Annuitants Association questions Carle’s ‘expansion’; Carle calls blame a ‘deflection’

URBANA, Ill. (WCIA) — An annual meeting of public employees and retirees was repurposed to air concerns about one topic: state-sponsored retirement health benefits.

The meeting, hosted by the University of Illinois chapter of the State Universities Annuitants Association (SUAA-UIUC), is typically attended by about 40 people. Instead, at least 700 retired state workers and some family members (including roughly 300 people on Zoom) packed the Alice Campbell Alumni Center in Urbana Tuesday to air their fears and grievances over the state’s decision to make a new Aetna Medicare Advantage plan their sole health insurance option starting Jan. 1.

The overwhelming concern is that the Illinois Department of Central Management Services (CMS) isn’t offering a second plan option as it has for the past decade and soon, their new singular option may mean losing access to the largest health care provider in the area.

Carle Health leadership made it clear they won’t commit to treating retirees once they’re moved to Aetna’s ‘preferred provider organization’ (PPO) plan in January without a contract with the CVS-owned company.

More than 550 providers are a part of Carle’s eastern-central Illinois network. Between Champaign, Vermilion and Coles Counties, it’s the primary health care resource for nearly 11,000 retired state workers.

At least a dozen — most, if not all, former UIUC employees — took a turn with the microphone to comment on the importance of keeping their doctors, “including mention of ongoing care with Carle and distant hospital specialists,” the meeting program read. Many referenced decades-long relationships with their providers.

“My services would be greatly impacted if I had to leave my Carle doctor,” retiree Francis Hacker said to the room.

Hacker has oral cancer, which requires frequent visits to her Carle oncologist. Finding a new specialist is “very difficult to change midstream,” she told WCIA 3 in September.

“My cancer is not curable, it’s delayable,” another retiree shared Tuesday night. “So if I have to wait four months for a new doctor, for example, I may not be here.”

“I’m really desperate to stay with Carle,” the next said.

“I do most of my doctoring at Christie [Clinic], but I just had a need to have a pacemaker put in my chest. Guess where it was done,” another said before several in the room echoed “Carle” in unison.

“I contacted Christie and OSF to transfer from Carle to them,” someone else spoke up. “And they say that they have a limited, very limited number of people they can take.”

“As we all know, things are very tight in his other cities right now,” Marlin said in an interview prior to the meeting.

“Is there enough capacity here and in Charleston and Danville to pick up the patient load that would end up leaving Carle?”

There was disagreement and a fair amount of finger-pointing over who is responsible for the uncertainty seniors are experiencing.

SUAA executive director Linda Brookhart on Tuesday blamed Carle Health.

“We’re questioning the need for an Aetna contract with Carle, as well as you should be,” she said at the podium.

Carle Health doesn’t have to be contracted (or in-network) to accept patients on Medicare Advantage PPO plans with ‘extended service areas’ (ESAs), like the current and upcoming state-sponsored plans. Carle Health was also never expected to be in-network in eastern-central Illinois under the Aetna plan.

Since its providers have been treating retirees enrolled through the state program in United HealthCare’s Medicare Advantage PPO plan for nearly a decade without a contract, the apparent assumption from CMS and Aetna — and now Brookhart — was that wouldn’t change.

Rick Frommeyer, Aetna’s senior vice president of group retiree solutions, has said the company would reimburse Carle at the same rate — “100% of the Medicare allowable rate” — as they are reimbursed by United HealthCare.

“Key aspects of Medicare coverage, such as provider networks and rates of reimbursement are set by the federal government,” Brookhart claimed in support of the contract being unnecessary.

Traditional Medicare rates are set and often act as an anchor for provider reimbursement rates, but they are negotiable in the Medicare Advantage market.

“Nearly one-third of Medicare beneficiaries are enrolled in a Medicare Advantage (MA) plan, yet little is known about the prices that MA plans pay for physician services,” a publication in the National Library of Medicine reads.

“…the extent to which MA physician reimbursement reflects traditional Medicare (TM) rates vs negotiated commercial prices is unclear.”

Either way, negotiated prices can only be mandated by contract.

Blaming Carle Health for the uncertainty over access to its doctors “appears to be a deflection of the issue created by the State awarding Aetna a contract in a region in which Aetna does not have an adequate network,” Dennis Hesch, executive vice president and chief finance and strategy officer for Carle Health responded in an email to WCIA 3 Wednesday.

That said, Carle Physician Group (all 550+ eastern-central Illinois doctors) and Carle Foundation Hospital in Urbana don’t currently have a contract with any Medicare Advantage plans except Health Alliance, with is a part of the Carle Health system.

“Aetna and Carle, technically, are competitors,” Marlin said.

“Carle could be wanting to force the TRAIL [the state-sponsored health benefits program] members into their Health Alliance plan. I have two verifications today that this is true,” Brookhart said to the room of retirees.

“There was a gentleman who emailed me this afternoon. His wife had called and talked to Carle, and they said that they were only going to accept Health Alliance and that she should sign up for Health Alliance. And, ‘one way to get all this calm down is just to move everybody in the state to Health Alliance,'” she elaborated in a post-meeting interview with WCIA 3.

“And then Carle would be happy, basically.”

WCIA 3 asked Carle Health officials earlier this month if they would have continued to see retirees with United HealthCare Medicare Advantage PPO insurance come January had the state renewed that plan instead.

A media representative said the company “will not comment on a hypothetical scenario.”

“Locally, they carry a big stick, so to say,” Brookhart said of Carle Health.

“If they’re not going to take care of the people around here, one has to question some of the expansion that’s going on,” Marlin said in the pre-meeting interview.

“Carle wants to be the big player. In fact, they’re trying to get state approval now to buy three more hospitals in the Peoria area.”

Aetna: ‘Encouraged’ deal is coming; Carle: Deal ‘depends on Aetna’

“The simple fact is that Aetna can rectify this situation by agreeing to a fair and equitable contract with Carle Health,” Hesch said.

Frommeyer on Tuesday — in the first interview Aetna agreed to since WCIA 3 started covering the company’s involvement in state retiree benefits in March — said he’s “encouraged” that a deal will be reached by Jan. 1.

State retirees have to decide whether to keep or drop their state-sponsored benefit plan before then. Open enrollment starts next week and closes on Nov. 30.

“There’s certainly enough time to get a deal done,” Frommeyer said when pressed about the November deadline.

“We do not know if retirees will know the answer to whether a contract will be agreed upon before enrollment closes,” a Carle media representative responded Tuesday to questions about the status of contract negotiations between Carle and Aetna.

“Whenever Aetna is ready to enter into an equitable contract for the high-quality medical staff, technology and facilities we offer our patients, we are ready.”

“We made what we believe was a fair offer to Carle several weeks ago,” Frommeyer said. “And they have responded, you know, very diligently, very thoughtfully. You know, we’re, you know, I think that was kind of mid-last week, if I recall correctly, and, you know, we’re in the process of evaluating that and preparing a response.”

Without a “fair” contract, Hesch said, Carle would be operating “at a significant loss while both the State and Aetna reap millions of dollars of benefit as a result of the contract that was awarded.”

Aetna offered CMS a $0 premium for the initial five-year contract term and according to a presentation from SUAA UIUC executive committee member Carol Livingstone Tuesday night, Aetna will be paying the state $7 million.

“Aetna is sending $7 million to CMS for promotional materials and CMS is still collecting the payments from employees who contribute,” read one of the presentation slides.

Although, it’s unclear if other companies (including United HealthCare) that bid for the retiree health plan contract offered the same perk. United HealthCare also offered a $0 premium.

The plan will come with a “significant reduction” in contributions for retirees and dependents, CMS deputy director of communications Cathy Kwiatkowski said in September.

‘We have no choice’: Retirees demand health plan options

“We like the plan, you should like the plan. It’s Carle that doesn’t want to take you,” Brookhart said during retiree comments Tuesday night.

“I disagree,” an attendee interrupted from across the room. That was echoed by a few as dozens grabbed their coats before the end of the meeting and headed for the door.

“I wrote to you. Aetna is an awful company,” one retiree shouted while Brookhart was speaking.

“I have an inch-thick folder where they approved an HMO procedure at Carle and then denied it when they got the bill. They sent me the bill for $11,000.”

The U.S. Centers for Medicare & Medicaid Services downgraded Aetna’s Medicare Advantage PPO plan from 4.5 to 3.5 stars in its annual ratings this month, placing it nationally below average.

“I’ve worked at the U of I, put all my years in. We’ve always had choices. We have no choice,” former employee Tenna Knox said to applause.

CMS followed proper procedure in contracting the plan, Brookhart said. She echoed Kwiatkowski in saying the state agency did away with the HMO option because of low enrollment.

2022 TRAIL MAPD benefits map includes four plans.

“10% is very low because there were like three or four companies involved in that. So it was basically a business decision not to include an HMO,” Brookhart said in the post-meeting interview.

Four different HMO plans and one PPO plan were offered over the last decade, one HMO per county (with the exception of two HMO options in six counties) and a statewide PPO plan. Just one of those existing HMO plans, run by Aetna in 47 counties, covers 7,983 retirees and their dependents statewide, including 559 in Champaign County, according to Kwiatkowski.

Sen. Scott Bennett, (D) Champaign, and Rep. Mike Marron, (R) Fithian, sat in the front row of the meeting.

“One of the constituents that has a very big concern about this is my mother,” Rep. Marron said in an interview after it concluded.

There is language in the Constitution of the State of Illinois that states the benefits of members in “any pension or retirement system…shall not be diminished or impaired.”

“Certainly I’m not a constitutional attorney, so I’m somewhat limited. But I think that that’s something that’s worth looking at,” Marron said when reporters asked if the state cutting plan options from two (or in some cases three) down to one is a diminishing of benefits under the State Constitution.

Marron was open to additional legislation to ensure options and transparency in the process of vetting insurance companies.

“You know, I think that’s something that’s come up. Myself and Senator Bennett talked about that tonight, possible legislation that may fix this problem, maybe potentially expanding options under the TRAIL plan,” he said.

If legislation were to be passed during the Illinois General Assembly session in the spring, it wouldn’t impact retiree benefits for at least five years. That’s how long Aetna has the contract. CMS also has the option to extend it another five years beginning in 2028, or the state agency can start another procurement process.

“I think that we can, as legislators, try to address solutions for future problems so this doesn’t happen again, but the time is very short, the legislative process takes time,” Marron said.

“So I think we need to make sure that Carle and Aetna come to an agreement and these people are taken care of, and I know that’s what I will be doing: advocating on the on behalf of my constituents that have these concerns.”

SUAA says there’s ‘life after TRAIL’

SUAA leadership encouraged retirees to look at other Medicare Advantage plans in the meantime. revealed 23 options in Champaign County, Marlin said.

“They are not the same type of care as PPO, where you can go anywhere in the country and be served. They’re mostly HMO-type things.”

HMO plans are typically more affordable but come with more limited provider and hospital options, especially for seniors who travel often.

However cheap, several retirees in attendance worked for the state long enough that they don’t have to — and don’t expect to have to — pay a dime in health insurance premiums.

“I actually worked in the private sector for many, many years. And I went to work at the University of Illinois for much less money than the private sector,” Knox said in an interview before the meeting.

“I was looking ahead at my retirement and having good health insurance.”

There are a lot of unknowns in the Medicare Advantage market, Marlin said.

“The issue becomes, what is the difference in payment? What is the difference in care? There are all kinds of things that we haven’t had any time to research yet,” he continued.

“And most of the people involved with the state system, they’ve been in the system for 20 or more years. And they’ve never had to go through the process of trying to evaluate all these different options for care.”

SUAA leadership answered a lingering question Tuesday night: Retirees can opt out of state-sponsored benefits and opt back in as early as the following year. That includes spouses and dependents.

Brookhart strongly encouraged retirees to write Aetna and Carle with their stories. Associated addresses are posted on the SUAA website.