One of our stories that generated a fair number of page views involved a state legislator and a New Castle County Council member raising a fuss over Delaware moving to a Highmark Medicare Advantage plan for retired state employees eligible for the federal program
Medicare Advantage adds benefits to conventional Medicare. In return, recipients use physicians within the network, and some procedures require pre-approval. (More than 90% of such requests get an OK).
Regular Medicare requires fewer pre-approvals but struggles with the issue of fraud in areas such as medical equipment. In such cases, an OK may be needed, or you get one shot at the item advertised on TV and denials for other things you might need down the road.
The conversion to Advantage plans caused issues in some states and led retiring state Rep. John Kowalko and New Castle County Council member Lisa Diller, to sound the alarm, perhaps without some of the background information on the process that took place in coming up with the Highmark plan.
Their comments and the announced formation of an organization that would serve as a watchdog for retirees in a state where a sizable chunk of its population is covered under the state retirement/pension program.
While the State of Delaware and others working on the changes and could have done a better job on the communications front (every employer and pension plan has that problem), the confusion was needlessly amped up.
It turns out that organizations representing retirees and the state had been working on changes needed for a state pension post-retirement benefits system that is generous by private industry standards.
Moreover, the Highmark Medicare Advantage plan does not come with some of the problems seen elsewhere that were cited by Kowalko and Diller.
The physician network is large and growing. In a letter to members, the Delaware State Education Association noted that 93% of providers under the earlier state program have signed up with Highmark.
After concerns were expressed that some patients might lose physicians not in the Highmark network, adjustments were made for doctors outside the network accepting Medicare to be included, based on current Medicare reimbursement rates during the length of the three-year contract with the state. The physician has the right to not accept Medicare patients.
What was not brought up by critics are benefits that come with similar Highmark plans that can include fitness center memberships and a representative checking in regarding the use of medications, and even a home visit from a nurse.
None of this is done out of the goodness of Highmark’s heart. Instead, it’s a way to deal with reducing expensive hospital stays, especially for patients with chronic conditions.
The bottom line is that the conversion to the Highmark plan was the right move for both taxpayers and recipients. The larger issue of an underfunded pension and benefits system remains, but thanks to some changes, we are not at the critical yet. – Doug Rainey, chief content officer.
