Terri Davis was getting frantic last weekend. Her husband was being discharged from a local hospital and needed long-term care, but Davis, a Fresno Unified employee, was being told that the higher-quality facilities in the area weren’t covered by their insurance, the Aetna Medicare Advantage PPO Plan.
Davis posted on social media that she was struggling to find a skilled nursing and rehabilitation center that Aetna would cover. Despite the outreach, she hit a wall.
“The answers so far remain the same, few facilities options with our Aetna, I can pay out of pocket and hope to be reimbursed but not certain if it will be, can we qualify for Medicaid???” she wrote in a DM to GV Wire. “Any one with any sense wouldn’t ask that.
“This insurance change was a ‘mandatory’ mid-year change from a combo of our own Medicare and a supplemental policy that was provided by FUSD. We had no choice except to keep our Medicare (under our own control) and purchase our own supplemental policy. We were assured anywhere they took Medicare we would be covered. Not true.”
Trustee Susan Wittrup began hearing from Davis’ friends, seeking her assistance and letting her know of other problems with the healthcare plan, which they said was blocking patients from being able to schedule life-saving procedures and limiting access to quality nursing care.
Board Told Coverage Would Stay the Same
Wittrup said that the School Board was told that the same health services would be covered by Aetna when they voted to approve the contract, so she was alarmed to hear from Davis and others that it apparently wasn’t the case.
Davis said her attempts to reach out to advocates at the district’s Joint Health Management Board, which oversees the self-funded health plan, had been stymied. The benefits office was dealing with new, end-of-the-year enrollments, making it hard to even get someone on the phone, she said.
By Wednesday’s board meeting, Superintendent Bob Nelson said district officials recently became aware of problems with the health plan, which covers active employees and retirees.
“We are actively working with Aetna as our new provider to address those issues as they materialize in live time,” he said “But we’re asking if you are having problems with the Aetna … portion of our health insurance, please, please, please call our benefits office at 457-3520 so that we can escalate that issue and get it resolved as quickly as possible.”
Members should call the benefits office to raise questions about denials of service and other benefits-related questions, concerns, or complaints, the district said.
Three-Year Evaluation Was Conducted
The district switched to the Aetna Medicare Advantage PPO plan on July 1, and it was designed for Medicare-eligible Fresno Unified retirees to replace their prior PPO plans. It preceded the “bridge to Medicare” plan that was recently agreed to in the teacher contract negotiations to guarantee health coverage for employees retiring after 20 years of service at age 57 1/2.
The district said the JMBH board conducted a three-year evaluation and a “very arduous” bid process before deciding to award the contract to Aetna. The decision was based on several factors, including the size of the network, experience in the market, financials, and overall benefits for participants, the district said.
Patrick Jensen, the district’s chief financial officer, said that it appeared that communications issues were preventing plan participants from getting their benefits, but that work was underway to rectify that.
On Wednesday, Wittrup said she was confident that the district is addressing the participants’ concerns “because I put a spotlight on this issue.”