Category Archives: Stanford Medicare

Using Medicare At Stanford Healthcare- Stanford Hospital

Using Medicare At Stanford Healthcare- Stanford Hospital. Perhaps a better article title would be “Keeping Access To Stanford for Medicare Beneficiaries,” rather than “Using Medicare At Stanford.”

The purpose of this article is to acknowledge the thousands of Northern Californians impacted by recent Medicare plan changes, and to review possible solutions and resources to help gain Medicare access to the Stanford Health Care system or the Sutter system in the future.  If your plan changed and you have Sutter or “PAMF” doctors, read this related article.

Topics and Questions Addressed In This Article:

  • Are there any Medicare Plans that include Stanford after January 1st 2024?
  • Is Traditional Medicare Part A and Part B better than Medicare Advantage PPO?
  • Strategies to keep Stanford Healthcare as an individual Medicare beneficiary
  • Resources – Recommendations

Background: “Stanford” is popular with Medicare beneficiaries.  Prior to 2024, many individuals not covered on employer or retiree health coverage gained access to Stanford from Essence Healthcare, an individual Medicare Advantage HMO. 

Losing Your Plan, What To Do Next?

First, you could enroll in a different Medicare Advantage (HMO) i.e. give up your Stanford doctors, but this is probably not your first choice. Next, you might hope another Advantage plan picks up Stanford at the last minute.

Some suggest 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 use, make sure your doctors have “in-network” status on the plan, otherwise, your out of pocket costs will be higher with “Advantage” PPO plans, when you use non-network providers.  

“Yes. 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).“ ref:  Page 19

(Medicare ref: page 19):  https://www.medicare.gov/Pubs/pdf/12026-Understanding-Medicare-Advantage-Plans.pdf

(Author: pay particular attention to the condition stated above, “if the provider agrees to treat you.”)

Original Medicare (Part A and Part B) + Medigap

Another term for “Medigap” is “Medicare Supplement Insurance” (It is unfortunate, but Medicare uses both terms interchangeably, which is confusing.).

Original Medicare is popular with individuals who wish to receive care from specialists in assorted medical groups and/or geographic regions.  Generally, this is not possible with “Advantage” HMO plans.

If you return to original Medicare and need coverage for outpatient medications, you should purchase a standalone Part D prescription drug plan (available at medicare.gov or by phoning Medicare directly, the plan directly or via your independent agent who can coordinate the enrollment details). 

Is Traditional Medicare (Part A Part B) Better Than Medicare Advantage PPO?

According to the nonpartisan research group, KFF (formerly Kaiser Family Foundation), 1% of physicians have opted out of Medicare.  The implication is clear:  Medicare beneficiaries have access to the vast majority of physicians across America. 

https://www.kff.org/f262da9/

If you subscribe to the financial publication, Barron’s, read the September 16, 2023 article comparing original Medicare and Medicare Advantage- it’s one of the best we have seen:

How to Decide Between Medicare and Medicare Advantage When You Turn 65

If You Do Not Have An Agent

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 (PAMF in the bay area).  We advise using a competent, experienced agent to increase your probably of success, because the rules and the timing are complex and physicians are leaving and joining plans up to the last minute.  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 there’s no added cost to using an independent agent, but if you really don’t want to talk to one, “do-it-yourselfers” could try to self-enroll at this site.

Finding a Local Agent

https://www.myuhcagent.com

Key Words:  Stanford Health Care- Stanford Hospital, Medicare

US News Article Link:

https://health.usnews.com/best-hospitals/area/ca/stanford-hospital-and-clinics-6932330/doctors

Resources:

Finding a Local Agent

Medicare publishes a guide to medigap policies; here’s an excert:

“Cost is usually the only difference between Medigap policies with the same plan letter sold by different insurance companies.” CENTERS FOR MEDICARE & MEDICAID SERVICES (2023 Choosing A Medigap Policy): Section 2 

https://www.medicare.gov/Pubs/pdf/02110-Medigap-guide-health-insurance.pdf

From Barron’s: How to Decide Between Medicare and Medicare Advantage When You Turn 65
https://www.barrons.com/articles/medicare-choice-medicare-advantage-e9d7f1f2?reflink=article_emailShare

From MedPage Today, a very detailed story about medical groups cancelling Medicare Advantage contracts:

https://www.medpagetoday.com/special-reports/exclusives/106483

Whatever Happened To The California Blues?

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

Whatever Happened To The California Blues?