The recent decision by Scripps Health to stop its clinic and coastal medical groups from participating in Medicare Advantage plans created uncertainty for thousands of seniors. But there might be one bit of good news.
Research performed by San Diego’s widely-respected Health Insurance Counseling & Advocacy Program indicates that patients with preferred provider organization Medicare Advantage plans will retain their ability to visit affected Scripps Health doctors after their groups no longer accept such coverage starting in 2024.
Sophie Exdell, program manager for the program, which is often called “HICAP,” said in an interview this week that out-of-network access is a right of all who buy Medicare Advantage PPO plans.
“When someone’s in a Medicare Advantage PPO, they can go out-of-network to any provider that accepts Medicare,” Exdell said, adding that billing procedures can also change significantly.
However, as is the case in employer-sponsored health coverage, patients pay more to go outside the “health management” group of contracted physicians that their carrier has built to meet their needs.
“PPO plans tend to have really high out-of-network rates, like 30 percent or 40 percent higher, and that can add up to more than it costs for original Medicare,” Exdell said.
The current understanding of PPO access, as explained by HICAP in its official documents, appears to conflict with a written statement that Scripps made that indicated out-of-network access for these plans was “not open for patients to any individual Medicare Advantage Plans where Scripps Clinic and Scripps Coastal medical groups are in network for 2024.”
Asked what’s changed, Scripps said in a statement: “We feel our statements to date are aligned with what HICAP is saying. PPO is largely not available, as we stated before; that is determined by the insurance companies.”
As Medicare is currently just beginning its annual open enrollment period, which started on Oct. 15 and runs through Dec. 7, many of the estimated 60,000 Medicare Advantage enrollees affected by Scripps’ decision to remove its most-popular medical groups from participation are considering how they might preserve access.
The federal government’s Medicare Advantage program allows Americans who qualify for coverage to have their benefits administered by a private health insurance company, which will often offer lower up-front costs in exchange for an agreement to receive care from a set list of providers. Original Medicare allows beneficiaries to see any doctor who accepts Medicare, but only pays for 80 percent of outpatient care and does not cover prescribed medications. Generally, supplemental “Medigap” and “Part D” drug plans are necessary for those who choose to original Medicare, and those extra policies come with additional monthly premiums.
PPO plans allow a sort of middle ground, allowing beneficiaries to stay within a plan’s contracted network of providers and pay lower fees for the bulk of their needs but preserve the option to visit a much wider range of care givers if the need arises.
While HICAP does not make recommendations, it does work to lay out all of the available options with as much accuracy as possible. In this situation, Exdell said, the most important factor seems to be whether or not an individual is currently receiving treatment for a diagnosed medical problem.
“Generally speaking, someone who needs a lot of health care and is in the middle of treatment, they’re probably going to find that original Medicare with a Medigap supplemental plan is a better value and safer option to keep seeing their doctors,” Exdell said. “If someone is mostly willing to switch providers and pick a different in-network medical group, but just has maybe one or two Scripps specialists that they want to see every once in a while, then the PPO route could be an affordable option.”
But that comes with a caveat.
Generally, in order to buy a Medigap plan and switch coverage from an advantage plan to original Medicare during open enrollment, health insurance companies require underwriting, a process that allows denial of coverage if there are pre-existing medical conditions. While most Medigap plans on the market require underwriting, Blue Shield of California currently has an underwriting holiday for one of its plans through the end of the year.
Given that it is not clear if the same opportunity will be available during the open enrollment period of 2024, those who can afford the extra premiums and have pre-existing conditions could find themselves facing underwriting the next time they have the option to switch plans.
One final question remains regarding how Scripps will handle patients with PPO Medicare Advantage patients who arrive at its coastal and clinic offices. Providers, HICAP notes, are not required to bill a patient’s Medicare Advantage plan and can require patients to pay out-of-pocket and later seek reimbursement from their insurance companies.
Asked how it would handle such situations, Scripps said that, while each individual patient needs to verify the particulars with their health insurance company, “we will bill normally by submitting a claim to the insurance company,” which would provide technical information and “give us instructions for how much the patient owes.”
These amounts, Scripps stressed, would vary depending on a person’s specific plan. It is not clear how long Scripps would continue billing PPO plans or if it would ever change to an approach that required patients to pay up front then seek reimbursement after care is provided.
While HICAP offers free Medicare consultations to those in the region who need help, Exdell said that the Scripps change has generated so much demand that the organization is not able to extend that level of help to all who reach out.
However, several documents that break down the organization’s research on the topic are available at elaca.org/get-help.
