July 8, 2023

What a mess. Full stop.

That’s the email we got yesterday which proves at least one thing: the UFT knows how to keep us informed efficiently, clearly and rapidly when they want to – or when their back’s up against a wall.

The whole health care swap is on hold again now that the court has granted a preliminary injunction “enjoining the City from forcing retirees to switch from their existing healthcare benefits, and from being required to either enroll in an Aetna Medicare Advantage Plan or seek their own health coverage.”

Anyone can follow the reporting by googling it, but I’m most interested in some of the wording used in the legislation and rulings through the filings and appeals. NYC Admin. Code §12-126 is not entirely clear in the very first paragraphs. The first problems come in the definitions of “coverage” and “payment”:
a. Definitions
iv. “Health insurance coverage.” A program of hospital-surgical-medical benefits to be provided by health and and hospitalization insurance contracts entered into between the city and companies providing such health and hospitalization insurance.
b. Payment of health insurance costs
(1) The city will pay the entire cost of health insurance coverage for city employees, city retirees, and their dependents, not to exceed
one hundred percent of the full cost of H.I.P.-H.M.O. on a category basis.
No mention of “premiums” here. It says the city will be paying the “entire cost” of the coverage defined in clause a.iv. not to exceed the “full cost” of the HIP HMO, which could easily be interpreted to mean it would include copays and coinsurance in addition to premiums. Costs could also include the $50 deductible that Senior Care people have to pay out of pocket before the plan starts picking up Part B leftovers mounts, as well as the $300 deductible ($750 max per year) for each benefit period of in-patient service and the $50 deductible for an emergency room visit.

Judge Frank didn’t help when he quoted this ambiguous part in yesterday’s ruling:
... to this Court, section 12-126 does appear to be a codification that the City must pay “the entire cost of health insurance coverage”... the Code makes no mention of the word “premium” but rather uses the word “coverage.” 
What?  Is he saying the Code uses “coverage” for “premium” when these two terms do not equate? You pay a premium to get coverage.  He might have meant the Code doesn’t use the word “premium,” only the word “entire cost,” but who knows.

Apart from what costs the city is supposed to be covering, there’s also a problem with the phrase “on a category basis,” which even the appellate court ruled was unclear in November last year. It said “further evidence is necessary to determine, for example, the meaning of the phrase ‘on a category basis.’”

Judge Frank’s ruling yesterday was sloppy in the following excerpt, and not only because of two typos.  Writing about the Code, he stated just before the passage I already quoted above:
This section provides that “[t]he City will pay the entire cost of health insurance coverage for city employees, city retirees, and their dependents ... [typo 1, end quote missing] To this Court, this wording is unambiguous [Really? It’s ambiguous to me if you can’t tell from the wording whether “entire cost” means just premiums or premiums plus all the other costs in the plan] and applies to this matter. Moreover, the history of section 12-126 shows that the City intended to provide all retired employees health plans and intended to assume full payment for them. [Again, “full payment” to me means premiums plus the rest of the costs, not just premiums.] Gardener Aff., Ex. H at 27-28. This section was originally enacted through the City’s expanded powers, under a 1965 amendment to [NYS] General City Law § 20, passed around the same time as § 12-126, empowering the City to pay the “for [typo 2, I think it should have been “pay for”, not “pay the for”] premium charges for supplementary medical insurance benefits under the federal old-age, survivors and disability insurance benefit program.” ) [I don’t have access to the Gardner affidavit, but the § 20(29-b) of NYS General City Law he’s citing doesn’t use the word “pay” for premium charges. Instead, it says cities are empowered to “reimburse”retirees for premium charges. There’s part of the payment mechanism in here that’s not at all clear to me, since retirees can’t be “reimbursed” for something they never paid for in the first place. And if the judge is bothering to explain this history, he certainly left out an explanation of how “costs” in the Code got reinterpreted to mean just “premiums” by the NYS law.]
Wouldn’t it be nice to have somebody at any level of the judicial system clean this mess up.

Apart from all this and getting back to the Definitions clause above, it’s clear that the “health insurance coverage” as defined by the Code does not extend to prescription drugs, even though all of Part D is done through “health insurance” plans similar to medical plans. In fact, if you don’t have drug coverage for 2 months through some kind of health insurance plan, Social Security will slap you with a penalty that never will go away. Drug coverage is an essential part of health care. Without drugs, some people can't stay alive. Without drug coverage, some people can't afford to stay alive.

Not defining what “costs” are involved with coverage, not clarifying the term “category basis” at all, calling bits of legislation unambiguous when ambiguity clearly remains, and making strange word substitutions like the ones mentioned earlier doesn’t help us understand anything.

I’m going to be staying out of these court docs from now on. They’re really upsetting. 

But, I’m not intending to stop writing about how retiree insurance works, because I think most people haven’t the vaguest idea – of course through no fault of their own. It’s really a dumbass system we have in this country.

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