Raise your hand if you know what Medicare is

Right up front I want to say how grateful I am to the NYC Organization of Public Service Retirees for their ongoing fight since 2021 to protect retiree health care, unexpectedly winning some major victories. 

After they thwarted the City’s attempt to shove us into an Advantage plan, our weird union even removed its support for these things, and both mayors since have shown little interest in pursuing that matter further. The organization also got us some relief from the Senior Pay copays for a couple of years. Bravo. Thank you.

With interest, then, I just watched the interview that the organization’s lawyer, Jake Gardner, just did with RTC’s Arthur Goldstein regarding Intro 1008. That’s the local bill to amend NYC’s administrative code to protect health insurance coverage and contributions for Medicare-eligible retirees and their dependents. The RTC endorsed this bill “as Written,” and Arthur, one of its officers, has already told us what he thinks of the UFT’s position on this bill: “Unity now wants us to believe that they support 1008. If you believe that, I suggest you drag a rotary phone to the supermarket and try to exchange it for groceries.” 

Around 14:00, he reminds us that the people who run the union get two pensions – from the City and from the union. It’s not apparent that these people understand the financial strains on retirees that have only one pension, which in many cases isn’t even all that big. 

I love the point Gardner makes around 12:30 about the $15 copays – that the more doctors retirees see, the more copays they rack up. “They’re forcing the sickest, most vulnerable group to shoulder the greatest burden ... I don’t think that’s fair. That seems anti-union to me.”  He also believes the union’s bringing up the Taylor Law isn’t even a good faith argument, that it’s just a pretext for hiding its true position, that they want to be able to sell off retiree benefits to benefit their active members (around 18:00). 

(More on Intro 1008 at Ednotes here and here.)

But all this is not the real reason for this post, which is to object ONCE AGAIN to the annoying misuse of Medicare terminology by people who should know better.

Near the very beginning of the video, Arthur introduces Jake saying he’s “a big part of why we still have Medicare.”

This is ENTIRELY UNTRUE. 

As good a lawyer as Jake is, he has nothing to do with our keeping our Medicare. 

Part A and Part B Medicare are not going away even if the city stops giving us any retiree health insurance whatsoever. 

We will always have Medicare Part A if we sign up for it with Soc. Security. It’s funded by what we’ve paid into the system through payroll and self-employment taxes.

We will always have Medicare Part B as long as we continue to pay our Part B premiums. Part B is funded by those premiums, deductibles, penalties, and government sources.

Saying that the City or the union is working to take away our Medicare is uneducated and possibly a way of rallying the troops. What’s under threat is Senior Care, but Senior Care is not Medicare. Senior Care is only the supplementary coverage that pays for what Medicare has not been designed to cover in the first place.

Senior Care resembles a comprehensive Medigap, a federally designed supplemental plan that people who don’t have plans from their unions or employers get to pay the bits that Original (or Traditional) Medicare doesn’t cover. 

There are notable differences between Senior Care and private Medigaps. It has a $50 deductible and annoying $15 copays. That deductible and those copays are “negotiated” bits, they don’t exist in private Medigaps.

The Emblem/Anthem coverage we have with Senior Care is a kind of PPO. 

PPOs are negotiated plans for the delivery of Medicare and the leftover amounts it doesn’t cover. The supplementary Part B coverage we get with Senior Care is labelled a “GHI PPO” on our individualized Medicare.gov accounts, and if you look at the Anthem card (relating to Part A), you’ll see the little suitcase logo actually declaring this coverage a “PPO.” This kind of PPO does not have middlemen entities managing our benefits. Medicare pays its share, and Senior Care picks up the rest.

What’s confusing is that we’re more familiar with the other type of PPO, the kind of Advantage plan the City was trying to put us into. These Advantage plan PPOs have elements we absolutely detest – prior authorizations, denials, networks, verticalization, and middlemen control. It’s privatized health insurance:  the government sends companies stipends from various funds (Medicare, what Social Security collects from us in premiums, and other sources) to manage our health care benefits. 

It’s infuriating to hear people so committed to fighting for our current health insurance arrangements imply that the city is working to take away our Medicare. 

No one who keeps up with their Part B premiums is “losing” their Medicare.

Even if the City took away Senior Care and all the other plans they offer, we’d still have Original Medicare. It’s not going anywhere unless Congress kills the whole damn thing nationwide.               

Coverage by cartel

GREAT way to call the healthcare monopolies what they really are.

I heard it listening to the James Talarico / Mark Cuban interview, where they seem to be teaming up to go after “Big Medicine,” at least in Texas.

https://www.youtube.com/live/3aOl8nE2sPI?is=p2Fw1whNZFKTq4Ug

I’ve already used Cuban’s CostPlus firm once, to buy a generic that my oh-so-wonderful retiree plan decided to push out of its formulary this year. Prime Therapeutics (our new pharmacy benefit manager) is now forcing the brand on us for that particular med, when I’ve been getting the generic for more than a decade. It’s been working fine. And it’s cheaper.

Curious if they can get any of the scaredy-cat Congresspeople on their side. Though my eyes are open.

Talarico talks religion way too much – I hate it when these Christian politicians keep bringing in the Bible when you don’t have to be religious to know the difference between right and wrong and want to help your neighbors. Cuban’s a billionaire, which in my book is a big strike against him right there.

But I like the sound of that phrase:  Coverage by cartel. It’s catchy.

Our village idiot - continued . . .

[[[ MAJOR UPDATE below  ..... ]]]

Just look at that face.

I can’t tell which is more Simple Simon stuff – the vapid smile or the drivel he wrote us in a recent email. 

 

Subject:  Boost your brain health

Right.

When Medicare is giving way to privatization...

When  prior authorization denials mean big bucks for shareholders and doctors can’t control outcomes...

When pharmacy benefit managers decide which meds you’re allowed to get and how much they cost...

When the rules are changing for selling insurance...

We get this from him:

 

Trust me, I am eating and sleeping well enough.

I am socializing (enough) and taking care of business.

I’m using my brain.

I’m taking my medicines and keeping my appointments.

That’s what seniors do – but only if they have the money, and if they have the time and aren’t still working past retirement age. And only if they have good insurance, take reasonably priced drugs and have back-up support.   

There’s no evidence that those problems matter much to Oz & Co. 

Just in!  A new email from him today.  Now he’s telling us to move our bodies regularly.  It goes from stupid to stupider, I can’t believe it. 

We’re in a financial and health delivery crisis at the moment, and the infinite capacity of these guys to gaslight us is stunning. And predictable.  

Imbecile or shyster.  It’s hard to tell.

 

Those nasty little 2025 copays

We heard from UFT Welfare Fund Exec Director Geof Sorkin a few days ago about the recent class-action settlement retirees that reached with the city and EmblemHealth regarding the copays thrust upon Senior Care people in 2022 and 2023.

Towards the end of Geof’s email were instructions on how to get reimbursed for 2025 copays, which I decided to follow just for the heck of it.

The nice lady at the right is Pat Rojas, who runs SHIP.  She says in a short video that SHIP enrollees – not everyone who paid copays that year, mind you – could get back up to $105 of them.

Sounds like the cost of a dinner for two at a moderately priced restaurant, but okay if there’s not much work involved.

Not what happened, though.  After spending some time going through what needed to be done, I felt the overwhelming urge to tell my friends and Medicare counseling buddies what I encountered, but why stop there.  Everyone should know about it.

Thus this post.

----------------------------------------------------------------------------------------------

  

Hello, good evening,

You must have received the notice from the UFT below (or a similar email from your own union) that SHIP will reimburse copays between Jan 2022 and Feb 2023. I’m not sure all the unions have SHIP, so only read further if you do have it.

At the end of that email is a link to website explaining that SHIP, if you’re enrolled in it (and not everyone in Senior Care is), will reimburse you for up to $105 in copays per calendar year once you’ve met your annual deductible. You can do this for 2025, dating your request up to the end of the following year (in this case Dec. 2026). I’m not sure if it’s just too late to process the 2024 copays this way, or if this arrangement was only meant for 2025 and later.

They of course mean the Medicare deductible, not the $50 Senior Care deductible, which the video doesn’t even mention.  That’s always confusing on the Emblem statements, by the way.

If you are in Medicare, then this chart during the video tells you what you need to collect and send them.

The SHIP exec implies it’s easy:  “You have to get a hold of 4 documents.”    

What a hoot.

In reality, you have to go through all your bills, receipts, and statements from Medicare, providers, and EmblemHealth, then fill out a SHIIP form and send it all off to them. This is not 4 documents. This is multiple items in 4 categories, not 4 documents.

I tried it anyway. 

 

Going through my 2025 papers, which I have kept but always been tempted to throw out the minute I get them, I ran into these problems: 

1.  Medicare Part B summaries:  She asks to find page one of the MSN to show that the deductible has been met, and I can save you some trouble by telling you exactly where to look. Start with the first MSN of the year and look towards the top of the first page: it tells you where you are in meeting that deductible.  Keep going through one or two more MSNs until you get one that says the it’s been met.  Here are those lines from my first two statements in 2025:

I assume they want me to send them the 2nd one, and presumably from here down, they’re looking for items after that 2nd statement, until that $105 is reached.

2. Now for provider statements, with dates and copays paid. I guess they mean bills, which in my case came in all different forms, some requested the day of the visit, some billed later. Some I paid in cash, or didn’t collect a statement for at the time, so I had to call a doctor or two to ask them to send me a bill by email.  

3. Receipts: again in different formats, or none at all and you have to rely on your credit card statement or your checkbook. I hadn’t even asked for a receipt for some of the ones I paid for in cash. My bad. 

4.  Emblem Health in my case. The problem with EmblemHealth is that it always sends duplicate statements. (And ALWAYS snail mail, even though I’ve asked for electronic ones and may have even filed a grievance about that waste of our money.)  Pat asks for complete EOBs for all the service dates that match the invoices.  Not to mention that these are ridiculously hard to scan, I could reduce the pile by half because of their tremendous duplicative mailings, but I still had to go through each one looking for the copays. If you do this search online, it still means screenshotting each one.

Then you have to get all this to them one way or another.

I ask you:  is this worth it for a max of $105?  

The hourly rate for tech editing is $32 - $42.  I did about an hour and a half just the first 3. By the time I got to no. 4, I decided it wasn’t worth it and just quit. 

To whom can I complain about this?  The unions who set up this arrangement?

The question is:  did the city and SHIP actually rely on the fact that we all wouldn’t bother?

Moron, clown, sycophant. Maybe all 3.

Just look at that face. 

It’s in the email he just sent us seniors to tell us how to stay healthy.

Would you trust that face?  I’d call it half a bubble off.

But it matches the simplistic, dumbass advice he’s giving us for staying healthy.

Eat.

Drink.

Move around.

See your doctor from time to time.  

And for this, he gets a salary of around $200K from federal funds. 

I guess I’d be content if that’s all Oz and CMS were doing for us - giving us advice we already know.

Because while he’s writing his silly emails with his silly face on them, his whole agency is working hard to cut Medicare protections and keep the entirety of the health care situation as inscrutable as ever and the fiendishly difficult to navigate. 

Here’s some of what they’ve been working on ... 

The final rate payment for Medicare Advantage will now be even higher than what had been proposed by the Trump administration. Even for 2025, Families USA calculated that Medicare Advantage plans were paid 20% more per enrollee in 2025 than people with straight Medicare. I guess Oz is comfortable with these giveaways to private companies.

According to Protect Our Care, CMS’s proposed rule will enable drug companies to skirt Medicare price negotiations.  I guess Oz approves of the the backroom deals Trump’s cutting to orchestrate loopholes for big pharma.

CMS is not going to finalize the proposal to make a special enrollment periods for people whose providers drop out of Advantage plans. Nor will it require mid-year notices to remind people to use their supplemental benefits. Or require marketing agencies to refer people to State Health Insurance Assistance Programs. I guess Oz likes it that people won’t be told to ask state agencies for help with their Medicare choices. Heaven knows they might be advised to stick with Original Medicare rather than get involved with privatized health insurance.

And now we’re going to get back-to-back educational and marketing events.  CMS has removed the required 12-hr delay between the two.  And no delay either now between the Scope of Appointment form and the marketing appointment. That 48-hr cooling off period is gone.  I guess Oz favors marketing rules that help brokers swoop in for the kill. The less time people have to think over what they’ve learned, the better for marketers, right? 

CMS has has seriously changed the Star Ratings system for Advantage plans. No need to include admin performance (more here). I guess Oz is thrilled that insurance company ratings will rise and lead to bigger bonus reimbursements for his cronies. 

And what about that new LEAD model that’s going to replace ACO REACH. If your doctor joins an ACO, you go with him into the new arrangement or find another provider. That’s helpful, right?  Staying within narrow networks is incentivized, and your personal medical information will be shared with providers, networks and 3rd-party care (more here).  Nothing wrong here, according to Oz.

I can’t get over that face. Fatuous. Ditzy. Happy-go-lucky. Fiddling while Rome burns.

And don’t get me started on any involvement Oz has with that other clown, RFK Jr.

 

 

My new heroes at the Capitol

Some have been busy up at the House, despite it being run for almost a year by a despicably misguided and cruel group of Republicans.

Rep. Mark Pocan and 12 others just introduced 8 – EIGHT! – bills to address the worst offenses of Medicare Advantage and try to get traditional Medicare back on track.

They grouped the bills into three categories:

Delays and denials – disincentivizing companies, automatic appeals, transparency

Overcharging – history of defrauding, reduce unnecessary spending, improves process and clarity

Strengthening Traditional Medicare – prohibits Medicare Advantage from becoming the default option for seniors (proposed in Project 2025!), doctor directory**  

**I’m not sure about that doctor directory thing. My experience is that no matter how good their intentions are on this, the provider directories always fall short.   Offices don’t keep them up-to-date, locations are incomplete, situations change throughout the year, etc. This thing shouldn’t even be in the 3rd category, as it has to do with Advantage plans, not Original Medicare.

But read the press release for yourself, it’s here: https://pocan.house.gov/media-center/press-releases/pocan-introduces-package-bills-reform-medicare-advantage-strengthen

Do I think these bills need immediate attention?  Yes.

Do I think any of them will come out of committee?  No.

A roadmap to sadism

Or ...  

How Not to Treat Seniors and People with Disabilities.

Bernie and two of his colleagues (Sens. Kaine and Alsobrooks) put together a list of the harms this madman and his sycophants have done in their first 100 days.

I’ll make this short, as the document speaks for itself. Down below is the Table of Contents, and you can click this link for details.

Let me just say: until Congress reinvents itself, lots of health delivery is going to get harder with these maniacs in charge of the nation’s procedures and medicines.  

Everyone who doesn’t have a retiree plan from someone should be checking their plan’s description for 2026. The ANOCs (Annual Notices of Change) are supposed to be sent out this month. That means if you don’t like what they’ve designed for next year, you can use the plan finders on Medicare.gov and this NYS website to find more suitable coverage and sign up for new ones between October 15 and December 7.   

Our OLR plans work differently.  Senior Care people shouldn’t be expecting any ANOC from Medicare itself, maybe because CMS considers it too stable a program to warrant the cost of an annual change notice. 

But for the supplemental coverage and other choices offered by our unions, you could check out the July versions of the OLR’s comprehensive plan manual and separate rate chart. We can change from one plan to another each November. 

A final thought, on COVID vaccines.  

Gov. Hochul signed an executive order allowing pharmacies to administer these to anyone who wants them for at least another month, but the details are less clear.  

As one pharmacist told a reporter for the Buffalo Spectrum News 1:  If the federal government isn’t giving clear guidance on the rollout, and particularly how these vaccines are going to be paid for, insurance companies are “not likely to follow suit and just cover these products.” Coverage may end up being plan-specific, so you need to make a phone call or two before assuming these will be free. 

Please do some homework this fall. Help yourselves, and help others who can’t help themselves so easily.

Just “Wow.”

We’re on a roll here with this RFK Jr. / Oz combo running healthcare.  Maybe “ruining” is a better word.

Continuing my rants against prior authorizations (see July 7 post below and a column I wrote for the Examiner), I came across a remarkable video by Dr. Elisabeth Potter trying to get information out of UnitedHealthcare on a procedure they had denied.   

Witnessing malfeasance this up close and personal is something else.

She can’t get proof the “doctor” she’s speaking to is even a doctor.

That’s because he refuses to give his name. 

Without a name, she can’t check him out.

He as much says he has no experience in the procedure she’s being denied.  His supposed field of expertise is not hers. 

Listen for yourself.

Dr. Potter has done other videos.  In this one from a month ago on the Oz’s press conference on prior auths, she says:

We’re at a boiling point in our society...

What RFK/Ox are promising “doesn’t land”:  it’s a voluntary promise, there are no new rules, no repercussions, and no deliverables.
We as patients are demanding more from the system.

I’m joining an Elisabeth Potter fan club.

Things very slippery at CMS

Additional videos on the hypocrisy posted at the end of this article....

I had just finished a guest column for the Westchester Examiner on how Dr. Oz is scamming us into believing he and RFK Jr. are doing great things for us by making Medicare so easy. 

Oz is a showman. Several weeks ago he put out a video encouraging people to get help from the experts at Medicare. But he doesn’t point us at traditional Medicare – there’s no profit in that. He directs us squarely to the industry’s privatized version, Medicare Advantage. 

He’s also a salesman. Later in the month he put out a video about how CMS and their corporate collaborators are now pledging to clean up Medicare Advantage’s scandalous abuse of prior authorizations to delay or deny care. Mind you, they’re just pledging for the moment. No new laws or punishments as yet.

As I wrote in the Examiner, I believe fixing prior authorizations in Medicare Advantage is part of a larger campaign, to turn a proposal in Project 2025 into a reality, that Medicare Advantage (Part C) rather than traditional Medicare (Parts A and B) will become the default for new enrollees. 

Having no trust in Oz or his boss RFK Jr. already, I was not totally surprised reading yesterday’s CMS press release that said they’re going after prior authorizations in Original Medicare as well.

But, the thing about prior authorizations in O.M. is that there isn’t much use of it there at all. If doctors want you to have something done, there’s no middleman private insurance company gatekeeper barring your access to that procedure. Medicare will pick up its share of the cost, and you or your supplemental policy will pick up the rest. No unexpected delays or denials.

Today’s post in HEALTH CARE un-covered explains how the limited use of prior authorizations works in O.M.:

Not many people realize that prior authorization is used in traditional Medicare (TM) at all, likely because it applies to a very small small number of services. Currently, TM requires prior authorization for 52 outpatient medical services, some durable medical equipment, and repetitive scheduled non-emergent ambulance transport. The prior authorizations are processed by the Medicare Administrative Contractors (MACs) and are required to be reviewed in a very short timeframe. Perhaps most importantly, the prior authorization decisions under the current process have been found to be more than 98% accurate. The limited scope, MAC review, and high accuracy ensure that current policies and procedures governing the use of prior authorization in traditional Medicare meet the intended goal of preventing wasteful spending without delaying or denying necessary care.

In the guise of going after “fraud, waste, and abuse,” Oz’s newsletter says the agency is now planning to test something in traditional Medicare called the WISeR (Wasteful and Inappropriate Service Reduction) Model. Here’s how it’s described:

Combining the speed of technology and the experienced clinicians, this new model helps bring Medicare into the 21st century by testing a streamlined prior authorization process, while protecting Medicare beneficiaries from being given unnecessary and often costly procedures . . .

The WISeR Model will test a new process on whether enhanced technologies, including artificial intelligence (AI), can expedite the prior authorization processes for selected items and services that have been identified as particularly vulnerable to fraud, waste, and abuse, or inappropriate use. . .

Under the model, providers and suppliers in the assigned regions will have the choice of submitting prior authorization requests for selected items and services or their claim will be subject to pre-payment medical review.

In the 6 years they’re planning to run this model, there’ll be plenty of time to open up new pathways to abuse in our health care system. We’ll soon be seeing poorly regulated and widespread use of prior authorization in traditional Medicare as well.

And just like with Medicare Advantage, it’s not only that private companies who’ll be running these requests through their AI systems, the final decisions will be made by “licensed clinicians, not machines.” They don’t say doctors, and they specifically don’t say your doctor, the guy who asked for the procedure in the first place.

I don’t trust these people at all. 

And I don’t trust the link for an “overview” that CMS gives in the press release. You have to sign into read it, I’m not inclined to sign into anything from the government that should be open to the public.   

I did go to another link at the bottom of the release, which has more of the same gobbledygook we’re used to reading:  “working with companies experienced in using enhanced technologies to expedite and improve the review process,” “ensure people . . . receive the most appropriate care,” “best health outcomes,” “ease administrative burdens,” “empowers patients to partner” with their providers.  The whole thing was probably written by A.I.

Check out the more informative post in HEALTH CARE uncovered mentioned above. You’ll hate what you read, but consider it medicine. 

If only they’d stick to selling snake oil and not perpetrate the worst of their greedy, slimy instincts on us.

NEWS FLASH !

Christopher Westfall is as horrified as I was over this issue of prior auths in Original Medicare. 

In his latest video (July 29), he says that if they want to get rid of fraud, waste, and abuse, why not go after the corruption in the Durable Medical Equipment industry - $10.6 billion in fraudulent claims reported in 2025.  He also talks about the private industry that will be trusted with the algorithmic approvals (yup, the same ones that produce the denials in Advantage plans). Highly recommended 20 min., but only if your blood pressure can stand the stress.

Here’s another one just this morning, from Ed Weir, a  former Soc. Sec. manager. Gives more details on the use of A.I. in this process.  

The lawsuits — googled for clarity

UPDATE on Bentkowski (#2 below):      On June 18th, the Court of Appeals reversed the order of the Appellate decision, remitting the case to the Supreme Court.  But read Jeff Kaufman’s take on the decision on EdNotes. He’s a retired teacher, and a lawyer.

The first meeting of the UFT’s newly constituted Retired Teachers Chapter took place this past week — the rundown of which you will not find on its website, but happily and colorfully described on Arthur’s Union Matters and Norm’s EdNotes. 

A key feature of that meeting had to be the update Marianne Pizzitola gave us on the healthcare battle that her retiree group has been waging on our behalf in the courts since 2021.  

When she turned the mic over to one of the lawyers (Jake Gardener) to give us the rundown, I was all set to take some serious notes. That didn’t get very far. 

Too much has happened in the past few years to be condensed into a 15-minute briefing, and much of what I came out with looked like “We won in the trial courts and at the appellate” and “It’s still in litigation.” Oh, and there might be a fourth lawsuit. So, I spent the whole of yesterday and today fleshing out the darn thing for myself and anyone else who cares.

What follows is not complete, as there were motion, hearings and thousands of paper submissions in between the delivered opinions. I’m leaving out the super-technical points of law, which you can follow yourself at the links.  But most of the “wins” were solid, we still have Senior Care at no premium cost. The $15 copays, though, will bite us in 2025.  

In each case below, I start with my notes from the meeting and follow up with what I found online.  Fingers crossed I got these right. 

#1.  “Campion.”   Something to the affect that in 2021 the City said it wouldn’t fund any plans except the new PPO. Marianne/her NYC Retirees challenged that, won at trial court, won at appellate [Supreme]. Next month he’ll be arguing the case in Albany at the highest level [Court of Appeals].

Google results 

The City announced it was changing retiree health insurance in July 2021, saying it wouldn’t fund any plans except the new PPO and that retirees would have to pay $192/month if they wanted to keep the Senior Care plan they were on come Jan 2022. Marianne’s group challenged that decree on Sept 26, 2021 with an Art. 78 Petition against the City. They claimed they couldn’t be forced into an Advantage for three reasons: the City’s Admin Code §12-126 requires the City to pay for any plan up to the HIP HMO statutory cap (at the time $859/month) and the projected cost of Senior Care was far below that ($191/month); their existing health insurance benefits were protected, and the new plan violated the NYS Moratorium Act (see the Nov 29, 2022 complaint below in #3, and a user-friendly explanation here on the Pollack Cohen website). 

The Supreme Court issued a temporary injunction on Oct 21, 2021, saying that the MLC could not intervene in this case (since former unions could not represent retirees), that an Advantage plan might be “rational” but its implementation was “irrational, and thus arbitrary and capricious” and would cause irreparable harm if retirees were made to opt in or out of it by Oct 31. Everything had to stay the same until it could rule on underlying arguments.  

More hearings and document submissions followed. The Court’s March 3, 2022 decision vacated that Oct 2021 ruling. It determined among other things that because the City had addressed some of the implementation issues of the new plan, it was no longer irrational. Some of the legal arguments made by the retirees were “unavailing,” amendments could be made to health insurance during collective bargaining, and that the NYS Constitution does not guarantee specific health insurance for retirees. But the $191/month fee to remain in Senior Care was prohibited, as it would run afoul of Admin Code §12-126. In other words, if given the option of Senior Care, retirees could not be charged “any costs” for it except for the part that rises above the HIP amount. Additionally, the deductible would only apply to 2022. The new Advantage plan couldn’t start until April 2022 and retirees could opt out of it if they wanted to. 

Apparently, within days of that March decision, the City withdrew the Alliance plan. But the copays remained.

[I’m not sure whether the City appealed AGAIN or whether what follows is further clarification by the Supreme Court of that March 3, 2022 decision.] The Court ruled on Nov 22, 2022 that the issue raised on this appeal by the City regarding the $192/month premium “is one of pure statutory interpretation,” that there were factual issues in the Code surrounding the phrase “on a category basis” that couldn’t be determined at this time.  In short, the Court affirmed the earlier decision in favor of the retirees, that no costs of Sr Care could be passed onto the Sr Care enrollees at this time.

#2.  “Bentkowski.”  Won at trial and at the appellate, and that the City made a motion at the highest court to appeal, but he doesn’t know yet...

Google results:      

As explained in the class action lawsuit filed by the lawyers for Bentkowski et al. on May 31, 2023 (complaint and brief), the City told Medicare-eligible retirees in March 2023 they could no longer get Senior Care and would be automatically enrolled in a new Aetna PPO come Sept 1. The retirees objected to the fact that should they opt out of the new plan, not only would they be required to pay their own Part B premiums and supplemental costs, but the City would be “unjustly enriching” itself.

The plaintiffs claimed they’d be harmed in various ways, including that not all providers would accept the proposed PPO, prior authorizations could be denied, continuity of care would become problematical in the switch, delayed or no payment of claims would mostly likely occur, non-Medicare retirees would be discriminated against, no full and accurate description of the new plan had been provided, and moving out of state might mean difficulty in finding a replacement Medigap. (A very nice list of negatives indeed!!)  In fact, as they say on p. 77 of the complaint, there’d be a whole set of “new healthcare ‘rules’” for retirees had not been adopted in compliance with CAPA (the NYC Admin Procedure Act), and worse still: the City “conspired with Aetna to unlawfully restrain competition” in the health insurance market.

BTW ... there’s a really good description of Medicare, Advantage plans, and supplements on pp. 23–31  (though I disagree with a bit of wording in §129). 

On Aug 11, 2023 the Supreme Court ruled that the City could not remove retirees from their current plans, require them to enroll in the proposed PPO, or seek their own coverage. 

On Sept 19, 2023, the Court vacated motion sequence 001 in that Aug 11 decision, reverting to the July 6, 2023, opinion. Referring to motion sequence 002, a preliminary injunction that had been issued on June 5, 2023 was now “ripe for a final determination.” Accepting the reasons put forth in the July 6 opinion, it ordered that the City would be permanently enjoined from removing retirees from their current plan, requiring them to enroll in the Aetna PPO, or making them seek their own coverage.

On May 21, 2024, the Supreme Court upheld those Sept. 19th rulings, giving a whole lot of explanation and background. It said that the City had disputed the retirees’ claims, but had not presented “any evidence controverting them” — in fact, it had submitted only “minimal evidence” and relied heavily on Summary Program Descriptions. The record was clear, the Court said, that for 50 years, the City had promised that it would cover as a secondary payer any benefits that Medicare didn’t cover as primary. It also said that the record shows that retirees had relied detrimentally on the promise, i.e., they relied on the City’s long-standing commitment to that comprehensive supplemental coverage, and losing it would cause them harm. The Court ruled that injury had been demonstrated in the affidavits, and opting out altogether would cause financial strain, since the City had no intention of reimbursing the Part B premiums. The retirees were therefore entitled to relief, but the Admin Code had not, in fact, been violated, since the City has never actually covered “the entire cost” of healthcare for Medicare retirees in the first place (i.e., Medicare picks up some of the costs), and no one is disputing that.  It permanently enjoined the City from eliminating the existing health insurance and enrolling retirees in the new Aetna PPO, it couldn’t enforce the June 30, 2023 deadline to opt out of the new plan, or implement any other aspect of the City’s new healthcare policy.

#3.  Copays (“Bianculli”).     Dec 2021 the City put in $15 copays for outpatient benefits in Sr Care, to begin Jan 1, 2022. Retirees filed suit claiming that that was unlawful. They’re litigating it but the trial court granted an injunction. Retirees won the appeal on that, so now there’s a hold on those copays. But Emblem changed the documents. Copays will start Jan 2025.

Google results:

A class action lawsuit was filed on Nov 29, 2022 by lawyers Cohen and Gardener on behalf of retirees against the City for breach of contract. The “class” of the action were the 183,000 retirees and Medicare-eligible dependents in Senior Care in 2021. The retirees had claimed that the City illegally charged them a $15 copay for every outpatient procedure or test, though the contract didn’t permit the imposition of copays on Medicare-eligible retirees. More than $55 million of the cost of copays had been illegally charged to date. The retirees also charged that the City has been unjustly enriched by those copays through a “bait-and-switch” operation: there weren’t any copays when retirees chose that plan in the fall of 2020, and because they were not allowed to make changes to that choice in the fall of 2021, they had to live with that plan in 2022 even though copays had been illegally attached at the beginning of that year. No restitution was made to the retirees who paid those copays. 

The retirees also claimed that Emblem/GHI misrepresented the copay situation and the whole Sr Care plan itself, knowingly conveying these “misrepresentations” directly and indirectly to the retirees.  The City had a duty, the retirees claimed, to describe Sr Care accurately. That didn’t happen. The City had “engaged in consumer-oriented conduct that has misled and harmed Retirees” and used “false advertising” about the nature and coverage of the plan. The City’s ongoing imposition of copays were “arbitrary and capricious and clear abuses of discretion.”

Some more granular statements are interesting.  One of the claims in that lawsuit says: “In short, payments to medical providers are paid by GHI either out of a City account controlled by GHI, or out of GHI’s coffers and then charged back to the City in the form of a premium. Regardless of whose account is used to pay the medical provider – the City’s or GHI’s – Defendants, not Retirees, are contractually obligated to pay.”  They say that if a $15 copay is imposed, it should be paid the the City, not the retirees.

Some fascinating details regarding the nature of the GHI retiree plan and the plan for in-service members are given on pp. 15-16 of this document, particularly that both plans are addressed in the same Certificate of Insurance (COI), that the COI specifically says that this certificate is not a “Medicare Supplement Plan,” that benefits for retirees and in-service are very different from each other, that there is no publicly available guide for Medicare enrollees into this plan, and that the benefits for retirees (now on Medicare) are specified in section 14 of the COI. Additionally, nowhere in the 2004 rider does it say that retirees must pay a copay. In sum, whereas copays have been allowed in the plans for in-service members, they have never been used for retirees (who have Medicare as the primary payer). 

Interestingly, the lawyers made the point (on p.22) that “had GHI/Emblem increased the Sr Care premium charged to the City – to properly account for the tens of millions of dollars in healthcare costs improperly imposed on retirees in the form of co-pays – the resulting premium would continue to be far below the HIP HMO statutory cap, which the City is required to pay.” 

Also of note: it says (on p.25) that the 2022 brochure explaining the health plan made no mention of copays, except for ER and an optional drug component outside of GHI. Apparently for a few weeks around Dec 2021, the online version of this document did mention copays. 

In an unpublished opinion, the Supreme Court enjoined the City from charging copays on Jan 11, 2023, since there’d be irreparable harm to retirees on fixed incomes with modest means, outweighing the “the steps that [the City] would have to take to undo the apparent imposition of the co-payments.”  The Court also said that copays would likely be found as violating the contract between NYC and Emblem. A preliminary injunction against copays was granted. 

A published opinion on May 25, 2023 kept that January preliminary injunction in place. It agreed that “plaintiffs established a likelihood of success on the merits,” and since the City hadn’t made any arguments against class certification, it was reasonable to conclude that the named retirees were representative of the class. Furthermore, the hardship to plaintiff retirees were more burdensome than any administrative hardships the City claimed they’d be subjected to.

An unpublished opinion issued by the Supreme Court on May 25, 2023 reviewed the requirements for class certification and listed additional factors in determining whether the action should proceed as a class action. It cited the City’s argument against class certification, namely that there are other methods to adjudicate these claims, which the retirees refuted. The Court found the City’s argument “unavailing.” Class certification is indeed appropriate, that “the commonality of factual and legal allegations is abundantly clear,” and “as a class action, judicial economy would occur.”  It ordered the plaintiffs’ motion for class certification was granted.

#4. Copays again.   Gardener said this is a fourth suit, but it’s not filed yet. 

Words, words, words . . .

I’m reacting today to Arthur’s post “Unity Has a New Health Care Narrative,” where there is some talk of the new $15 copay for each benefit in Senior Care and the out-of-pocket maxes.

I’ve been saying for years that muddled terminology gets you into muddled thinking, and I’m pretty sure that the lack of clarity in the ongoing health care negotiations isn’t going to produce the best results. 

It started a couple of years ago when hundreds of our colleagues were shouting all over the place that they didn’t want to “lose their Medicare.”  I was told they needed that kind of rhetoric to gin up rank-and-file support against the Aetna PPO we were being pushed into. Those protesters certainly got the job done, and I love that, but I think their health care concepts are not yet firmly in place. If they’re going to negotiate for us, I want them to spot on with that. 

Trying now AGAIN to clarify some things about Senior Care. 

It has always been a hybrid plan – the result of negotiations between the unions and NYC. It’s never been a straight “Medigap,” the kind you get in the open market.  Those true Medigaps are designed by the feds and managed by the states. The screenshot below shows how each of those 10 plans supplement Medicare (it’s from Medicare & You 2025, p.76).

Here’s the differences between our Senior Care and those Medigaps and why it’s a hybrid:

• First.  The most comprehensive of the 10 true Medigap designs – F, G, and their high-deductible versions – do not have copays. The popular N plan does have one, but only for two things: a doctor visit (up to $20, it can be waived altogether) and a $50 copay for the emergency room if you’re not formally admitted. The less popular B, C and D plans don’t have doctor or ER copays either. For all of these, there aren’t any copays at all for therapists, lab tests, and x-rays. The union negotiated a $15 Senior Care copay for every little thing, but for now they’re stopped by the Court. Supposedly they’re coming back January 1. 

Weird note:  I just signed into my plan at EmblemHealth. It says we have a $15 copy for specialist visit, $15 for each allergy visit, $50 for hospital emergency room, and various copays or percentages for other services. I’m not sure that screen is accurate. My card says specifically says no copays for doctor visits, so why is the website saying there’s one for a specialist? Who knows.

• Another difference.  Plans F and C pay Medicare’s Part B deductible ($2,096 this year). The other designs don’t pick that up, and neither does Senior Care. But the City reimburses us for it, and for any IRMAA surcharges, as long as we get a pension and take one of its health care plans. That’s a real blessing, but negotiations led to Senior Care’s own $50 annual deductible. True Medigaps don’t have this feature at all.

• Still another difference.  Senior Care handles inpatient hospitalization differently from true Medigaps. The F, G, and N all pay Medicare’s Part A deductible $1,632 per admission, and so do the less popular B, C and D plans. But, Senior Care does not pay that whole thing. We still have a $300 deductible per benefit period, to a max of $750 a year. That kind of limited deductible each benefit period in lieu of Original Medicare’s $1,632 deductible is exactly the kind of arrangement Medicare Advantage plans generally have.

As I’ve been saying, these things are what the unions and City negotiated for us. Senior Care is not a strict Medigap, but a hybrid mix, borrowing some characteristics from true supplements, and some from Advantage plans. 

In fact, look at our Anthem card and you’ll see at the bottom where it’s called a “PPO.” Then sign into your Medicare.gov account, and you’ll see that Medicare itself calls it a “PPO.” These are mine: card on left, Medicare.gov screenshot on the right:

“PPO” is the term most associated with Medicare Advantage plans, the two most common of which being the HMOs (Health Maintenance Organizations) and the PPOs (Preferred Provider Organizations). 

We have Original Medicare Parts A and B (through Social Security), yes, and supplemental insurance through Senior Care for the remaining costs, but not in the same way as open-market supplemental plans.  Our Senior Care supplemental coverage is through this hybrid kind of PPO plan. The other plans offered by the City are also kinds of “supplemental” coverage. 

Regarding the drug component. People without employer/union retiree coverage need to have drug coverage if they don’t want a penalty.  They either get a stand-alone Prescription Drug Plan (PDP) or an Advantage plan that includes drugs. Vets can get drugs through the VA.

We get the drug coverage through a “rider,” which is $120 a month if we have Senior Care and $178 a month if we have the HIP VIP HMO. They’re negotiated with the pharmacy benefit manager, Express Scripts. This is certainly drug coverage, but not a normal stand-alone Part D plan like the ones in the open market.  In fact, our coverage has an “open” formulary, which usually allows access to many more drugs than “closed” formulary coverage. How much the union has been involved with the creation of that formulary I have no idea. I just know those rider premiums are steep, I’m not crazy about them.

I’ve been accused of “using the insurance talking points,” but I would love it if people started using industry terminology. What I’m asking for is clarity – in our negotiations, in our responses to Mulgrew et al., and when we take to the streets to get the best retiree health care deal in this absolutely scandalous for-profit industry.

Prop 1 “YES” – kill the dangerous loopholes

The Prop 1 wording on the Nov. 5 ballot is not as clear as some people would have wanted, so we have to keep talking this up to make it sure it won’t fail. 

Here’s the message that needs spreading around:

 

All New Yorkers deserve the freedom to control our own lives, futures, and healthcare decisions, including our right to abortion. 

No New Yorker should be discriminated against, or taken advantage of, by those in power. 

Prop 1 is a NY state constitutional amendment that puts the power in the hands of New Yorkers, not politicians. 

This November, vote YES on Prop 1 to protect abortion rights and our freedoms.

From the NYCLU:

We might like to think we’re safe from these attacks here in New York, but the truth is there are dangerous loopholes in our state constitution that leave us vulnerable to the whims of politicians…

… laws aren’t enough, because they can be easily changed, as we’ve seen time and again in recent years as political winds shift.

When we enshrine a right in the state constitution, we protect it from political attacks.

That’s why we need Proposal 1, or what has been previously called the New York Equal Rights Amendment, which will protect our rights and reproductive freedoms — including the right to abortion. 

Proposal 1 will keep New Yorkers — not politicians — in charge of our personal decisions and will enshrine equal rights into our state constitution. 

More at New Yorkers for Equal Rights.

Make sure people know to look for Prop 1 on the ballot. Then vote “YES.”

 

So they just sacked CVS/Aetna prez Brian Kane

CEO Karen Lynch thought he really had to go when CVS’s income fell 9% in the 2nd quarter compared to last year at the same time. 

Mulgrew should be thrilled, then, that Marianne and the courts forced him out of the Aetna plan he built for retirees a couple of years ago. 

Whew. Dodged a bullet.


Hardly. 

Mulgrew couldn’t have cared less what would have happened to the retirees after a year or two when Aetna’s promises would no longer be viable. Prior authorizations won’t get in your way, he told us. Almost everything is free, you can see any doctor you want, go to all the hospitals you want.  What don’t people understand? The plan is the cat’s whiskers and all that.

According to Forbes, parent company CVS was having problems with its insurance businesses (Aetna) – particularly with Medicare Advantage, which had seen “higher costs from increased utilization of services from seniors.”

Wendell Potter puts it much more simply. The company was paying out too many claims in its Advantage plans. Brian Kane wasn’t doing his job.

Potter reports that CVS is planning to get rid of about 10% of Advantage enrollment, leaving these unfortunate rejectees to look around for the best personal health care solution in a swamp of underwhelming options. And looking to turn things around, CVS is apparently planning some operational changes described in this bit of corpo-speak:

It will initiate a “a multi-year expense management opportunity to deliver $2 billion in savings” that will include “streamlining and optimizing operations and processes.” Executives also plan to accelerate the use of artificial intelligence and automation across the company’s businesses.

We better start getting used to the health insurance strategies du jour,  which none of us learned about in high school. What’s become standard procedures in this for-profit industry is mind-bending obfuscation in how they work, coupled with our deep belief that a serious health catastrophe might leave us stranded physically and financially. 

In a guest column I wrote for the Examiner a couple of months ago called “Navigating the Medical Maze” (here) I tried to highlight how thick the industry has become with insider strategies meant to help Them, not Us. 

We no longer know what to expect from our coverage when even simple terms like “hospital,” “out-of-pocket medications,” or “skilled nursing” don’t actually guarantee the cost or extent of services, the medications or the equipment we’re being prescribed.

Here’s the handful of terms I included in that article:

Upcoding.  When providers are encouraged to assign inaccurate or additional codes for procedures in order to trigger a higher reimbursement from public agencies such as Medicare.

Overutilization.  Decisions on medical necessity are often subjective. Overutilization is when doctors are incentivized to prescribe or charge more for services and equipment because they know public or private insurance is picking up the tab.

Defensive medicine:  When doctors recommend tests or treatments not so much for their patient’s benefit but to protect themselves from potential lawsuits. 

Click-and-close: a term (used at Cigna) to describe how the company encourages staff physicians to review first-stage or questionable denials as quickly as possible, neglecting time-consuming research into guidelines, medical studies, and medical records. More money stays with the insurance company and often keeps patients from getting the vital but more complicated services they might need.

Direct-to-consumer advertising:  When patients are encouraged to ask their doctors for specific drugs, tests or equipment, a practice that frequently puts the doctor in the position of having to explain why these may not be in the patient’s best interest.

Pharmacy benefit managers:   These middlemen between insurance companies and the pharmacies run every aspect of the delivery of prescription drugs, from formularies, to prior authorizations and co-pays, to rebates. They profit at almost every stage in the supply chain.

Kickbacks: Rewards to medical professionals for prescribing specific procedures, equipment or drugs. Free vacations, cash, speaking positions, and research grants are some of the many kinds of gifts that can call into question the value of what you’re being prescribed.

That was a short list. We could easily add AI and automation to it, both of which just slipped off the tongue in the Forbes article.

I KNOW that Mulgrew is out of his depth with this stuff, just like the rest of us. 

How on earth do we get the union to put people in charge of these decisions not only to get us the best deal with this corrupt industry, but to stop pretending they know what they’re doing and stop lying to us to make us believe they’re on our side.