A dispute between Community Health System and Fresno Unified’s health insurance provider, Aetna, has caused thousands of district retirees to be cut off from care.

“Here I am about 2 1/2 years later and instead of lying in a bed paralyzed on my left side and unable to communicate, I’m healthy, active,” a retiree, who previously had a stroke, told GV Wire. “Strokes happen most often to the elderly, which most retirees are. I was 72. To deprive us of access to this level of care would be terrible.”

Aetna and Community, the region’s largest healthcare provider, failed to reach an agreement, ending the contract between them on New Year’s Day. Immediately, Aetna’s Medicare Advantage Plan removed Community from their network of care.

“Unfortunately, (Community) offered no extension of the current agreement to enable the parties to continue discussions to avoid member impact. Aetna is open to continuing negotiations if they wish to reconsider,” Aetna Senior Manager of Corporate Communications Shelly Bendit said.

Community also communicated an willingness to continue negotiations.

“We understand the urgency of this situation and certainly welcome any additional discussions with Aetna on our current agreement,” Lisa Ferrari, Community’s vice president of payer strategy-managed care. The health system will continue to provide emergency care to everyone effected.

1,500 Retirees Receive Care From Community Health

About 6,500 retirees and dependents are enrolled in the program, and 1,500 received primary care services at Community, according to the district.

“We understand that uncertainty about healthcare access is concerning, particularly for our retirees with ongoing medical needs,” Fresno Unified Superintendent Misty Her said in a statement.

Currently, Fresno Unified is working alongside partners to evaluate all options and assess potential paths forward, she said.

Sharon Hart, a former Fresno Unified employee, whose husband is battling cancer, expressed frustration for what she considered a passive district response.

“When kids don’t come to school, (the district) calls them. Administrators make home visits,” Hart said. “That’s how the district gets money… We’re the opposite. We take money. We already sacrificed, now we’re just a drain. No one’s calling us.”

Community Medical Center Hub of Care

Community Health includes four hospitals, which provide most of Fresno County’s hospital care. Additionally, the health care provider employees a vast number of specialists in the area.

Now, at least 1,500 retirees are losing easy access to this care.

Aldo De La Torre, Community’s division president of insurance services and managed care,  explained retirees can request authorization from Aetna for a “continuity of care.”

“This would allow Community providers to continue to provide services for up to one year upon Aetna’s approval,” said De La Torre.

This is a convoluted process that requires energy and proper awareness, according to Hart. She has taken over this burden for her husband but emphasized that not everyone has a support system.

“Honestly, he told me yesterday when we were talking about this that he would just die (without her help),” Hart said.

Fresno Teachers Association President Manuel Bonilla says there is a way to rid retirees of this paperwork burden.

“Community just could simply see folks and bill out of network without having our folks to fill out additional paperwork,” Bonilla told GV Wire. “What we’re calling on is for (Community) to allow our retired teachers to continue to see their providers while there’s an ongoing negotiation.”

Out-of-network care raises costs that often must be paid out-of-pocket — a problem people are running into, Bonilla said.

Expired agreements and failed negotiations are not new nor a localized issue. Community did not accept Anthem Blue Cross insurance for six months in 2023 as negotiations raged on between the two. Additionally, Aetna’s contract with UConn Health in Connecticut recently expired.

Retirees Unhappy with Aetna

Even before this dispute, many retirees have been unhappy with the level of coverage provided through Aetna, a private profit-driven company, since its implementation in 2023.

The Fresno Unified Retirees’ Association sent a letter of demand, threatening litigation, due to lack of access and higher costs through Aetna.

“FURA has learned that the district has disregarded its promise and has been imposing various changes on retirees’ expected health benefits. In particular, more expensive health benefit charges have been made requirements for many retirees,” the letter states. “Retirees have also experienced a lack of medical services coverage through the new Aetna Plan, imposed upon them by the District.”

At the Dec. 17 School Board meeting, trustees unanimously agreed to renew the district’s contract with Aetna despite sharing concerns of their own.

“At this particular point in time, we’re between a rock and a hard place,” Trustee Elizabeth Jonasson-Rosas said at the dais. “Regardless of the Community situation, (there is) dissatisfaction amongst our retirees with the current level of service.”

The district can end its agreement with Aetna if it is unable to maintain a service with a major hospital chain, such as Community, Fresno Unified CFO Patrick Jensen told the School Board. However, the change would be a long and laborious process, he said.

“I would like to challenge the notion that it would take six months. It did not take six months to move 6000 retirees (onto Aetna),” said Elisabeth Robeldo, a current Fresno Unified teacher who works with FURA. “That was done at a breakneck pace. In fact, it happened so quickly that it was a bit of a surprise.”

The district said terminating the contract would be a last resort.

History of Healthcare in Fresno Unified

Decades ago, Fresno Unified agreed to provide lifetime healthcare benefits to employees, who in turn forewent salary increases.

But retirees believe the district is failing to properly uphold their end of the bargain.

Hart said she feels “absolutely screwed over, absolutely screwed over. There is no other way to say it.”

Retirees who qualify for Medicare, ages 65+, were shuffled into an Aetna Medicare Advantage Plan.

Prior to the advantage plan, retirees had Medicare as a primary insurance and the district provided supplemental plan. Meaning, the district paid uncovered medical expenses from its own health fund, with a third-party handling paperwork.

Now, Aetna Medicare Advantage or Kaiser Permanente Medicare Advantage are the only options of retirees ages 65+.

The plan was negotiated by the Joint Health Management Board — comprised of union representatives and district staff — and approved by the School Board. There is no retiree representative on JHMB from FURA.

“There are retirees who sit on the JHMB board who are part of their unions,” JHMB member Steven Shubin told GV Wire. “And the JHMB did meet with the FURA multiple times to review and discuss the plan changes in late 2022.”

Aetna extended in-network options to out-of-state retirees and reduced out-of-pocket expenses, Shubin said. However, Robeldo said that there are retirees who now live outside the region and struggle to find in-network healthcare.

During that time, Fresno Unified paid $450 per member per month and Aetna Medicare Advantage submitted a bid of $298 per member per month, according to documents obtained by GV Wire. At the time, this created an annual net saving of $12.7 million.

Yet, the district will pay about $531 per member per month in 2026 — a 78% increase from 2023. Meanwhile, Medicare’s self-reported costs increased 24-25% in the same period, placing it on track to exceed traditional costs. But the new figure is not bigger than what would be paid with traditional Medicare, Shubin said.

Bonilla declined to comment on JHMB, saying it isn’t related to or involved in negotiations between Aetna and Community.

However, Fresno Unified Trustee Susan Wittrup said, “It’s all connected.”

The next JHMB meeting is on Thursday, Jan. 15.

Medicare Advantage Causes High Costs and Less Care

Medicare eligible retirees have been unhappy with the restrictive advantage plan that pushes prior authorization for procedures, referral rules, denials, and insurer-run appeal — causing undue stress and longer wait times.

The extra paperwork and delays, sometimes for life-saving treatment, more costs for medical providers and retirees who are on fixed incomes.

“From Community’s perspective, what they’ve told me is that costs them a lot of money. That’s very expensive when they have to use doctors’ time and nurses’ time to appeal these denials,” Hart said.

Additionally, there was a lack of communication about the change, according to Hart and Robeldo.

“Folks were not informed and feel as though these things happened in private and in secret and with a lack of transparency,” Robeldo said.

The district told the Board that the health services would remain the same under Aetna when they voted to approve the contract, Wittrup said. However, it has been producing complications since.

“There have been rumblings of problems ever since that Medicare Advantage Plan came in. Lots of people are saying that if they just had Medicare, they would do much better on coverage,” she said.

Related Story: Fresno Unified’s Health Insurer Creating Headaches for Some Retirees

Bottom line: a large portion of retirees are seeking the choice to return to traditional Medicare.

“The main thing now is to have the option to return to their traditional Medicare program with their employer subsidized supplemental program. Those who want to stay on Medicare Advantage, who enjoy the care and are happy with the service (can stay). We do not wish to separate folks from their preferences, just as we would appreciate the same. So that is the idea of choice,” Robeldo said.