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CHAMPAIGN — It will be at least until after Labor Day before the state of Illinois retirees learn more about a pending decision that’s causing anxiety for many.
With six weeks to go before open enrollment begins for health coverage for Medicare-eligible state retirees, few details are available about what coverage the state may be making available.
After undergoing a request for proposals process required every decade, the state chose an Aetna PPO for retirees in every county but is currently in the midst of an appeal filed by UnitedHealthcare — the insurer currently offering a statewide PPO plan to state retirees through the end of this year.
Cathy Kwiatkowski, spokeswoman at the Illinois Department of Central Management Services, responded to an inquiry about the time frame for a decision by saying after Labor Day would be a good time to check back.
Finalized contracts will be made public, she said, and plans are for the new MAPD (Medicare Advantage Prescription Drug) PPO contract to be finalized for the open enrollment period in October.
Linda Brookhart, executive director of the State Universities Annuitants Association, said concerns about the new contract are largely coming from this local area of the state where people are worried about losing access to Carle Health.
“I think it all goes back to Carle and the unknown, and I try to tell people, there are no facts,” she said. “It could be nothing changes as long as your doctor wants to continue to see you.”
In other words, nothing changes if your doctor is willing to accept Medicare patients and to accept the payment provided by the health plan, even if the health plan lacks a contract with the doctor.
In fact, state retirees in the current UnitedHealthcare PPO are already accessing Carle on that basis.
“United Healthcare does not currently have a contract with Carle for Medicare Advantage. But Carle Foundation Hospital and Carle Physician Group, despite this fact, have continued to provide care to these members,” Carle spokeswoman Brittany Simon said.
“Selling Medicare Advantage coverage in areas in which national payers do not have an adequate provider network continues to be a trend, and puts the burden on the members covered by these plans to find a care provider that will treat them,” she said.
“As national insurers are becoming increasing more difficult for providers to deal with, creating more administrative hoops to jump through and denying payment for services rendered, providers across the country are reconsidering whether they will be able to afford to continue to see these out-of -network Medicare Advantage members,” Simon said. “Carle will continue to evaluate our ability to support these members and is pending a formal announcement of payor contract decisions from the state.”
While state retirees currently have two health plan choices — which, in this area of the state, includes the United Healthcare PPO and an Aetna Medicare HMO — Brookhart said it’s her understanding that the state won’t be providing an HMO.
“It will be a PPO. There will be no HMO, and that’s OK,” Brookhart said. “I can’t imagine the state would leave their retirees with no network and no doctors.”
Kwiatkowski said provider network adequacy requirements are governed by the US Centers for Medicare and Medicaid Services.
The state “relies on this regulatory authority to ensure that the plan is in compliance,” she said. “To date, CMS has received no notification from the regulatory entity regarding a deficiency in provider network adequacy.”
Uncertainty and anxiety
Much of the current anxiety among state retirees is coming from the uncertainty and lack of information available, according to John Marlin, president of SUAA’s University of Illinois chapter.
“This whole thing’s been a mess,” he said Thursday.
Marlin said this time in the ongoing pandemic is the worst time to make a change in health plans.
“People chose, or were forced, to put off doctor visits during the worst of the COVID event, which is still ongoing,” he said. “Now many retirees are discovering previously undiagnosed serious medical issues. They are dealing with local doctors and coordinating with major hospitals in other cities for specialized care. They are quite concerned that a new insurance provider will not honor their current arrangements.”
The state has assured things won’t change if a switch is made from United Healthcare, Marlin said, but there’s no guarantee that Aetna would be working with Carle and other providers plan members need to access.
“There’s simply no information available other than trust us,” Marlin said.
State Sen. Chapin Rose, R-Mahomet, says he’s also been left in the dark about the status of the contract, and he’s heard from several worried people — some with urgent medical issues.
“These are people I’ve known for years and they’re scared,” he said. “This isn’t a way to govern a state. You don’t treat people that way.”
Meanwhile, open enrollment starts Oct. 14, Rose said.
“Whoever wins this at the end of the day could go strike up a conversation with Carle and bid up a network,” he said. “But how likely is that to happen?”
Both Aetna and UnitedHealthcare emphasize their experience in working with group Medicare Advantage plans.
Aetna serves more than 200,000 state of New Jersey retirees, 120,000 of them retired educators; 135,000 state of Ohio retirees, 100,000 of whom are retired educators; and retirees in Maine, New Hampshire and Pennsylvania, according to Rick Frommeyer, senior vice president for Aetna Group Retiree Solutions.
“This highlights our substantial experience supporting state retirement systems and, most importantly, our understanding of the needs of state retirees,” he said.
Frommeyer said he was a caregiver for both his parents, and experienced “the challenges of navigating and accessing care for the aged.”
“We understand changing to a new health plan can create fear and uncertainty. We know retirees want reassurance they can continue to see their doctors and can go to their hospital of choice,” Frommeyer said. “We know retirees want simplicity instead of complexity and, finally, after giving so much of themselves in services to others during their careers, we know retirees want to feel respected in their retirement.”
Aetna’s proposal includes offering a Medicare Advantage PPO plan with Medicare prescription drug services using an extended service area waiver established by the Centers for Medicare and Medicaid Services, Frommeyer said.
Aetna’s proposal states its plan “offers members the option to access care from any provider that is eligible for Medicare payment and willing to accept the plan,” he said. “The member cost sharing will be the same regardless of whether the provider is in or out of our contracted network.”
Aetna pays Medicare Advantage PPO plan non-contracted providers 100 percent of the Medicare allowable rate for covered services, “and as noted in our proposal, state of Illinois retirees can continue to access these non-contracted providers through Aetna PPO at current levels of benefit ,” Frommeyer said.
UnitedHealthcare spokeswoman Heather Soule said United Healthcare’s bid was to keep the current plan that’s in place today for more than 140,000 Illinois retirees who are enrolled — a national group Medicare Advantage plan with prescription drug coverage.
A statement she sent on behalf of the company said UnitedHealthcare has a proven partnership with the state, “having successfully administered its group Medicare Advantage plan for Illinois retirees since 2014.”
“UnitedHealthcare’s plan is the only major national five-star group Medicare Advantage plan and also has a 98-percent member satisfaction score based upon the state retiree surveys that have been conducted,” the company said. “UnitedHealthcare has filed an appeal and hopes to have the opportunity to continue to serve Illinois retirees.”