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.