Prior authorizations, there's the rub

I have to respond to a couple of comments made after my last post. For starters:

“People want to be in traditional medicare vs this version.”

So many people still think that Senior Care – the GHI/CBP plan that many retirees have and are trying to hold onto – is “traditional Medicare.” It’s not.

Traditional Medicare (Parts A and B) is run by the federal CMS with money from two trust funds – replenished by payroll taxes and Congressionally-authorized monies – and premiums (hhs.gov). As everyone knows, Medicare doesn’t cover all medical costs, far from it. There remain deductibles, copays and coinsurances, which are paid by the seniors themselves, or by their employers, a private insurance company, or the government. Even when people do buy a supplemental plan, they mostly still have to pay some things out of pocket.

The OLR has been offering retirees a choice of such plans, the most popular of which, I guess, has been Senior Care GHI. In a lot of ways it acts like a private market plan (a Medigap), but the city has negotiated it to include a general medical deductible, a fee-structure for hospital stays, and copays – none of which exist in market Medigaps.
What the commenter is really saying is these retirees want to keep the supplemental Senior Care plan and not be shoved into an Advantage plan.


The next part of the comment is balderdash:

“In essence you are repeating what Mulgrew keeps claiming - aw shucks it’s still medicare and I wish we could just call it that instead of that badly misnamed Medicare Adv — Mulgrew would call it wonderful medicare.”

Even if Mulgrew did say what’s being claimed here, it’s not worth all that much. He’s shown no deep comprehension of the way Medicare works or he’d have been explaining it better and cutting out all the PR. No one believed him when he said “We will continue to monitor its implementation” (The Gothamist): there are doctors who have still not heard about the new plan yet, and others are saying “Absolutely not, we’re not taking any Advantge plans.”

But where the commenter says:

“I think you need to qualify the differences in how med and Medadv are administered.”

that’s half right.  I haven’t really spelled out in recent posts how billing works with Traditional Medicare.

In the Traditional scenario, providers submit bills to Medicare for processing. According to Kaiser, “for most payment systems ... Medicare determines a base rate for a specified unit of service, and then makes adjustments based on patients’ clinical severity, selected policies, and geographic market area differences.” The remaining costs get forwarded to the supplemental plan, and the enrollee gets billed for what’s left to be paid. Prior authorizations virtually do not exist: this is mostly a fee-for-service situation.

I did touch on how Advantage plans work on my June 19th post, but I’ll be more specific here. Per capita amounts are sent to the Advantage plan companies (I said that), who design their own packages based on Medicare rules and government regulations (that too), but can deny coverage for certain services (and that in a different way). It’s these potential denials, based on a structure of prior authorizations in Advantage plans, but not in Traditional Medicare, that terrifies some retirees. (Not all retirees: me and some of my friends are in Advantage plans and have been getting the care we need.) But I acknowledge that the scandals surrounding Advantage plans have too frequently involved denials of coverage (for the reasons on the left, from DHHS, April 2022).

Parenthetically, I’m pretty sure the newer scandals will at some point involve upcoding:

Upcoding occurs when a health care provider seeks reimbursement using a fraudulent CPT code that provides a higher reimbursement than the CPT code which corresponds to the services actually rendered to a Medicaid or Medicare patient.

An example of upcoding would be if a doctor saw a patient for a routine check-up (which has a CPT code with a reimbursement of say $60), but when billing Medicare the doctor provides the CPT code for an extended check-up, which provides a reimbursement of $100. (Kohn, Kohn and Colapinto)

and in the Part D side of Medicare (stand-alone drug plans or drug components inside of Advantage plans), watch out for Pharmacy Benefit Managers (PBMs):

Pharmacy Benefit Managers (PBMs) are third party companies that function as intermediaries between insurance providers and pharmaceutical manufacturers. PBMs create formularies, negotiate rebates (discounts paid by a drug manufacturer to a PBM) with manufacturers, process claims, create pharmacy networks, review drug utilization, and occasionally manage mail-order specialty pharmacies. In light of rising health care costs, the role of PBMs are being reviewed due to the cost of prescriptions drugs and the effects on consumers. (NAIC Center for Insurance Policy and Research)

Here’s what our new Aetna brochure on prior authorizations says you can expect from the plan, some of which is no surprise (like cosmetic and experimental services), but some are pretty scary for people who have serious conditions and are afraid of delays and outright denials:

Compare the above the list to the city’s Medicare Advantage Plus plan of 2019, which gave 32 (!) outpatient procedures needing prior authorizations. What might be considered “normal” senior outpatient services – like endoscopy – don’t seem to require prior auths in the new Aetna plan. I actually confirmed one or two of them by phone with Aetna a couple of weeks ago. The physicians will just book the procedure and that’s that.

Back to the comments:

Who ya gonna call when there’s a problem? Right now we call Medicare. After Sept 1 we call Aetna and their most probable non-unionized, lower paid and insentivized staff to help profit motive.

Energetic, but not true. When there’s a billing problem, you don’t always have to call Medicare, and even with Advantage plans, a conversation with the doctor’s office and/or the company itself might find a coding issue, which can be fixed by correction and resubmission. Other times, the doctor has to supply more information, which annoys them no end, but the purpose is not always maniacal.

I don’t know anything about “non-unionized, lower paid and insentivized staff” on the decision panels, and I’m sure the commenter doesn’t either. What I’m reading is that there are rules on who can authorize or deny: “The ultimate decision on a prior authorization request rests with a clinician — a physician or nurse — who works for the health plan to which the request was submitted. All final denials or redirects commonly are decided by a clinician at the insurance carrier.” Another report says the “prior authorization is then reviewed by clinical pharmacists, physicians, or nurses at the health insurance company. Somewhere else I read that any of these people can approve a procedure, but only physicians can deny one.

But there have been so many complaints about access to care that CMS had to act. Last April it issued a final rule that will take effect in 2024 to address these. Here are some main points relating specifically to medical prior authorizations in Advantage plans (choices and numbering mine):

The final rule clarifies clinical criteria guidelines to ensure people with MA receive access to the same medically necessary care they would receive in Traditional Medicare. Specifically, [1] CMS [requires that] MA plans must comply with national coverage determinations ... local coverage determinations ... and general coverage and benefit conditions included in Traditional Medicare regulations ... [2] when coverage criteria are not fully established, MA organizations may create internal coverage criteria based on current evidence in widely used treatment guidelines or clinical literature made publicly available to CMS, enrollees, and providers  ... [3] streamlines prior authorization requirements, including adding continuity of care requirements and reducing disruptions for beneficiaries ... [4] all MA plans [are required to] establish a Utilization Management Committee to review policies annually and ensure consistency with Traditional Medicare’s national and local coverage decisions and guidelines ... [5] approval of a prior authorization request for a course of treatment must be valid for as long as medically reasonable and necessary to avoid disruptions in care in accordance with applicable coverage criteria, the patient’s medical history, and the treating provider’s recommendation.

“The rules are designed to ensure people with MA plans get access to the same necessary care – prescriptions, medical tests, equipment, and procedures – they would receive in traditional Medicare” (Fortune.com).

For the rest of the comments left on yesterday’s post:

By the way, the GHI emblem plans we’ve had I am told is for a non-profit agency.

I also think to talk about how the money moves and the amounts Aetna gets from medicare to cover costs and profit. And that the admins of Medicare have nothing to gain personally compared to Aetna — say the person you deal with has employee stock options. So to blandly say Medicare Advantage is just medicare without qualifying comments is misleading.

I have never ever said Medicare Advantage is “just Medicare,” because I’ve always been a single-payer kind of girl and still wear my Bernie tee-shirt to prove it. But I do have things to say about for-profit and non-profit health insurance companies, and will save those for another day.

Choices

I need to clarify something I said yesterday, that at this point we have to “jump on board or get run over” by the Medicare Advantage juggernaut.

I was not talking about abandoning activism against the health insurance industry. 

You can stand up against Advantage plans and all the other corporately designed arrangements for managing Medicare and still want to get the best coverage for yourself at the present time.

The “juggernaut” I referred to in yesterday’s post is the health care apparatus the city has been trying to push us into for the past couple of years. They developed the Empire and Aetna PPOs behind closed doors, rolling out the first one poorly, and not convincingly fixing all the bumps in this new one. (Are you sure all your doctors will even take this new plan, or will you be denied some procedures you used to get in Senior Care without a problem?)  Neither plan has been capable of earning our complete trust.

That’s because these things are negotiated plans, and the city has only negotiated the terms of the Aetna one to last for two years. What will happen to individual parts of the coverage after that is anyone’s guess. 

Protest as much as you want at the rallies, like the one of a few days ago at the introduction of legislation to stop the Aetna plan from going through. Join other campaigns for single payer, like the very active Physicians for a National Health Program and National Nurses United, or all the other groups supporting the Medicare for All bills in the House (HR1976) and Senate (S1655). Donate to Public Citizen, or to legislators like Sanders and Jayapal. Read and support the work of people like Wendell Potter, who rails against the Medicare Advantage industry, Pharmacy Benefits Managers, and the any other corporate invention that sucks millions out of public funds. 

But  while you’re taking to the streets and sending money to causes, you still have to figure out which coverage arrangement best suits you right now. I don’t see any way around this.  There’s only a couple of options, and you need to sort through them. 

 

If you let yourself be placed into the new Aetna PPO (presuming it gets through the lawsuit), you’ll still be in Medicare, but in addition:  

      •  You’ll get pretty decent in- and out-patient coverage for “normal” senior health conditions.

       • You’ll get reimbursed for your Part B premium and IRMAA surcharge. (Last year Part B was $2041 a year per person, and additional IRMAA amounts were calculated in tiers of income.)

If you opt out of the new plan, you’ll still have Medicare, but: 

       • You’ll have to get supplementary coverage through one of 10 different kinds of Medigaps on the open market. These pick up some or most of the remaining Part A and B costs, but don’t include drugs or extras (like an annual physical, meals after surgery, etc.). Under no circumstances should you choose an Advantage plan. That would make no sense whatsoever, as the MAPs offered by employers and unions usually have better coverage. 

      • You will not get reimbursed for Part B or IRMAA. 

 

If you keep the HIP VIP HMO, things will stay as they are, including the reimbursements  for Part B and IRMAA. 

  

Any way you go – taking one of the two Advantage plans (Aetna PPO or HIP VIP HMO) or opting out altogether – you still get:

      • Drug coverage if you purchase the drug rider (from January 1st, $103.50 a month with the Aetna plan, roughly $180 with the HIP)

      • Dental, vision and hearing aid help through the Welfare Fund. No premiums, just union membership.

      • SHIP reimbursements for quite a few health-related services, with a $100K lifetime cap. It costs $120 a year. 

That’s it, folks. The good thing is that you can change your mind every fall.  The bad thing is, there’ll still only be these same choices. 

Unless the lawsuit succeeds, of course. We’ll have to then see what they come up with next.

The juggernaut's comin' at you

As an advocate of a country-wide single-payer health care system, I sympathize with the protests and lawsuits against the city for pushing us municipal retirees into a Medicare Advantage Plan.

MAPs are just another way that corporate entities get to fleece one of the country's service sectors. 

Think charter schools.

But it’s not a bad idea to remember that most workers don’t get employer retiree coverage at all. Freelancers are also out there on their own.

So who do these people turn to when they have to navigate this minefield of a health care system just when they’re entering the most vulnerable decades of their lives. It's one hot mess of corporate and political interests out there, much of it directed at survival of the fittest.

Social Services mostly don’t have time for any but the lowest incomes. Brokers are of course always looking for your business, and a few communities may actually have some volunteer counselors. The bravest among us will turn to the online plan finders to search for available health plans on their own (you can find them at Medicare.gov and NYS). You need a tutorial and some real patience with all that. All of this to figure out something that matches your current pocketbook and your projected needs. It's the country's self-inflicted form of Russian roulette.

Putting our situation into perspective, Kaiser FF reported that last year that only 13% of large employers (with 200+ workers) were actually offering retiree health coverage at all. Half of that group gave their people Advantage plans, and 44% of that subgroup didn't let them choose between MAP and non-MAP coverage.

Currently the dozen or so plans we've been able to choose from are a mix of HMOs, PPOs and supplemental arrangements like GHI Senior Care (they're listed here on the OLR website). So come September 1st, NYC will be one of the few large employers offering retiree coverage at all, and if they clear the court challenges, they’ll be limiting the choice to a couple of Advantage plans and offering no non-MAP alternative at all. Check those three Kaiser boxes.

More data from Kaiser shows that retiree health plans are more likely to be offered by companies with over a 1000 workers, that they're public employers (63% offer retiree coverage), that they belong to certain industries (government being one of them), and they’re unionized. 88% of these extend coverage to spouses as well. We here in the municipal unions can tick all these boxes too.

I guess you could say we’re lucky – especially since they're reimbursing our Part B premium (including the IRMAA surcharge when our incomes are high enough to get these), refunding us some extra things through SHIP, and keeping up some financially beneficial Welfare Fund arrangements (e.g., dental plans, reasonable drug costs). Few American retirees get what we get.

Yet, I'm still against Medicare Advantage, which has been around under different names since Medicare became law in 1965. That’s because Medicare’s original design was imperfect and people really needed help with the leftover costs, like deductibles and the 20% of Part B we have to pay for ourselves. Private companies stepped into that void pretty quickly, and there they were again in 2006 lobbying their corporate heads off to control the whole of the newly created Part D.

As long as lobbyists and legislators block changes to the tax structure that might get everyone in this country access to the health care they need no matter where they live, work, retire or breathe, this is the system we got.

I’ve been doing Medicare work for almost a decade and am amazed at the new structures corporations have been allowed to design and push through Congress just to keep single-payer from ever happening in this country. How many of these things do you actually recognize?

Accountable Care Organization
Direct Contracting
ACO Reach
Medicare Shared Savings Program
Pharmacy Benefit Managers
etc.

I could go on, but it’s giving me agita.  As laymen, we won't be understanding any of these schemes any time soon, but these guys are working overtime to get at our cash reserves.

So best of luck with the lawsuit. The juggernaut has been heading right at us for years, and I hate to say it, but at this point we gotta jump on board or get run over.

Tighten up the messaging, please!

Updated 6/25: I had to add a no. 7 below . . .

I want to comment on some things in the press release Norm included in advance of the rally yesterday against the new Aetna plan.

It’s only a C+, and that's because of the lousy messaging. You can’t tell if they really know what they’re talking about, for example here:

This legislation is a simple bill that requires the City to offer ... a Medigap plan to supplement Federal Traditional medicare as they have had for 56 years.

What Pizzitola and her organization almost get right is their demand that the city offer a plan to supplement what Medicare doesn’t pay for.  What is dead wrong, though, is that that the current Senior Care is not a Medigap plan. It is a hybrid, chunks of which smell very much like an Advantage plan.

Medigaps are issued by private companies to cover some or most of the deductibles, copays, and co-insurances that Parts A and B of Medicare have never covered from the get-go. As you can see in the chart on p.2 here, there are 10 Medigap designs, created by the feds and administered by the states in various ways.

Employers and unions negotiate various types of supplemental coverage for their retirees, but these are not Medigaps.  In fact, the Senior Care plan that so many city retirees have has been called “GHI/CBP” for at least a couple of years. “CBP” stands for “Comprehensive Benefits Plan” – not a Medigap at all, but a plan the city negotiated with GHI and Empire that equates to some, but not all, of the coverage that the most expensive Medigaps offer. 

Here’s the description of Senior Care from the OLR website:

And here’s how Senior Care is not a “Medigap.” 

• One. There’s a $50 deductible above Medicare’s annual Part B deductible.  Medigaps don’t have deductibles in themselves. Their job is to cover some or all of Medicare’s deductibles. 

• Two. There’s a $300 hospital deductible per admission ($750 max for the year).  Medigaps don’t work that way. Some cover the whole Part A deductible ($1600 this year), others cover a percentage of it. 

• Three. You enhance your Senior Care hospital benefit to 365 days with a rider. All Medigaps give a 365-day benefit, it’s how they’re designed. 

• Four. Senior Care included an annual physical. Neither Medicare or Medigaps cover an annual physical.

• Five. In late 2021 members got a letter saying there would be $15 copays for common services. Medigaps DEFINITELY don’t do that. (And I know, the city rescinded these later, but they negotiated this and wanted these to happen.)

•  Six. On a phonecall last spring, the UFT Welfare Fund referred to Senior Care as a “PPO.”   PPOs are Medicare Advantage plans, not Medigaps.

• Seven. Senior Care is premium-free, the city negotiated it that way for union retirees.  But all Medigap plans have premiums. The most comprehensive ones cost the most, particularly in NYS.

Getting back to that darn press release . . . 

To preserve retiree health care choice, the City shall offer . . . at least one Medigap plan with benefits equivalent to ...

Medigaps do not have benefits, at least not in the form of services.  They only pick up remaining costs.

For months, retirees have ... rallied to bring attention to the fact that they will be forced off their current Medigap plan and Traditional Medicare losing access to their doctors, physicians, and treatment facilities.

A. Retirees don't have a Medigap at the present time. They have a negotiated plan with some elements of Medigaps.
B. The implication that retirees are going to lose their doctors, physicians (same thing as doctors in my book – what’s with that?), and treatment facilities is a grossly hyperbolic. Not one person who authored this release knows what will happen. All they're doing is terrifying you.

This legislation will allow them to maintain access to Federal Medicare and their doctors ...  This legislation ... also preserves Medicare,

We will all maintain access to our Medicare, and we don’t need new legislation to “preserve” it. We’ll keep paying premiums into Social Security, and CMS will continue to determine what the plans must cover and must do. What Pizzitola meant is that city retirees want to keep Original (or Traditional) Medicare and have the city pick up the remaining costs with the equivalent of a standard Medigap.

Remember, Advantage plans like the new Aetna PPO can (and frequently do) offer more than what’s in Original Medicare. Annual physicals and SilverSneakers are two easy examples, and pp. 123-56 of this .pdf list many benefits not covered by Medicare that will be covered by Aetna (e.g., meals after inpatient discharge, monetary rewards, transportation, allowance for OTC items, some money for a hearing aid,  etc.).

... they are enabling a for-profit insurer access to NY taxpayer dollars at the expense of the retirees! 

Honestly, who do the Pizzitola protesters think the insurance company behind Senior Care is? It’s EmblemHealth, and sure, the company bills itself as a non-profit, but CEO Karen Ignagni is “working to benefit health insurance companies” and in 2021 made $3,095,534 (Crains). 

You tell me what defines a not-for-profit company these days. One contributor to medium.com writes:

Not distributing its profits to any private individual is the crucial difference between nonprofits and for-profits. Besides that, the executives of the system still get salaries and salary raises. In reality, the term “nonprofit” is misleading, as numerous nonprofit organizations even take in millions of dollars annually and consistently run in the dark. 

and Elisabeth Rosenthal reported in Stanford Medicine several years ago:

To some extent insurers do better if they negotiate better rates for your care. But that is true only under certain circumstances and in a limited way. “They are methodical money takers, who take in premiums and pay claims according to contracts — that’s their job,” said Barry Cohen, who owns an Ohio-based employee benefits company. “They don’t care whether the claims go up or down 20 percent as long as they get their piece. They’re too big to care about you.

 As far as I can see, it’s all just one big game. 

Our job is to push for reform – that’s where I do agree with the press release. But for heck’s sake, please do something about the messaging. I’m so tired of reading stuff that looks more like Swiss cheese. 

Will it fly?

After posting my take on the UFT’s trust issues (June 17th), where I wrote:

On June 8th we learned that the Comptroller declined to register the Aetna contract, something that UFT brass claimed a few days ago is not actually needed. Huh?  They read the Comptroller’s objection as more of a stance.

Could the Comptroller stop the city from moving forward with this plan? 

According to the Daily News:  No, he can’t, because the Mayor can override it, which he did last Thursday, the 15th:

Mayor Adams used executive authority Thursday to enact his controversial Medicare Advantage Plan for the city’s retired municipal workforce — overruling Comptroller Brad Lander, who has refused to sign off on the private health insurance switchover.

Last week, Lander announced he had invoked a rare comptroller authority to block Adam’s contract to shift the city’s roughly 250,000 retired workers into an Advantage plan administered by private health insurance giant Aetna. 

This is the kind of exact information I would have preferred at the retiree meeting. Instead we got spin.

Within the past couple of days we found out that the city has delayed the opt-out time for the new plan from June 30th to July 10th, and as usual we’ve not been told why. Even if they did give an excuse, I’m not sure I would believe them. 

After all, there is that rally Thursday to support the introduction of legislation requiring the city to offer a Medigap plan, not to mention that at last week’s UFT meeting we learned that not all the members had received a welcome package regarding the new plan. That kind of sloppiness has happened before. Heck, it’s even happened when they send out ballots that somehow don’t arrive in my mailbox. 

A lot of people are still opposed to Advantage plans. Joe Maniscalco’s article in Work-bite cites quite a few comments about the city’s full-throttle support of this Aetna Advantage plan, and I’m in total agreement with all the bits in bold:

Jeff Johnson, former head of the Washington State Labor Council, AFL-CIO and co-president of the Puget Sound Advocates for Retirement Action [PSARA], tells Work-Bites Medicare Advantage programs and ACO REACH plans allow corporate America to “fleece the Medicare system by taking excessive administrative costs and profits from what would otherwise be money available for expanded services for Medicare beneficiaries and for lowering Medigap premium costs.”

Stu Eber, president of the Council of Municipal Retiree Organizations [COMRO], says . . .  “Our tax dollars should not be going to a company that is under multiple investigations for fraudulent practices.”

UFT retiree and CROC member Martha Bordman calls Medicare Advantage an “insurance racket,” and says it’s “heartening to hear the comptroller recognizes this, and is showing integrity by not rubber-stamping the Aetna MA contract.”

We’re in a wait-and-see moment, whether the UFT can pull it off this time round.

As for myself, have been in the HIP VIP HMO for years. No problems, so why rock the boat when we’re not sure if this new thing will fly.

All about inconvenient truths

To tell you the truth, I've not been wholeheartedly able to join all the protests against the city's new retiree Medicare Advantage plans because I've been too frustrated by the poor messaging. (More on all that some other time.)

But one thing puts me exactly in sync with a big part of what my fellow activists are saying – that for-profit corporations insidiously worm their way into how public services are delivered, and some unions, like ours, are just playing along.

We've seen this before. In the Bloomberg/ Klein era the UFT just had to have its own charter school, didn't they. And now instead of fighting back against the behemoth health care industry and throwing their weight behind a single-payer system, our oh-so-centrist unions are going full tilt into Medicare Advantage. 

Up to now, retirees had a choice.  You could sign up for one of many in the dozen or so plans on offer, or you could opt for GHI Senior Care, which is a kind of hybrid plan at this point. It operates in some ways like the Medigaps people can buy in the open market, supplementing what Medicare doesn't pay for.

But that's the point: we had a choice. Now the city is saying we have to choose one of two Advantage plans or go out and find health care on our own. 

Privatized Medicare in the form of Medicare Advantage plans, MAPs for short (like HMOs and PPOs), have been around since the 1970s. It's Medicare Part C, which allows the feds to give private insurance companies per capita amounts to help fund health care packages of their own design. The companies are bound by Medicare rules and governmental regs, but these plans don't look like the pure form of Original Medicare, and they don't work the same way. 

Through enormous lobbying and woefully ignorant legislators, MAPs have, according to a Kaiser FF study, seduced more than half of Medicare-eligible beneficiaries this year into their webs.

Parenthetically, it's not stopping there. A new delivery structure called Direct Contracting got off the ground a couple of years ago and has been recently tweaked by the Biden administration into ACO Reach. Both give any entity on Wall St. the ability to offer health care insurance, even without the approval of Congress. (See what Katie Porter has to say about these....)

But I digress.  

The point is, I'm making an effort to find common ground with the protesters and overlook their foolishness in playing loose with industry terminology and demonstrating a disconcerting unwillingness to understand how Medicare works. 

And my starting point today was to take another look at the great, great film my comrades put together ten years ago against the corporatization of NYC education under Bloomberg and Klein. 

If you want to see excellence, watch this film again. The messaging is impeccable, articulated as clearly as possible from every angle. 

Some of what's in this film is the same battle we're in today. It's certainly against the same greedy types in the for-profit industry run by multi-millionaire CEOs who want so desperately to grab a part of the service sectors. We protested when they set their eyes on public education, and we're protesting now, when our unions collaborate with them to run our heath care plans.

What Medicare Advantage plans DON'T give us is the security that we're going to get the services we need when we need them. As long as CEO salaries and admin costs run as high as they do, Advantage plans are going to rely on co-pays, upcoding, and coverage denials – if not at this moment when they're courting the unions, but two years down the line when the negotiated terms run out.

Many of the things said in the Inconvenient Truth apply right now to the health care wars of today. Here's a sampling:

Brian Jones (04:35): "Our collective experience does not show us that public services in the hands of private entities will solve the problems that we face."
UA: Not all of us are going to get the services we need or see the doctors we want

Julie Cavanagh (08:32): billionaire hedge funders donating millions to the city highlight the "insincerity and cynicism" behind the so-called reform
UA: The trust is still not there: millions for top salaries, and lobbying out of control (see the graphs at OpenSecrets to see how the numbers keep going up). "Some firms may be wielding an outsized influence on policy making" (JAMA research letter). 

Sally Lee (17:07): "You can say it's a business approach to schools . . . a direct attack on the mostly low income and working-class people who schools serve, in that they don't have decision-making power."
UA: The "inconvenient truth" is that some retirees can afford to opt out of the new plan, but the lowest paid retirees in the city unions do not have that choice. And they certainly didn't have decision-making power to come up with the new agreement.

Mona Davids (20:11): "Charters are now run by corporate interests."
UA: Yup, and so is Aetna (owned by CVS) and UnitedHealthcare (reported $5.6 billion profits in the first quarter of 2023).

Lisa Donlan (20:27): "Money vs. democracy. We have an incredibly powerful monied forces that are trying to privatize education."
UA: And health care.

Brian Jones (26:14): "You're giving up the right to education, and we're giving it over to these private companies."
UA: Other countries believe health care is a right. Our legislators go where the money is to stay in office.

Leonie Haimson (34:17): "A handful of billionaires have been allowed to subvert our democracy by feeding [us] distortions and lies."
UA: And that's what I think the UFT was doing in its first sales pitch two years ago. I can't be sure what's going on now, but I expect more of the same.

Sally Lee (49:17): "We have a large and powerful union, and yet so many teachers don't feel connected to their union."
UA: That's for darn sure. They increasingly hide their negotiations and obscure what they don't want us to know. See this EdNotes post on how they're handling the new contract. But, sticking with health care, take the $15-copays that caught Senior Care retirees by surprise in 2023. Take the footnote in Aetna's brochure: "The customized City of New York prior authorization list can only be modified when there is mutual agreement among the City, MLC and Aetna every two years." That sure looks like whatever they say about prior authorization can be bargained away down the line. 

Brian Jones (1:00:08): "We can't accept the status quo, but we also can't accept Wall Street's vision of education."
UA: Or health care either. Profit motives have no business in the nation's health systems.

 

It's all about trust, ain't it.

The class-action lawsuit that got filed against the City at the end of May is as yet unresolved.

People still don't like that the Senior Care coverage arrangement, which functioned as a kind of Medigap, is getting axed. They tried suing before. Round 1 slowed down the process a year or two. 

This time, the UFT swears it's happening. You can let yourself be enrolled in one of the two Advantage plans they're offering or take your business elsewhere.

But then a glitch.  On June 8th we learned that the Comptroller declined to register the Aetna contract, something that UFT brass claimed a few days ago is not actually needed. Huh?  They read the Comptroller's objection as more of a stance. Nothing's gonna stop this train.

Aetna has submitted documentation to show the "merits" of the new PPO and their "efforts to educate retirees about the changes underway" (Gothamist). But, all that's neither here nor there.  I don't know how much we can trust any of these Advantage plan managers. Too much scandal and overbilling, too many denials of coverage, too many roadblocks to services when you're the most vulnerable. 

There's no refuting that the word "Advantage" brings up the immediate question:  Advantage to whom?  Us or the people running those things.

We'll have to see what happens in the next week or so, but again we have moving parts, just like the last time. 

For example, the widely advertised opt-out date of June 30th has just been pushed back.  Here's the new banner on the OLR's health benefits webpage: 

Honestly, who knows what to believe with these guys.

Building blocks

I never thought I’d come out of retirement to write another UA post, but here we are.

 

So I was trying to find out the name of the speaker at yesterday’s Zoom meeting for retirees on the new Aetna PPO. It had been mentioned early on, but I thought I wouldn't need it and hadn't written it down.  

But a question came up in the last half hour, and the speaker told us to contact her if we knew a case where a drug would cost more in the new SilverScript plan than what we pay for it now in Express Scripts. She would bring it up with the plan's actuaries, which was quite frankly more than I expected. 

As it happens, I did have a good example for her. A 60-day supply of the generic for Restasis eye drops cost me last week $7.50 – even cheaper than what I remembered from the last time I bought it. The same generic on the Aetna hotline (1-855-648-0389) was priced at $386.41 for a 90-day supply. Now, if only I could find that lady to let her know . . .

I called the UFT main switchboard, who put me through to someone who didn't know. I was transferred (or referred) to various other extensions in an order I can't remember now, but one was the retiree chapter (who told me specifically and unbelievably that the director "didn't know" who the speaker was), the automatic "forms" line of the Welfare Fund (idiotic), the Welfare Fund live person, the Aetna hotline (I knew that wouldn't work, because though the speaker was an Aetna rep, she was talking at a UFT meeting), and back to the UFT retiree programs.  From this last nice person, I did get the first name of the speaker, but that was it. Called Aetna again, and though they couldn't help me with finding the person I was looking for, the service person was equally shocked at the price discrepancy between the two companies and said she would escalate my question northward, someone would get back to me.

I then decided that the UFT needed to know about this unnecessary run-around, so I tried to find an email address for Tom Murphy, which is not on the website (or again: not obviously on the website) and the people at healthbenefithelp@uftwf.org. But I did find Tom's email in some old correspondence and wrote the following (some typos corrected):

Dear Mr. Murphy,

The retirees attended a Zoom meeting yesterday, June 13.

One of the two speakers on the new Aetna plan was Dr. Serrano.

There was another lady who did most of the explanations, worked for Aetna: I think her first name was Sabrina, but nobody at the UFT knew her last name when I called this morning.  Unbelievable.

She specifically said to contact her if we knew of drug that we cost MORE in SilverScript than it costs currently in Express Scripts. She would want to let their actuaries know if it needs a new pricing.

[gave them the pricing of the drug in both plans....]

My drug . . . will cost more in SilverScripts, but I don’t know how to tell her this because I’ve made 6 calls to the union today (kept being transferred, dead-end everywhere, and one to Aetna helpline) and nobody seems to know who the speaker was at yesterday’s general meeting — nor how to report this difference in pricing. 

I find this union obfuscation/resistance/ignorance pretty disgraceful, that no one could tell me who spoke at a Zoom meeting that you said had more than 3000 attendees.  

 

And nobody can tell me how to report this pricing discrepancy to this lady?

His pretty quick response was nevertheless strange:

Sorry you see the worst motives rather than the best in people. Her name was announced several times and her contact information was posted there and on our website. 

I am forwarding your messages to her.

In solidarity,

Tom Murphy

Anyone who knows me knows I couldn’t let this go unanswered. 

Explaining in my next email that the speaker's name was not mentioned in the last half hour of the meeting when I needed it, that I had made many phone calls and checked several webpages on the UFT site to find it, and that my purpose – and here's the main thing – was not only to have her look into the pricing of that popular drug, but to circulate my notes from the meeting to my union friends and the Medicare counselors I work with through Westchester County and the library system (see https://seniors.westchesterlibraries.org/senior-benefits/ and http://seniors.westchesterlibraries.org/demystifyingmedicare/), I concluded the exact opposite and told him so: 

It is YOU who were looking for bad motives, not me. My question for the speaker (which nobody on the 6 phone calls could help me with) and the hours I put into getting these updates to people who need them are signs of dedication and helpfulness. Not a bad motive in sight. 

If union leadership objects to the words "obfuscation," "resistance," and "ignorance," they can do something about it. 

Direct our phone calls to the right department. Don't throw us off to an outside entity when a question about a UFT Zoom meeting has nothing to do with them. Put some more contact and program information on your website, or fix your search engine to be able to find things. Circulate your own notes from the meeting. And for heaven's sake, don't project on me the bad feelings you're harboring against us pesky retirees.

The building blocks are in your hands, not ours.