NJ health plan retirees must be wary of the new Aetna Medicare replacement plans; here’s why.

Posted on by bill

NJ health plan retirees must be wary of the new Aetna Medicare replacement plans; here’s why.

If you work for the state of New Jersey and are a NJ health plan retiree and are Medicare eligible , you are no doubt aware that there are changes to your coverage.

We have warned our patients about most Medicare Advantage plans, since they are bait and switch vehicles for insurers to give you less than Medicare does, while promising to give you more.

In NJ, you can still maintain Medicare as your primary, and Horizon or Aetna as your secondary in retirement.   These plans include:

  • Horizon NJ Direct 1525
  • Horizon NJ Direct 2030
  • Horizon HMO10
  • Horizon HMO 1525
  • Horizon HMO 2030

Last year, NJ state retired employees were automatically switched into a new Horizon Medicare replacement plan called Horizon NJ Direct 10 or Horizon NJ Direct 15.  These plans maintain chiropractic benefits for those who use in network providers however, the use of out of network providers has a maximum reimbursement of $35 dollars.  If your chiropractor is in network, you have nothing to worry about and the state claims these new plans are comprehensive and save the state money.

On the other hand, if you are in Aetna and move to their Advantage plan, which will automatically happen if you do not request a change by November 30th, you will find out that visiting a chiropractor got more expensive.  These state plans, unlike the Horizon plans do not cover exams, x rays and other types of work that chiropractors are licensed to do and they only cover what Medicare covers.  Traditional Medicare only covers manipulation, and does not cover other services required by Medicare such as exams and other services many chiropractors use to get their superior outcomes.

Our advice is that in retirement, you should consider either the Horizon NJ Direct 10 or Horizon NJ Direct 15 if your chiropractor is in the Horizon network or request that you maintain your Medicare as primary, and use one of the Horizon NJ direct plans as secondary.  HMO plans require referrals and have artificial road blocks to visit your chiropractor if your physician is not up on the latest research and refuses to refer you.

These are excerpts from an email we received from our state society.  Below is the complete info, links you need and information on what you should do now.  You must act before the end of November to assure you are properly covered for chiropractic services in NJ. If you have not used a chiropractor, you may wish to in the future, as more information suggests that chiropractors may be your best choice for problems in the back, neck and extremities.

We have previously reported that all Medicare eligible retirees under the SEHBP (teachers) who are enrolled in traditional Medicare with either the NJ Direct 10 or NJ Direct 15 plans will be automatically enrolled into new Aetna Medicare Advantage plans.  It has come to our attention that additionally, any retired SHBP (police, fireman, etc.)  employees who had been enrolled in the Horizon Medicare Advantage NJ Direct 10 or 15 will also be moved to new Aetna Medicare Advantage plans.  Unlike the Horizon Medicare Advantage plans, the Aetna plans state that they will only cover spinal manipulation for chiropractic care.

It is important to note that all these employees under the SHBP and SEHBP do have the option to maintain their traditional Medicare coverage with one of 5 Horizon plans as their secondary to Medicare.  These plans are the:

  • Horizon NJ Direct 1525
  • Horizon NJ Direct 2030
  • Horizon HMO10
  • Horizon HMO 1525
  • Horizon HMO 2030

The details of these plans can be viewed here: https://www.state.nj.us/treasury/pensions/hb-sbc-state-retired-19.shtml.    

To simply understand the new changes, here is the newest info on this

  1. The Aetna MA plan covers only spinal manipulation for chiropractic vs. full scope of practice, and all services previously allowed under traditional Medicare with a Horizon secondary AND the Horizon Medicare Advantage plan that the SHBP adopted in 2016.
  2. The Aetna MA plan will impose pre-authorization requirements on all physical medicine to include at least chiropractic, physical therapy and occupational therapy.
  3. Generally under Medicare Advantage plans, the government pays a carrier a fixed amount, and the carrier is then responsible for the cost of its members’ care.  Therefore, these carriers can profit more by limiting care and paying out less than the government pays them, and they could lose money if they pay out more than the government pays them.  It may be difficult to define precisely when a particular patient will be affected by this – but the gatekeeper of their care has financial incentive to allow and pay for less care under the Medicare Advantage plans.

If you do not want to be automatically enrolled in the Aetna Medicare Advantage plan, you must act by Nov. 30th. Links to the other plans available as secondary to traditional Medicare may be found at www.savemybenefitsnj.com.