Frequently Asked Questions

• What is Medicare Direct Contracting?

  This is a special Medicare program for patients with Original Medicare that allows doctors to work together to keep patients healthy.

• How do I know if I have Original Medicare?

  Patients with Original Medicare have a card that is red, white, and blue that says “Medicare Health Insurance” at the top. This includes those who are also covered by Medicare Supplement Insurance, also known as Medigap, secondary coverage offered by private health insurance companies.

• What is Sutter Medicare Direct?

  Sutter Medicare Direct contracts with Medicare to participate in the Medicare Direct Contracting program. Sutter Medicare Direct is not an insurance company. It is part of the Sutter Health network, and it works with doctors and other providers who coordinate with one another to deliver high-quality care to patients.

• Is Sutter Medicare Direct an HMO?

  No. Sutter Medicare Direct is not an HMO, a health plan, or an insurance company. It is part of Sutter Health and works with your doctors and care teams to better coordinate your care. You can continue to see any doctor, hospital, or other provider who accepts Original Medicare and you do not need any prior authorizations other than those already required by Original Medicare.

• Why did I receive a letter from Sutter Medicare Direct?

  Your primary care doctor is now working with Sutter Medicare Direct. We are required to send a notice to patients with doctors who have decided to participate in this program.

• Is there anything I need to do?

  No. The letter was sent to you for informational purposes only.

• Is there any change in my coverage, benefits, or doctors?

  No. There are no changes to your coverage, benefits or doctors.

• Are my pharmacy benefits changing?

  No. Your pharmacy benefits will remain the same.

• Can I continue to see other doctors or specialists?

  Yes. Patients continue to have the freedom of choice to go to any doctor, hospital or other healthcare provider that accepts Original Medicare.

• Will this impact any referrals or prior authorizations?

  No. You will only need a prior authorization if Original Medicare requires one.

• How will this program help my doctor get me the right care?

  This new program allows Sutter team members to provide essential support services to your doctor, such as new tools, resources, or information—all with a focus on helping them coordinate and manage your care. For example, Sutter team members will contact patients following an unplanned hospital admission to help them schedule a primary care follow-up visit and help facilitate a smooth transition from hospital to home and avoid preventable hospital readmissions in the future. We also have case managers who will partner with patients identified as being at high or rising risk of complications to help them develop personalized goals to address medical or other issues.

  Another important initiative underway is ensuring all patients get a Medicare Annual Wellness Visit with a personalized prevention plan. Annual Wellness Visits also help us gain a better understanding of each patients’ unique care needs and can even enable us to address issues that affect patients’ health beyond the traditional care setting, such as housing, food stability, transportation, or social isolation.

• Will this program change the relationship I have with my doctor?

  No. This program does not change the relationship between you and your doctor. There are no networks or prior authorizations unless Original Medicare requires one. Sutter Medicare Direct simply works behind the scenes to coordinate otherwise siloed care with a focus on making care more efficient, eliminating waste and unnecessary services, and encouraging prevention. Additionally, patients may also receive more benefits at no cost through the program’s Benefit Enhancements.

• What additional benefits may be available to me as a patient?

  One of the most important ways the program will help patients is by providing certain Benefit Enhancements for services that are not typically covered by Original Medicare. Examples include:

  • Skilled nursing facility (SNF) care for patients who don’t need an extended hospital stay but are not yet ready to be discharged home. Under routine Medicare rules, patients must have an inpatient hospital stay of no fewer than three consecutive days to be eligible for coverage of SNF care—regardless of their need for post-acute care. However, SMD patients who meet certain criteria and need skilled nursing or rehab services may be admitted for SNF care without a three-day inpatient hospital stay
  • Home health services for patients with multiple chronic conditions who are not homebound
  • Extended coverage of telehealth services for patients at home beyond the current Public Health Emergency (most Medicare coverage for telehealth will end 151 days after Health and Human Services lifts the Public Health Emergency)
• Will this change my monthly premiums or out-of-pocket costs?

  No. This will not change what you pay out-of-pocket, such as any monthly premiums for Medicare Part B (Medical Insurance) or Medicare Part D (Prescription Drug Coverage), or the coinsurance you pay for doctor’s visits.

• How do I opt out of data sharing?

  You can opt out of or modify data sharing preferences by calling (800) MEDICARE. However, CMS will still engage in limited data sharing with Sutter Medicare Direct for quality improvement.

• Who can I contact to learn more?

  You can learn more about Sutter Medicare Direct or Medicare Direct Contracting by emailing SutterMedicareDirect@SutterHealth.org or by calling (833) 674-2323.