IRTA Members,
The Illinois Retired Teachers
Association would like to make our members aware that according to a recent
article, Aetna Medicare Advantage PPO will be the sole insurer offered to
Illinois retired state workers and retired teachers. This means that, in
addition to removing United Healthcare, the State is also removing all HMO
options from retired teachers. IRTA understands that in some areas,
members will not be able to continue to see their current healthcare providers
at the same cost.
The attached article makes it
clear that this will be true in the Champaign area, but your area could be
impacted as well. You may want to check with your healthcare providers about
how the State’s decision to contract Aetna as the sole provider could impact
your benefit.
Open enrollment for retirees has
been pushed back to November
1st from the
typical October
1st start
date. The new plan will go into effect for enrollees January 1, 2023. Communication regarding
the change will begin within the next couple of weeks. To read the full
article, please click here [or continue reading].
Sincerely,
Jim Bachman
IRTA Executive Director
CHAMPAIGN COUNTY, Ill.
(WCIA) — “I feel like this is a real slap in 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 only health insurance option for
roughly 140,000 retired state workers for the next five or more years. It’s an
outcome seniors in Champaign and surrounding counties feared for months.
United
HealthCare, the company that previously held the PPO contract that
Aetna will step into Jan. 1, appealed the decision 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 were a handful of companies for state retirees to choose between but that
is set to sunset at the end of the year. Aetna will be the sole insurer after
selling the state on a group PPO (Preferred Provider Organization) plan that
the company has not previously offered in Illinois.
Aetna and state
representatives were confident in the upcoming plan’s ability to provide 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 give you any sense of security.”
We first met the
retired teacher back in March. For years, she’s been enrolled in 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 find various doctors that would be covered under her plan since early this
year when Aetna Medicare plans stopped being accepted at Carle Health
facilities within an hour of Champaign, including a network of more than 500
doctors.
“I am concerned about
Aetna,” she said. “They’re making it sound like that they have all these people
to help us, all these doctors that can help us. And yet, when you actually try
to find something, it isn’t what it looks like on the surface.”
These days, Good is
looking at needing multiple hand surgeries for carpal tunnel, including a joint
replacement. All of the above require a hand surgeon, which is a specific type
of orthopedic specialist. “[My primary care doctor] said, ‘I know a good one at
Carle, but you can’t go to Carle because of, you know, because you’re with
Aetna,'” she explained. “So he is sending me to Springfield.”
In the meantime, Good
said she called Aetna to see if there happened to be any closer options. A
representative on the phone sent her a list of 27 doctors. The first three were
the wrong type of specialists, a spine specialist, a hip and knee specialist,
and another that handled only shoulder and knee replacements. “And then the
next 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 want to go to a walk-in
clinic looking for a hand specialist.” The remainder of the list was more of
the same or repeated names.
Aetna’s upcoming Medicare
PPO plan should, in theory, come with more options than the Medicare HMO plan
she’s on. Because of a federal waiver, the PPO-ESA (or Extended 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 formal 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 will pay 100% of the Medicare allowable rate for covered
services,” an Aetna representative responded Friday, claiming “the member will
pay in-network co-pays” regardless of what an out-of-network provider charges.
The CVS-owned
insurance company called on Carle Health to “maintain their focus on 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 assumption by CMS
and Aetna that Carle doctors ‘should’ be available in the same way they have
been for retirees on the state’s current United HealthCare PPO plan “broad and
misleading.”
“It is our
understanding that if a member in question is seen by an
out-of-network provider, the cost to the member will be the same as it would be
if they saw an in-network provider. BUT, ultimately that is dependent on the
out-of-network benefit design by the insurer,” she said.
“It’s very unfortunate
that individuals in our communities have been and likely will be placed in a
situation in which they will have to find an out-of-network provider locally or
travel outside the region as a result of the passive PPO offering and the lack
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. Because of the aforementioned
federal waiver, Carle chooses to accept some Medicare Advantage insurance
plans. Right now, that includes the United HealthCare group PPO plan that more
than 100,000 retirees are on.
“As insurers are
becoming increasingly more difficult for providers to deal with, making it more
costly for providers, creating more administrative hoops to jump through, and
denying payment for services rendered, providers across the country are
reconsidering who they contract with and whether they will be able to afford to
continue to see out-of-network members,” Carle Health communications said in
response to a question of why the facilities and provider group no longer
contract with Medicare Advantage plans.
There’s been no
response from Aetna regarding the nature of contract negotiations with Carle
Health, only that the company says it’s open to revisiting the conversation. “I
was very seriously considering switching to United Health[Care],” Good said.
“Of course, now there’s no United Health option. It’s only an Aetna option, and
that seems 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 continue to offer 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 health insurance program are set forth in our collective bargaining
agreement and must be met for the upcoming 2023 plan year,” Martha Merrill,
Director of Research and Employee Benefits for AFSCME Council 31, said.
But why did
CMS cut out options? Because 90 percent of enrollees already choose the PPO
plan, according to Cathy Kwiatkowski, deputy director of communication and
information at CMS. The remaining 10 percent enrolled in the HMO options is
nearly 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 come with a
“significant reduction” in contributions for retirees and
dependents, Kwiatkowski said.
For the dozens of
retirees who’ve called, emailed and messaged WCIA 3 News, it’s not about the
money. It’s about keeping the doctors they’ve grown to trust at a critical time
in their lives for medical care. “I didn’t make big bucks when I was teaching,
but I taught because I loved it. And part of teaching, I always knew that there
was going to be a pension there for me, and I would have health care,” Good
said summarizing her remaining fears and frustration. “And now they’re just
kind of reneging on their promises to us of, you know, what they would provide
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 should have options. Sen.
Koehler said CMS is required to present the 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 advice. Koehler, after
learning reporter questions and retiree concerns were going largely unanswered,
penned a letter to the state agency in September asking, in part, “How did CMS
determine adequate network coverage” during the TRAIL MAPD bidding process?
“Offerors to this
Request for Proposal (RFP) were required to demonstrate 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 did not respond
when Target 3 reporters asked directly if independent verification was a part
of the process. Open enrollment for state retirees has been pushed back to Nov.
1 from the typical Oct. 1 start date. The new plan will go into effect for
enrollees Jan. 1.
“Communication
regarding the change to the MAPD PPO plan will begin within the next couple of
weeks, with open enrollment decision guides mailed by the end of October.
Members will also receive communications directly from Aetna and the Center for
Medicare and Medicaid Services. The State of Illinois will be issuing
several communications to retirees, detailing the changes, including
announcement home mailers, letters, emails, and in-person seminars during the
open enrollment period,” Kwiatkowski added.
Aetna’s contract lasts
at least 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 are not involved in the decision-making process, another source
of complaints over the past several months. Contacting state legislators via
phone or email is the most local way to share complaints.
Medicare complaints are filed here with
the U.S. Centers for Medicare and Medicaid. United HealthCare did not respond
to request for comment as of this report.
This article
has been updated to clarify that Carle Foundation Hospital and Carle Physician
Group do accept certain Medicare
Advantage plans, but do not contract with any.