1. What is the difference between the Medicare plan we had until 2017 and the Aetna Medicare Advantage plan we have now? Medicare (what we call traditional Medicare to distinguish it from Medicare Advantage) is the original public health insurance nonprofit program for the over age 65 population that the Johnson Administration established in 1965. It pays negotiated fees to healthcare providers for their services. Ninety-eight percent of the nation’s healthcare providers (doctors, hospitals, clinics) are contracted with Medicare and can be seen by any Medicare participant.
The U.S. Congress established Medicare Advantage as a privatization program so that private insurance companies, such as Blue Cross, Aetna, and United Healthcare, could be paid by the federal government from Medicare funds to deliver insurance on a profit-making basis to the over 65 population.
Up until 2017 we had traditional Medicare plus supplemental Medigap insurance. Supplemental insurance was necessary because Medicare only paid eighty percent of doctors’ and other fees. The supplemental insurance was from private companies such as Blue Cross.
In 2018, the state switched us from traditional Medicare to United Healthcare Medicare Advantage. After competitive bidding, the state changed vendors in 2023 to Aetna.
2. Do we have the same choice of providers that traditional Medicare participants have? No. Our Aetna PPO plan will pay any Medicare-affiliated provider, but those providers are not legally required to accept Medicare Advantage insurance. Many do not. There are reasons other than payment why hospitals, doctors, or other providers might not accept Aetna insurance. They may have had a bad experience with Aetna. It may have a high rate of denying claims. It may have an overly complicated procedure for filing claims. It may delay payments. If Aetna denies a claim, a hospital or provider must absorb the loss because, by law, it cannot pass the cost on to the patient, what is called balance billing.
3. Do we have any recourse if a provider will not take our Aetna Medicare Advantage plan? You can always look for a provider who is in Aetna’s network or an out-of-network provider who will agree to take the insurance. But if you really need that particular provider, you will have a problem. If you contact the state comptroller directly or through your union, that office will contact Aetna to call providers directly and try to convince them to take the Aetna insurance. If the providers absolutely refuse, there is no further recourse.
4. Does our Aetna Medicare Advantage plan require preauthorization? Both Medicare and Medicare Advantage plans can require preauthorization for particular services. In general, Medicare Advantage plans require far more preauthorization than traditional Medicare.
5. Why did Connecticut change us from Medicare to Medicare Advantage? The short answer is, to save money. The longer answer is that Congress, at the behest of the private insurance industry, created a very high rate of federal subsidies for Medicare Advantage plans so they could outcompete in cost traditional Medicare + Medigap insurance. The cost of the Aetna Medicare Advantage group plan to the state budget is significantly less than the cost of traditional Medicare + supplemental Medigap insurance. The tradeoff, unfortunately, for that cost saving has been less choice of providers, a higher risk of claim denials, and other problems that potentially could affect any member even if they do not currently have problems with the plan.
6. I like the Aetna Medicare Advantage plan. Would I be able to keep it if you win your reform? Absolutely. We only want members to be able to choose which plan–traditional Medicare or Aetna Medicare Advantage–serves them best.
7. Is this issue important to me if I have a long way to go before retiring? Yes, definitely. Lifetime quality medical insurance may be the most important fringe benefit we have as Connecticut state employees. It becomes more important after retiring because aging brings with it more expensive illnesses. There has been a significant deterioration in the quality of that insurance for retirees with serious illnesses, which could occur to anyone. Current, active employees have a long term interest in having full medical insurance awaiting them upon retirement to replace what they have now.