Executive hopes that Scripps Medicare Advantage departure can be solved [The San Diego Union-Tribune]

Scripps Health insisted last week that it remained open to keeping its most sought-after medical groups working with Medicare Advantage plans, and one key health insurance executive says he is feeling more hopeful than was previously the case.

Sachin Jain, chief executive officer of the Senior Care Action Network, which offers its SCAN Medicare Advantage plans throughout San Diego and most of California, said in a recent interview that Scripps had initially been unequivocal about its intent.

"We received a clear indication from Scripps that they were leaving the Medicare Advantage business, but it seems, more recently, that there may be a softening of that position," Jain said. "We are hopeful that we can preserve access to care for some of San Diego County's most-worthy older adults."

An internal memo that surfaced last week indicated that two of the local health system's medical groups — Scripps Coastal Medical Center and Scripps Clinic — had notified the region's half-dozen Medicare Advantage plans that they were terminating contracts, effective Jan. 1, 2024.

It is a move that would have significant implications for thousands of local enrollees who use the HMO-style Medicare coverage gain access to Scripps doctors. If terminations held, many would have to switch doctors or change their coverage, a decision that could lead to hundreds more per month in premiums.

What's more, a quirk in federal and state law makes it difficult for those looking to purchase supplemental Medicare plans — often called "Medigap" coverage — if they have pre-existing conditions.

Jain said he believes that about 32,000 San Diego County residents use the two affected doctor groups through various Medicare Advantage plans. Nearly 20,000 are on SCAN plans.

He said that the medical groups exiting Medicare Advantage would hurt seniors of more modest means the most, because they generally cannot afford the supplemental plans that could allow them to switch their coverage and retain their doctors.

"Our sincere hope is that Scripps, its board of directors, its management, will view this, in some ways, as reducing access for some of society's most frail, most vulnerable, low-income individuals," Jain said.

Last week, Scripps' public relations director cited rising health care costs and "reimbursements not keeping up" as a reason why the Medicare Advantage situation has reached its current state.

Asked for an update Friday, Chris Van Gorder, Scripps' CEO, said in an email that there is "no change until there is a change."

It appears that Scripps is not alone in its apparent Medicare Advantage aversion.

A recent piece in a health care industry publication found that major health systems in many states have recently notified patients that they will no longer accept certain Medicare Advantage plans. Many have cited claim denials and prior-authorization requirements as reasons why they are taking such actions, and billing fraud has also been alleged in some cases.

Medicare, available to most Americans on their 65th birthdays, comes in two basic types: Standard and Advantage.

Medicare Advantage plans are run by private companies that build their own networks of doctors and other services, requiring that their members use only these resources if they wish to have their services covered.

Medicare Advantage plans generally offer a wider range of services such as dental and vision and tend to offer a wide variety of copays and deductibles similar to HMO coverage that companies offer their employees.

Every year, during Medicare's fall open enrollment period, each Medicare beneficiary gets to decide whether or not to choose a different Advantage plan or switch to or from original Medicare which pays health providers directly for their services.

Original Medicare allows beneficiaries to select any provider enrolled in the program and is accepting new patients. There is also no requirement to see a primary care doctor before seeing a specialist.

Original Medicare does have its own set of copays and deductibles but expects beneficiaries to pay 20 percent of the cost of most services after those up-front costs are satisfied.

In order to avoid massive bills, many who choose original Medicare opt for supplemental health insurance plans, often called "Medigap" coverage. And, while Medicare Advantage plans generally include prescription drug coverage, original Medicare has none, meaning that a second extra drug policy is usually required.

Depending on age and coverage details, Medigap plans, with drug plans added in, can cost hundreds per month.

But added cost is not the only issue.

Those with pre-existing medical conditions can face an uphill battle buying a Medigap plan if they did not select one when they first enrolled in Medicare.

Medical underwriting, the practice of basing coverage and premium decisions on a person's health history, is not allowed for new Medicare enrollees. But, once a person has been in a plan for a year, health insurance companies are allowed to take pre-existing conditions into account. This can put survivors of serious medical problems such as cancer and heart disease at a severe disadvantage.

There are some caveats, however.

Federal and state law guarantees the purchase of Medigap coverage in certain instances, such as if a patient's Medicare Advantage plan stops offering coverage in their area.

California law goes even further, extending guaranteed issue policies — coverage without underwriting — to those whose Medicare Advantage plan increased their premium or copayments more than 15 percent, reduced benefits or "terminated its relationship with your medical provider who was treating you."

While that might seem like it pertains directly to the Scripps situation, Bonnie Burns, a consultant with California Healthcare Advocates who helped craft the state's enhanced Medicare protections, said the operative word is "terminated."

"The requirement is that the health plan drop the provider, but not if the provider is dropping the plan which is what it sounds like may be happening in this instance in San Diego," Burns said.

Technically, then, Medicare Advantage plans, if they became certain that Scripps intended to follow through with its terminations, could proactively drop Scripps doctors, insuring that their current customers could buy Medigap policies without underwriting.

Asked whether it might take such a step, a SCAN representative had no comment.

But it's not likely to be much of an issue for most current Medicare Advantage enrollees, because they cannot afford to pay the supplementary and drug plan premiums, Burns said.

"They should be looking at the Medicare savings programs, because people with limited resources may be eligible," Burns said.

For the first time next year, she said, savings programs will no longer have asset tests, opening up qualification to some who might not have qualified in the past.

Those who need help sorting out Medicare coverage options have a free option available. The San Diego HICAP Office offers consultations which can be scheduled by calling (858) 565-8772 or by visiting elaca.org.

This story originally appeared in San Diego Union-Tribune.

©2023 The San Diego Union-Tribune. Visit sandiegouniontribune.com. Distributed by Tribune Content Agency, LLC.