UnitedHealthcare Pauses Implementation of New MA Model in NC, GA

The American Association for Homecare (AAHomecare) reported that UnitedHealthcare (UHC) recently notified suppliers of its plans to delay implementation of substantially revised HME order and fulfillment processes for DME for members of their Medicare Advantage (MA) plans who are enrolled in HMO and PPO products in North Carolina and Georgia. The implementation date is being moved back one month, from August 1 to September 1.

Under the new program, which was first announced on May 1, suppliers would be part of a capitated arrangement with Synapse Health for standard DME products and supplies, as detailed here.

This delay offers DME suppliers in North Carolina and Georgia additional time to familiarize themselves with new processes and requirements. AAHomecare said providers in other states should also be interested in learning more about this new model being implemented by a payer with a large national footprint.

Below is information provided by AAHomecare:

Understanding New Requirements and Standards 

AAHomecare recommends that suppliers thoroughly read and understand the requirements and standards laid out in Synapse Health’s DME Provider Handbook (v. 2/24) and how they may impact your business.

AAHomecare members who have reviewed the Provider Handbook have pointed out several requirements and standards that suppliers should note. The provisions below are taken directly from the Handbook sections listed.

Section 2: DME Performance Standards—page 6:

• Maintain 24−hour on-call coverage seven days per week and respond to Synapse Health within 30 minutes of call, including after normal business hours, weekends and holidays.
• Do not attempt or collect member/patient copayment, coinsurance or deductible amounts. Synapse Health collects all member/patient payments.

Section 3: DME Orders & Delivery—pages 6-9:

• Standard Orders: Providers are required to access, fulfill and respond by accepting or rejecting the order within two hours of the email notification. 
• STAT Orders/Hospital Discharge Orders: Providers are required to access, fulfill and respond by accepting or rejecting the order within one hour of the email notification.
• STAT Orders: Orders that have the checked “STAT” indicator box are considered STAT and require 1-2 hour or, up to, a 4–6-hour delivery time window and are dependent on clinical need. In the event the provider cannot fill the order on the indicated day, the provider will message Synapse Health by using the NOTES feature in the Fulfill portal to communicate an alternative date/time when the order can be fulfilled.
• Urgent Requests: The DME provider has a responsibility to promptly address urgent requests for the maintenance or replacement of durable medical equipment. This typically involves making an in-person visit to the patient’s home or residence. During regular business hours, the urgent request will be communicated to the DME provider through the standard order email notification process and by phone. In the case of after-hours urgent requests, Synapse Health will reach out to the DME provider’s on-call or after-hours contact. The DME provider is required to respond to Synapse Health within 30 minutes of receiving the request and ensure the delivery of the urgently requested durable medical equipment within four hours. 

Section 4: Patient Transfers—pages 10-11:

• When a provider becomes subcontracted with Synapse Health, patient care and management shift to Synapse Health as the new provider of record. This transition ensures that patients continue to receive the highest quality of care and services seamlessly under the Synapse Health Network.

See the Provider Handbook for a complete listing of requirements, standards and guidance.

Monitoring the Transition

AAHomecare met with UHC in late June to discuss the new model. It shared that it had received many calls from its members in Georgia and North Carolina raising concerns.

AAHomecare asked UHC if PPO patients that have out-of-network coverage and wish to stay with their current provider would have their DME paid for under their out-of-network benefits. UHC responded that it will be working to make sure all patients are transitioned for the “good of the patient,” but it will honor out-of-network benefits for those patients.

In a subsequent email exchange with UHC, AAHomecare requested contact information for providers and patients that have questions regarding this change in their contract or coverage. UHC responded with:

• If providers have question about Synapse Health they can reach out to [email protected]—visit synapsehealth.com—or call Synapse Health at (888) 336-9363. They can also contact their Network Account Manager within UnitedHealthcare—If they are not familiar with who that is they can reach out to UHC’s DME mailbox: [email protected].
• If patients have questions, they can call the number on the back of their UnitedHealthcare ID card. 

AAHomecare will be meeting again with UHC prior to the Go Live date.  

Scope of Coverage

The new arrangement will impact DME care for approximately 480,000 individuals in North Carolina and Georgia, combined—and millions more could be added if the capitated model is applied in other states. The following information is based on publicly available information.

• UHC Enrollment Facts – per data from Experience of the Five Largest Publicly Traded Companies Operating Medicaid Managed Care Plans During Unwinding (Kaiser Family Foundation, April 2024)
  • UHC insures 52 million people nationwide as of 12/31/2023
  • 23% fall under Medicare Advantage, 62% commercial, and 15% Medicaid
  • UHC covers 28% of the Medicare Advantage population nationwide – 9,458,000 enrollees
  • UHC has a 9% share of the Medicaid MCO market
• Current Estimated Synapse Impact – per CMS enrollment information
  • Georgia: 42% of UHC MA population impacted by Synapse – 147,168 enrollees
  • North Carolina: 88% of UHC MA population impacted by Synapse – 332,495 enrollees
  • Approximately 480,000 combined.
• Potential Expansion
  • Additional contract numbers could be added to Synapse and impact 9.5 million enrollees for Medicare Advantage population. 
  • If expanded to Medicaid, approximately 7.8 million enrollees could be included.
  • Commercial plans can be added at any time, which could add up to 34 million enrollees.
  • UHC is the Medicaid Managed Care (MMC) plan in North Carolina where the MA plan is being rolled out. If expanded to MMC for North Carolina, 370,000 enrollees would be impacted.
  • See AAHomecare’s analysis of Synapse MA expansion potential for state-by-state estimates.

“DME suppliers in North Carolina and Georgia should familiarize themselves with the requirements and standards under the Synapse capitated model and how they will impact your business and ability to serve your patients,” AAHomecare said. “We will continue to monitor this transition and the potential broader implications for our industry’s ability to support millions of individuals with high-quality home-based care.”

Please note: The information in this alert does not constitute legal guidance or advice. Companies and individuals are encouraged to obtain advice from a health care attorney.