As you are no doubt aware, Governor Quinn has decided, once again, to not include Health Alliance in its package of available health providers – this time for retirees. But don’t think that just because you don’t have Health Alliance or aren’t a retiree that you are in the clear. Far from it. Everyone should read this because it applies to all Medicare eligible individuals and those who will become eligible in the future. There is a lot of confusion – driven mainly by the fact that the Governor’s office will not release the details of the plans they have chosen. However, in hopes of giving you the latest information, here is what I have been able to learn so far:
- This change applies to Medicare eligible households – where ALL dependents are Medicare eligible. As mentioned, however, just because you may not be in this pool, you should still pay attention because this has the potential to apply to everyone. This is because, as current employees or younger retirees reach the age of Medicare eligibility – they will be moved out of the normal state insurance pool and into this Medicare Advantage pool. So if you are 64 years old, about to turn 65 and your spouse is already there, as soon as you become Medicare eligible, you will both be moved into this plan.
- It will apply to those of you in TRIP - in addition to, the state retirement systems – this is a major departure from the past.
- The Governor claims, that even though none of the chosen HMO’s will have a local provider network in east central Illinois, that under the PPO option – you will be able to see any doctor of your choice that accepts Medicare.
The devil is always in the details. And while the governor is pointing out the PPO option for local choice of physician, so far he has refused to publicly release the details of the PPO plans.
This is an extremely important detail because PPO’s, with “out of network” providers, are typically more expensive for the patient. Even if the maximum “out-of-pocket” between the plans is the same, there could still be problems and we won’t know for sure until he publicly releases the details of each plan. PPO “co-pays” are variable (and are actually called “co-insurance”) - based upon a percentage of cost for the service. Whereas, HMO co-pays are fixed per service. So you could easily envision a scenario in which a HMO “co-pay” patient would never hit the maximum annual allowable, whereas a variable “co-insurance” PPO patient could hit it on a single surgery on the first day of the year. You have to be wary of someone who makes a contract award but won’t release the details.
For those of you wondering where this change to Medicare health plans came from, the answer is simple. A year and a half ago Governor Quinn requested that the legislature give him the power to unilaterally determine how much retirees will pay for their health care. As you will recall, I voted against this proposal feeling that it was a dangerous precedent to give him (or any Governor) such unfettered authority.
But, that is not the end of the story. The timing of the passage of this legislation coincided with the beginning of negotiations over a new state employees contract. Under the state Constitution, Governor Quinn, as chief executive officer, has the sole authority (without any legislative input) into negotiating and agreeing to contracts with the state employee’s union, AFSCME. Ultimately, it was this contract agreement that moved all Medicare eligible retirees into Medicare Advantage - even if you are not an AFSCME member because they negotiate the health plans on behalf of all state employees.
While the contract with AFSCME outlined the move of retirees to Medicare Advantage, it was Governor Quinn acting alone under his Constitutional authority as chief executive officer who ultimately negotiates and awards health provider contracts. Simply put: once the contract with AFSCME went into effect last spring, Quinn went right to work, soliciting bids for new providers and as we know now, he has selected HMO providers with no east central Illinois ‘in-network’ doctors. Is it not odd that his administration has yet to produce a map that shows “in-network” coverage areas?
I know that the legislative Commission of Government Forecasting and Accountability (COGFA – of which I am a member) will be holding a hearing soon on this matter. However, I have to tell you that we need more information – information at this point that the Governor has not released. Two years ago, we were able to stop a similar attempt by him to do the same thing – in that case, we prevailed largely based upon the fact that 1). he changed the bid specs after the bids were in, without giving all parties and opportunity to update their bids and 2). because it involved the state’s self-insurance program over which the legislature has authority – not just the Governor alone. This second aspect does not exist in this Medicare Advantage contract and we do not have enough information yet on the first – which is why COGFA will be meeting.
My goal is to make sure people have local options. It is absolutely inconceivable that for the second time in as many years Governor Quinn does not appear to share that same goal. I would urge all of you to call him with your comments and, perhaps, give him few choice words as well. His number is 217-782-0244. I would advise against emails-a call is always best. I will send additional information as it becomes available.