CENTRAL ILLINOIS (WCIA) — Aetna’s Medicare is poised to be the only health insurance option next year for roughly 140,000 retired state workers, barring successful protests from United HealthCare.

The Illinois Department of Central Management Services (CMS) initially selected the CVS-owned health insurance company to provide the sole PPO plan, generally the benefit of choice for retirees who spend a fair amount of time traveling, or live out of state.

The choice was made despite months of outcries from seniors in Champaign and surrounding counties and despite apparent inaccuracies in the list of providers and hospitals that Aetna submitted to CMS in its April application.

Digging into Aetna’s PPO proposal; State retirees fear the unknown

Sandy Goss Lucas has been on the state-sponsored PPO plan through United HealthCare since the inception of CMS’s Total Retiree Advantage Illinois Medicare Advantage Prescription Drug (TRAIL MAPD) program in 2014.

Goss Lucas retired from the University of Illinois Department of Psychology in 2009. She meets with a group of other university and state college retirees on weekday mornings for exercise at West Side Park in Champaign.

The unknowns for the future of the health benefits she and her former colleagues count on has been the topic of conversation as the group wraps up day after day in the weeks since Target 3 reporters discovered Aetna was picked for the PPO contract.

“We don’t know what Aetna is offering. And we know that there have been problems with the plan they have for the employees,” she said referring to the Medicare HMO plan Aetna currently provides for state retirees in Champaign and 46 other counties.

Health care coverage on that plan was depleted when Carle facilities and doctors in-and-around Champaign County fell out of the plan’s network.

HMO plans cover local services only (barring an emergency) and typically come with cheaper premiums as a result. With the exception of a handful of counties, the state has offered one HMO option and one PPO plan in each county. The PPO option is the same statewide and the HMO option differs between counties based on the number of medical providers the plans say they have in those local areas.

The choice for retirees 47 counties, including much of central Illinois, has been Aetna Medicare HMO or United HealthCare’s PPO. Aetna is poised to take over the statewide PPO plan in 2023 and provide a network of doctors for eight times the number of enrollees.

Goss Lucas said her biggest concern is not knowing what to expect. She likes the comfort of the plan she’s on, knowing doctors outside of Champaign County are covered when she visits her grandkids upstate.

“And we weren’t included in any of the decisions or even kept up to date on any of the decisions,” she added.

“Nobody would talk about it. And then I found out at the farmer’s market Saturday from the United Health people that were handing out free vegetables to retirees, that they had lost the contract.”

John Bennett taught at Lakeland College before retiring in 2011. He, like many in the early morning exercise group, goes to Carle doctors he says are covered under United HealthCare.

“My wife and I were having lunch with friends of ours, both of whom are retired physicians, and when the topic turned to health coverage and the possibility of having Aetna, both of them just grimaced at Aetna’s reputation,” he said.

“You don’t have to say you’re rationing health care if, in fact, you offer health care with so few providers that people can’t get in or can’t get in for months and months.”

Carle Physician Group, a network of at least 550 eastern-central Illinois doctors, and Carle Foundation Hospital are no longer in-network for seniors on all Aetna Medicare plans, state retiree or otherwise, HMO or PPO.

The list of providers Aetna submitted to the state in its application for the PPO plan still included these doctors and the Urbana hospital. Both are accurately marked as out-of-network, but in the next column on the spreadsheet reporters obtained, the insurer claimed Carle is willing to accept the plan.

In a statement Friday, following Thursday’s on-air report, an Aetna representative said Carle advised the company that its doctors “can see” retirees on the new PPO plan, “and accept payment from us under this plan, even though they are not a contracted provider with Aetna.”

Aetna would also pay for covered services at “100% of the Medicare allowable rate,” according to the same email response, meaning the insurer would pay the maximum amount a plan will pay for a specific healthcare service.

Carle Health did not clarify whether these out-of-network patients would be charged more for those services.

“Once a formal announcement from the State of Illinois is made, Carle will evaluate how this may impact its patients,” a representative there said in an email Thursday.

A note on Aetna’s website makes it clear, “They are under no obligation to treat Aetna members, except in emergency situations.”

United HealthCare Medicare is not listed as an accepted plan either. State retirees said they have no trouble getting services with their Carle doctors approved and covered at an affordable rate. They also said it took some time to settle into routine health care and appeal the initial costs associated when they first enrolled, and their concern is ‘not knowing’ what to expect with a new insurer, one that their former colleagues continue to complain about.

“To start over with that, you know, at our age, we’re very concerned,” Mike Sims, a retired University of Illinois building service worker said.

“We have to take what the state offers us.”

CMS gave Aetna and United HealthCare the same score for their PPO doctor networks.

Bennett, who is diabetic and requires a regular endocrinologist checked Aetna’s network out for himself online.

“I looked under endocrinology within a 25-mile radius, so 50-mile diameter,” he shared.

“There were four listed, and the first two were at Schnucks grocery stores. And they weren’t endocrinologists, they were just pharmacies. So apparently that means that they offer two endocrinologists in this 25-mile radius. And that has me hugely concerned.”

Reporters also checked Aetna’s online provider listings using a Champaign zipcode. Before getting to the page where you would specify a specialty for the PPO plan, a notice popped up. “There are no network providers in your county,” it read.

“The state needs to be more concerned about their employees and what they’ve contributed to the state and be more concerned about making sure that their needs are met,” Sims said.

“And more so than about how much money they can save at the expense of their employees who have dedicated all their time and service over those years being loyal to the state.”

The price tag on Aetna’s proposal to the state earned the company the maximum possible 2800 points in the price evaluation portion of the scoresheet.

It showed the company offered the state at least one year free of premiums, something the other applicants did not offer.

“We did offer the State of Illinois not only one year of no premiums, but five years of no premiums for the PPO plan,” Aetna said Thursday when asked to clarify the submission.

It’s unclear how common practice that is. CMS didn’t respond to questions about the bidding process, only saying “CMS remains committed to administering health care coverage programs for State employees, their dependents and retirees in accordance with all federal regulations and requirements.”

The statement came in after 5:00 p.m. Thursday after nearly a month of silence from the state agency on reporters’ questions.

According to an Aetna representative “there really is no standard practice” for prices in the Medicare Advantage industry.

United HealthCare confirmed Wednesday the company plans to file a second protest with the state. According to the existing PPO insurer, CMS didn’t follow its own rules when officials failed to meet to set standard scoring criteria before reviewing applications.

The state agency can’t officially sign any TRAIL MAPD contracts, including with Aetna, until protests have been resolved.

A look into Aetna’s HMO proposal; Lawmakers begin to consider accountability legislation

SPRINGFIELD, Ill. — Aetna also applied to remain an HMO provider for state retirees in 2023 despite the loss of Carle in an area highly concentrated with state retirees, something dozens have been calling reporters about for months after losing access to their trusted doctors.

More than 17,000 state retirees are currently enrolled in Aetna’s Medicare HMO plan. Unlike the uncertainty with the PPO plan, HMO enrollees would pay the out-of-network rate for services with the Carle Physician Group and at Carle Foundation Hospital.

State Senator Chapin Rose, R-Mahomet, says the state’s executive branch is not listening to its retired workers who fear for the future of their health benefits.

“We’ve been fielding these calls, we’ve got a bunch of angry people, honestly, almost on a daily basis,” he said in an interview at the Illinois State Fair Thursday. Now.

“In fact, our office can’t even get a word out of CMS at all when we call, other than to say that they’re not going to tell us anything.”

Reporters also dug through Aetna’s application to provide an HMO plan in 100 counties starting next year. In that submission, the insurer incorrectly listed Carle Foundation Hospital as an in-network provider.

“This is part and parcel of the Pritzker Central Management Services,” Sen. Rose said when asked about the state’s responsibility to catch the apparent error.

“They haven’t vetted any of this for almost a year now.”

Aetna did clarify in a separate questionnaire that Carle is out of network and that the insurer did not apply to provide services in Champaign County this time around, but the company did include Cumberland County in its proposed service area.

There, patients like Mike Rodebaugh counted on Carle doctors for 30 years before discovering that was no longer an option in late March. Rodebaugh said he sat through two doctor appointments, one on March 18 and one on March 23, before he was notified.

No HMO plans have been awarded at this point to any of the four companies that applied (Aetna, United HealthCare, Humana and Health Alliance).

CMS also gave Aetna the highest score for its HMO doctor network, raising questions about whether the state agency is verifying these doctor lists or taking the companies’ word for them.

“After your other stories, I called CMS and I said, ‘Guys, this network doesn’t exist.’ And they’re like, ‘Oh, yeah, it does.’ ‘What do you mean?’ ‘Oh, no, it’s there. There are no problems. We don’t know what you’re talking about.’ And then I called Aetna, and they’re like, ‘It’s not there,’ and so even Aetna agreed it wasn’t there,” Rose said.

The senator, a member of the Senate Insurance Committee, said they’ve been looking into whether there’s a way for the Illinois General Assembly to tighten the rules around how CMS vets insurance companies.

“But I think the appropriate place here would be for the state government, for the House and the Senate to fire up some hearings to try to figure out what is actually going on. And frankly to put some light, put some sunshine onto this issue,” he continued.

“These seniors deserve straight answers and better access to care. Insurers, especially through the state, must guarantee reliable coverage under their plans,” Sen. Ann Gillespie, D-Arlington Heights, said in an email statement Thursday.

“I call on Congress to explore legislative options on how to better administer and procure Medicare plans to provide continual coverage. If insurers are providing inaccurate information to CMS during the bidding process, legislation on accountability should also be considered.”

There are no finalized contract awards for these new state-sponsored plans that are expected to go into effect on Jan. 1. Finalized contracts will be made public, according to CMS.

Open enrollment for retired state workers begins on Oct. 1.