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One large health system with hospitals in Virginia and Ohio this year cut off in-network access to consumers enrolled in some Anthem Blue Cross Blue Shield Medicare and Medicaid health insurance plans.
Two doctors groups with Scripps Health in San Diego are terminating contracts with private Medicare plans over concerns about payments and routine denials.
For years, hospitals, doctors and health insurance companies have squared off over how much to pay for medical services. Insurers negotiate contracts with hospitals and doctors so their customers can get lower, in-network rates at those facilities. These negotiations, usually hammered out behind the scenes, are becoming increasingly tense and public as hospitals seek adequate payments and health insurance companies attempt to check spiraling medical bills.
Experts say these disputes could be an early warning sign of more contract terminations ahead as hospitals and large doctor groups seek lucrative payments to offset inflation, healthcare workers' double-digit raises and escalating prices for medical supplies.
But for patients caught in the middle of these disputes, the results can be devastating. Some need to switch doctors or insurance plans or potentially pay higher, out-of-network rates at a time when half of Americans are struggling to afford the rising cost of medical care.
Scripps Health ended the 2024 Medicare Advantage plan contracts with two medical units, called Scripps Clinic and Scripps Coastal. The decision will affect about 32,000 patients who will either need to switch Medicare plans or find new doctors.
“We’re unfortunately on the vanguard of what I think is going to be a very ugly few years between hospitals and commercial insurance companies,” said Chris Van Gorder, President and CEO, Scripps Health.
Many contract terminations involve hospitals rejecting terms for private Medicare insurance plans, known as Medicare Advantage plans. While traditional, government-run Medicare allows enrollees to choose from a wide variety of doctors and hospitals, private Medicare plans restrict access through networks and impose some cost-sharing requirements such as copayments or deductibles.
Hospitals that are rejecting private Medicare plans say they don’t reimburse at the same levels as traditional Medicare, delay or deny care through prior authorizations or impose other limitations.
Van Gorder said Scripps' Medicare Advantage exit was a “very difficult decision” but one he had to make due to more than $75 million in annual losses. He tried to negotiate more lucrative reimbursement rates, but those talks fizzled.
While private Medicare plans are funded by government-run Medicare, they're also profitable because insurers keep a portion of those payments before paying for care, he said.
Van Gorder described private Medicare offerings as “delay, deny or don’t pay” plans. "They're in the business of making money," he said.
In 2022, a government watchdog report said private Medicare plans routinely rejected claims that should have been paid and denied services found to be medically necessary. These private plans rejected nearly one in five claims allowed under Medicare coverage rules and denied 13% of authorizations for medical services that government-run Medicare would have allowed, the U.S. Department of Health and Human Services inspector general investigators found.
Doctors and hospitals "are more willing to publicly express their frustration," Lipschutz said, because these private Medicare plans get what "many people would characterize as overpayments."
More than a half dozen other hospital systems from Bend, Oregon to Nashville, Tennessee have announced private Medicare contract terminations or lapses.
St. Charles Health System in Bend said it will end Medicare contracts next year with Humana, HealthNet and WellCare.
Mark Hallett, St. Charles' chief clinical officer, said sticking with those private Medicare plans would "result in restrictions to patient care, longer hospital stays and administrative burdens" for doctors.
An Opinion from NATHAN LEVENTHAL-NY DAILY NEWS
[October 8, 2023 at 5:00 a.m.]
Mayor Adams has rightly been critical of a series of misguided decisions by the United States Supreme Court, expressing outrage at the high court for stripping away federal protection for a woman’s right to choose, in consultation with her doctor, concerning her reproductive rights. And yet, the mayor need not look as far as Washington for an example of the government attempting to limit the medical choices of individuals needing health care. In a shameful deal with some of the city’s more powerful municipal labor unions — a deal opposed by many other municipal unions — he has sold 250,000 city retirees down the river by continuing to attempt to remove their earned traditional Medicare benefits, proposing to limit their choice by forcing them into a Medicare Advantage Plan. First proposed during the de Blasio administration, switching retirees into Medicare Advantage was claimed by the proponents in City Hall and some union leaders to save the city hundreds of millions of dollars every year, a figure that is almost certainly inflated. Those additional dollars would then presumably be available to fund the inflationary wage increases recently granted to those unions — without so much as even a token effort by the city to lower operational expenses through productivity increases and other savings. In seeking to impose on city retirees an Aetna “advantage” medical plan — a misnomer if there ever was one — Adams is continuing the de Blasio effort to try to privatize city retirees’ health care by placing it in the hands of a for-profit corporation, whose every incentive is to maximize subsidy from the federal government and minimize costs expended for the health care of city retirees.
And this is not just conjecture. Private, for-profit Medicare alternative insurance companies have long been scrutinized for their refusal to approve doctors’ decisions as to the proper care of their patients. Indeed, there is a congressional and Department of Justice investigation into the actions of Medicare Advantage Plans — including of CVS/Aetna — of their unjustified refusal of doctor-ordered health care, overbilling, and general Medicare fraud practices.
Municipal employees rally against Medicare Advantage, in lower Manhattan on March 9, 2023. (Barry Willilams for New York Daily News) On Oct. 2, the Washington Post reported on an audit by the inspector general of the Department of Health and Human Services in which it was revealed that Aetna received more than $25 million in Medicare overpayments from the federal government. One standard process Medicare Advantage Plans use to limit care is called “prior authorization,” which allows for-profit bureaucrats to second-guess medical decisions made by your doctor. All Medicare advantage programs impose this requirement, including Aetna’s. Indeed, Aetna has the highest percentage of denied claims of any Medicare advantage plan, overruling doctors 12% of the time compared to half that number for other advantage plans. But, recognizing the unpopularity of this limitation on doctors’ ability to care for their patients, Aetna has agreed to limit the number of prior authorizations in its five-year contract with the city. However, in a classic bait and switch, this limitation will sunset in only two years, after which Aetna is free to renegotiate with the city a return to the traditional position of Medicare Advantage plans so that even routine procedures such as X-rays and MRIs are likely to be subject to prior review and approval.
Aetna claims they only want the opportunity to require prior authorizations for new and experimental medical procedures or drugs, but nothing in the contract limits future restrictions. Indeed, Eric Adams (a retired city employee himself, as he often pointed out) campaigned for mayor in 2021 with a promise that he would never force them into a for-profit, Medicare advantage plan, also calling the de Blasio plan a “bait and switch.” What changed his mind? Like all Advantage plans, the city’s new plan is limited to doctors who have agreed to be part of Aetna’s network or are willing to accept it for payment. As a result, retirees who have had the same doctor for decades may be forced to abandon their physicians and see new doctors who know nothing about their medical history or personal lives. Furthermore, a significant number of doctors and hospitals within and outside New York City refuse to accept Medicare Advantage Plans and refuse to accept payment from the plan as out-of-network physicians. Also, retirees living in Continuing Care Residential Communities will not have access to needed care as these communities do not accept Advantage Plans. Admittedly, there is a cruel way for New York City retirees to remain in their original Medicare. To do so, they must waive all city health benefits, which means (1) they will have to secure and pay for their own Medicare supplement and prescription drug plans, and (2) they will be compelled to give up all city reimbursement for their part B and other premiums they now pay.
Retirees protesting the Medicare Advantage situation relating to the 12-126 law outside of City Hall, Manhattan, New York, Wednesday, October 12, 2022. (Shawn Inglima for New York Daily News) How does that look if you’re a family of two city retirees? The net financial effect of waiving city health care will approach $20,000 annually, well beyond the ability of most retirees to afford. Equally concerning for municipal retirees and those currently on disability, in all but four states, retirees applying for new Medicare supplement plans can be denied coverage based on their medical history. While this is not true in New York, many city retirees live in other states, including Florida, which does permit medical underwriting. As a result, with a gun pointed at their head, these retirees will be forced to accept substandard health care. Many individuals opted for city employment because, even though city salaries were considerably lower than what many of them could make in the private sector, they were attracted by the substantial pension benefits and the city’s commitment, codified in the City Charter that their health care would be taken care of throughout their retirement.
Having given 20, 30, 40, or more years of service to New York City citizens, the retirees are now being abandoned by Mayor Adams and some of our city unions, including DC37 and UFT. Thanks to the pioneering efforts of the NYC Organization of Public Service Retirees under the inspired leadership of Marianne Pizzitola, retirees have won six successive court battles in Manhattan state Supreme Court and the Manhattan appellate division with the courts repeatedly striking down the endless attempts to limit retiree health care. But the city continues to incessantly appeal all such decisions, and constantly creates new plans that must be fought in court, and again invalidated. City retirees have no labor union to protect their interests; municipal labor unions only represent current city employees. The best way to ensure that retirees will continue to have the health care to which they are entitled, would be to pass local legislation enshrining this right in the city’s administrative code. Before the City Council is Intro. 1099-2023, legislation that will guarantee city employees a Medicare supplement plan similar to what they have had for nearly 60 years. Despite considerable political pressure from some of the city’s labor unions and this mayoral administration, a bipartisan group of 18 sponsors has already signed onto this bill.
The city’s present workforce, especially those approaching retirement age, should realize that they will eventually be placed in the same substandard system now sought to be imposed on current retirees. The interests of current and retired city employees are identical! And they’re all being sold out by a few powerful, municipal labor unions, even though more city unions voted against Medicare Advantage than voted for it! Current city workers should demand that their union leadership change course and continue to support Medicare for all city retirees, as they have for nearly six decades. If the city is successful in imposing this restrictive plan on city retirees, it’s only a matter of time before the city seeks to find additional savings by cutting back health care for current employees Leventhal has served at the highest levels under four New York City mayors, including as chief of staff to Mayor John Lindsay, deputy mayor to Mayor Ed Koch (in charge of all city services, including labor relations), and transition chairman for both Mayor David Dinkins and Mayor Mike Bloomberg.
BY CHRIS SOMMERFELDT NEW YORK DAILY NEWS
A bipartisan legislative push is afoot on Capitol Hill to prohibit all U.S. employers from forcing their retired workers into Medicare Advantage coverage — a proposal that could spell trouble for Mayor Adams, who’s trying to mandate the privatized health insurance program for New York City’s
250,000 municipal retirees.
The anti-Advantage effort formally got underway Thursday, when Reps. Nicole Malliotakis and Ritchie Torres, both of whom represent parts of New York City, co-introduced a bill that would amend U.S. Social Security law so that it’d become illegal for “public and private employers” to “involuntarily” shift Medicare-aged retirees into Advantage plans.
Under the legislation, a copy of which was exclusively shared with the Daily News ahead of its introduction, the only way an employer could legally enroll a senior in an Advantage plan is if it secures consent from the person to do so.
Malliotakis, a Republican who represents Staten Island and parts of southern Brooklyn, said the bill is directly aimed at blocking a long-running bid by Adams to switch the city’s municipal retirees into an Advantage plan on the auspice that it’d save the city money on health care costs.
“Mayor Eric Adams broke the city’s commitment to our civil servants,” Malliotakis said of the attempted Advantage switchover. “Our teachers, firefighters, police officers, sanitation workers and other municipal workers did not deserve this bait and switch. Our bipartisan legislation rectifies this injustice by giving them a choice in their earned healthcare benefit.”
Torres, a Democrat who represents a section of the Bronx, did not call out Adams by name like Malliotakis.
But he did say he’s sponsoring the bill after hearing from retired city workers who oppose the Advantage switch over fears the privatized plan would provide inferior coverage compared with traditional Medicare.
“Medicare is how millions of seniors and retirees are able to go to the doctor, get the care they need, and live decent, dignified and healthy lives,” he said. “We must do everything we can to prevent and defend Medicare from being privatized, including preserving the rights of seniors to access the coverage of their choosing. No employer should be able to involuntarily kick retirees off the plan they chose and earned in favor of a private plan they don’t want.”
Adams spokesman Jonah Allon came out guns blazing against the Malliotakis-Torres bill, calling it “a direct attack on collective bargaining and worker rights,” echoing an argument made by the mayor that legislation standing in the way of his Advantage plan could set a problematic precedent for
public sector union negotiations.
“We’d urge Congress to instead work with us to allow unions and employers to work together to provide high-quality health care while providing much needed savings, as we’re doing,” Allon said. “What’s more, a number of states and unions have already switched to providing Medicare Advantage to active and retired employees, and report high rates of satisfaction with the coverage.”
Unlike traditional Medicare — which has typically consisted of the universal federal program and a city-subsidized Medigap supplement for municipal workers — Advantage plans are administered by
private health insurance providers.
A grassroots group composed of thousands of retired city workers say the Advantage plan favored by Adams would dilute their benefits. One of their top concerns has been findings in federal studies that Advantage, due to its privatized structure, can deny plan holders “medically necessary care.”
The advocacy group, the NYC Organization of Public Service Retirees, has successfully sued the Adams administration multiple times to block it from implementing its Advantage plan, with judges finding it violates local laws requiring the city to provide its public sector retirees with
premium-free heath care for life.
Most recently, the administration was blocked by a Manhattan Supreme Court judge from having its Advantage plan take effect Sept. 1; the administration is appealing that ruling.
The current structure of Adams’ plan would make Advantage the only health care option available for retired city workers, eliminating even the possibility for them to enroll in traditional Medicare, unless they want to do so on their own on the open market.
An aide to Torres acknowledged that the bill the congressman and Malliotakis are introducing would not be retroactive. That means the bill would not derail Adams’ Advantage plan should he manage to implement it before their legislation potentially passes Congress and is signed
into law on the federal level.
For starters, the bill only has Malliotakis and Torres listed as sponsors. But the Torres aide said the bipartisan nature of the measure out the gate is promising.
“We’re encouraged it’s starting with bipartisan support, and hope to see more members sign on, particularly from [New York City],” the aide told The News.
Adams and the Municipal Labor Committee, which operates as an umbrella group for most of the city’s public sector unions, back Advantage because they say it will generate as much as $600 million in annual health care savings — a sizable sum at a time the city’s projecting massive budget deficits
in coming years.
Adams and labor brass also say the customized Advantage plan they’re advancing, which would be administered by health insurance giant Aetna, should provide retirees with coverage that is up to par
with traditional Medicare.
The Advantage advocacy from Adams and the MLC has drawn
The Torres-Malliotakis bill is the second piece of legislation aimed at preventing Adams from going down the Advantage path.
The first legislative effort is a bill introduced in the City Council. That bill, introduced by socialist Brooklyn Councilman Charles Barron, would enshrine into law that the city government must provide its retirees with at least one premium-free traditional Medicare plan.
Barron’s bill has also earned bipartisan support. As of Thursday, 18 of the Council’s 51 members are listed as co-sponsors of the measure,
Council records show.
Shared from NYDailyNews iPad app
You should have all received a letter from the Office of Labor Relations, Employee Benefits Program. In it, it shares with you, information regarding the Aetna Medicare Advantage PPO Plan:
IT WILL NOT BE IMPLEMENTED ON 9/1/23.
ALL CURRENT HEALTH PLANS REMAIN IN EFFECT.
NO RETIREE WILL BE MOVED INTO THE NEW AETNA MEDICARE ADVANTAGE PPO PLAN.
NO OPT-OUT REQUESTS MADE THROUGH AETNA VIA THEIR CALL CENTER OR WEBSITE WILL BE PROCESSED AT THIS TIME.
NO WAIVER OF CITY HEALTH BENEFITS, ENROLLMENT INTO THE AETNA MEDICARE ADVANTAGE PPO PLAN OR ADDING THE PRESCRIPTION DRUG RIDER THAT HAS BEEN SUBMITTED ON THE RETIREE SPECIAL ENROLLMENT/WAIVER FORM WILL BE PROCESSED AT THIS TIME.
THE OLR WILL POST UPDATES FOR RETIREES ON ITS' WEBSITE
Her Team needs donations to continue the barrage of Lawsuits she is bringing against the city. She's "ALL IN" for all of us, so step up and help even if its only 25 bucks,
GET IT UP!
Click on the Link below.
THE BILL # IS AS FOLLOWS:
Protecting the health care choice of retired employees of the city of N.Y.
A Local Law to amend the administrative code of the city of New York, in relation to protecting the health care choice of retired employees of the city of New York
This bill would require the City to offer Medicare-eligible city retirees and their Medicare-eligible dependents at least one Medigap plan with benefits equivalent to or better than those available to city retirees and their dependents as of December 31, 2021. The bill would not impair employee organizations from negotiating terms and conditions of employment for their employee members.
CITY COUNCILPERSON CHARLES BARRON (from District 42 in Brooklyn) stood up in the afternoon session of the
Stated Meeting of the NYC Council on Thursday June 22nd, 2023 and introduced into the City Council a Bill which would give Retirees
a 3rd Choice for a Health Care Plan. Beginning July 10th The City would force us into the AETNA Medicare Advantage Plan,
however Judge Frank Lyle still
has to rule on whether the AETNA Plan will be enacted.
He could rule 3 different ways; 1-OK The AETNA Plan, then the Plan would move forward, 2-Call for an Injunction, whereby it would give more time for both sides to argue further or 3-Tell the City to add a Third Plan for retirees to have as a choice. We are hoping that he chooses the 3rd item.
To view Council Member Barron introducing the resolution, click on the following link,
Once there scroll down to the 6/22/23 Stated Meeting,
then click on the VIDEO link.
Once the VIDEO Screen appears move ahead in the video to 1:04, so 1 hour and 4 minutes after the meeting started Councilman Barron introduced the resolution that Marianne Pizzitola and her Team want as a law in the City Charter.
A Great turnout of all different Union Retiree Representatives were there. The crowd estimated at 700 was the best crowd so far.
WAIT AND SEE:
Our next step is to see what the Judge will rule on AND to see if the Bill in the City Council will become a law and then in turn we will ALL have a 3rd Choice for a Health Care Plan.
HERE ARE THE CITY COUNCIL MEMBERS WHO BACKED IT:
PLEASE START CALLING THE OTHER CITY COUNCIL MEMBERS TO CONVINCE THEM TO ALSO BACK IT SO IF THE MAYOR VETOES IT, IT WILL HAVE THE VOTES TO OVERRIDE HIS VETO, GO TO THE ACT NOW PAGE TO VIEW THE PHONE NUMBERS OF THE CITY COUNCIL MEMBERS WHO NEED TO BE CONTACTED. YOU CAN ALSO CALL THE MEMBERS WHO ALREADY BACK IT AND THANK THEM.
REMEMBER, THIS IS AN ELECTION YEAR FOR ALL OF THE CITY COUNCIL REPS, ELECTION DAY IS 11/7/23, SO IF YOU LIVE IN THE CITY DON'T FORGET TO VOTE!
We are Retired NYC Firefighters of all ranks. We meet five times per year at two locations; 901 Lakeville Road in New Hyde Park and 3051 Nostrand Ave in Brooklyn, NY. Through our Newsletter and this website we hope to keep you informed about your pensions.
Are you passionate about what we're doing? Let us know! We are always looking for volunteers to help us make our organization better for our members. We'll help you find a way to volunteer that best suits you. We're excited to have you join the team!
Whether you help through monetary donations, volunteering your time, or spreading our mission through word-of-mouth, thank you. We couldn't accomplish our goals without the help
of supporters like you.
RETIRED MEMBER'S ASSOCIATION, INC
Fire Department, City of New York
ORGANIZED JANUARY 1ST, 1946
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