CHAMPAIGN COUNTY, Unwell. (WCIA) — “I feel like this can be a real slap within the face to teachers,” retired Paxton-Buckley-Loda teacher Vicki Good reacted to Monday’s news that an Aetna Medicare Advantage plan will officially be the one medical health insurance option for roughly 140,000 retired state employees for the following five or more years. It’s an consequence seniors in Champaign and surrounding counties feared for months.
United HealthCare, the corporate that previously held the PPO contract that Aetna will step into Jan. 1, appealed the choice by the Illinois Department of Central Management Services (CMS) in July. The state’s Chief Procurement Office denied the protest, CMS confirmed late Friday.
Previously, there have been a handful of corporations for state retirees to choose from but that is ready to sunset at the tip of the yr. Aetna might be the only insurer after selling the state on a bunch PPO (Preferred Provider Organization) plan that the corporate has not previously offered in Illinois.
Aetna and state representatives were confident within the upcoming plan’s ability to supply an adequate network of doctors under federal network adequacy standards.
Some current Aetna members were more skeptical.
“So I’m still upset,” Good began in a Monday morning interview. “It doesn’t offer you any sense of security.”
We first met the retired teacher back in March. For years, she’s been enrolled within the Total Retiree Advantage Illinois Medicare Advantage Prescription Drug program (TRAIL MAPD). Good is on Aetna’s existing state-contracted Medicare HMO plan.
She’s been struggling to seek out various doctors that will be covered under her plan since early this yr when Aetna Medicare plans stopped being accepted at Carle Health facilities inside an hour of Champaign, including a network of greater than 500 doctors.
“I’m concerned about Aetna,” she said. “They’re making it sound like that they’ve all these people to assist us, all these doctors that may help us. And yet, while you actually try to seek out something, it isn’t what it looks like on the surface.”
Lately, Good is taking a look at needing multiple hand surgeries for carpal tunnel, including a joint alternative. The entire above require a hand surgeon, which is a particular style of orthopedic specialist.
“[My primary care doctor] said, ‘I do know a superb one at Carle, but you’ll be able to’t go to Carle due to, you realize, since you’re with Aetna,’” she explained. “So he’s sending me to Springfield.”
Within the meantime, Good said she called Aetna to see if there happened to be any closer options. A representative on the phone sent her an inventory of 27 doctors.
The primary three were the flawed style of specialists, a spine specialist, a hip and knee specialist, and one other that handled only shoulder and knee replacements.
“After which the following 1, 2, 3, 4, 5 that they sent me were walk-in clinics, they’re Christie walk-in clinics,” she continued.
“I don’t think I would like to go to a walk-in clinic in search of a hand specialist.”
The rest of the list was more of the identical or repeated names.
Aetna’s upcoming Medicare PPO plan should, in theory, include more options than the Medicare HMO plan she’s on. Due to a federal waiver, the PPO-ESA (or Prolonged Service Area) plan allows patients to see some out-of-network doctors at an in-network rate if the doctor’s office or hospital chooses to see that patient.
A representative with Carle Health — the ‘major provider’ of Central Illinois and a staple for a concentrated population of state retirees in-and-around Champaign County — said late Monday that Carle Foundation Hospital in Urbana and Carle Physician Group (those 500+ doctors) are still evaluating their “ability to support these passive PPO members,” citing cost concerns and “awaiting a proper announcement of a payor contract decision from the State.”
“If an out-of-network provider is willing to see a member and is eligible to receive Medicare payment, Aetna can pay 100% of the Medicare allowable rate for covered services,” an Aetna representative responded Friday, claiming “the member can pay in-network co-pays” no matter what an out-of-network provider charges.
The CVS-owned insurance company called on Carle Health to “maintain their deal with the health and well-being of Illinois retirees by continuing to see them as patients as they do today.”
The Carle communications official called the belief by CMS and Aetna that Carle doctors ‘should’ be available in the identical way they’ve been for retirees on the state’s current United HealthCare PPO plan “broad and misleading.”
“It’s our understanding that if a member in query is seen by an out-of-network provider, the price to the member might be similar to it could be in the event that they saw an in-network provider. BUT, ultimately that depends on the out-of-network profit design by the insurer,” she said.
“It’s very unlucky that individuals in our communities have been and sure might be placed in a situation wherein they are going to have to seek out an out-of-network provider locally or travel outside the region because of this of the passive PPO offering and the shortage of contracted providers offered,” an email from the Carle representative late Monday read.
Carle Foundation Hospital and Carle Physician Group don’t have contracts with any Medicare Advantage plans, including the currently state-contracted United HealthCare plan. Aetna Medicare was the last chip to fall. Due to aforementioned federal waiver, Carle chooses to simply accept some Medicare Advantage insurance policy. Right away, that features the United HealthCare group PPO plan that greater than 100,000 retirees are on.
“As insurers have gotten increasingly tougher for providers to cope with, making it more costly for providers, creating more administrative hoops to leap through, and denying payment for services rendered, providers across the country are reconsidering who they contract with and whether they are going to have the option to afford to proceed to see out-of-network members,” Carle Health communications said in response to an issue of why the facilities and provider group now not contract with Medicare Advantage plans.
There’s been no response from Aetna regarding the character of contract negotiations with Carle Health, only that the corporate says it’s open to revisiting the conversation.
“I used to be very seriously considering switching to United Health[Care],” Good said. “After all, now there’s no United Health option. It’s only an Aetna option, and that appears to be almost like a monopoly to me.”
Cutting the HMO option for retirees could pose a legal concern for CMS. The state’s labor contract with AFSCME Council 31 — the Illinois branch of the American Federation of State, County and Municipal Employees — specifically states that “the State shall proceed to supply enrollment in HMOs.” Whether that extends to retirees is unclear from an email statement from AFSCME in response to contract questions.
“The terms of the retiree medical health insurance program are set forth in our collective bargaining agreement and should be met for the upcoming 2023 plan yr,” Martha Merrill, Director of Research and Worker Advantages for AFSCME Council 31, said.
But why did CMS cut out options? Because 90 percent of enrollees already select the PPO plan, in keeping with Cathy Kwiatkowski, deputy director of communication and knowledge at CMS.
The remaining 10 percent enrolled within the HMO options is sort of 20,000 people.
Aetna also offered the state a $0 premium for the initial five-year contract term, Kwiatkowski cited in support of the singular option.
It doesn’t appear retirees or employees will get a $0 premium. Although the plan will include a “significant reduction” in contributions for retirees and dependents, Kwiatkowski said.
For the handfuls of retirees who’ve called, emailed and messaged WCIA 3 News, it’s not in regards to the money. It’s about keeping the doctors they’ve grown to trust at a critical time of their lives for medical care.
“I didn’t make big bucks once I was teaching, but I taught because I loved it. And a part of teaching, I at all times knew that there was going to be a pension there for me, and I’d have health care,” Good said summarizing her remaining fears and frustration.
“And now they’re just form of reneging on their guarantees to us of, you realize, what they would supply for us after we retired.”
Some state lawmakers have also been puzzled by the bidding process, including COGFA Co-chair Sen. Dave Koehler, (D) who said Monday that retirees must have options.
Sen. Koehler said CMS is required to present the brand new contract to lawmakers on the Commission on Government Forecasting and Accountability, but that meeting isn’t expected until the spring, too little too late for any change.
COGFA’s role is solely advisory, Koehler said. CMS can “take or leave” the recommendation.
Koehler, after learning reporter questions and retiree concerns were going largely unanswered, penned a letter to the state agency in September asking, partially, “How did CMS determine adequate network coverage” through the TRAIL MAPD bidding process?
“Offerors to this Request for Proposal (RFP) were required to show compliance with standards set by the authority having jurisdiction, the Federal Center for Medicare & Medicaid Services,” CMS responded in writing.
If our previous reporting and Vicki Good’s hand surgeon list are any indication, independent verification of insurer-provided networks has revealed a plethora of inaccuracies.
CMS didn’t respond when Goal 3 reporters asked directly if independent verification was a component of the method.
Open enrollment for state retirees has been pushed back to Nov. 1 from the standard Oct. 1 start date. The brand new plan will go into effect for enrollees Jan. 1.
“Communication regarding the change to the MAPD PPO plan will begin inside the following couple of weeks, with open enrollment decision guides mailed by the tip of October. Members will even receive communications directly from Aetna and the Center for Medicare and Medicaid Services. The State of Illinois might be issuing several communications to retirees, detailing the changes, including announcement home mailers, letters, emails, and in-person seminars through the open enrollment period,” Kwiatkowski added.
Aetna’s contract lasts a minimum of an initial five years “with a guaranteed $0 premium for the initial term,” Kwiatkowski explained. “There are an optional 5 years of renewals.”
State retirees will not be involved within the decision-making process, one other source of complaints over the past several months.
Contacting state legislators via phone or email is probably the most local strategy to share complaints.
Medicare complaints are filed here with the U.S. Centers for Medicare and Medicaid.
United HealthCare didn’t reply to request for comment as of this report.
This text has been updated to make clear that Carle Foundation Hospital and Carle Physician Group do accept certain Medicare Advantage plans, but don’t contract with any.