URBANA, Ill. WCIA — There is no guarantee Carle Health will continue to treat retired state workers after the end of the year.

“Carle is not committing” to see patients who enroll in the only health insurance plan the state has offered its retirees for the next at least five years — Aetna Medicare Advantage PPO — without a contract with Aetna that “Carle feels is fair and protects Carle’s interest,” executive vice president & chief financial officer Dennis Hesch says.

In essence, 140,000 seniors who retired from the state, namely the roughly 10,000 in-and-around Champaign County, are poised to lose access to a network of more than 550 Carle doctors and Carle Foundation Hospital in Urbana barring an agreement.

Hesch’s statement goes against what the agency that selects the plan(s) offered to retirees — the Illinois Department of Central Management Services (CMS) — and Aetna have apparently assumed for months.

In its application to the state, Aetna claimed that even though Carle West Physician Group and the hospital were out of its network, Carle Health was willing to accept the plan.

Carle does accept the current state plan for a majority of retirees in central Illinois — United HealthCare — even though it’s out of network. In fact, Carle doesn’t have a contract with any Medicare Advantage plans except Health Alliance, which is part of Carle Health.

Hesch cited “historical challenges in dealing with Aetna” in particular which is a concern because, without a contract, insurers tend to hold control over doctor reimbursement rates.

“To be clear, Carle is welcoming and treating this exact group of State retirees today at the exact same rate that they would be paid under our plan starting 1/1/23,” Rick Frommeyer, Aetna’s senior vice president of group retiree solutions said in response.

Aetna has continued to assert it would pay “100% of the Medicare allowable rate for covered services” at Carle, which would not be ‘set in stone’ without a contract.

It’s part of a larger, nationwide pattern: Insurers selling plans in places where they don’t have sufficient provider networks. In this case, Carle made a choice to treat retirees if they come to a contracted agreement with Aetna, leaving seniors without assurance about a basic resource: health care.

Target 3 reporters sat down with a group of retired state workers Thursday. Francis Hacker, like the other four in the room, retired from the University of Illinois. They are all on the state-administered United HealthCare plan set to expire at the end of the year, and they all rely on Carle doctors.

What’s unique for Hacker is a diagnosis that requires frequent visits to a Carle specialist.

“I was very upset and disturbed,” she said in reaction to Hesch’s statement.

“Because I have cancer, and I’m still on chemo.”

As she explained, finding a new oncologist is “very difficult to change midstream.”

“There’s a University of Chicago doctor that works with Carle,” she continued. “And I have been seeing him.”

Without Carle acting as the middleman, Hacker said she’d need help making the four-hour round-trip roughly every three months.

“At this point, I have no idea what I’ll be doing or what my care will be following the turnover in January,” she concluded.

“It’s a problem,” Diana Johnson, 80, said. “I’ve been with Carle for 50,” she paused. “…more than 50 years.”

“I don’t have real serious medical problems,” retiree Michael Page began. “But I’ve got doctors I’ve been seeing for 15-20 years.”

“Now we have no choice,” Sandy Goss Lucas said, referring to the state — for the first time — choosing only one plan for retirees.

“Whatever the state picks is what our health insurance is.”

The group of retirees met at Goss Lucas’s home. Target 3 reporters first met her at West Side Park in Champaign where she is part of a morning exercise group with other retired state college employees. That August conversation hinged around concern over the possibility of losing access to Carle.

“Aetna put in their bid that they had Carle doctors on board, which is a blatant lie,” she said Thursday. “I think they should have been disqualified from the very beginning.”

“We do not know why Carle is suddenly deciding that they cannot commit to seeing these retirees once they are on the Aetna [Medicare Advantage] PPO plan,” Frommeyer said, apparently deferring blame to Carle.

“While we note that, in their media statement, Carle did not say that they will not see the State’s retirees, we recognize that they stated that they will not commit to do so. We are concerned, as retirees are, around Carle’s unwillingness to commit to continue seeing their current and future patients who are State retirees.”

CMS has been advertising to retirees that it’s “unlikely” they would have to switch doctors under the new plan in the last couple of weeks since Target 3 first reported CMS finalized the TRAIL MAPD (Total Retiree Advantage Illinois Medicare Advantage Prescription Drug) contract with Aetna.

“Carle currently accepts the Aetna Medicare PPO plan and Medicare,” said CMS deputy director of communications Cathy Kwiatkowski, appearing to echo the justification Aetna leadership has leaned on (or vice versa).

“I think that’s another lie,” Goss Lucas said of the language in a mid-September letter addressed to TRAIL participants.

Excerpt from a mid-September letter Target 3 obtained. CMS addressed it to TRAIL participants.

Carle’s latest statement seemed to change what CMS called “unlikely” to a likelihood, without a contract with Aetna.

“[CMS] knew from the beginning that for us, in this county, Carle is the biggest provider, health care provider,” Goss Lucas said. “Most of us…” she paused. “I have doctors that I have had for 45 years.”

Newly obtained documents from the application and evaluation process for the TRAIL MAPD plan included the request for proposal (RFP) instructions, criteria, etc.

In describing how the agency intended to select a vendor, CMS wrote: “The proposed MAPD PPO plans should mirror the current MAPD PPO benefits…”

Without Carle, it would appear that the plan’s benefits — which are “the health care items or services covered under a health insurance plan,” according to healthcare.gov — would be quite different starting in 2023 for a majority of retirees in central Illinois.

CMS differed on definitions when asked about this clause in its RFP document.

“Benefits are considered to be the plan design that identifies deductibles, out-of-pocket maximums, coinsurance/copayment, and medical visit/procedure coverage.  Benefit plans do not guarantee access to particular providers,” Kwiatkowski said.

The state has pointed to Aetna’s “guaranteed $0 premium for the initial [5-year contract] term” in its decision not to offer an HMO option and for choosing Aetna as the sole PPO provider, meaning, the new plan will come at no cost to the state and “all members will see a significant decrease in their contribution amount,” according to Kwiatkowski.

The newly obtained vendor evaluation documents revealed United HealthCare also offered the state a $0 annual premium.

“There are numerous criteria considered as part of the evaluation process; pricing was just one of the factors,” Kwiatkowski responded when asked to clarify the reason for Aetna’s selection based on the new information. 

“Both carriers bid a $0 premium; however, within the technical evaluation, Aetna scored higher.  Due to the combination of all evaluation criteria, the contract was awarded to Aetna.”

Aetna and United Healthcare landed within a 16-point difference from evaluators out of 1,400 possible points in the technical evaluation, which included network adequacy. The companies scored the same on financial evaluation, which was worth up to 2,800 possible points.

Aetna remained “confident” it “will meet the health needs of the State of Illinois Medicare Advantage retirees,” according to Frommeyer, directly following that statement with a “hope” that Carle will continue to see patients “as they do today.”

The loss of Carle, as Target 3 has previously reported, is a domino effect for patients in and around Champaign-Urbana. The impact would spill over to Christie Clinic patients.

Although the clinic accepts Aetna Medicare, its doctors only coordinate hospital care in Champaign-Urbana at Carle.

In wake of the news, OSF HealthCare noted on Facebook that it continues to accept Aetna Medicare plans at all of its facilities, including Heart of Mary Medical Center hospital in Urbana.

“OSF has been in the Aetna Medicare network since 2010,” said spokesperson Tim Ditman.

At Goss Lucas’s home, retirees expressed worry about the number of people who would be in search of new sources of medical care at once.

“If this all goes as it looks like it’s going to, there’ll be a lot of us out there just looking for general practitioners and specialists,” Page said.

“If you have a lot of people who all of a sudden need doctors — and I’m not the only one who I’m sure that has cancer that’s in the probe that’s with UnitedHealth now that will be going to Aetna — It’ll be very hard to get in,” Hacker added.

Although consistency of care is direr for some than others, all of the retirees interviewed throughout months of this reporting simply want to keep their doctors of decades, especially now that they’re all beyond 65 years of age.

“I’ve been with the same doctor from the time he came here more than 30 years ago, so he knows all about me,” Johnson said. “And I’d like to keep him.”

Beyond the concern for their health and the uncertainty of what’s to come, their big message to CMS is: “We should have been able to at least make input,” as Page put it.

“I don’t like the fact that they never even asked us how we evaluated United HealthCare, whether we were satisfied or not,” Johnson added. “So that was a very stunning point that they forgot.”

“I think the state needed to do a better job of their signing up someone for the employees who’ve worked and knew we’re guaranteed this,” Hacker said.

“And for Aetna, and for Carle, they need to get together and work it out.”

In July, a Carle representative said negotiations with Aetna had stalled. Another communications official on Thursday couldn’t say whether they’ve started back up but said Carle is open to the conversation, something Aetna has repeated as well.

“We believe reaching an agreement with Carle Foundation Hospital and Carle Physician Group is the right thing to do for the State of Illinois Medicare Advantage retirees,” Frommeyer said. “And we will continue to try and bring them in network.”

“If Aetna offers a contract Carle feel is fair and protects Carle’s interest, Carle will treat these members,” Hesch said.

“When there is a gap between the high-quality care delivered and the reimbursement for that care, patients suffer and providers shouldn’t be left alone to bear the weight of treating these patients with no contract and be forced to accept terms dictated by insurers,” he added, alluding to the aforementioned “historical challenges” in working with Aetna.

CMS excused itself from involvement in the conflict affecting the retirees its tasked with providing a health insurance plan for.

“The State of Illinois is not a party to any contractual negotiation or dispute between an insurance carrier and provider,” Kwiatkowski said. 

“Until such time as there is a resolution to the current discussions between the insurance carrier and a provider, the State of Illinois as the employer plan, are unable to communicate any changes.”

Goss Lucas and her husband are looking into enrolling in a United HealthCare policy independently.

“I don’t know how much that would cost us,” she said. “But I know there are a lot of people that would not be able to afford that, so they are stuck with whatever options Aetna gives us.”

Seniors can only enroll in one Medicare Advantage Part D plan at a time, so that decision could require opting out of the state-administered benefits. To do so, “visit MyBenefits.illinois.gov or call the MyBenefits Service Center at 1-844-251-1777 during TRAIL open enrollment” (Nov. 1-30), the mid-September CMS letter reads.

Although, health care advocates have cautioned against this because opting back in later may not be an option.

State statute doesn’t call for any review of this executive branch RFP process by the Illinois General Assembly. Legislators on the Commission on Government Forecasting and Accountability (COGFA) have the ability to advise CMS, but CMS “can take it or leave it,” COGFA Co-chair Sen. David Koehler (D, Peoria) said.

The Legislature created COGFA to be an evaluator of the state budget. These days, its role has expanded.

The commission does hold hearings every year with CMS and the insurance companies it has contracted for the MAPD plans, Koehler said. That won’t happen until at least January, if not April.