A response to Medicare or Medicare Advantage – CT employees want a choice by James W. Russell:

I agree with Russell’s frustration over the increasing privatization of Medicare. The health care eco-system, in Connectiut and nationally, is ever-changing and is now very different today than it was in 2018 when the State of Connecticut implemented a private, customized Medicare Employer Group Waiver (EGWP – pronounced “egg-whip”) plan for its’ retirees.

At that time, providers were generally accepting EGWP Medicare beneficiaries nationwide. Today, in-state and beyond, more providers are rejecting private Medicare, both EGWP plans and individual Medicare Advantage (MA) plans, for all the reasons Russell articulated – high claim denials, delayed payments, and crushing administrative requirements – plus, increasingly, extremely low provider reimbursement rates.

Unlike State of Connecticut retirees, Connecticut teacher retirees are not limited to one Medicare plan. Retired Connecticut teachers may choose between a customized EGWP plan (different from state retirees), or original Medicare with a supplement for out-of-pocket costs.

Only about 10% of retired teachers choose the original Medicare/supplement option. Those who do are typically older individuals with higher health care resource needs who pay dearly for what they get from original Medicare – access to most providers nationwide and for their own treating provider (not an insurance company) to determine their medical needs and amount/length of services.

There’s no perfect solution, and there are unintended consequences for every health care decision balancing access to care, quality, and cost, but the conversation about how best to achieve that balance must be continuous for state retirees, retired teachers, and for one in five state residents insured by Medicare.

In the meantime, the best answer is to fight the fights you can win against private Medicare plans.

A 2018 report by the Centers for Medicare and Medicaid (CMS) Office of the Inspector General (OIG) found that less than one-percent of Medicare beneficiaries appeal a denial, but when they do, 75% of the time, that denial is over-turned on the first appeal.

Challenging insurance companies is critical, even if you do not have the time or energy to pursue a problem yourself. Connecticut has several free insurance assistance options for Medicare beneficiaries, in addition to professional help through the Comptroller’s Office (for state retirees) or the Teacher’s Retirement Board (for retired teachers).

For further help with free insurance appeals, and other health insurance assistance, such as seeking exceptions to insurance company rules, contact the CT Office of the Healthcare Advocate (866) 466-4446, Healthcare.Advocate@ct.gov; or the private, non-profit law organization, the Center for Medicare Advocacy (860) 456-7790, Communications@medicareadvocacy.org.

Kathleen Holt is the Acting CT Healthcare Advocate. She is an appointed public member of the CT Teacher’s Retirement Board, Chairs the Board of Lawrence and Memorial Hospital, and was previously Associate Director of the Center for Medicare Advocacy.