REGION — Thousands of seniors receiving primary care through Scripps Health have been left scrambling after executives announced that two of their most popular medical groups would no longer accept Medicare Advantage plans.
Scripps began sending out letters early last week notifying members that beginning Jan. 1, 2024, Scripps Clinic and Scripps Coastal would no longer accept Advantage plans from carriers including Anthem Blue Cross, Blue Shield of California, UnitedHealthcare and Centene Health Net.
The change affects an estimated 32,000 San Diego County seniors, according to Scripps. The groups will continue to accept Original Medicare, or Parts A and B.
Representatives for the popular San Diego health network said continuing to accept Advantage plans was no longer financially viable after trying unsuccessfully to negotiate with private insurers to be reimbursed for their costs.
“Scripps has long served seniors and others in our community who are enrolled in Medicare and Medicare Advantage plans. Scripps and health systems across the country are facing unprecedented financial pressures. We are looking at all we do and when necessary, making difficult decisions to ensure that we can continue to meet the needs of the community we serve,” spokesperson Steve Carpowich said Tuesday. “The revenue from Medicare Advantage plans is not sufficient to cover the cost of the patient care we provide.”
Nearly half of Medicare beneficiaries in the United States use the Advantage plan, which has the benefit of lower monthly premiums and built-in limits on certain out-of-pocket costs compared to the Original plan.
Patients wishing to avoid gaps in coverage now face a difficult choice on a tight timeline. They can change medical groups and leave behind the Scripps providers and care they’ve come to rely on before Jan. 1, 2024, or stay with Scripps and switch to original or supplemental Medicare, also known as Medigap.
The latter option comes at the price of increased monthly premiums, sometimes up to several hundred dollars, which many obtained Advantage plans to avoid in the first place. Supplemental plans also increase in cost the higher the person’s age.
Perry Hayes of Solana Beach has been with Scripps for years through a Medicare Advantage plan and said he was flabbergasted by the news that his plan would be dropped.
The 70-year-old said he has also already spent the past two years dealing with insurance issues when he was denied coverage for gastric cancer treatment at UC San Diego under his Advantage plan through SCAN. Hayes switched to an Advantage plan with another private group but had to delay treatment until 2023 for the new plan to kick in.
Thinking about switching insurance plans again while still undergoing chemotherapy is daunting. Hayes does not want to leave his Scripps primary doctor, who has been an excellent advocate for his care.
“I don’t know if I can get into new insurance because I don’t know what the requirements for pre-existing conditions are,” he said. “I guess in the best of all worlds, some insurance gap plan will allow us to stay with our current primary, who is really good and fought for me to go to UCSD.”
Carpowich said certain affiliated independent physician medical groups will continue to accept Medicare Advantage plans at this time, including Scripps Physicians Medical Group, Scripps Mercy Physicians Medical Group and Optum Care in San Diego.
Carpowich could not confirm whether these groups have contracts with all Scripps hospitals, including Scripps Mercy, Scripps La Jolla and Scripps Memorial in Encinitas.
Scripps is the latest health group to drop Medicare Advantage plans, preceded by the Mayo Clinic, Ohio’s Adena Regional Medical Center, Samaritan Health Services in Oregon and others.
Several systems have opted to part ways due to high prior authorization denial rates and slow reimbursements to providers. Scripps Health President and CEO Chris Van Gorder told Becker’s Hospital Review, “It’s become a game of delay, deny and not pay” with Medicare Advantage.
Hayes said it is a shame that profit is the driving factor in these decisions, which significantly affects his and other people’s health.
“It should be about caring for patients, and it’s not — it’s about caring for patients while you make money,” Hayes said.
Scripps said if patients have specific insurance-related questions, they should first contact their insurance plan or broker, as Scripps is better able to help patients with questions about their care and access to medical records.
Additionally, patients should be receiving emails and/or letters from their insurance plans which should answer some of their insurance coverage questions and provide additional resources, Scripps said.
