Buffalo, N.Y. (WBEN) - Starting July 1, 2025, anyone who is covered under a Highmark Blue Cross Blue Shield of Western New York Medicare Advantage Plan will become out-of-network if their primary care physicians are with the Buffalo Medical Group (BMG).
BMG announced to its patients on Tuesday that after a lengthy negotiation period with Highmark, both parties were not able to reach an agreement for BMG to remain part of Highmark’s Medicare Advantage provider network after June 30, 2025.
Dr. John Notaro, medical director at Buffalo Medical Group, says it wasn't the typical reason for BMG deciding to break ties with Highmark.
"We did not ask Highmark for a higher fee schedule or for a different fee schedule than the community. It was a different kind of issue. That is to say that we are looking to develop relationships with insurance companies that help us to support certain kinds of investments that we think are good for patients," explained Dr. Notaro with WBEN.
BMG says it's committed to specialized clinical programs that help patients avoid lengthy delays at the emergency room, reduce out-of-pocket costs and personalize care to deliver better outcomes. That's why BMG is encouraging anyone that still wishes to receive this level of care to select a Medicare Advantage Plan that supports it.
"In our Essjay office, we've built an urgent care office that is different than the normal urgent care. It's different than a normal urgent care you might go to in the community, in the sense that it's capable of doing CT scanning, it's capable of drawing blood work. It's capable of giving IV antibiotics and IV fluids, which means we can do a lot of things there that are RE-like. And so consequently, for our patients, very often we can go there instead of asking them to go to the emergency room, so it's more convenient for them, it's easier for them, it's less expensive for them," Dr. Notaro explained. "Those are the kinds of investments we've made, and we want to develop relationships with insurance companies that support those kinds of investments. And that was one of the differences we had with Highmark, and why we're making this decision."
BMG is offering patients help with switching Medicare Advantage Plans with an open enrollment that continues now through Dec. 7.
"A Medicare beneficiary has the perfect freedom of movement to sit down with an independent insurance broker, review all their options, and to change their Medicare coverage to any one of the other products that we participate with. That goes through Dec. 7, so we're urging our patients to do that," Dr. Notaro said.
If anyone happens to miss the Dec. 7 timeframe for open enrollment, there is another window that will occur in the first quarter of 2025.
If patients don't make a change to their Medicare Advantage Plan but wish to remain with their Buffalo Medical Group primary care physician, that doctor would become out-of-network with Highmark.
"For most people, that would mean higher copays not only to see your primary care physician, but potentially more difficulties with if your 'prim' [primary] refers you for a CAT scan, for example, or if you're a 'prim' refers you to a specialist. It creates more impediments if you're working in an out-of-network situation with your 'prim'," Dr. Notaro noted.
He adds it's been made very easy for patients to be able to make a switch with their Medicare Advantage Plans.
"Medicare gives a lot of opportunity for patients to review their options. There are good independent brokerage firms. We have representatives from the Davies Group, which are independent brokers that sit in our lobbies, and they represent any number of insurance products," Dr. Notaro added. "They can sit down with a patient, they can look at the medicines you take, they can look at where you like to go on vacation, maybe you go to Florida in the winter, and they can calculate for you what would be the best product for you. Lowest copays on your medicines, a good network in Florida if you happen to go there on vacation. It's actually very easy if you work with a broker like that, which is a free consultation to the patient."
Anyone looking for further assistance changing Medicare Advantage Plans to remain with the Buffalo Medical Group is encouraged to contact the BMG Insurance Help Line at (716)-243-8090, or by visiting https://seniorhealthconnect.com/bmg/m101/#medicare-resources.