Under Assault: teaching in NYC

Coverage by cartel

noreply@blogger.com (Unknown) — Wed, 02 Sep 2026 15:53:27 +0000

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 . . .

noreply@blogger.com (UA) — Wed, 26 Aug 2026 14:43:10 +0000

[[[ 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

noreply@blogger.com (Unknown) — Fri, 07 Aug 2026 15:07:19 +0000

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.

noreply@blogger.com (UA) — Thu, 18 Jun 2026 15:30:28 +0000

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

noreply@blogger.com (UA) — Fri, 21 Nov 2025 16:47:00 +0000

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

noreply@blogger.com (UA) — Thu, 11 Sep 2025 16:46:00 +0000

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.”

noreply@blogger.com (UA) — Fri, 01 Aug 2025 15:03:00 +0000

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

noreply@blogger.com (UA) — Mon, 07 Jul 2025 19:34:00 +0000

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

noreply@blogger.com (UA) — Sat, 26 Oct 2024 01:20:00 +0000

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 . . .

noreply@blogger.com (UA) — Mon, 14 Oct 2024 21:18:00 +0000

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

noreply@blogger.com (UA) — Thu, 05 Sep 2024 23:25:00 +0000

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

noreply@blogger.com (UA) — Fri, 09 Aug 2024 00:55:00 +0000

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.

What’s going on with corrective legislation, fed and NYS

noreply@blogger.com (UA) — Mon, 05 Aug 2024 01:38:00 +0000

All stuck in committees.

I’ve updated the page tabs at the top of this website with recent bills and related info in five categories.

Under the tab Medicare for All

Just some background info on this topic.

Under the tab In Congress

Bills relating to Medicare for All. They’re all sponsored and co-sponsored by Democrats, with the exception of our favorite spokesperson on this issue, the Independent senator from the great state of Vermont, Bernie Sanders.

NEW! Added to the list of items and services in the most recent MfA bills (S.1655 and HR.1655) that are “medically necessary or appropriate to maintain health or diagnose, treat, or rehabilitate a health condition” are “gender affirming care, and reproductive care, including contraception and abortions.”

The Senate version calls for a 4-year transition, the House version 2 years. The Senate bill got referred to a single committee (Finance), the House bill to seven of them.

In addition to these bills, there are two letters from legislators – still only Dems + Bernie – asking for more protections against Medicare Advantage plan abuses.

Under the tab Medicare Advantage

Lists some of the more important bills attempting to rein in the shenanigans of for-profit insurance companies.

Under the tab Pharmacy Benefit Mgrs

There’s much more bi-partisanship in these bills, but I’m not sure why.

Under the tab New York Health Act

What’s going on with Single Payer in New York State.

Mulgrew’s new resolutions: an exercise in futility

noreply@blogger.com (UA) — Thu, 25 Jul 2024 23:51:00 +0000

It’s hard to figure out what the heck Mulgrew’s saying when he talks about Medicare. I’m not even sure he knows himself.

I’ve only been able to keep up with the UFT’s shenanigans with retiree healthcare by following Arthur Goldstein over at Union Matters, who’s indefatigable and we all benefit from reading his detailed posts. Kudos also, of course, to Marianne Pizzitola for the lawsuits she and the NYC Retirees pushed through the courts. We’re obviously safer and less financially stressed than we would have been without their fortitude and skills.

Yesterday we got a letter from Mulgrew telling us that said he had motivated a resolution on the AFT floor to seek federal legislation to protect Medicare and see it would never be diminished. “Our members pay into Medicare and Social Security throughout their careers, and we cannot let opponents chip away at these programs.”

It’s obvious that everyone who has a job pays into Medicare and SS. You don’t have to be a member of a union to want to keep these programs going once you’ve paid into them all your working life. Where could he going with this? And why now?

Maybe the Resolution he attached would clarify his position, so here it is in full:

The First of the four Resolved clauses calls for “improving ... our healthcare safety net, including ... Medicare.” That’s where I start to lose him. Is Mulgrew wanting to improve Medicare itself, meaning “Traditional Medicare” – Title XVIII of the Social Security Act created in 1965, the foundation of senior healthcare arrangements for all enrollees nationwide? Fighting for Traditional Medicare has never been on the UFT agenda as far as I know. It’s hardly within its purview.

Perhaps, Mulgrew’s conflating two very different things: Traditional Medicare (=TM) on the one hand, and a TM + a supplemental arrangement of some kind – a combo, as it were – that the unions do have some control over. One of these arrangements that adds to TM is Senior Care, others offered by the OLR are Advantage plans. These plans are additional to TM. The union negotiates them with private companies to pick up what TM does not pay for, and without them, the sickest of us would certainly go bankrupt. The graphic left shows the differences.

The UFT has neither protected or improved our safety net over the past few years, which is why those courageous retirees filed lawsuits to block what was being foisted upon us. And they won: the courts ruled against the changes, saying these proposed arrangements would indeed cause irrevocable harm.

So right here in this First resolved, I’m not sure I know what part of healthcare delivery Mulgrew is trying to protect and improve. Might be Traditional Medicare, but he might want to be protecting the whole shebang: TM + one of the supplemental arrangements in the blue and green parts of the chart.

The Second resolution is practically meaningless. No candidate at the federal or state level is currently trying to find a real solution to preserve “high-quality and affordable benefits.” The only way to do that would be to change the tax structure and cut the ravenous middlemen corporations out altogether – those giant entities that have taken over the healthcare industries from top to bottom, eating up Medicare dollars. That solution would be Single Payer, and I don’t hear anyone talking much about it these days.

Like the rest of us, legislators seem to be stuck with the current healthcare delivery system, dependent as they are on lobbyist moneys that have been thrown at them to keep them from making too many waves.

REMEMBER: Traditional Medicare leaves a lot of costs on the table. Medicaid picks those up for people with lower incomes, and the rich can afford to pay them out of pocket. It’s the middle-income people like us who feel the changes – in our pocketbooks when premiums, deductibles and copays change, and physically, when services and drugs are denied. The UFT has always favored the status quo, which is TM + private supplemental arrangements. It has fiercely opposed Single Payer, thwarting all attempts to eliminate those profit-driven middlemen companies.

As for the Third resolution: there are no “simple solutions” to healthcare. (I don’t even understand what Mulgrew means by “simple solutions to necessary changes” – and I don’t think he knows either.) If by “earned benefits” he’s referring in part to Traditional Medicare, that program has in no way been entirely successful or comprehensive. So much is left to Wall Street and monopolistic private entities. Nor do I think Congress would ever actually get rid of Traditional Medicare. Not everyone has a sugar daddy like Clarence Thomas to pay their mother’s bills.

Now for the Fourth, where Mulgrew says they’ll seek federal legislation to ensure that Medicare and SS won’t be diminished. Exactly what form will that “seeking” take? The AFT won’t find big solutions with the lobbyists. And even if they could all agree to tweak something somewhere somehow, Mulgrew’s basically saying that TM is pretty good – even though you need supplemental insurance to pick up that hefty hospital deductible and a ton of copays for lengthy hospital stays, a Part B deductible, copays and 20% coinsurance for outpatient services or equipment. The Part B deductible is out of pocket, unless you’re lucky enough to be in a union that reimburses you for it. Because that’s how Traditional Medicare works on its own, no supplemental coverage to pay these parts of it. Part D is not even contained in Traditional Medicare. It’s all managed by private companies, getting funds from the government.

I do want all that to change. I don’t want the premiums, deductibles, copays in TM. Is TM what Mulgrew and the AFT want to protect?

I’m thinking not. I’m thinking Mulgrew just conflates Traditional Medicare (Parts A and B on their own, no supplements) with the way the union delivers Medicare to us, which is TM + the private, for-profit “supplemental” plans that keep us from going bankrupt (Sr Care and the Advantage plans).

If I’m correct, it means he favors a system where pieces of our benefits are controlled by industrialists who want to make money off of healthcare. That system most definitely will never be in our interest, and he shouldn’t be spending our dues money trying to shore those plutocrats up.

Yummy!

noreply@blogger.com (UA) — Wed, 29 Nov 2023 22:08:00 +0000

I really enjoyed reading this message from Wendell Potter’s Health Care Un-covered where he says:

Our reporting and advocacy is having an impact, in Washington and across the country. Members of Congress on both sides of the aisle and the Biden Administration are beginning to scrutinize and crack down on the business practices of Medicare Advantage insurers. And there is growing evidence that employers, including county and municipal governments that planned to force their retirees into Medicare Advantage plans . . . are having second thoughts. Those employers are learning that they may have been sold a bill of goods – and misled and outright lied to – by insurers that make huge profits from their Medicare Advantage business.

Potter draws heavily on a recent ProPublica report pointing out that patients are being “cheated” by Advantage plans ignoring state laws regarding life-threatening conditions.

Across the country, health insurers are flouting state laws like the one in Michigan, created to guarantee access to critical medical care, ProPublica found. Fed up with insurers saying no too often, state legislators thought they’d solved the problem by passing hundreds of laws spelling out exactly what had to be covered. But companies have continued to dodge bills for pricey treatments, even as industry profits have risen. ProPublica identified dozens of cases in which plans refused to pay for high-stakes treatments or procedures — from emergency surgeries to mammograms — even though laws require insurers to cover them.

Apparently, “thinly staffed state agencies” don’t bother investigating a denial unless a patient files a complaint. State agencies are in a position to investigate patterns of improper denials, but generally do not, at least in Michigan. Only when someone complains, I’m assuming in the form of an appeal.

And this from a ProPublica article this past month, “Health insurers have been breaking state laws for years”:

Over the last four decades, states have enacted hundreds of laws dictating precisely what insurers must cover so that consumers aren’t driven into debt or forced to go without medicines or procedures. But health plans have violated these mandates at least dozens of times in the last five years.

Companies find ways to “weasel out” of paying for benefits that cost big bucks. If the law requires them to cover “cancer drugs,” for example, they’ll just call it something else — like, I don’t know, “gene therapy.” Poof. No need to pay.

Thirty years ago a Michigan doctor and state senator named Joe Schwarz helped write a law requiring companies to pay for cancer drugs that would make chemotherapy more effective. He thinks “You shouldn’t split hairs between the term gene therapy and the term chemotherapy or the term radiation therapy or the term surgical therapy. They’re all cancer therapies and they should all be covered.”

Most salient is the point made by one patient’s widow: “Insurance is meant to protect people ... not to make them fight through the last day to get what they should.”

I’m with her.

So every time groups like the one Potter runs, or ProPublica, or PNHP, or Public Citizen, or the Center for Medicare Advocacy report on the scandalous ways Advantage plans bump up their profits at our expense, I can’t help but salivate.

I truly despise these sociopathic business models, and I hope our municipal unions stop going down such antisocial, nefarious paths.

The OLR gets an “S” – for “Sloppy”

noreply@blogger.com (UA) — Thu, 09 Nov 2023 02:25:00 +0000

I just tried to change my health plan and couldn’t trust any single thing in the application process.

Changing health plans is a very scary thing for older people, especially when we have no idea how the Russian roulette of life will turn out for us in the coming year.

But the OLR made the process so much worse than it needed to be. Their website was loaded with incomplete instructions, missing forms, awful ambiguities, and buggy software.

With no way to complete this application on my own, I had to call the UFT Welfare Fund to solve its mysteries. Fortunately, the rep there was great. But why on earth did I have to go through her to get this thing done.

Here’s what I just wrote the OLR, even though I have zero expectations that they’ll fix anything or even care. After all, the site still has all the Aetna info on it (as if any of that is relevant), and if you call one of their phone numbers, the recorded message from months ago is still telling people there’s going to be so many workshops to help us understand the new – now court-stopped, defunct – plan.

I just sent a version of this to Tom Murphy as well. If I’ve done something wrong in this application process, I’ll own up to it, call myself a dodo bird and apologize. But in the meantime, what I found out may be useful to others who are trying to switch plan now during the November change period.

_________________________________________________________________________

Dear Sirs:

I am writing to describe to you the difficult process I went through yesterday trying to change from EmblemHealth HIP VIP to GHI Senior Care.

I still am not 100% sure that I have done this correctly, as so much was not explained clearly on the OLR website for Retirees: https://www.nyc.gov/site/olr/health/retiree/health-retiree-responsibilities-assistance.page.

Here is a list of things that I needed to get help with by calling the UFT Welfare Fund. All problem areas are in red ink.

1. From the above link, I clicked “Health Benefits Program Retiree Application” (https://www.nyc.gov/site/olr/health/retiree/health-retiree-forms-and-downloads.page).

It directed me to submit forms electronically using the link: https://nycemployeebenefits.leapfile.net. There were two categories that could apply to my situation:
Retirees only - Health Benefits Application (Retiree enrollment)
Changes (address changes, death certificate, Medicare cards, etc.)
You can see the problem: I am a retiree and want to enroll in a different plan. Should I click the first link (Retirees - Health)? or the 2nd link (Changes)? I don’t remember which I one I did, but they both seem to lead to the same cover screen. I wrote a message and selected files to send individually.

2. Back to the Retiree page to get the forms. I clicked on “Health Benefits Program Retiree Application” but the DATE OF BIRTH cell did not accept my date of birth because of a bug. So I could not fill it out electronically. Instead I had to print it out, fill it in by hand, and scan it to the computer to submit electronically.

3. I did not know how to fill in some of the other boxes and had to call the UFT Welfare Fund to ask for help on these things:

(a) That change form asks for “Pension no.” I checked my TRS account, and the only nos. listed there are called a “Retirement no.” [starts with “U”] and a “Membership no.” The UFT rep told me to use “the one with the U”. Who knew!@?

(b) After the box for name of current health plan is a box for “MBI NUMBER”. I had no idea what that was – my Medicare ID? my plan enrollment no.? The UFT rep said “Don’t worry about it,” as it wasn’t needed.

4. The UFT rep told me I actually had to upload TWO forms – the change form above, plus a disenrollment form for my current plan. That was not mentioned on the website, and I could not locate a link for that 2nd form either. She had to send it to me by email.

c) That form asks for an “effective date,” but I wasn’t sure which date should be there. Does it mean to enter the last date that my current plan should run to (end of year: Dec. 31, 2023) or end “by” the first date of the new year (Jan. 4, 2024). It would be clear if the wording were more specific, like: “Final date of current plan.”

5. I asked the UFT rep whether it was better to send electronically or by mail. She said “do both.”

6. When I submitted electronically, the software said “Success,” but how do we trust that message where there is no date or other details of the submission. I would have liked to take a screenshot (if details were there) or receive an email from the software that my documents were received.

7. I am now supposed to wait 4 - 6 weeks to see if this goes through?????? That’s insane.

Please can you tell me if you have received my application for change of health plan and that everything is in order.

I'm switching.

noreply@blogger.com (UA) — Tue, 03 Oct 2023 16:56:00 +0000

I just found out staying in the union’s HIP VIP Premier (HMO) will cost me $2K next year. And as far as I know, I’m not even sick.

That’s because the HIP plan, which has honestly served me well all these years, has a nasty little cost I had overlooked.

Part B drugs are covered at only 80%, which means an out-of-pocket 20% when I need to get one of those twice a year.

GHI Senior Care doesn’t do that, and the new Aetna plan wouldn’t have either.

Here’s how this happened, and why I didn’t expect it.

Doctor recommends a “shot” to boost bone density. I have to get this thing at a facility, in my case, the infusion center at the hospital. First time round, no bill – and I hadn’t expected one either. I thought a shot’s a shot, always covered, even though I know Part B drugs don’t always work the same way in Medicare as Part D drugs. I still thought the union’s got me covered.

So I take the 6-month repeat dose of this thing a month ago and get a bill yesterday for $1000. That can’t be, I’m thinking, it must be a coding error. So I called the plan only to find out it’s correct, I need to pay 20%.

Why wasn’t I billed first time round? Because something like this needs pre-certification by the doctor before the plan pays out. The first time, the office staff had failed to go through that process with the plan, so the plan wouldn’t pay out. The office also missed a 3-month window to correct the situation and had to actually eat that mistake, they weren’t allowed to pass the cost on to me.

Learning the bitter truth of biannual bills at $1000 a pop for the rest of my life, I checked the comparison documents on the OLR site to see what Senior Care people pay for Part B drugs. Results were clear: my HIP plan charged me 1000 times what the other two were charging (except for a $50 deductible in GHI).

So if I stay with my HIP plan into next year, I will definitely be stuck with $2000 or more a year for those useful shots. If I switch to Senior Care, there will only be that $50 deductible.

As I said, no brainer. Have to switch.

And now a word about our union "collaborators"

noreply@blogger.com (UA) — Wed, 27 Sep 2023 19:19:00 +0000

Obviously the situation has calmed down and we’re not being shoved into a plan that so many people have objected to for the moment, though I’m sure they’re working on it.

When I say “collaborators,” I mean CVS/Aetna of the proposed but stalled new plan, and Cigna for our dental arrangements, though that one has not yet been structurally tweaked.

So I was interested to read Wendell Potter’s recent essay on the size of the revenues that seven of the big health insurers have reported. Why am I not surprised that our two are included in this super avaricious group of megacorporations.

Potter warns that “Wall Street’s unhappiness goes a long way toward explaining the double-digit premium increases many American employers and families will be hit with come January 1, 2024.”

Investors don’t seem to have been satisfied with the profits the insurance companies have been making this past year, at a time when many of them used AI and other means to deny coverage for needed care and reject legitimate claims en masse. Potter tells us that revenues and profits did, in fact, rise.

As a group, the companies (Centene, Cigna, CVS/Aetna, Elevance/Anthem, Humana, Molina and UnitedHealth Group) saw their total revenues increase from $618.2 billion in the first half of 2022 to $683.8 billion during the same period this year.

In spite of profits up from $37 billion to $40.2 in a year, investors thought they’d better shift their money elsewhere to get an even better return on investments. That resulted in the stock prices of these companies going down this past year: while Dow, S&P, and Nasdaq shares went up, Cigna’s went down 23.2% and CVS/Aetna went down 27.7%.

“It’s not that the companies aren’t growing. It’s just that at least some of that growth has not been as profitable as Wall Street demands.” Apparently, these companies were paying more in claims than Wall Street was finding “acceptable.”

BOY, ARE WE IN TROUBLE.

Because, as Potter says, “most of the companies’ growth continues to come from the taxpayer-financed Medicare and Medicaid programs.”

And because 3 of them – our Cigna and CVS/Aetna buddies plus UnitedHealth – control 80% of the Pharmacy Benefit Manager (PBM) market and now operate their own practices and clinics, they can shift monies around to keep their medical loss ratio low (which means less spent on our health care and more on overhead and profits.)

Here’s Potter’s scary conclusion:

To get back into Wall Street’s good graces, you can expect the companies to try to squeeze more money out of their commercial customers in the form of higher premiums and out-of-pocket requirements; boost enrollment in their Medicare Advantage and Medicaid plans; and refuse to pay for more doctor-ordered care and medications.

But you can read the whole thing yourself if you want to know more specifically why you’re about to throw up.

Somebody shoulda thought this through

noreply@blogger.com (UA) — Fri, 11 Aug 2023 22:49:00 +0000

The ruling on the Aetna PPO just in . . . it's not happening.

For now.

NYSCEF DOC. NO. 101
PRESENT: INDEX NO. 154962/2023
RECEIVED NYSCEF: 08/11/2023
SUPREME COURT OF THE STATE OF NEW YORK NEW YORK COUNTY
HON. LYLE E. FRANK
---------------------------------------------------

ROBERT BENTKOWSKI, KAREN ENGEL, MICHELLE FEINMAN, NANCY LOSINNO, JOHN MIHOVICS, KAREN MILLER, ERICA RHINE, ELLEN RIESER, BEVERLY ZIMMERMAN, THE NEW YORK CITY ORGANIZATION OF PUBLIC SERVICE RETIREES, INC.,
Plaintiff,

-v-

THE CITY OF NEW YORK, ERIC ADAMS, THE CITY OF NEW YORK OFFICE OF LABOR RELATIONS, RENEE CAMPION, THE NEW YORK CITY DEPARTMENT OF EDUCATION, DAVID C. BANKS,
Defendant.

DECISION + ORDER ON MOTION

The following e-filed documents, listed by NYSCEF document number (Motion 001) 44, 50, 95, 96 were read on this motion to/for INJUNCTION/RESTRAINING ORDER .
On June 5, 2023, the Court issued a preliminary injunction in this matter. The Court has been informed by the parties that they do not wish for the Court to hold any additional argument, nor will there be further submissions. As such, this matter is ripe for a final determination.

The Court therefore grants the petition for the reasons indicated in the July 6, 2023, namely that both the doctrine of collateral estoppel and the provisions of New York City Administrative Code Section 12-126 bars the actions sought to be taken by respondents. The Court does not reach the last point of relief in the petition, namely that the respondents should be enjoined from disseminating alleged false and misleading statements of the Aetna Medicare Advantage Plan.

Based on the foregoing, it is hereby ORDERED that the Respondents are permanently enjoined from requiring any City retirees, and their dependents from being removed from their current health insurance plan(s), and from being required to either enroll in an Aetna Medicare Advantage Plan or seek their own health coverage.

Have to say I wasn't surprised by the Judge's comments a couple of weeks ago.

Now what's the city gonna do.

There's more than one boogeyman

noreply@blogger.com (UA) — Fri, 04 Aug 2023 23:57:00 +0000

While a whole bloc of retirees are fighting tooth and nail against the new Aetna PPO, I want to take a moment to say something about the company Senior Care uses to supplement Medicare Part A: Empire BlueCross BlueShield.

Its name is changing on January 1st to Anthem Blue Cross and Blue Shield. You can see it in the banner on its webpage.

Does that mean it will convert to a for-profit company? Because Anthem became publicly traded in 2001.

Fast forward to February 2022 when Ednotes reported that in spite of a lawsuit still pending against Anthem for fraudulent practices, NYC chose that company to to provide its workers with healthcare coverage.

A few months after that, Anthem shareholders rebranded the company to Elevance Health. Its CEO, Gail Boudreaux, is quoted to have said “this change is the next important chapter in our journey, and better reflects our business and the company we are today.”

For that kind of pap she earned big bucks that year: $20,931,081, according to this report. It included $1.6 million in salary, $3,840,000 in non-equity incentive plan compensation, $11,100,128 in stock awards, $3,699,929 in option rewards, and $691,024 for all other compensation, whatever that was but I’m sure it wasn’t ham sandwiches at the local deli.

The for-profit / not-for-profit debate is getting to be ridiculous. Why one website lists Empire Blue Cross Blue Shield in the publicly traded column and another says it’s not-for-profit is beyond comprehension. This one and this one cleverly avoid saying one way or the other.

I can understand when retirees demand that the city follow legislative codes stipulating what it has to pay for our coverage.

I can understand their anger against middlemen insurance companies soaking up Medicare funds, denying or delaying coverage, juicing up profits, and seeing all of us as consumers rather than patients. I’m angry about all that as well.

What I can’t understand is why people see Aetna as the only boogeyman on the scene, when for-profit insurance companies or their counterparts have been part of our healthcare landscape for years. If it’s not CVS Health/Aetna, it’s still Empire/Anthem/Elevance Health, and it’s still CVS Caremark/SilverScript.

And they’re not the only ones. The chart on the left shows the top Medtech salaries in 2020 (from here) – look at Helmy’s. $113.9 million! The one on the right the top Pharma salaries in 2021 (from here) - look at Ari’s. It’s a lot more than Gail’s.

We have to focus our wrath on the lot of them, not just Aetna, Aetna, Aetna.

What happened to the "optional" rider?

noreply@blogger.com (UA) — Thu, 27 Jul 2023 21:39:00 +0000

If you’re enrolled in the Senior Care health plan, you don’t have to take the $125/month rider for drug coverage through Express Scripts. Both the book and the UFT webpage say it’s is “optional,” you could get a stand-alone plan from the open market (listings at Medicare.gov), or from the VA, or not at all. Up to you.

But, most everyone I know who’s in Senior Care takes the rider. It’s the same as a premium, except we get reimbursed for a lot of it through the “City Optional Rider Reimbursement Benefit.”

A question recently came up about whether the rider in the proposed Aetna PPO arrangement is also “optional.” Would you be required to take the SilverScript plan for meds if you moved into the new PPO?

I tried to answer this on my own from the OLR materials, from which this screenshot has been taken of the top of the p. 9 in the FAQ brochure:

The last paragraph above says two things. First, that once you allow yourself to be moved into the Aetna PPO, you’ll be automatically disenrolled from any stand-alone drug plan you may have, and secondly, that you’ll “need” to get drug coverage through your union or through a drug rider.

What’s not particularly clear is the difference between obtaining coverage through “your union” or “by purchasing the prescription drug rider.” Do some of the city unions offer a drug plan directly and others through a welfare fund? This article says that “many” of the city unions established welfare funds for drugs and other benefits, which implies that not all of them do. Certainly the big ones like ours have welfare funds. Is it saying that the unions who don’t have welfare funds offer drug coverage in some other way?

Also not clear is the phrase “You will need to obtain ... coverage.” Does that mean if you want drug coverage at all, you’ll have to get it in one of the ways mentioned, or can you in fact choose not to get a drug plan at all? It probably means the former, that the rider is no longer optional: if you take the Aetna PPO, the drug coverage comes with it and the cost will be $103.50/month. If the latter, it means the rider is still optional, in that you could sign up for the PPO but choose not to have any drug coverage at all.

(Parenthetically, if you don’t have creditable Part D coverage for two months, Social Security will slap you with a penalty once you rejoin the Part D system, but some people do make that choice. For example, they may get their drugs from abroad, or from a spouse's plan, or feel so healthy they’ll take their chance for a year. Admittedly those cases are rare.)

I decided to make some calls to see if someone could clarify these points. Starting with the Aetna hotline, the rep told me that since the plan is now on hold, they were not able to advise us properly. They might renegotiate certain items. The bosses had, in fact, removed some of the notes the staff had been relying on to clarify what was in the manuals. The rep did end up writing a ticket for her superiors to check out the wording on p. 9 of the manual and tighten it up.

That got nowhere, so I called the UFT Welfare Fund. The first rep couldn’t help, but she passed me over to someone who was more specialized in the medical questions. From that person I got three definitive statements, the main one being: “There is no Aetna plan.” There was no point in clarifying anything about the new PPO because it does not exist at this time and she could only really answer questions about our current health care.

She then confirmed that the current rider is indeed optional for Senior Care people, that you could go in the open market and buy a stand-alone plan if you wanted to.

And after I posed the hypothetical question that if the Aetna deal were to go through and you allowed yourself to be enrolled in it, would you be required to get the rider?

Her answer: Yes, you’d have to take the rider, it would not be optional.

What, no outrage over Part D?

noreply@blogger.com (UA) — Wed, 26 Jul 2023 03:48:00 +0000

One of the reasons I haven’t been able to get totally on board with the protests against the new Aetna plan is that Medicare has from its inception left a lot of coverage costs on the table. Legislators either didn't care you'd be out of pocket for these, or they were comfortable with insurance companies picking up the remaining costs they didn't want to cover.

The deductibles, coinsurances and copays that Medicare does not pay for are significant, and you’d be crazy not to buy a Medigap to help with these bills.

The companies that sell Medigaps are pretty much the same ones that sell Advantage plans, and sometimes even stand-alone drug plans. The for-profit ones are driven to make money for their shareholders, but those that are private are still middlemen entities that incur typical middlemen admin expenses.

Except for the shareholder aspect of the business model, I don’t as a patient see much of a difference between the way the public and private ones operate. All of them use mechanisms to delay or deny care (e.g., prior authorizations), and all of them make extra money off of Medicare and Medicaid (e.g, by encouraging upcoding and unbundling). These and other questionable practices are normal operating procedures whether the company is private or public. The goal of either kind is to stay afloat and make money.

When the government added Part D for prescription drugs in 2006, that whole new part of Medicare got put into the hands of insurance companies. Unlike with Parts A and B, there’s no such thing as governmental Medicare for prescription drugs. Part D is entirely run by middleman companies, or as CMS calls them, “Part D sponsors.” (I wrote about these and the Pharmacy Benefits Managers last week, the PBMs being the intermediaries between insurance companies and the drug manufacturers, entities that manage drug spending, rebates, claims, pharmacy networks, mail-order, and other components in the distribution chain.)

The city negotiates Part D Medicare for us, so let’s talk about that for a minute.

According to a Citizens Budget Commission report, members of municipal unions get “generous health insurance benefits at a significant cost to taxpayers,” with NYC funding hospital and medical insurance centrally for all the workers and retirees.

But additional benefits – dental, optical, prescription drugs, etc. – come through the unions' benefit funds, specifically the welfare fund of each union. The CBC says these funds are supported primarily by city contributions on a per capita basis, and each union works its own fund separately in accordance with the trust agreement it has with the city. Retirees nevertheless pay a hefty rider for the plan they come up with.

On the open market, Medicare Advantage plans usually include Part D drugs in addition to the benefits of Parts A and B, but it doesn’t work that way with our retiree coverage. The proposed Aetna PPO will not include Part D. Instead, Senior Care members will be transitioned from Express Scripts (or whatever drug plan they now have) into a negotiated Aetna Medicare Rx plan run by SilverScript. The UFT website says:

It [will not be] not part of your Aetna Medicare Advantage PPO plan. You will receive a separate Aetna Medicare Rx/SilverScript member ID card for prescription drug services.

Presumably if you stay in the Emblem HIP VIP HMO, the drug component will still be managed by Express Scripts. Both SilverScript and Express Scripts resemble the stand-alone Part D plans in the open market, but they're structurally different from them. The stand-alones in the open market are entirely separate from Medicare Parts A or B or the Medigap you might purchase to help with remaining medical costs. But in the union arrangement, the rider can only get you the SilverScript plan when you have the Aetna PPO or Express Scripts if you have the Emblem HMO.

I just went to the Medicare plan finder to see which companies offer non-union stand-alone Part D plans in the NYC area, and lo and behold: each of the 7 listed in the search results are all themselves publicly traded companies or owned by one:

SilverScript (owned by publicly traded CVS Health)
Cigna (publicly traded; mail-order Express Scripts)
Humana (publicly traded)
Wellcare (owned by publicly traded Centene; mail-order through CVS)
AARP Medicare Rx (offered through publicly traded UnitedHealthcare)
Empire BlueCross BlueShield (owned by Elevance Health – was Anthem, which became a publicly traded in 2001)
Elixir (owned by publicly traded Rite Aid)

So as I read about the tremendous outrage and street protests against the new Aetna PPO, I can’t help wonder why there haven’t been equally forceful demonstrations against the way seniors have to get their meds through these for-profit insurance companies and PBMs.

Actually I know the answer: the pharmaceutical industry is just too big to fail.

With the whole of Medicare Part D run by insurance companies, we’ve come to just accept them. And when that happens, all we can do is look around for the best priced plan for the specific drugs we take. If like in our case there’s a welfare fund running the show, it’s more of a take-it-or-leave-it situation. I’m not sure greater transparency negotiating these plans would help: the whole industry is unbelievably complicated and riddled with fraud.

Perhaps the union looks for the best Part D deal it can get. Rank-and-file members are mostly oblivious. Some have taken to the streets against the new Part A, B and C the city is cooking up, but everyone in the unions has turned a collective blind eye to the absolute scandal of the Part D design and how it’s morphed into a monster. It's a legislated for-profit enterprise we’ll never get rid of in our lifetime.

If people are going to get all up in arms, I’m thinking they should have started doing it decades ago against Part D, way before the Aetna PPO became became a twinkle in Mike Mulgrew’s beady eye.

Keeping track of the Aetna mess (part I)

noreply@blogger.com (UA) — Fri, 21 Jul 2023 20:11:00 +0000

I had to make a timeline for a workshop I ran, so thought it might be useful to put it up here.

Much of this history I got from the PSC CUNY union website, particularly What’s Happening to Our Healthcare. It all started in 2018, when the city shifted new hires from EmblemHealth to HIP

June 28, 2018 – OLR-MLC agreement set a $1.1 billion target in healthcare savings to be generated between 2019 and 2021, and “for every fiscal year thereafter $600 million per year . . . on a citywide basis.” Sustainability would need to be studied by special Committee. Eight large topics are outlined, but PSC says they only “seriously considered one, reaching for the low-hanging fruit: retiree health benefits” (see History and Timeline).

I'm skipping to . . .

July 2021 – The massive restructuring was announced. By January 2022, the city would (a) move people by default into a MAP (an EmblemHealth and Empire Blue Blue Shield partnership called the Alliance), and (b) let them opt to stay in their supplemental care program if they paid a premium of $191.57/month.

Oct 2021 – LAWSUIT 1 (NYC Org’n of Public Service Providers)
Judge blocked this lawsuit over implementation: the city hadn’t established an accurate list of providers and sent retirees a flawed enrollment guide.
https://nysfocus.com/2021/10/20/retirees-flee-medicare-advantage/

LAWSUIT 2 (Aetna against the city, violations in the bidding process)

Dec 2021 – Judge extended injunction to stay implementation until April 1, 2022.

March 3, 2022 – Judge ruled that the city charging a premium would violate §12-126 of the city’s Admin Code (enacted 1967), which stipulates that “the city will pay the entire cost of health insurance . . . not to exceed 100% of the full cost of HIP-HMO.” City had argued it was following that law as long as it covered the full cost of one health plan, and that it could legally charge people a premium if they wanted a different plan. The city appealed and lost.
https://www.work-bites.com/view-all/retirees-win-in-court.

July 18, 2022 – Anthem/Empire withdrew, ending this first effort.

Sept 8, 2022 – The MLC (which negotiates health insurance on behalf of city unions) agreed to propose a change to Admin Code to eliminate the HIP-HMO rate as single standard for determining city’s obligation to pay the full cost for employees, retirees, dependents. (In practice, when the cost of the Senior Care plan exceeds the HIP plan in a given year, the Health Insurance Stabilization Fund reimburses the city the difference.) Under the new proposal, the city and MLC could agree on a different plan as the “standard” – or benchmark: for either retirees+dependents or for actives+dependents.
https://psc-cuny.org/news-events/psc-opposes-weakening-nyc-health-insurance-protections/

Nov 2022 – Appeals court rules retirees can’t be forced to switch to a MAP: Admin Code §12-126(b)(1) requires respondents to pay the entire cost up to the statutory cap of any health ins plan a retiree select.s
https://www.work-bites.com/view-all/retirees-win-in-court/

Dec 15, 2022 – Arbitrator cleared the way to switch retirees into a MAP (Aetna).
https://www.thecity.nyc/2022/12/15/23511966/mediccare-advantage-25-day-clock-from-abritrator-could-end-senior-care-innew-york-city

Jan 11, 2023 – Judge blocked the $15 copays.
https://www.nydailynews.com/news/politics/new-york-elections-government/ny-judge-blocks-nyc-charging-retired-workers-copays-20230111-4sbubgj6ujdgtlbjgytgbsfn2m-story.html

March 9, 2023 – MLC votes to accept Aetna MAP, as only alternative to HIP VIP (full Aetna contract not made available before the vote, but posted on March 10, 2023); City signs contract on March 30

May 25, 2023 – Appellate court affirmed Judge Frank’s Jan 11 decision blocking the copays.
https://iapps.courts.state.ny.us/nyscef/ViewDocument?docIndex=T7cQMiFRJdpEmd_PLUS_lMgmasQ==

May 31, 2023 – LAWSUIT 3 (NYC Org’n of Public Service Providers)
Seeks temporary restraining order against the Aetna plan, saying NYC violated city charter by not offering choice and violated state and city human rights laws prohibiting discrimination against disabled people. It also failed to follow proper procedures.
Documents: https://iapps.courts.state.ny.us/nyscef/DocumentList?docketId=_PLUS_IDYK0flEDapsoEVXJNmnw%3D%3D&display=all&courtType=New%20York%20County%20Supreme%20Court&resultsPageNum=1&fbclid=IwAR0LUAbRq8dHnk2C6YhIYmHeICHViyH8MjfiGEP9ahNglx2pWJn7wB-oRu0
About it: https://www.nydailynews.com/news/politics/new-york-elections-government/ny-nyc-retirees-sue-to-block-mayor-adams-new-medicare-advantage-plan-20230531-bnhtvbxonvfrle3gqwflqx5cxy-story.html

June 8, 2023 – Comptroller declined to register the Aetna contract because of pending litigation.
https://comptroller.nyc.gov/newsroom/comptroller-lander-declines-to-register-medicare-advantage-contract-pending-litigation/

July 7, 2023 – Judge issued temporary injunction blocking the move: the city can’t order retirees off the current plans.
https://psc-cuny.org/news-events/judges-decision-temporarily-blocks-aetna-medicare-advantage/
Court document: https://law.justia.com/cases/new-york/other-courts/2023/2023-ny-slip-op-32251-u.html/

I guess to be continued . . .

The biggest bog of all

noreply@blogger.com (UA) — Sat, 15 Jul 2023 02:19:00 +0000

A few months ago CMS issued its first guidance on the drug pricing controls legislated under the Inflation Reduction Act of 2022, and revised it last month (here). As everyone knows, Medicare couldn't until this legislation negotiate any drug prices with the industry – the VA being the only agency able to that – so I was hoping that the new law would remove those shackles quickly and irrevocably.

But alas, only some changes looked promising (see the full timeline here), among them being:

2022 – rebates to Medicare if certain Part D drug prices increased more than inflation
2023 – insulin caps ($35 a month per prescription)
2023 – free vaccines for seniors
2023 – rebates to Medicare and lower coinsurances for certain Part B if prices increased more than inflation
planned for 2024 – no copays or coinsurances for people in the “catastrophic” phase of Part D.

Also in the timeline, spread over many years, is the IRA’s new Drug Negotiation Program for dealing with overpriced drugs. It looks grindingly slow.

They’ll select the first 10 high-priced drugs – really? only 10? – in 2023, letting us know the negotiated prices for these in 2024, and putting the new pricing into effect in 2026. In 2025-2027 and 2026-2028 there’ll be two more groups of 15, and 2027-2029 another 20. More specifics in the new guidelines, but I don’t know how anyone could think this slow-mo program is fair to consumers.

The city is wanting to move us from Express Scripts into SilverScript. There’s no premium for either of these plans. The laws governing the healthcare components the city has to pay for do not include drug coverage, so we get “riders” for medications through our welfare funds. The SilverScript rider will be cheaper than the current one, but it's still more expensive than the normal Part D plans in our local area. That's because most employer-negotiated plans have “open” formularies, which means all drugs are included, some in expensive tiers. Premiums for “closed” formulary plans cost less because certain brand names and higher tier medications are excluded altogether.

An interesting group called PissedConsumer has published some polling on which plan people like better, Express Scripts or SilverScript. Apparently they’re both disliked pretty much the same.

The sample of people polled is small, but it does not reflect contentment.

Both Express Scripts and SilverScripts are actually not plans but Pharmacy Benefit Managers. I first heard about PBMs in a recent chat with my local pharmacist, though most of what he ranted about quite honestly went right over my head. The gist of it was that middlemen PBMs play a huge role in the distribution chain, and lots of the other components — patients, pharmacies, insurers, employers, other payers — just have to play along.

According to an April 2019 post by the Commonwealthfund,

“PBMs are companies that manage prescription drug benefits on behalf of health insurers, Medicare Part D drug plans, large employers, and other payers. By negotiating with drug manufacturers and pharmacies to control drug spending, PBMs have a significant behind-the-scenes impact in determining total drug costs for insurers, shaping patients’ access to medications, and determining how much pharmacies are paid.“

Here’s the graphic they adapted from a Congressional Budget Office document of January 2007:

The only thing I can figure out in this picture is that the PBM is dead center, big, and I won't be getting a handle on most of this in my lifetime.

Here’s what I did got from the rest of the article:

Rebates from the manufacturers (not publicly disclosed): Should PBMs be able to keep these or pass them through to insurers, who could then reduce premiums and copays? Pass-through amounts don’t always reach small insurers or employers. Reform would require PBMs to pass through rebates to patients. Reform would also require more transparency so federal and state policymakers could see what’s going on.

Spread pricing: in the case of generics, insurers and employers reimburse PBMs more than what the PBMs actually pay pharmacies for these. PBMs keep the difference and the schedules are “kept confidential” from the health plans. Reform would ban spread pricing altogether, so that insurers and employers would not overpay.

The recurrent themes in what I've been reading are the lack of transparency, the use of opaque contracts to maximize profits, shorting pills, selling patient data, misrepresentation, covertly shifting patients to higher-priced drugs, the pocketing of manufacturer rebates, and similar bad practices. Bottom line: nobody can figure out what’s going on.

Katherine Eban writes in a Fortune magazine article of Oct. 28, 2013:

Express Scripts vehemently insists it saves money for clients and that the vast majority are satisfied with its service. And like any company – to state the obvious – it’s entitled to a profit. The question is, Who is making out better – the PBM or its customers? Many experts say the former. They argue that many companies stick with traditional PBMs because drug pricing is so impossible to untangle that customers have no way to verify how much they’re saving, if anything. ... The PBMs’ claims of cost savings are difficult to prove or disprove. Drug pricing is an almost impenetrable bog.

She quotes a PBM auditor as saying: “The nation’s employers are being taken for a ride.”

And she says a VP of one of the more transparent PBMs puts it this way: “Basically it’s a ‘confuse-opoly.’ Buyers don’t understand the PBM industry, and that’s why they hire consultants – who don’t understand it either.”

You’ll be paying different copays for your drugs in SilverScript. That’s what I found out when I priced my expensive drug over the phone at the number the OLR has been giving out for questions about the new plan: 1-855-648-0389. Maybe you’ll have better luck, but one of mine ended up way more expensive in the new SilverScript plan than what I’ve been paying in Express Scripts.

And the thing is, I’ll never know why.

Brian Lehrer (WNYC) needs to do better

noreply@blogger.com (UA) — Tue, 11 Jul 2023 17:04:00 +0000

Granted this move to shove all of us retirees into Medicare Advantage is a huge topic, but if you’re going to bother to do a half hour on the temporary hold, please try harder next time.

Lehrer started yesterday’s segment with a sentence filled with disinformation:

“NYC government retirees – 250,000 of them about – have been bracing for, if not dreading, a major change in health care coverage from traditional Medicare with supplemental coverage paid for by the city to a privatized Medicare Advantage plan run by Aetna.”

Nope.

Not all 250,000 retirees have been “bracing for” or “dreading” this major change, because not all of them have a “traditional Medicare with supplemental coverage” at this time. Just the ones in Senior Care, who don’t want to lose this arrangement where the city picks up the cost of a Medicare supplement and they can stay out of Medicare Advantage. The class action lawsuit says there are 183,000 retirees that have Senior Care, which leaves 67,000 who don’t.

The city actually offers at least seven plans to retirees living in the metro area, and other plans for people who live elsewhere. In the new arrangement, people in one of these, Emblem HIP VIP Premier, would have been allowed to keep it.

The Emblem plan is already an Advantage plan, the most restrictive kind because it’s an HMO. I’m sure tens of thousands of people are currently enrolled in it, since it’s been around longer than the decade I’ve been retired. Maybe they’re in it because they had a version of it when they were working and didn’t want to change anything once they moved into retirement. Maybe they’ve kept it because Emblem is a private company and not publicly traded like Aetna, relying on its reputation as a non-profit insurer. In any case, I don’t think any of these retirees are doing any “dreading” or “bracing.” They seem to be getting the care they need.*

*Saying that, I have friends who switched to Senior Care because a specialist they wanted was not not taking the Emblem plan. So, it’s not that these people got delayed or denied service, but they didn’t want the restrictions in choosing a provider or facility and preempted the situation.

The instructions for the July 10th deadline said do nothing if you wanted to keep your Emblem HMO and only let them know if you wanted to switch into the new Aetna PPO.

Lehrer mentioned that only 1,600 retirees had opted out as of last week, but he did not tell us how many people chose to keep the Emblem HMO they have. Nor did the reporter on the show (Caroline Lewis) correct him, to clarify that a fair percentage don’t have Senior Care, but the Emblem plan. This omission skews the whole issue, because I suspect the thousands who decided to keep the HMO are either happy with it, or didn’t trust the transition to the new Aetna, or were just taking a “wait and see” position until November, when they’d have another chance to make a coverage change.

Reporting on only part of the whole scenario is kind of like malpractice. The show made it seem like the all the city retirees are in same class action, whereas it’s only the ones who are losing Senior Care. As for the others who have the Emblem HMO, nobody is telling us how many of those people decided to keep what they have. That’s just bad reporting.

There was also some confusion relating to the cost of Medicare and supplements people would have to buy if they opted out.

Responding to Lehrer’s question “What’s the cost for those additional city health benefits” if people do opt out, Ms Lewis must have just misunderstood the question:

“Paying for the premium for Medicare Part B on your own and not having it through the city I think starts at around $165 and goes up depending on your income ... people might want to pay for a Medigap plan ...”

He was asking her about the cost of the “additional” benefits, meaning the ones Senior Care gives you, not Part B. Part A is free for most everyone, and she's right that there's a premium of around $165/month for Part B, more when income is higher. It's paid to Social Security and city retirees get that reimbursed if they remain inside the city system. But Lehrer wasn't asking about Part B, he was asking about the "additional" coverage they'd have to get if they were to opt out.

This almost obligatory extra coverage is not something that "people might want to pay for," as Ms Lewis says, but something they'd be a fool if they chose not to. Medicare leaves so many costs on the table that you need to have supplementary coverage, which can come through a Medigap, resembling Senior Care. There are 10 different kinds of these in the open market, with several companies in each zipcode competing for your business. Checking the plan finder at the NYS Dept of Finance for this month's choices in the metro, they range in price from the most comprehensive, never-see-a-bill type at $332/month to a high-deductible kind at around $68/month. (People could also supplement Parts A and B through a premium-free Advantage plan, but why would they want to do that when the city is offering Aetna PPO at no cost. That would be utterly stupid.)

Admittedly the subject is turgid and inscrutable, but the questions and answers on this program showed neither the interviewer or the reporter was up to the task. So disappointing.