.
Bob Boos:Yeah.
Speaker 1:So we are not going to send you that bill until that is resolved. That is very disheartening for us. And our folks that work so hard, you know, explain that, and then they read some of the, you know, some of the background or some of the noise about that. And it's just not true.
Bob Boos:It's tough.
Speaker 1:It's tough to read, and our folks take it very seriously and want to help patients. So if you see this, please don't be angry and pay it, and then just don't say it, call us. We would love to explain it to you why it took so long, what was going on, what we were trying to get paid, what the payer did. We want to explain it to you. So please, please call us.
Cami Smith:Yeah, context is everything. We'll put that number in the description as well. Um, because to be informed, not just about the care that is available to you and the Medicare decisions that you do have to make in this open enrollment season, um, but then what is happening with your specific bill, um, to just know that there's that number as a resource to call, I think is huge. So we will make sure you all have that as well. Um this has been so informative. It's a lot, Cammy. Isn't it? It's so much a lot. It's so much. And and I encourage you all keep um keep educating yourself on this information and advocating for yourself with this information. Um, start with the website, centerhealth.com forward slash humana. Um, and then we'll put that number down there for you to call as well. And thank you for joining us.
Speaker 1:Thank you, Cammy.
Cami Smith:Um, and thank you all for joining us on and so much more.
