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For retired teachers, the state is pushing a risky health-care switch

‘To keep our original Medicare, Vermont’s retired teachers must opt out by Oct. 27. This deadline has been given scant notice, and State Treasurer Beth Pearce avoided all mention of opting out in her announcement.’

David Kolkebeck runs the Southern Vermont Driving School in Brattleboro. A former teacher, internship coordinator, and dean of students in the Windham Southwest Supervisory Union, he is a former president of the Windham Southwest Teachers Association.

RE: “Seniors, beware this poison pill” [Viewpoint, Sep. 29]:

Vermont’s current teachers are headed for arbitration on health care, but its 10,000 retired teachers have no such mechanism to counter State Treasurer Beth Pearce’s decision to abandon their traditional Medicare coverage for a Medicare Advantage plan that takes effect Jan. 1, 2022.

In an Aug. 2 letter to retirees, Pearce was “pleased to announce” we’d be paying less for new plans that closely match current benefits with “significant enhancements,” plans she said were “of equal or greater value.” An added bonus was that we needn’t “take any action regarding this change.”

It would all be automatic. It was a done deal.

Absent from Pearce’s letter was any mention of Advantage risks — well-documented in the national media and brought home in numerous wrenching individual cases — or the peace of mind that has come with the traditional or “original” Medicare we welcomed when we retired.

* * *

One would hardly expect any sales pitch to be balanced, so let me say the switch is good for the insurance provider Vermont Blue Advantage (VBA, a BlueCross BlueShield of Vermont affiliate) and depleted state retirement coffers, but it may be harmful to teacher retirees, especially those facing difficult diagnoses.

Traditional Medicare, including Medigap and prescription drug coverage, eliminates much cost and uncertainty after a doctor, heaven forbid, gives us bad news.

Retiree Ed Stein of Denver sailed along for eight years with his Advantage plan until he got a diagnosis of “aggressive” bladder cancer [“Medicare’s Private Option Is Gaining Popularity, and Critics,” The New York Times, Feb. 21, 2020]. Stein said he liked the low premiums and enhancements like a gym membership and a “very good” drug plan when he signed up.

The cancer diagnosis prompted Stein to quit Advantage for original Medicare when he discovered that the local specialist who’d recommended chemotherapy and a “complex surgical procedure” wasn’t in his provider network.

But Stein was effectively out of luck.

Because he hadn’t opted for original Medicare in the first place, he was unable to buy a Medigap plan, indispensable for covering the 20 percent that Medicare doesn’t pay for. The cost was now stratospheric or no insurance company would enroll him.

Only four states “provide some level of guarantee to enroll at a later time with pre-existing condition protection,” according to the Times article. Vermont isn’t one of them, but could be if our Legislature saw fit.

Even after surgery and hospitalization, Stein “found himself enmeshed in a series of conflicting messages about whether the treatment was covered.”

“When you’re in the middle of a health crisis, the last thing you need is to be negotiating with health providers and insurance,” Mr. Stein’s wife, Lisa Hartman, told the Times. “We spent as many hours talking with all these people about squaring away our insurance as we did actually getting treatment.”

* * *

Writing in The Commons [“Seniors, beware this poison pill,” Viewpoint, Sept. 29], retired Brattleboro pediatrician Jane Katz Field suggested Medicare Advantage plans have a basic flaw: Medicare pays insurance plans like VBA “a fixed monthly amount per subscriber.” VBA “keeps as profit what it doesn’t pay out in care.”

There’s a built-in incentive to deny coverage to subscribers, especially when they need expensive care. The Times article notes this is when many try to exit Advantage plans.

Say your highly regarded out-of-network specialist in Boston recommends a total hip replacement. Make sure you first call your Advantage plan and talk with a gatekeeper, often in some distant call center.

Should they even let you go out of plan, they may decide a hip repair or physical therapy is indicated instead, though they’ve never examined you.Now, try to get the hip replacement paid for.

Traditional Medicare with good Medigap coverage makes this fight unnecessary.

* * *

VBA phone reps have promised us retired teachers an Advantage information “kit” for mid-October. One kit has arrived; another, with Evidence of Coverage, is promised by Jan. 1, a day late and a dollar short. VBA’s website is still “under construction.”

To keep our original Medicare, we must opt out by Oct. 27. This deadline has been given scant notice, and Pearce avoided all mention of opting out in her announcement.

Sure, Advantage plans are great if you’re healthy, but who can predict you’ll stay that way?

Sure, lower premiums and the baubles of vision and hearing benefits are enticing, but who knows in what amount without the details?

Sure, one-stop health-care shopping is convenient. It’s point-of-care and out-of-pocket costs that mount with Advantage plans, quickly wiping out any premium savings and the often-meager value of enhancements.

That’s why I’ll be opting out by Oct. 27. We retirees can pay now or we can pay later, and I’m choosing the former.

My current premiums will double when I sign up for Medigap and prescription plans with Blue Cross and Blue Shield of Vermont, which will be getting my money either way.

But I’ll have the comfort of knowing I can see any doctor I want, avoid being rejected by Advantage gatekeepers more focused on cost control than good care, and limit my out-of-pocket expenses to known copays and deductibles.

I doubt we retirees will sleep a whole lot better at night — that’s another matter — but having traditional Medicare with Medigap and prescription coverage should help.

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Originally published in The Commons issue #634 (Wednesday, October 13, 2021). This story appeared on page C1.

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