Under Assault: teaching in NYC
NYC teachers are enormously educated and committed, but you'd never know it from the treatment they get at the hands of the DOE corpocracy. If the press won't write about the assault on the profession, we have to do it ourselves. Now advocating MEDICARE FOR ALL. NO HALFWAY MEASURES!
July 25, 2024
Mulgrew’s new resolutions: an exercise in futility
November 29, 2023
Yummy!
Our reporting and advocacy is having an impact, in Washington and across the country. Members of Congress on both sides of the aisle and the Biden Administration are beginning to scrutinize and crack down on the business practices of Medicare Advantage insurers. And there is growing evidence that employers, including county and municipal governments that planned to force their retirees into Medicare Advantage plans . . . are having second thoughts. Those employers are learning that they may have been sold a bill of goods – and misled and outright lied to – by insurers that make huge profits from their Medicare Advantage business.
Potter draws heavily on a recent ProPublica report pointing out that patients are being “cheated” by Advantage plans ignoring state laws regarding life-threatening conditions.
Across the country, health insurers are flouting state laws like the one in Michigan, created to guarantee access to critical medical care, ProPublica found. Fed up with insurers saying no too often, state legislators thought they’d solved the problem by passing hundreds of laws spelling out exactly what had to be covered. But companies have continued to dodge bills for pricey treatments, even as industry profits have risen. ProPublica identified dozens of cases in which plans refused to pay for high-stakes treatments or procedures — from emergency surgeries to mammograms — even though laws require insurers to cover them.Apparently, “thinly staffed state agencies” don’t bother investigating a denial unless a patient files a complaint. State agencies are in a position to investigate patterns of improper denials, but generally do not, at least in Michigan. Only when someone complains, I’m assuming in the form of an appeal.
Over the last four decades, states have enacted hundreds of laws dictating precisely what insurers must cover so that consumers aren’t driven into debt or forced to go without medicines or procedures. But health plans have violated these mandates at least dozens of times in the last five years.
Thirty years ago a Michigan doctor and state senator named Joe Schwarz helped write a law requiring companies to pay for cancer drugs that would make chemotherapy more effective. He thinks “You shouldn’t split hairs between the term gene therapy and the term chemotherapy or the term radiation therapy or the term surgical therapy. They’re all cancer therapies and they should all be covered.”
Most salient is the point made by one patient’s widow: “Insurance is meant to protect people ... not to make them fight through the last day to get what they should.”
I’m with her.
I truly despise these sociopathic business models, and I hope our municipal unions stop going down such antisocial, nefarious paths.
November 8, 2023
The OLR gets an “S” – for “Sloppy”
Changing health plans is a very scary thing for older people, especially when we have no idea how the Russian roulette of life will turn out for us in the coming year.
But the OLR made the process so much worse than it needed to be. Their website was loaded with incomplete instructions, missing forms, awful ambiguities, and buggy software.
With no way to complete this application on my own, I had to call the UFT Welfare Fund to solve its mysteries. Fortunately, the rep there was great. But why on earth did I have to go through her to get this thing done.
_________________________________________________________________________
Dear Sirs:
I am writing to describe to you the difficult process I went through yesterday trying to change from EmblemHealth HIP VIP to GHI Senior Care.
I still am not 100% sure that I have done this correctly, as so much was not explained clearly on the OLR website for Retirees: https://www.nyc.gov/site/olr/health/retiree/health-retiree-responsibilities-assistance.page.
Here is a list of things that I needed to get help with by calling the UFT Welfare Fund. All problem areas are in red ink.
It directed me to submit forms electronically using the link: https://nycemployeebenefits.leapfile.net. There were two categories that could apply to my situation:2. Back to the Retiree page to get the forms. I clicked on “Health Benefits Program Retiree Application” but the DATE OF BIRTH cell did not accept my date of birth because of a bug. So I could not fill it out electronically. Instead I had to print it out, fill it in by hand, and scan it to the computer to submit electronically.You can see the problem: I am a retiree and want to enroll in a different plan. Should I click the first link (Retirees - Health)? or the 2nd link (Changes)? I don’t remember which I one I did, but they both seem to lead to the same cover screen. I wrote a message and selected files to send individually.
- Retirees only - Health Benefits Application (Retiree enrollment)
- Changes (address changes, death certificate, Medicare cards, etc.)
3. I did not know how to fill in some of the other boxes and had to call the UFT Welfare Fund to ask for help on these things:
(a) That change form asks for “Pension no.” I checked my TRS account, and the only nos. listed there are called a “Retirement no.” [starts with “U”] and a “Membership no.” The UFT rep told me to use “the one with the U”. Who knew!@?
(b) After the box for name of current health plan is a box for “MBI NUMBER”. I had no idea what that was – my Medicare ID? my plan enrollment no.? The UFT rep said “Don’t worry about it,” as it wasn’t needed.4. The UFT rep told me I actually had to upload TWO forms – the change form above, plus a disenrollment form for my current plan. That was not mentioned on the website, and I could not locate a link for that 2nd form either. She had to send it to me by email.
c) That form asks for an “effective date,” but I wasn’t sure which date should be there. Does it mean to enter the last date that my current plan should run to (end of year: Dec. 31, 2023) or end “by” the first date of the new year (Jan. 4, 2024). It would be clear if the wording were more specific, like: “Final date of current plan.”5. I asked the UFT rep whether it was better to send electronically or by mail. She said “do both.”
6. When I submitted electronically, the software said “Success,” but how do we trust that message where there is no date or other details of the submission. I would have liked to take a screenshot (if details were there) or receive an email from the software that my documents were received.
7. I am now supposed to wait 4 - 6 weeks to see if this goes through?????? That’s insane.
October 3, 2023
I'm switching.
September 27, 2023
And now a word about our union "collaborators"
As a group, the companies (Centene, Cigna, CVS/Aetna, Elevance/Anthem, Humana, Molina and UnitedHealth Group) saw their total revenues increase from $618.2 billion in the first half of 2022 to $683.8 billion during the same period this year.
In spite of profits up from $37 billion to $40.2 in a year, investors thought they’d better shift their money elsewhere to get an even better return on investments. That resulted in the stock prices of these companies going down this past year: while Dow, S&P, and Nasdaq shares went up, Cigna’s went down 23.2% and CVS/Aetna went down 27.7%.
“It’s not that the companies aren’t growing. It’s just that at least some of that growth has not been as profitable as Wall Street demands.” Apparently, these companies were paying more in claims than Wall Street was finding “acceptable.”
BOY, ARE WE IN TROUBLE.
Because, as Potter says, “most of the companies’ growth continues to come from the taxpayer-financed Medicare and Medicaid programs.”
And because 3 of them – our Cigna and CVS/Aetna buddies plus UnitedHealth – control 80% of the Pharmacy Benefit Manager (PBM) market and now operate their own practices and clinics, they can shift monies around to keep their medical loss ratio low (which means less spent on our health care and more on overhead and profits.)
Here’s Potter’s scary conclusion:
To get back into Wall Street’s good graces, you can expect the companies to try to squeeze more money out of their commercial customers in the form of higher premiums and out-of-pocket requirements; boost enrollment in their Medicare Advantage and Medicaid plans; and refuse to pay for more doctor-ordered care and medications.
But you can read the whole thing yourself if you want to know more specifically why you’re about to throw up.
August 11, 2023
Somebody shoulda thought this through
For now.
NYSCEF DOC. NO. 101
PRESENT: INDEX NO. 154962/2023
RECEIVED NYSCEF: 08/11/2023
SUPREME COURT OF THE STATE OF NEW YORK NEW YORK COUNTY
HON. LYLE E. FRANK
---------------------------------------------------
ROBERT BENTKOWSKI, KAREN ENGEL, MICHELLE FEINMAN, NANCY LOSINNO, JOHN MIHOVICS, KAREN MILLER, ERICA RHINE, ELLEN RIESER, BEVERLY ZIMMERMAN, THE NEW YORK CITY ORGANIZATION OF PUBLIC SERVICE RETIREES, INC.,
Plaintiff,
-v-
THE CITY OF NEW YORK, ERIC ADAMS, THE CITY OF NEW YORK OFFICE OF LABOR RELATIONS, RENEE CAMPION, THE NEW YORK CITY DEPARTMENT OF EDUCATION, DAVID C. BANKS,
Defendant.
DECISION + ORDER ON MOTION
The following e-filed documents, listed by NYSCEF document number (Motion 001) 44, 50, 95, 96 were read on this motion to/for INJUNCTION/RESTRAINING ORDER .
On June 5, 2023, the Court issued a preliminary injunction in this matter. The Court has been informed by the parties that they do not wish for the Court to hold any additional argument, nor will there be further submissions. As such, this matter is ripe for a final determination.
The Court therefore grants the petition for the reasons indicated in the July 6, 2023, namely that both the doctrine of collateral estoppel and the provisions of New York City Administrative Code Section 12-126 bars the actions sought to be taken by respondents. The Court does not reach the last point of relief in the petition, namely that the respondents should be enjoined from disseminating alleged false and misleading statements of the Aetna Medicare Advantage Plan.
Based on the foregoing, it is hereby ORDERED that the Respondents are permanently enjoined from requiring any City retirees, and their dependents from being removed from their current health insurance plan(s), and from being required to either enroll in an Aetna Medicare Advantage Plan or seek their own health coverage.
Have to say I wasn't surprised by the Judge's comments a couple of weeks ago.
Now what's the city gonna do.
August 4, 2023
There's more than one boogeyman
July 27, 2023
What happened to the "optional" rider?
(Parenthetically, if you don’t have creditable Part D coverage for two months, Social Security will slap you with a penalty once you rejoin the Part D system, but some people do make that choice. For example, they may get their drugs from abroad, or from a spouse's plan, or feel so healthy they’ll take their chance for a year. Admittedly those cases are rare.)
July 25, 2023
What, no outrage over Part D?
Except for the shareholder aspect of the business model, I don’t as a patient see much of a difference between the way the public and private ones operate. All of them use mechanisms to delay or deny care (e.g., prior authorizations), and all of them make extra money off of Medicare and Medicaid (e.g, by encouraging upcoding and unbundling). These and other questionable practices are normal operating procedures whether the company is private or public. The goal of either kind is to stay afloat and make money.
When the government added Part D for prescription drugs in 2006, that whole new part of Medicare got put into the hands of insurance companies. Unlike with Parts A and B, there’s no such thing as governmental Medicare for prescription drugs. Part D is entirely run by middleman companies, or as CMS calls them, “Part D sponsors.” (I wrote about these and the Pharmacy Benefits Managers last week, the PBMs being the intermediaries between insurance companies and the drug manufacturers, entities that manage drug spending, rebates, claims, pharmacy networks, mail-order, and other components in the distribution chain.)
The city negotiates Part D Medicare for us, so let’s talk about that for a minute.
On the open market, Medicare Advantage plans usually include Part D drugs in addition to the benefits of Parts A and B, but it doesn’t work that way with our retiree coverage. The proposed Aetna PPO will not include Part D. Instead, Senior Care members will be transitioned from Express Scripts (or whatever drug plan they now have) into a negotiated Aetna Medicare Rx plan run by SilverScript. The UFT website says:
It [will not be] not part of your Aetna Medicare Advantage PPO plan. You will receive a separate Aetna Medicare Rx/SilverScript member ID card for prescription drug services.Presumably if you stay in the Emblem HIP VIP HMO, the drug component will still be managed by Express Scripts. Both SilverScript and Express Scripts resemble the stand-alone Part D plans in the open market, but they're structurally different from them. The stand-alones in the open market are entirely separate from Medicare Parts A or B or the Medigap you might purchase to help with remaining medical costs. But in the union arrangement, the rider can only get you the SilverScript plan when you have the Aetna PPO or Express Scripts if you have the Emblem HMO.
I just went to the Medicare plan finder to see which companies offer non-union stand-alone Part D plans in the NYC area, and lo and behold: each of the 7 listed in the search results are all themselves publicly traded companies or owned by one:
- SilverScript (owned by publicly traded CVS Health)
- Cigna (publicly traded; mail-order Express Scripts)
- Humana (publicly traded)
- Wellcare (owned by publicly traded Centene; mail-order through CVS)
- AARP Medicare Rx (offered through publicly traded UnitedHealthcare)
- Empire BlueCross BlueShield (owned by Elevance Health – was Anthem, which became a publicly traded in 2001)
- Elixir (owned by publicly traded Rite Aid)
Actually I know the answer: the pharmaceutical industry is just too big to fail.
With the whole of Medicare Part D run by insurance companies, we’ve come to just accept them. And when that happens, all we can do is look around for the best priced plan for the specific drugs we take. If like in our case there’s a welfare fund running the show, it’s more of a take-it-or-leave-it situation. And I don’t think greater transparency negotiating these plans would help: the whole industry is unbelievably complicated and riddled with fraud.
I think the city looks for the best Part D deal it can get, and rank and file members are mostly oblivious. Some have taken to the streets against the new Part A, B and C the city is cooking up, but everyone in the unions has turned a collective blind eye to the absolute scandal of the Part D design and how it’s morphed into a monster. It's a legislated for-profit enterprise we’ll never get rid of in our lifetime.
If people are going to get all up in arms, I’m thinking they should have started doing it decades ago against Part D, way before the Aetna PPO became became a twinkle in Mike Mulgrew’s beady eye.
July 21, 2023
Keeping track of the Aetna mess (part I)
June 28, 2018 – OLR-MLC agreement set a $1.1 billion target in healthcare savings to be generated between 2019 and 2021, and “for every fiscal year thereafter $600 million per year . . . on a citywide basis.” Sustainability would need to be studied by special Committee. Eight large topics are outlined, but PSC says they only “seriously considered one, reaching for the low-hanging fruit: retiree health benefits” (see History and Timeline).
I'm skipping to . . .
July 2021 – The massive restructuring was announced. By January 2022, the city would (a) move people by default into a MAP (an EmblemHealth and Empire Blue Blue Shield partnership called the Alliance), and (b) let them opt to stay in their supplemental care program if they paid a premium of $191.57/month.
Oct 2021 – LAWSUIT 1 (NYC Org’n of Public Service Providers)
Judge blocked this lawsuit over implementation: the city hadn’t established an accurate list of providers and sent retirees a flawed enrollment guide.
https://nysfocus.com/2021/10/20/retirees-flee-medicare-advantage/
LAWSUIT 2 (Aetna against the city, violations in the bidding process)
Dec 2021 – Judge extended injunction to stay implementation until April 1, 2022.
March 3, 2022 – Judge ruled that the city charging a premium would violate §12-126 of the city’s Admin Code (enacted 1967), which stipulates that “the city will pay the entire cost of health insurance . . . not to exceed 100% of the full cost of HIP-HMO.” City had argued it was following that law as long as it covered the full cost of one health plan, and that it could legally charge people a premium if they wanted a different plan. The city appealed and lost.
https://www.work-bites.com/view-all/retirees-win-in-court.
July 18, 2022 – Anthem/Empire withdrew, ending this first effort.
Sept 8, 2022 – The MLC (which negotiates health insurance on behalf of city unions) agreed to propose a change to Admin Code to eliminate the HIP-HMO rate as single standard for determining city’s obligation to pay the full cost for employees, retirees, dependents. (In practice, when the cost of the Senior Care plan exceeds the HIP plan in a given year, the Health Insurance Stabilization Fund reimburses the city the difference.) Under the new proposal, the city and MLC could agree on a different plan as the “standard” – or benchmark: for either retirees+dependents or for actives+dependents.
https://psc-cuny.org/news-events/psc-opposes-weakening-nyc-health-insurance-protections/
Nov 2022 – Appeals court rules retirees can’t be forced to switch to a MAP: Admin Code §12-126(b)(1) requires respondents to pay the entire cost up to the statutory cap of any health ins plan a retiree select.s
https://www.work-bites.com/view-all/retirees-win-in-court/
Dec 15, 2022 – Arbitrator cleared the way to switch retirees into a MAP (Aetna).
https://www.thecity.nyc/2022/12/15/23511966/mediccare-advantage-25-day-clock-from-abritrator-could-end-senior-care-innew-york-city
Jan 11, 2023 – Judge blocked the $15 copays.
https://www.nydailynews.com/news/politics/new-york-elections-government/ny-judge-blocks-nyc-charging-retired-workers-copays-20230111-4sbubgj6ujdgtlbjgytgbsfn2m-story.html
March 9, 2023 – MLC votes to accept Aetna MAP, as only alternative to HIP VIP (full Aetna contract not made available before the vote, but posted on March 10, 2023); City signs contract on March 30
May 25, 2023 – Appellate court affirmed Judge Frank’s Jan 11 decision blocking the copays.
https://iapps.courts.state.ny.us/nyscef/ViewDocument?docIndex=T7cQMiFRJdpEmd_PLUS_lMgmasQ==
May 31, 2023 – LAWSUIT 3 (NYC Org’n of Public Service Providers)
Seeks temporary restraining order against the Aetna plan, saying NYC violated city charter by not offering choice and violated state and city human rights laws prohibiting discrimination against disabled people. It also failed to follow proper procedures.
Documents: https://iapps.courts.state.ny.us/nyscef/DocumentList?docketId=_PLUS_IDYK0flEDapsoEVXJNmnw%3D%3D&display=all&courtType=New%20York%20County%20Supreme%20Court&resultsPageNum=1&fbclid=IwAR0LUAbRq8dHnk2C6YhIYmHeICHViyH8MjfiGEP9ahNglx2pWJn7wB-oRu0
About it: https://www.nydailynews.com/news/politics/new-york-elections-government/ny-nyc-retirees-sue-to-block-mayor-adams-new-medicare-advantage-plan-20230531-bnhtvbxonvfrle3gqwflqx5cxy-story.html
June 8, 2023 – Comptroller declined to register the Aetna contract because of pending litigation.
https://comptroller.nyc.gov/newsroom/comptroller-lander-declines-to-register-medicare-advantage-contract-pending-litigation/
July 7, 2023 – Judge issued temporary injunction blocking the move: the city can’t order retirees off the current plans.
https://psc-cuny.org/news-events/judges-decision-temporarily-blocks-aetna-medicare-advantage/
Court document: https://law.justia.com/cases/new-york/other-courts/2023/2023-ny-slip-op-32251-u.html/
I guess to be continued . . .
July 14, 2023
The biggest bog of all
- 2022 – rebates to Medicare if certain Part D drug prices increased more than inflation
- 2023 – insulin caps ($35 a month per prescription)
- 2023 – free vaccines for seniors
- 2023 – rebates to Medicare and lower coinsurances for certain Part B if prices increased more than inflation
- planned for 2024 – no copays or coinsurances for people in the “catastrophic” phase of Part D.
“PBMs are companies that manage prescription drug benefits on behalf of health insurers, Medicare Part D drug plans, large employers, and other payers. By negotiating with drug manufacturers and pharmacies to control drug spending, PBMs have a significant behind-the-scenes impact in determining total drug costs for insurers, shaping patients’ access to medications, and determining how much pharmacies are paid.“
Here’s the graphic they adapted from a Congressional Budget Office document of January 2007:
- Rebates from the manufacturers (not publicly disclosed): Should PBMs be able to keep these or pass them through to insurers, who could then reduce premiums and copays? Pass-through amounts don’t always reach small insurers or employers. Reform would require PBMs to pass through rebates to patients. Reform would also require more transparency so federal and state policymakers could see what’s going on.
- Spread pricing: in the case of generics, insurers and employers reimburse PBMs more than what the PBMs actually pay pharmacies for these. PBMs keep the difference and the schedules are “kept confidential” from the health plans. Reform would ban spread pricing altogether, so that insurers and employers would not overpay.
Express Scripts vehemently insists it saves money for clients and that the vast majority are satisfied with its service. And like any company – to state the obvious – it’s entitled to a profit. The question is, Who is making out better – the PBM or its customers? Many experts say the former. They argue that many companies stick with traditional PBMs because drug pricing is so impossible to untangle that customers have no way to verify how much they’re saving, if anything. ... The PBMs’ claims of cost savings are difficult to prove or disprove. Drug pricing is an almost impenetrable bog.
July 11, 2023
Brian Lehrer (WNYC) needs to do better
*Saying that, I have friends who switched to Senior Care because a specialist they wanted was not not taking the Emblem plan. So, it’s not that these people got delayed or denied service, but they didn’t want the restrictions in choosing a provider or facility and preempted the situation.
The instructions for the July 10th deadline said do nothing if you wanted to keep your Emblem HMO and only let them know if you wanted to switch into the new Aetna PPO.
Lehrer mentioned that only 1,600 retirees had opted out as of last week, but he did not tell us how many people chose to keep the Emblem HMO they have. Nor did the reporter on the show (Caroline Lewis) correct him, to clarify that a fair percentage don’t have Senior Care, but the Emblem plan. This omission skews the whole issue, because I suspect the thousands who decided to keep the HMO are either happy with it, or didn’t trust the transition to the new Aetna, or were just taking a “wait and see” position until November, when they’d have another chance to make a coverage change.
Reporting on only part of the whole scenario is kind of like malpractice. The show made it seem like the all the city retirees are in same class action, whereas it’s only the ones who are losing Senior Care. As for the others who have the Emblem HMO, nobody is telling us how many of those people decided to keep what they have. That’s just bad reporting.
Responding to Lehrer’s question “What’s the cost for those additional city health benefits” if people do opt out, Ms Lewis must have just misunderstood the question:
“Paying for the premium for Medicare Part B on your own and not having it through the city I think starts at around $165 and goes up depending on your income ... people might want to pay for a Medigap plan ...”
He was asking her about the cost of the “additional” benefits, meaning the ones Senior Care gives you, not Part B. Part A is free for most everyone, and she's right that there's a premium of around $165/month for Part B, more when income is higher. It's paid to Social Security and city retirees get that reimbursed if they remain inside the city system. But Lehrer wasn't asking about Part B, he was asking about the "additional" coverage they'd have to get if they were to opt out.
This almost obligatory extra coverage is not something that "people might want to pay for," as Ms Lewis says, but something they'd be a fool if they chose not to. Medicare leaves so many costs on the table that you need to have supplementary coverage, which can come through a Medigap, resembling Senior Care. There are 10 different kinds of these in the open market, with several companies in each zipcode competing for your business. Checking the plan finder at the NYS Dept of Finance for this month's choices in the metro, they range in price from the most comprehensive, never-see-a-bill type at $332/month to a high-deductible kind at around $68/month. (People could also supplement Parts A and B through a premium-free Advantage plan, but why would they want to do that when the city is offering Aetna PPO at no cost. That would be utterly stupid.)
Admittedly the subject is turgid and inscrutable, but the questions and answers on this program showed neither the interviewer or the reporter was up to the task. So disappointing.
July 8, 2023
What a mess. Full stop.
That’s the email we got yesterday which proves at least one thing: the UFT knows how to keep us informed efficiently, clearly and rapidly when they want to – or when their back’s up against a wall.
a. Definitionsand
iv. “Health insurance coverage.” A program of hospital-surgical-medical benefits to be provided by health and and hospitalization insurance contracts entered into between the city and companies providing such health and hospitalization insurance.
b. Payment of health insurance costsNo mention of “premiums” here. It says the city will be paying the “entire cost” of the coverage defined in clause a.iv. not to exceed the “full cost” of the HIP HMO, which could easily be interpreted to mean it would include copays and coinsurance in addition to premiums. Costs could also include the $50 deductible that Senior Care people have to pay out of pocket before the plan starts picking up Part B leftovers mounts, as well as the $300 deductible ($750 max per year) for each benefit period of in-patient service and the $50 deductible for an emergency room visit.
(1) The city will pay the entire cost of health insurance coverage for city employees, city retirees, and their dependents, not to exceed one hundred percent of the full cost of H.I.P.-H.M.O. on a category basis.
... to this Court, section 12-126 does appear to be a codification that the City must pay “the entire cost of health insurance coverage”... the Code makes no mention of the word “premium” but rather uses the word “coverage.”
Judge Frank’s ruling yesterday was sloppy in the following excerpt, and not only because of two typos. Writing about the Code, he stated just before the passage I already quoted above:
This section provides that “[t]he City will pay the entire cost of health insurance coverage for city employees, city retirees, and their dependents ... [typo 1, end quote missing] To this Court, this wording is unambiguous [Really? It’s ambiguous to me if you can’t tell from the wording whether “entire cost” means just premiums or premiums plus all the other costs in the plan] and applies to this matter. Moreover, the history of section 12-126 shows that the City intended to provide all retired employees health plans and intended to assume full payment for them. [Again, “full payment” to me means premiums plus the rest of the costs, not just premiums.] Gardener Aff., Ex. H at 27-28. This section was originally enacted through the City’s expanded powers, under a 1965 amendment to [NYS] General City Law § 20, passed around the same time as § 12-126, empowering the City to pay the “for [typo 2, I think it should have been “pay for”, not “pay the for”] premium charges for supplementary medical insurance benefits under the federal old-age, survivors and disability insurance benefit program.” ) [I don’t have access to the Gardner affidavit, but the § 20(29-b) of NYS General City Law he’s citing doesn’t use the word “pay” for premium charges. Instead, it says cities are empowered to “reimburse”retirees for premium charges. There’s part of the payment mechanism in here that’s not at all clear to me, since retirees can’t be “reimbursed” for something they never paid for in the first place. And if the judge is bothering to explain this history, he certainly left out an explanation of how “costs” in the Code got reinterpreted to mean just “premiums” by the NYS law.]Wouldn’t it be nice to have somebody at any level of the judicial system clean this mess up.
Not defining what “costs” are involved with coverage, not clarifying the term “category basis” at all, calling bits of legislation unambiguous when ambiguity clearly remains, and making strange word substitutions like the ones mentioned earlier doesn’t help us understand anything.
I’m going to be staying out of these court docs from now on. They’re really upsetting.
July 6, 2023
A tug of war, right?
a utilization management practice used by health insurance companies that requires certain procedures, tests and medications prescribed by healthcare clinicians to first be evaluated to assess the medical necessity and cost-of-care ramifications before they are authorized.
Medicare Part D is a whole other story, as the plans are not governmental, but offered competitively by non- and for-profit companies. They decide for themselves which drugs on their formularies will require prior auths and which won’t. More likely it's the Pharmacy Benefit Managers making decisions these days, not the companies themselves.
Medicare Part C – the Advantage plans (MAPs) – are also run by non- and for-profit companies, which in their capacity as middlemen between patient and government, have rightfully earned the contempt many people have for them. Their delays and denials of service have become scandalous, their procedures and paperwork burdensome to providers.
IMPORTANTLY, there’s not much information about how prior auths are used, how often it's denied, and how reviews affect patient care and cost (KFF, May 2022).
What's gone wrong
- Prior auths are sometimes delayed or denied in spite of meeting Medicare coverage rules (13%) or meeting both coverage and billing rules (18%). Some plans deny because of stricter criteria than Medicare itself uses, or ask for more documentation than Medicare.
- Most denials in their sample were caused by human errors in manual processing and system errors in the software (e.g., incorrect programing).
- Some denials were reversed after a patient filed an appeal – I read somewhere else that only 11% of patients go to the trouble – while others were reversed when the plan itself found it had made an error.
- CLINICAL COVERAGE: As a case in point, California now requires companies to use criteria “consistent with generally accepted standards of care and ... developed by a nonprofit association for the relevant clinical specialty.” It’s unfortunate, thought, that KFF says state laws like this wouldn't apply to employer-sponsored plans, nor would they, I assume, for retiree plans.
- TRANSPARENCY is apparently gaining momentum. There’s a House bill requiring Advantage plans to report which treatments need prior auths, and to give %s of approvals, denials, and appeals. This kind of reporting had already been written into the ACA, but alas and alack, according to KFF, it's been largely un-implemented.
- SETTING STANDARDS for prior auths. For example, the ACA had already banned them in emergency care. A new Michigan law now standardizes methods and demands transparency reporting. What interests me is the new “gold card” laws, whereby health plans have to waive prior auths requested by doctors with a track record of approval. Believe it or not, the first one seems to have been enacted in Texas, of all places (discussed here).
- ADMINISTRATIVE REFORMS. A bill that passed the House last fall – H.R. 3173 “Improving Seniors Timely Access to Care Act” would amend Title XVIII of the SS Act (which created Medicare in 1965) “to establish requirements with respect to the use of” prior auths in Advantage plans, including electronic submission, attachments, real-time decisions, declaring which ones would be routinely approved, data collection, transparency, etc. Impressive: it has 326 co-sponsors, but too early for champagne. It’s been sitting in not one but two committees for a couple of years ...
I'm sure I won’t be seeing Medicare for All in my lifetime, but I like that doctors associations and legislators are trying to fix some of the scandalous parts of Advantage plans as we know them, even if the shareholders and a lot of bad actors are contaminating the battleground.