In Medicare Advantage stalemate, Everett Clinic patients left in limbo

EVERETT — A few days after Christmas, Mel drove his wife to The Everett Clinic in Shoreline, their usual place of care. She was having trouble breathing, likely a complication of a respiratory illness and asthma.

But the clinic refused to see her, saying it would not accept patients with Regence Medicare Advantage plans, Mel said. They gave her a paper with a list of clinics that would probably treat her. This was about one week after Mel received care for the same respiratory distress in California, with no problems.

Mel, who asked that his last name not be published, wrote in an email: “We are shaken to realize that we have no contact allowed with our usual and long-standing sources of primary and specialty care! In our mid- seventies, this is no small development!”

As The Daily Herald reported in December, when Regence and Optum — the parent of The Everett Clinic — settled commercial contracts in late December, the deal did not include Medicare Advantage plans. Some seniors buy these plans from private insurers, rather than coverage through traditional Medicare. Regence and Optum are still negotiating.

Regence did not respond to a request for the number of affected Medicare members left in limbo. But a spokeperson confirmed denials of care: “We are very concerned by numerous reports we’ve received from our Medicare Advantage members who have been refused care by The Everett Clinic and The Polyclinic.”

Medicare Advantage operates under different rules than commercial plans, with the federal government dictating the ground rules and paying a fixed amount per patient each month.

But Regence had promised Medicare Advantage members that during the federal COVID public health emergency, they could “receive out-of-network services covered at in-network cost sharing” at Optum locations.

A spokesperson for the Center for Medicare and Medicaid Services confirmed that according to current regulations, during disasters or emergencies, including federal public health emergencies, “Medicare Advantage plans must cover services provided by non-contracted providers so long as there is a disruption of access to health care.”

Jo Ford, a patient of The Everett Clinic for more than 50 years, said she felt “alone” when she heard Regence and Optum had settled for all contracts except Medicare Advantage.

“We are just swimming in the ocean, just grasping for the life ring,” Ford said. “We’re on our own. And how many other seniors are in the water with us? We have no idea. I’ve heard it’s thousands, speaking with Regence.”

Ford said she loves the care The Everett Clinic has given her and her husband. But they recently told her she’d have to pay out of pocket for a routine screening. She talked with Regence, who told her that’s incorrect.

“It’s back and forth, the information I get is confusing,” Ford said.

In response to a question about how staff have been instructed to treat Regence Medicare Advantage members, spokesperson Tenzin Choephel said Optum is trying to resolve the dispute with Regence and provide patients the best care possible.

“We are hopeful that we can come to a mutually beneficial resolution with the Medicare Advantage contract. During this time, we have worked with Regence to ensure existing appointments, procedures and surgeries occur and continuity of care coverage is provided to qualified Medicare Advantage patients,” Choephel said.

After The Everett Clinic sent them away, neither Mel nor his wife contacted Regence. Instead, Mel reported he had burned through the battery on his cell phone on Friday, trying to find a nearby primary care provider who would accept new patients anytime soon. He had failed so far and did not feel optimistic.

Ford only just decided on Wednesday to find another primary care provider. They will require her to do an initial visit, and then schedule the screening — delaying her care for months, she said.

In the meantime, she has an important test scheduled with The Everett Clinic in March, and she’s worried about how that will work out. If the public health emergency is still in effect, which it most likely will be, she should be fine, according to Regence’s letters and statement.

The U.S. Department of Health and Human Services has promised to provide 60 days’ notice before ending the COVID public health emergency. If it follows that promise, the expiration will be pushed back 90 days after Jan. 11.

Medicare Advantage members can change their plan right now, during open enrollment. One of their options, UnitedHealthcare, is owned by the same parent company, Optum.

We will continue to report on access to health care in 2023. If you have faced barriers to accessing timely, convenient or affordable care in Snohomish County, please fill out this brief form: forms.gle/DcgfccCvwqVTh6Sk7

Joy Borkholder is the health and wellness reporter for The Daily Herald. Her work is supported by the Health Reporting Initiative, which is sponsored in part by Premera Blue Cross. The Daily Herald maintains editorial control over content produced through this initiative.

Joy Borkholder: 425-339-3430; joy.borkholder@heraldnet.com; Twitter: @jlbinvestigates.