Scripps Medicare Advantage cuts also kill out-of-network access [The San Diego Union-Tribune]

Scripps Health confirmed Friday that its recent decision to pull its two best-known doctor groups out of Medicare Advantage health insurance plans includes those that allow patients to seek out-of-network care.

Scripps began notifying about 32,000 beneficiaries Tuesday that, starting Jan. 1, 2024, its coastal and clinic medical groups would no longer participate in the popular Medicare option that has private health insurance companies administer benefits.

Now covering about half of the nation's Medicare beneficiaries, the Advantage plan has been popular for lower up-front costs, with many plans not charging additional monthly premiums beyond the monthly basic Medicare fee charged by the government.

Citing revenues that do not cover costs, Scripps announced it would join a growing number of providers nationwide that are backing out of Medicare Advantage, and its decision left thousands across the region with a decision to make by the end of the year: Stay in Medicare Advantage and find a new doctor or switch to original Medicare and buy supplemental "Medigap" insurance, paying hundreds in extra monthly premiums.

But some immediately wondered if there was a third option. Today, the San Diego market includes five "PPO" Medicare Advantage plans which allow a beneficiary to see doctors outside their plan's core contracted network at an additional cost.

For example, a PPO Medicare Advantage plan offered by health insurance giant Aetna caps out-of-pocket expenses at $6,700 per year in network and $9,500 if doctors are seen out-of-network.

After two days where many in the San Diego market said that calls to Scripps and their health insurance companies offered no firm answers, Scripps confirmed in a short statement Friday that PPOs are also on the outs.

"Regarding the PPO question, enrollment is not open for patients to any individual Medicare Advantage plans where Scripps Clinic and Scripps Coastal medical group doctors are in network for 2024," Scripps said. "The doctors from both Scripps Clinic and Scripps Coastal will continue to accept original Medicare (Part A and Part B) and Medicare Supplemental products (Medigap)."

Original Medicare, unlike Advantage, pays providers based on the specific services rendered rather than using "capitated" agreements that make global payments that put profits at risk.

Lucye Christiansen of Rancho Penasquitos, said by email Friday that she and her husband Don, who is currently undergoing cancer treatment, were holding out hope that PPO plans would still be available. She called the change "disgusting."

She said her husband has been treated for three different cancers for the past 19 years, most recently receiving 28 radiation treatments at the Scripps MD Anderson Cancer Center. There are also ongoing regular appointments for blood work, medication monitoring and injections.

"Now we must start all over again looking for new oncologists at some other medical facility," Christiansen said. "Will Don be able to receive the excellent care that has kept him alive through three separate cancer battles?

"Will it be without interruption to his care plan? How very stressful and very sad that Scripps is willing to lose over 32,000 senior patients, claiming that their Medicare Advantage plans to not pay Scripps enough money."

Asked Tuesday whether there were any exceptions for patients currently undergoing treatment for serious conditions such as cancer, Scripps chief executive officer Chris Van Gorder said no.

"This is an insurance issue," Van Gorder said Tuesday. "We'll carry on our care up until the point where the person has to select a different provider, and we will absolutely do everything we can to help transition that care to a different provider."

There may, however, be a way for those unable to afford the additional cost of supplemental Medicare insurance to maintain access to Scripps medical specialists.

A few Scripps groups, such as Scripps Mercy Physician Partners, are not included in the Medicare Advantage change and it is possible, said local health insurance broker Craig Gussin, that primary care doctors in those groups may use an overlapping group of specialists. Scripps doctors, no matter which medical group they are a member of, generally use Scripps hospitals when their patients need a procedure that requires hospitalization.

"If someone switches over to Scripps Mercy they've still got, from my understanding, the ability to use a Scripps hospital," Gussin said. "They may just need to change a primary care provider, depending on a person's individual situation."

Tuesday, it was not clear whether or not health insurance companies would allow the thousands affected by the impending Scripps change to buy "Medigap" insurance to cover the 20 percent of outpatient medical bills that original Medicare does not cover.

The big issue is buying one of these plans without medical underwriting, the process where a plan can deny coverage if an applicant has pre-existing medical conditions.

Blue Shield of California confirmed in writing Friday that it currently has an "underwriting holiday" allowing patients to buy its "plan G" Medigap plans without underwriting.

"We are working to ensure all Californians have assess to high-quality healthcare, and this is one way we can do that," the company said in a statement.

The underwriting arrangement does not, however, include prescription drug plans which are also needed for those who switch from Medicare Advantage to original Medicare which does not have built-in medication coverage.

But this option, Gussin noted, gets more expensive with a person's age.

"If you're 65, plan G is $146; if you're 70, it's $198; if you're 80, it's $337 per person insured," Gussin said. "Most of the people that I'm working with for drug plans is less than $10 a month, unless you take a lot of drugs."

The well-known broker said his phone has been ringing constantly since the Scripps Medicare Advantage news broke. Most, he said, simply can't afford the additional monthly premiums.

"I'm guessing, from the phone calls I've received, probably 80 to 90 percent are going to have to find a different Medicare Advantage plan because they can't afford supplemental premiums," Gussin said.

This story originally appeared in San Diego Union-Tribune.

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