Thousands to lose health insurance at major Mass. hospital systems as of Jan. 1

For thousands of Massachusetts residents, midnight on Jan. 1 will mean more than the onset of a new year — it’ll also signal the loss of health insurance coverage at several hospitals and their affiliated providers.

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Tufts Health Direct, one of the most affordable health insurance plans offered through the state’s marketplace, is ending in-network coverage for UMass Memorial Health and Boston Children’s Hospital, resulting in thousands of individuals and families scrambling to find new providers or insurance plans entirely.

Approximately 17,000 patients at UMass Memorial Health will be impacted. The number at Boston Children’s is around 5,000.

• Read more: Do you need health insurance in Mass.? Here’s how to sign up for 2025 coverage.

Point32Health, the state’s second-largest insurer that owns Tufts Health and Harvard Pilgrim Health, informed Tufts Health Direct members in late October of the upcoming changes. The insurer hasn’t been able to reach an agreement on a new contract with UMass Memorial Health or Boston Children’s Hospital “despite our best efforts,” it said in a statement to MassLive.

“The providers determined that for this product, Tufts Health Direct, they cannot accept the rate necessary to offer affordable coverage to these individuals who receive premium support due to low income,” a spokesperson said.

Meanwhile, the health care systems have cited Point32Health wanting to pay lower, unsustainable reimbursement rates.

A third hospital system could be affected, as well. Yet to be seen is the outcome of negotiations between Point32Health and Tenet Healthcare Corp., which owns Saint Vincent Hospital in Worcester and MetroWest Medical Center in Framingham and Natick. Those talks remain ongoing, while the parties trade barbs via public statements and in the media.

New providers or new insurance

The stalemate in negotiations came in time for open enrollment season, when residents can make coverage choices for 2025 via the Massachusetts Health Connector, the state’s marketplace for health and dental insurance, through Jan. 23.

It also comes at a juncture where the state is already plagued by a primary care shortage and sees some of the highest per-capita personal health care spending in the nation.

Last year, Dr. Barbara Spivak, then-president of the Massachusetts Medical Society, said the dearth of primary care physicians in the state was no longer a looming threat, but rather a major public health crisis.

While it’s likely that many patients of UMass Memorial Health and Boston Children’s will make different 2025 coverage choices given the news from Point32Health, complicating matters is affordability. Tufts Health Direct plans have some the most affordable monthly premiums on the marketplace.

• Read more: A new survey captures deepening pinch of health care costs for Mass. consumers

A review by MassLive of 2025 coverage offerings found Tufts Health Direct plans for a single person (dependent on zip code and income) range from $346-$668 per month, while plans through competitor Blue Cross Blue Shield of Massachusetts, for example, range from $570-$1,067.

What the health systems say

UMass Memorial Health is the largest health care system in Central Massachusetts. In addition to its flagship UMass Memorial Medical Center in Worcester, it also operates the HealthAlliance-Clinton Hospital and Marlborough Hospital.

A spokesperson for UMass Memorial Health said it was “mutually agreed” between parties that the contract with Tufts Health Public Plans “for its Qualified Health Plan (QHP) product offered through the Massachusetts Health Connector” would not be extended.

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Enrolled patients were sent letters ahead of the annual open enrollment period, advising them “of other health options available to them through the Connector which will provide continued access to UMass Memorial Health providers.”

UMass Memorial Health continues to negotiate a new commercial contract for private insurance with Point32Health ahead of expiration on Dec. 31.

The spokesperson also clarified that UMass Memorial Health also maintains a separate contract with Point32Health for their Medicare Advantage products (Tufts Medicare Preferred and Harvard Pilgrim Stride), which remains in effect.

Eric Dickson, chief executive of UMass Memorial, told the Boston Globe last month that Point32Health wanted to pay a lower reimbursement rate for Tufts Health Direct members than UMass Memorial could afford. The health system “would have lost money on every patient we saw and every patient we hospitalized and every patient we operated on,” he said to the Globe.

A spokesperson for Boston Children’s Hospital, which is the main pediatric training and research hospital of Harvard Medical School, said they were “unable to reach an agreement on renewal terms.”

Tufts Health Direct will, however, offer a 30-day “continuity of care” period for primary care until Jan. 30, 2025.

“We want to reassure our patients that we are here to support them during this transition, and assist them in their efforts to access the care they need,” the Boston Children’s spokesperson said. “We have reached out to patients to provide guidance on their options and ways to continue to receive care from their Boston Children’s affiliated providers.”

Patients who keep Tufts Health Direct may still be able receive treatment at Children’s out of network with prior authorization if alternate care is unavailable from the plan’s other providers.

If you are a patient who is impacted, please contact reporter Hadley Barndollar at [email protected] to share your experience.