Illinois Retirees Health Insurance Plan Yamalizidwa – InsuranceNewsNet

Champaign County, Illinois (WCIA) – “Ndikuwona ngati uku ndi kumenya kwenikweni kwa aphunzitsi,” mphunzitsi wopuma wa Paxton-Buckley-Luda Vicki Judd adayankha nkhani Lolemba kuti Aetna Medicare Advantage ikhala njira yokhayo ya inshuwaransi yazaumoyo. pafupifupi 140,000 ogwira ntchito m’boma Anapuma pantchito kwa zaka zisanu kapena kuposerapo. Ndi zotsatira zomwe akuluakulu ku Champaign ndi zigawo zozungulira akhala akuchita mantha kwa miyezi ingapo.

United HealthCare, kampani yomwe m’mbuyomu idagwira PPO yomwe Aetna adzalowa pa Januware 1, yachita apilo chigamulo chomwe bungwe la Illinois Central Management Services (CMS) linapanga mu Julayi. Ofesi yayikulu yogula zinthu m’boma idakana ziwonetserozi, ndipo CMS idatsimikiza Lachisanu kumapeto.

M’mbuyomu, panali makampani angapo oti opuma pantchito aboma asankhe, koma awa akuyembekezeka kutha kumapeto kwa chaka. Aetna adzakhala yekhayo inshuwaransi pambuyo pogulitsa boma pa dongosolo la PPO (Preferred Provider Organisation) lomwe kampaniyo sinaperekepo kale ku Illinois.

Oimira ochokera ku Aetna ndi boma anali ndi chidaliro kuti ndondomeko yomwe ikubwerayi idzatha kupereka chithandizo chokwanira cha madokotala malinga ndi malamulo a federal network adequacy.

Ena amakono a Aetna anali okayikira kwambiri.

“Ndiye ndidakali wokhumudwa,” Good adayamba kuyankhulana Lolemba m’mawa. “Sizikukupatsani lingaliro lililonse lachitetezo.”

Tinakumana koyamba ndi mphunzitsi wopuma pantchito mu March. Kwa zaka zambiri, wakhala akulembetsa mu Total Retiree Advantage Illinois Medicare Advantage (TRAIL MAPD) ​​Prescription Drug Program. Zabwino pamalingaliro apano a Aetna omwe adapanga mgwirizano ndi boma la Medicare HMO.

Iye wakhala akuvutika kuti apeze madokotala ambiri omwe angapangidwe pansi pa ndondomeko yake kuyambira kumayambiriro kwa chaka chino pamene mapulani a Aetna Medicare anasiya kuvomerezedwa ku Carle Health maofesi mkati mwa ola la Champaign, kuphatikizapo maukonde a madokotala oposa 500.

“Ndikuda nkhawa ndi Aetna,” adatero. “Amapangitsa kuti ziwoneke ngati ali ndi anthu onsewa kuti atithandize, madokotala onsewa omwe angathe kutithandiza. Komabe, pamene mukuyesera kupeza chinachake, sizomwe zimawonekera pamtunda.”

Masiku ano, Judd akufufuza kufunikira kwa maopaleshoni angapo a manja a carpal tunnel, kuphatikiza m’malo mwake. Zonse zomwe zili pamwambazi zimafuna dokotala wa opaleshoni yamanja, mtundu wina wa katswiri wa mafupa.

“[My primary care doctor] Iye anati, “Ndikudziwa zabwino za Carl, koma simungathe kupita ku Carl chifukwa, mukudziwa, muli ndi Aetna.” “Ndiye akunditumiza ku Springfield.”

Pakadali pano, Good adati adalumikizana ndi Aetna kuti awone ngati pali njira zina zapafupi. Woimirayo adamutumizira pa foni mndandanda wa madokotala 27.

Atatu oyambirira anali akatswiri amtundu wolakwika, katswiri wa msana, katswiri wa chiuno ndi mawondo, ndipo winayo anali kuthana ndi mapewa ndi mawondo okha.

“Kenako 1, 2, 3, 4, 5 otsatirawa adanditumizira anali No Appointment Clinics, ndi Christie’s No Appointment Clinics,” anapitiriza.

“Sindikuganiza kuti ndikufuna kupita kuchipatala popanda nthawi yokafuna katswiri wamanja.”

Zina zonsezo zinali za mayina ofanana kapena obwerezabwereza.

Dongosolo lomwe likubwera la Medicare PPO la Aetna liyenera kubwera ndi zosankha zambiri kuposa dongosolo la Medicare HMO lomwe mukugwira ntchito. Chifukwa cha kuchotsedwa kwa federal, dongosolo la PPO-ESA (kapena Extended Service Area) limalola odwala kuti awone madokotala ena omwe ali kunja kwa intaneti pamtengo wapaintaneti ngati ofesi ya dokotala kapena chipatala chasankha kuona wodwalayo.

Woimira Carle Health – “wotsogolera” wapakati pa Illinois komanso wogwira ntchito yofunika kwambiri pagulu la anthu opuma pantchito ku Champaign County – adati Lolemba mochedwa kuti Carle Foundation Hospital ku Urbana ndi Carle Physician Group (awo 500+) madokotala) ali ndi zomwe Iwo akuwunikabe “kuthekera kwawo kuthandiza mamembala a PPO omwe alibe,” kutchula nkhawa zamtengo wapatali komanso “kudikirira chilengezo chamgwirizano wa olipira boma.”

Woimira Aetna adayankha Lachisanu, “Ngati wothandizira kunja kwa intaneti ali wokonzeka kuwona membala ndipo ali woyenera kulandira malipiro a Medicare, Aetna adzalipira 100% ya Medicare yovomerezeka ya ntchito zophimbidwa,” ponena kuti “membalayo lipirani wolembetsa mu-network” mosasamala kanthu zomwe wopereka chithandizo amalipira kunja kwa netiweki.

Wothandizira inshuwaransi wa CVS adapempha Carle Health kuti “akhalebe ndi chidwi pa thanzi ndi moyo wa anthu opuma pantchito ku Illinois popitiliza kuwawona akudwala monga momwe amachitira lero.”

Mkulu wa mauthenga a Carle adalongosola CMS ndi maganizo a Aetna kuti madokotala a Carle “ayenera” kukhalapo mofanana ndi momwe adakhalira opuma pantchito mu ndondomeko ya United HealthCare PPO ya boma “yofalikira ndi yosocheretsa.”

“Tikumvetsetsa kuti ngati membala yemwe akufunsidwayo awonedwa ndi wothandizira kunja kwa intaneti, mtengo kwa membala udzakhala wofanana ngati awona wothandizira pa intaneti. Koma, pamapeto pake, izi zimatengera kapangidwe kake. -Kupindula kwa intaneti ndi kampani ya inshuwaransi. “

“Ndizomvetsa chisoni kuti anthu m’madera mwathu adayikidwa ndikuyikidwa m’malo omwe amayenera kupeza wothandizira kunja kapena kutuluka m’deralo chifukwa cha kuwonekera kwa PPO komanso kuchepa kwa makontrakitala. providers,” inawerenga imelo yochokera kwa woimira.” Karl mochedwa Lolemba.

Chipatala cha Carle Foundation ndi Carle Physician Group alibe mapangano ndi mapulani aliwonse a Medicare Advantage, kuphatikiza dongosolo la United HealthCare lomwe likuchita ndi boma pano. Aetna Medicare anali chip chaposachedwa kwambiri. Chifukwa cha kuchotsedwa kwa boma komwe kwatchulidwa pamwambapa, Karl adasankha kuvomereza mapulani a inshuwaransi ya Medicare Advantage. Pakadali pano, izi zikuphatikiza dongosolo la United HealthCare Group la PPO, lomwe limalemba anthu opuma pantchito opitilira 100,000.

“Makampani a inshuwaransi akakhala ovuta kuthana nawo, akuwonjezera mtengo wothana nawo, kupanga maulamuliro ambiri oti azitha kulumphira, ndikukana kulipira ntchito zomwe zaperekedwa, opereka chithandizo m’dziko lonselo akuganiziranso za omwe akuchita nawo mgwirizano komanso ngati angachite. Kutha kuwona mamembala omwe ali kunja kwa intaneti, “Carle Health Communications idatero poyankha funso loti chifukwa chiyani gulu lothandizira komanso wothandizira sapanga mgwirizano ndi mapulani a Medicare Advantage.

Sipanakhalepo yankho kuchokera kwa Aetna ponena za chikhalidwe cha zokambirana za mgwirizano ndi Carle Health, koma kampaniyo imati ndi yotseguka kuti aganizirenso zokambiranazo.

“Ndinkaganiza mozama kwambiri zosinthira ku UnitedHealth[Care]Chabwino, iye anati. Zachidziwikire, palibenso mwayi ku United Health. Ndi njira ya Aetna yokha, ndipo ikuwoneka ngati wolamulira kwa ine. “

Kudula njira ya HMO kwa opuma pantchito kungayambitse vuto lalamulo ku CMS. Mgwirizano wantchito wa boma ndi AFSCME Board 31 – mutu wa Illinois wa American Federation of State, County, and Municipal Employees – umanena mwachindunji kuti “boma lidzapitiriza kupereka kulembetsa kwa HMO.” Kaya izi zikufikira anthu opuma pantchito sizikudziwika bwino kuchokera ku imelo yochokera ku AFSCME poyankha mafunso amgwirizano.

“Zotsatira za pulogalamu ya inshuwaransi yaumoyo wa anthu opuma pantchito zalembedwa m’mapangano athu onse ndipo ziyenera kukwaniritsidwa chaka chomwe chikubwera cha 2023,” atero a Martha Merrill, Director of Research and Employee Benefits ku AFSCME Council 31.

Koma chifukwa chiyani CMS idadula zosankha? Chifukwa 90 peresenti ya olembetsa amasankha kale dongosolo la PPO, malinga ndi Kathy Kwiatkowski, wachiwiri kwa director of communications and information ku CMS.

Otsala 10 peresenti omwe adalembetsa muzosankha za HMO ndi anthu pafupifupi 20,000.

Aetna adapatsanso boma ndalama zokwana $ 0 pakanthawi koyambirira kwazaka zisanu, Kwiatkowski adanenanso kuti athandizire njira imodzi.

Sizikuwoneka ngati opuma pantchito kapena antchito adzalandira $ 0 umafunika. Ngakhale dongosololi lidzabwera ndi “kuchepetsa kwakukulu” kwa zopereka za opuma pantchito komanso odalira, Kwiatkowski adatero.

Kwa ambiri omwe adapuma pantchito omwe adayimba, kutumiza maimelo ndi kutumiza mauthenga a WCIA 3 News, sizokhudza ndalama. Ndi za kusunga madotolo omwe adawakhulupirira pa nthawi yovuta m’miyoyo yawo kuti alandire chithandizo chamankhwala.

“Sindinapange ndalama zambiri pamene ndinali kuphunzira, koma ndinaphunzitsa chifukwa ndinkakonda. Ndipo gawo la kuphunzitsa, nthawi zonse ndinkadziwa kuti padzakhala penshoni kwa ine, ndipo ndidzalandira chithandizo chamankhwala, “Good. anatero, akumanena mwachidule mantha ndi zokhumudwitsa zomwe zidatsala.

“Ndipo tsopano akungonyalanyaza malonjezo awo kwa ife, mukudziwa, zomwe atipatse tikapuma pantchito.”

Ena opanga malamulo aboma nawonso adadodometsedwa ndi ndondomekoyi, kuphatikiza wapampando wa COGFA, Senator Dave Koehler, (D) yemwe adati Lolemba kuti opuma pantchito akuyenera kukhala ndi zosankha.

Senator Koehler adati CMS ikuyenera kupereka mgwirizano watsopano wa opanga malamulo ku Government Prediction and Accountability Commission, koma msonkhanowu sukuyembekezeka mpaka masika, mochedwa kwambiri kuti asinthe.

Kohler adati udindo wa COGVA ndi upangiri wokha. CMS ikhoza “kuvomereza kapena kusiya” upangiri.

Koehler, atamva kuti mafunso a atolankhani ndi nkhawa za anthu opuma pantchito sizinayankhidwe, adalemba kalata ku bungwe la boma mu Seputembala akufunsa, mwa zina, “Kodi CMS idazindikira bwanji kufalikira kwapaintaneti koyenera” panthawi yofunsira TRAIL MAPD?

CMS yayankha molembera kwa omwe akufunafuna pempholi (RFP) kuti awonetse kutsata miyezo yokhazikitsidwa ndi akuluakulu oyenerera, Federal Center for Medicare and Medicaid Services.

Ngati malipoti athu am’mbuyomu ndi mndandanda wa maopaleshoni amanja ku Vicki Good ndi ziwonetsero, kutsimikizira kodziyimira pawokha kwa ma network operekedwa ndi kampani ya inshuwaransi kunavumbula zolakwika zambiri.

CMS sinayankhe pomwe atolankhani a Target 3 adafunsa mwachindunji ngati kutsimikizira kodziyimira pawokha kunali gawo la ndondomekoyi.

Kulembetsa kotseguka kwa opuma pantchito m’boma kwabwezeredwa mpaka Novembara 1 kuyambira tsiku lodziwika bwino la Okutobala 1. Dongosolo latsopanoli liyamba kugwira ntchito kwa olembetsa pa Januware 1.

Kulankhulana za kusintha kwa MAPD PPO kudzayamba mkati mwa milungu iwiri ikubwerayi, ndi umboni wotseguka wa chigamulo cholembetsa utumizidwa kumapeto kwa Okutobala. adzatulutsa mauthenga angapo kwa anthu opuma pantchito, kufotokoza zosintha, kuphatikizapo maimelo otsatsa kunyumba, makalata, maimelo, ndi masemina aumwini panthawi yolembetsa. “

Kwiatkowski adalongosola kuti mgwirizano wa Aetna umayenda kwa zaka zosachepera zisanu “ndi ndalama zotsimikizika za $ 0 kwa nthawi yoyamba.” “Pali zaka 5 zomwe mungasankhe kuti mukonzenso.”

Anthu amene apuma pantchito m’boma satenga nawo mbali popanga zisankho zomwe zakhala zikudandauliranso miyezi ingapo yapitayi.

Kulankhulana ndi opanga malamulo a boma kudzera pa foni kapena imelo ndiyo njira yakomweko yogawana madandaulo.

Madandaulo a Medicare pano amaperekedwa ku American Centers for Medicare ndi Medicaid.

United HealthCare sinayankhe pempho loti afotokozere momwe lipoti ilili.

Nkhaniyi yasinthidwa kuti imveketse kuti Chipatala cha Carle Foundation ndi Carle Physician Group amavomereza mapulani ena a Medicare Advantage, koma osapangana nawo.

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