United HealthCare, the company that previously held the PPO contract that Aetna will take effect Jan. 1, appealed the Illinois Department of Central Management Services (CMS) decision in July. The state’s Chief Procurement Office denied the protest, CMS confirmed late Friday.
Previously, there were a handful of companies that state pensioners could choose from, but that is due to disappear by the end of the year. Aetna will be the sole insurer after selling the state on a Preferred Provider Organization (PPO) group plan that the company has not previously offered in Illinois.
Aetna and state officials were confident in the ability of the upcoming plan to provide an adequate network of physicians under federal network adequacy standards.
Some current Aetna members were more skeptical.
“So I’m still upset,” Good began in an interview Monday morning. “It doesn’t give you any sense of security.”
We first met the retired teacher in March. For years, she was enrolled in the Illinois Medicare Advantage Total Retiree Prescription Drug Program (TRAIL MAPD). Good is on Aetna’s existing Medicare HMO plan.
She has struggled to find various doctors who would be covered by her plan since earlier this year, when Aetna Medicare plans stopped being accepted at Carle health facilities less than an hour from Champaign, including a network of more than 500 doctors.
“I’m worried about Aetna,” she said. “They make it look like they have all these people to help us, all these doctors who can help us. And yet when you’re actually trying to find something, that’s not what it looks like on the surface. “
These days, Good contemplates needing multiple hand surgeries for carpal tunnel, including joint replacement. All of the above requires a hand surgeon, which is a specific type of orthopedic specialist.
“[My primary care doctor] said, “I know a good one in Carle, but you can’t go to Carle because of, you know, because you’re with Aetna,” she explained. “So he’s sending me to Springfield.”
In the meantime, Good said she called Aetna to see if there were any closer options. A representative on the phone sent him a list of 27 doctors.
The first three were the wrong kind of specialists, a spine specialist, a hip and knee specialist, and another who only did shoulder and knee replacements.
“And then the next 1, 2, 3, 4, 5 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 rest of the list was more identical or repeated names.
Aetna’s upcoming Medicare PPO plan should, in theory, have more options than the Medicare HMO plan it’s on. Due to a federal waiver, the PPO-ESA (or Extended Service Area) plan allows patients to see certain out-of-network doctors at an in-network rate if the doctor’s office or hospital chooses to see that patient.
A representative from Carle Health — the “main supplier” to central Illinois and a staple for a concentrated population of in-state retirees in and around Champaign County — said Monday evening that Carle Foundation Hospital in Urbana and the Carle Physician Group (those 500+ physicians) are still evaluating their “ability to support these passive OPP members,” citing cost concerns and “awaiting a formal announcement of a state payer contract decision.” “.
“If an out-of-network provider wishes to see a member and is eligible to receive payment from Medicare, Aetna will pay 100% of the Medicare authorized rate for covered services,” an Aetna representative responded Friday, saying “the member will pay in-network co-payment”, regardless of the fees charged by an out-of-network provider.
The CVS-owned insurance company called on Carle Health to “maintain its focus on the health and well-being of Illinois retirees by continuing to treat them as patients as they do today.”
Carle’s communications manager called CMS and Aetna’s assumption that Carle’s doctors “should” be available the same way they have been for retirees on the current United HealthCare PPO plan. the “broad and deceptive” state.
“We understand that if a member in question is seen by an out-of-network provider, the cost to the member will be the same as seeing an in-network provider. BUT ultimately it depends on the design of the benefits out of network by the insurer,” she said.
“It is very unfortunate that individuals in our communities have been and likely will be placed in a situation where they will have to find an out-of-grid provider locally or travel outside the region due to the passive offer of PPO and the lack of contracted suppliers on offer,” read an email from Carle’s rep on Monday evening.
The Carle Foundation Hospital and the Carle Physician Group have no contracts with Medicare Advantage plans, including the United HealthCare plan currently under contract with the state. Aetna Medicare was the latest chip to fall. Due to the aforementioned federal waiver, Carle elects to accept certain Medicare Advantage insurance plans. Currently, this includes the United HealthCare Group’s PPO plan in which over 100,000 retirees participate.
“As insurers become increasingly difficult for providers to deal with, making them more costly for providers, creating more administrative hoops to navigate, and refusing payment for services rendered, providers across the country are reconsidering with who they contract and whether they will be able to afford to continue seeing out-of-network members,” Carle Health Communications said in response to a question about why the facilities and provider group are not concluding no more contract with Medicare Advantage plans.
There was no response from Aetna regarding the nature of the contract negotiations with Carle Health, only that the company says it is open to revisiting the conversation.
“I was very seriously considering moving to United Health[Care]“, Good said. “Of course, there is no United Health option anymore. It’s just an Aetna option, and it almost feels like a monopoly to me.”
Cutting the HMO option for retirees could pose a legal problem for CMS. The state’s employment contract with Council 31 of AFSCME – the Illinois branch of the American Federation of State, County and Municipal Employees – specifically states that “the State will continue to provide the enrollment in HMOs”. Whether this extends to retirees is unclear from an emailed statement from AFSCME in response to questions about the contracts.
“The terms of the Retiree Health Insurance Program are set out in our collective agreement and must be met for the next plan year 2023,” said Martha Merrill, Director of Research and Benefits for IAEA Council 31. AFSCME.
But why did CMS remove the options? Because 90% of enrollees already choose the PPO plan, according to Cathy Kwiatkowski, deputy director of communications and information at CMS.
The remaining 10% enrolled in HMO options represent 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 does not appear that retirees or employees will receive a $0 bonus. Although the plan comes with a “significant reduction” in contributions for retirees and dependents, Kwiatkowski said.
For the dozens of retirees who have called, emailed and texted WCIA 3 News, it’s not about the money. It’s about keeping the doctors they’ve come to trust at a critical time in their lives for medical care.
“I didn’t make a lot of money when I was teaching, but I was teaching because I loved it. And as part of teaching, I always knew there would be a pension there for me and that I would have health care,” Good said. said summing up his remaining fears and frustrations.
“And now they’re kind of giving up on what they promised us to, you know, what they would provide to us after we retired.”
Some state lawmakers have also been intrigued 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 at the Commission on Government Forecasting and Accountability, but that meeting isn’t expected until the spring, too little too late for any changes.
COGFA’s role is advisory only, Koehler said. CMS can “take it or leave it” advice.
Koehler, after learning that reporters’ questions and retiree concerns remained largely unanswered, wrote a letter to the state agency in September asking, in part, “How did CMS determine network coverage adequate” during the TRAIL MAPD bidding process?
“Bidders to this Request for Proposals (RFP) were required to demonstrate compliance with standards established by the competent authority, the Federal Center for Medicare & Medicaid Services,” CMS responded in writing.
If our previous reports and Vicki Good’s list of hand surgeons are any indication, independent verification of networks provided by insurers revealed a plethora of inaccuracies.
CMS did not respond when Target 3 reporters asked directly if independent verification was part of the process.
Open registration for in-state retirees has been pushed back to November 1 from the typical start date of October 1. The new plan will go into effect for enrollees on January 1.
“Communication regarding the MAPD PPO plan change will begin in the coming weeks, with open enrollment decision guides mailed out 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 send multiple communications to retirees detailing the changes, including in-home announcements, letters, emails, and in-person seminars during the open enrollment period,” added Kwiatkowski.
Aetna’s contract lasts for at least the first five years “with a guaranteed premium of $0 for the initial term,” Kwiatkowski explained. “There are 5 years of optional renewals.”
State pensioners are not involved in the decision-making process, another source of complaints in recent months.
Contacting state lawmakers by phone or email is the most local way to share complaints.
Medicare complaints are filed here with the US Centers for Medicare and Medicaid.
United HealthCare did not respond to request for comment from this report.
This article has been updated to clarify that Carle Foundation Hospital and Carle Physician Group accept certain Medicare Advantage plans, but do not contract with them.