United HealthCare, the company that previously held the PPO contract that Aetna will take effect on Jan. 1, appealed the decision to the Illinois Department of Central Management (CMS) in July. The state’s chief procurement officer denied the protest, CMS confirmed late Friday.
There used to be a handful of companies for state pensioners to choose from, but this will end at the end of the year. Aetna will be the only insurer after selling the state to a PPO (Preferred Provider Organization) group plan, which the company has not previously offered in Illinois.
Aetna and the state representatives were confident in the upcoming plan’s ability to provide an adequate network of physicians under federal network adequacy standards.
Some current Aetna members were more skeptical.
“So I’m still upset,” Goode began in an interview Monday morning. “It doesn’t give you any sense of security.”
We first met the retired teacher in March. She had been enrolled in the Total Retiree Advantage Illinois Medicare Advantage Prescription Drug Program (TRAIL MAPD) for years. Good in Aetna’s existing state Medicare HMO plan.
She has struggled to find a variety of doctors to be covered by her plan since earlier this year, when Aetna Medicare plans stopped accepting Carle Health facilities within an hour of Champaign, including a network of more than 500 doctors .
“I’m worried about Etna,” she said. “They make it sound like they have all these people to help us, all these doctors who can help us. Yet when you really try to find something, it’s not what it seems on the surface. “
These days, Good believes he needs multiple surgeries on his hands 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 in Carl’s, but you can’t go to Carl’s because, you know, because you’re with Etna,” she explained. “So he’s sending me to Springfield.”
In the meantime, Goode said she called Etna to see if there were any closer options. A representative on the phone sent her a list of 27 doctors.
The first three were the wrong type of specialist, a spine specialist, a hip and knee specialist and another who only did shoulder and knee replacements.
“And the next 1, 2, 3, 4, 5 that they sent me were guest clinics, they’re Christy guest clinics,” she continued.
“I don’t think I want to go to a clinic looking for a hand specialist.”
The rest of the list was more of the same or repeating names.
Aetna’s upcoming Medicare PPO plan should, in theory, have more options than the Medicare HMO plan she uses. Because of a federal exemption, a PPO-ESA (or expanded service area) plan allows patients to see some out-of-network doctors at the in-network level if the doctor’s office or hospital chooses to see that patient.
A representative for Carle Health — Central Illinois’ “major provider” and a staple for the 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 are still evaluating their “ability to support these passive PPO members,” citing cost concerns and “waiting for a formal announcement of a state payer contract decision.”
“If an out-of-network provider is willing to accept a member and is eligible to receive payment from Medicare, Aetna will pay 100% of the Medicare eligible rate for covered services,” an Aetna representative responded Friday, claiming that “the member will pay a copayment in-network’ regardless of out-of-network provider billing.
The CVS-owned insurance company urged 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 officer called CMS and Aetna’s suggestion that Carle doctors “should” be available the same way they were to retirees in the state’s current United HealthCare PPO plan “broad and misleading.”
“It is our understanding that if the 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 were seen by an in-network provider. BUT ultimately it depends on the design of out-of-network benefits by the insurer,” she said.
“It is very unfortunate that people in our communities have been and will likely be placed in a situation where they will have to find a local out-of-network provider or travel out of region as a result of passive PPO offerings and the lack of contract providers available.” , a Carle representative said in an email late Monday.
Carle Foundation Hospital and Carle Physician Group do not have contracts with any Medicare Advantage plans, including the current state-contracted United HealthCare plan. Aetna Medicare was the last chip to fall. Because of the aforementioned federal exemption, Carl elects to accept certain Medicare Advantage insurance plans. This currently includes the United HealthCare group PPO plan, which has more than 100,000 retirees enrolled.
“As insurers become more difficult to deal with, making them more expensive for providers, creating more administrative hoops to jump through and denying payment for services rendered, providers across the country are rethinking who they will contract with and whether you will be able to afford to continue to see out-of-network members,” Carle Health Communications said in response to a question about why the facilities and provider group no longer contract with Medicare Advantage plans.
There was no response from Aetna about the nature of the contract negotiations with Carle Health, only that the company said it was open to revisiting the conversation.
“I was very seriously considering switching to United Health[Care],” Goode said. “Of course, there is no United Health option now. It’s just an Aetna option, and that seems almost like a monopoly to me.”
Reducing the HMO option for retirees could create a legal concern for CMS. The state’s labor contract with AFSCME Council 31 — the Illinois chapter of the American Federation of State, County and Municipal Employees — specifically states that “the state will continue to offer enrollment in HMOs.” Whether that also applies to retirees is unclear from an emailed statement from AFSCME in response to questions about the contract.
“The terms of the retiree health insurance program are set forth in our collective agreement and must be met for the upcoming 2023 plan year,” said Martha Merrill, director of research and employee benefits for AFSCME Council 31.
But why did CMS cut the options? Because 90 percent of enrollees now choose the PPO plan, according to Kathy Kwiatkowski, CMS deputy director of communications and information.
The remaining 10 percent enrolled in HMO options is nearly 20,000 people.
Aetna also offered the state a $0 premium for the initial five-year term of the contract, Kwiatkowski cited in support of the only option.
It does not appear that retirees or employees will receive a $0 premium. Although the plan would come 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 trusted at a critical time in their lives for medical care.
“I didn’t make a lot of money teaching, but I taught because I loved it. And as part of teaching, I always knew there would be a pension there for me and I would have health care,” Dobre said, summing up his remaining fears and frustration.
“And now they’re just reneging on their promises to us about what they’re going to provide for us after we retire.”
Some state lawmakers also were 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 should present the new contract to lawmakers in the Government Estimates and Accountability Committee, but that meeting isn’t expected until spring, too little too late for any change.
COGFA’s role is purely advisory, Koehler said. CMS can “take it or leave it” advice.
Koehler, after learning that reporters’ questions and retirees’ concerns were going largely unanswered, wrote a letter to the state agency in September asking, in part, “How did CMS determine adequate network coverage” during the TRAIL MAPD bidding process?
“The offerors under this request for proposal (RFP) were required to demonstrate compliance with the standards set forth by the competent authority, the Federal Center for Health and Medical Services,” CMS responded in writing.
If our previous reports and Vicky Goode’s list of hand surgeons are any indication, an independent review of the networks provided by the insurer revealed numerous inaccuracies.
CMS did not respond when Target 3 reporters asked directly if the independent review was part of the process.
Open enrollment for government retirees has been pushed back to November 1 from the usual October 1 start date. The new plan will go into effect for enrollees on January 1.
“Communication regarding the MAPD PPO plan change will begin in the next few weeks, with open enrollment decision guides being sent by the end of October. Members will also receive communications directly from Aetna and the Centers for Medicare and Medicaid Services. of Illinois will issue several notices to retirees detailing the changes, including home mail announcements, letters, emails and in-person seminars during the open enrollment period,” Kwiatkowski added.
Aetna’s contract runs for at least the first five years “with a guaranteed premium of $0 for the initial term,” Kwiatkowski explained. “There are optional 5 year renewals.”
State pensioners are not involved in the decision-making process, another source of complaints in the past few months.
Contacting state legislators by phone or email is the most local way to share grievances.
Medicare appeals are filed here at the US Centers for Medicare and Medicaid Services.
United HealthCare did not respond to a request for comment on 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.