San Diego

Medicare Advantage Shakeup: Are Your Doctors at Risk?

Thousands of seniors in San Diego County, like Patti and Myron Monroe of Poway, are facing a frustrating reality: being forced to locate new doctors. This isn’t an isolated incident. A growing trend of healthcare systems reassessing their participation in Medicare Advantage plans is leaving beneficiaries scrambling for continuity of care.

The Scripps and UCSD Connection: A Pattern Emerges

The Monroes recently received new medical cards listing doctors they’d never seen, a jarring echo of what happened to 32,000 patients in 2023 when Scripps Health exited Medicare Advantage. Their SCAN health plan will no longer include UC San Diego (UCSD) primary care doctors as of March 1st. This situation highlights a concerning pattern. As Scripps did in 2023, many health care systems are citing low reimbursements and burdensome prior authorization processes as key drivers for leaving these plans.

Why Are Doctors Leaving Medicare Advantage?

Healthcare systems are increasingly questioning the financial viability of participating in Medicare Advantage. They argue that reimbursements often don’t cover the full cost of care, particularly for patients with complex medical needs. The administrative burden of prior authorizations – requiring approval from insurers for certain procedures or medications – adds to the problem, increasing overhead and potentially delaying patient care. This is leading to a reassessment of participation nationwide.

A National Trend: More Systems Opting Out

The situation in San Diego isn’t unique. Becker’s Hospital Review has published lists of health systems dropping Medicare Advantage plans for three consecutive years – 2024, 2025, and 2026 – with over 40 systems nationwide listed since 2024. Even as these lists aren’t exhaustive, they demonstrate a clear and growing trend.

Did you know? Medicare Advantage plans now cover 53% of all Medicare beneficiaries in San Diego County.

Original Medicare vs. Medicare Advantage: Understanding the Trade-offs

Medicare beneficiaries have a choice: stick with Original Medicare or enroll in a Medicare Advantage plan. Original Medicare offers the freedom to witness any doctor who accepts Medicare, but generally comes with higher monthly premiums and the need for supplemental insurance. Medicare Advantage plans often have lower monthly premiums and may include extra benefits like vision, dental, and hearing coverage, but restrict members to a network of contracted providers.

The Role of Risk Adjustment and Reimbursement

Rachel Schmidt, a professor specializing in Medicare policy at Georgetown University, notes increasing tension between plans and providers, especially those with strong reputations. This tension is fueled, in part, by changes to risk adjustment payments – adjustments made to account for the health status of enrollees – and quality bonuses that insurance companies receive. As these payments change, insurers are scrutinizing payment rates to providers.

UnitedHealth Group, for example, has faced scrutiny for potentially inflating patient illness levels to justify higher reimbursements. Simultaneously, concerns are rising about insurers denying care to boost profitability.

UCSD’s Response and the “Select” Plan

UC San Diego Health capped enrollment for SCAN members in its primary care clinic in 2025 to prioritize care for complex patients who transitioned after the Scripps changes. SCAN responded by creating a “select” plan that maintains in-network access to UCSD specialists, hospitals, and urgent care, but requires members to obtain primary care from outside the UC San Diego Health medical group. Other plans, like UnitedHealthcare, Blue Shield, and Humana, have as well stopped offering plans with full access to the UCSD Health network.

Pro Tip: If you’re affected by these changes, explore all your options carefully. Consider the costs and benefits of both Medicare Advantage and Original Medicare, and don’t hesitate to seek assistance from a Medicare counselor.

Navigating the Changing Landscape: What Can Seniors Do?

Affected seniors, like the Monroes, have the option to purchase a Medigap supplemental insurance plan to rejoin Original Medicare, allowing them to choose any doctor. However, this can significantly increase monthly premiums. SCAN has partnered with the UC San Diego Health Physician Network, an affiliation of independent doctors connected to UCSD, and Regal Medical Group, offering alternative options for accessing specialists.

It’s important to understand the distinction between the UCSD Health medical group (employees of the university health system) and the UC San Diego Health Physician Network (independent doctors affiliated with UCSD).

FAQ: Medicare Advantage and Provider Networks

• What is Medicare Advantage? A type of Medicare plan offered by private insurance companies that manages Medicare benefits.
• What is Original Medicare? The traditional Medicare plan administered by the federal government.
• What is a Medigap plan? Supplemental insurance that helps cover costs not covered by Original Medicare.
• Why are doctors leaving Medicare Advantage plans? Primarily due to low reimbursements and administrative burdens.
• Where can I get help understanding my Medicare options? Contact the Health Insurance Counseling and Advocacy Program (HICAP).

The situation facing seniors in San Diego County is a microcosm of a larger national challenge. As healthcare costs continue to rise and insurance companies navigate financial pressures, beneficiaries may face increasingly limited choices and potential disruptions in their care. Staying informed and proactively exploring all available options is crucial.

Have questions about your Medicare plan? Share your concerns in the comments below!