Summary

Palo Alto Medical Foundation participates in popular Medicare Advantage plans in Santa Clara valley, as well as San Mateo and Santa Cruz counties. Some individuals are doing a test drive, in order to gain access to Sutter/ PAMF.  Before you "drive," first, get independent advice, locally.

Are recent events tempting you to test drive any of the Medicare Advantage plans in Santa Clara valley? It seems more and more doctors are shying away from traditional Medicare (original Medicare Part A and Part B) in Santa Clara valley.  There is a buzz about reports that Sutter/ PAMF (Palo Alto Medical Foundation- formerly Camino Medical Group, Sunnyvale Medical Clinic etc.) is limiting access to new Medicare patients on traditional Medicare (read story). And in 2024, Stanford Medicine severed its only contract with Medicare Advantage.

According to the Kaiser Family Foundation, in 2021 42% of Medicare beneficiaries nationally have chose a Medicare Advantage plan over traditional Medicare.  This statistic has been growing for years.  So if your current physician is contracted with a Medicare Advantage plan…or if you are willing to try one of these plans, in order to gain access to Sutter/PAMF, should you give it a test drive (note:  the number of plans is expanding in 2023- see related story)?

Palo Alto Medical Foundation participates in popular Medicare Advantage plans in Santa Clara valley, as well as San Mateo and Santa Cruz counties. Some individuals are doing a test drive, in order to gain access to Sutter/ PAMF.  Before you “drive,” first, get independent advice, locally.

Before You Test Drive Medicare Advantage Plans

I would answer you first need a lot of information, including understanding the risks of Medicare Advantage plans. If I were to develop a list of best practices to research the issue, it would begin with finding a competent, local independent agent whom you are comfortable

with.  Make sure you discuss what, if any, trial rights (i.e. guarantees that you can return to traditional medigap coverage) would apply to your situation.  Another recommendation is… find a doctor, before you apply to Medicare.

Best Practices for individuals approaching Age 65

• Secure your primary care physician well before applying for Medicare
• Find a local, experienced Independent Agent, representing lots of insurance companies

Medicare Advantage Trial Period

When you enroll in a Medicare Advantage plan for the first time, you may have Medicare “trial” protections and additional rights under California law, which could allow you to return to traditional Medicare with supplemental (medigap) coverage.  However, these rights do not apply in all circumstances and you should seek a consultation from a competent independent agent before enrolling.  I cannot emphasize this enough.

How do Independent Agents Get Compensated?

Local Independent agents do not charge fees, using them does not add to the cost of your insurance.  In fact, they are only compensated when they help you complete an enrollment application for insurance coverage.  Medicare sets the compensation dollar amount and for Medicare Advantage plans, it is the same from insurer to insurer. So there is really no incentive to favor one plan over another.  However, not every agent is independent and not every independent agent represents a large number of plans. You need to ask questions.

When you find one, treasure that relationship, because good agents get booked up quickly through referrals.  You are going to need their help over the years because insurance companies have a tendency to bring new plans into the county and close older plans as time goes on.

By local, I mean an agent who is not out of state and not digital (online only).  Chances are good that local agents know your county better:  They hear and know what’s going on with local doctors and medical groups e.g.Sutter/ PAMF, SCIPPA, PMG.  Plus, Medicare Advantage and standalone prescription drug plans are contracted on a county by county basis. New plans are coming and going every year.

Here are my best practice suggestions for choosing a local, independent agent:

• Represents at least three Medicare Advantage plans
• Represents at least five Medicare Supplement (medigap) plans
• Represents at least four standalone Part D prescription drug plans
• Lots and lots of client references– ask for them or check YELP or both

Finding a Doctor

When I suggest “Find A Doctor” I am alluding to the recent development of some doctors shying away from traditional Medicare.  The Kaiser Family Foundation published an issue brief in 2020 that estimates 1.5% of California doctors have formally opted out of Medicare. While that leaves a healthy 98.5%, the recent Sutter/PAMF reports could be a game-changer.

Even Medicare Advantage (HMO) plans require you to designate a Primary Care Physician on your enrollment application.  Bottomline you need to find a doctor.

Here’s my suggestion:  Find your doctors(s) before you apply to Medicare and solidify the relationship by making sure you have been seen within the last year or two.  According to reports, PAMF is defining “existing patient” to mean someone who has been seen by their doctor within the last three years.

I have additional ideas for individuals working past 65 (read story).

Bottomline, find a doctor and find a competent, local independent agent.