Category Archives: Palo Alto Medical Foundation

LOSING SUTTER MEDICARE

Losing Sutter Medicare

Updated September 13, 2024

Losing Sutter Medicare

On January 1, 2024, thousands were at risk of losing Sutter Medicare coverage, as Essence Healthcare and United Healthcare closed out Medicare Advantage HMO plans in Santa Clara, San Mateo counties and elsewhere. While some found replacement medicare advantage plans, many consumers returned to traditional Medicare (Parts A and B) and purchased a supplemental medigap policy e.g. medigap Plan G.

Access to Sutter Medicare coverage continues to frustrate members in the bay area and Northern California, as reported in previous articles.  Locally, many members lost access to Sutter Medicare coverage last January 1, 2024. We have received feedback from some UHC members who recently realized their PCP was changed from a Sutter doctor to a new doctor in the SCCIPA organization.

Is It Too Late To Return to Original Medicare?

Were you one of the thousands impacted from losing Sutter Medicare coverage [see our latest article on returning to original Medicare]?  If you acted timely, your options included returning to traditional Medicare Parts A and B, and enrolling (with guaranteed acceptance eligibility) with supplemental medigap insurance.

Generally, one should proceed cautiously when returning to traditional Medicare, unless you are assured underwriting approval for a medigap insurance policy: Without supplemental medigap protection, your Medicare copayment responsibility would be too great. Side note: Another term for “medigap” is “medicare supplement insurance” (it’s unfortunate, but Medicare uses both terms interchangeably…confusing!).  Here are some features of Original Medicare:

  • According to the nonpartisan research group, KFF (formerly Kaiser Family Foundation), approximately 1% of physicians have opted out of traditional (original) Medicare.  The implication is clear:  Medicare beneficiaries have access to the vast majority of physicians across America.  This offers unmatched flexibility and control.
  • Original Medicare is popular with individuals who wish to maintain control and choice over their medical providers.  For example, the flexibility to access specialists in more than one medical group and/or in different geographic regions.  Generally, this is not possible with “Advantage” HMO plans (although it could be possible with some Medicare Advantage PPO plans).

Medicare Advantage PPO

Consider if a Medicare Advantage PPO plan would solve your provider issues:  Options include i. getting help from an independent agent, ii. visiting medicare.gov, iii. phoning Medicare directly or iv. contacting each PPO plan directly.  Whichever resource you prefer, make sure your doctors have “in-network” status on the plan, otherwise, your out of pocket costs will be higher with Medicare Advantage PPO plans if you use non-network providers.

“You can also use out-of-network providers for covered services, usually for a higher cost, if the provider agrees to treat you and hasn’t opted out of Medicare (for Medicare Part A and Part B items and services).“ (Medicare ref: page 19):  https://www.medicare.gov/Pubs/pdf/12026-Understanding-Medicare-Advantage-Plans.pdf

If You Do Not Have An Agent

If you do not have an agent or if you bought your current policy directly from an insurance company, then we suggest you find a local independent agent who is familiar with major medical groups, such as the Stanford Health Care system or the Sutter system e.g. PAMF in the bay area.  Using a competent, experienced agent increases your probably of success, because the rules and the timing are complex.  Medicare is ever-changing, and once the current crisis has passed, you will probably need your agent in the future.

An alternative option for those who don’t want an agent is to phone Medicare for assistance.  They are open 24/7 at (800) 633-4227 or to attempt an application on your own at californiaenrollment.com.

Resources

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