Connecticut Medicare Advantage Plan Raises Access Concerns Despite Cost Savings

Connecticut's Medicare Advantage plan for retired state employees, a cost-saving switch implemented in 2018, has led to $1.7 billion in savings but has raised concerns over access to care. The plan, administered currently by Aetna, replaced traditional Medicare coverage as the default, covering 64,000 retirees. Instances of denied or delayed coverage for essential treatments have spurred advocacy efforts by groups like Connecticut State Employees for Medicare Choice, which seeks to restore an affordable traditional Medicare option alongside Medicare Advantage.

Criticism stems from cases like James Russell, diagnosed with lung cancer, who faced treatment access issues due to limited Medicare Advantage network acceptance, and the family of Gary Bent, who was denied coverage for intensive rehabilitation after brain surgery. These experiences highlight network restrictions and prior authorization barriers within Medicare Advantage plans, which contrast with the broader acceptance of traditional Medicare.

UnitedHealthcare, which administered the plan before 2023, and Aetna have noted the necessity of prior authorizations to manage care appropriateness but have faced scrutiny over transparency and claims that prior authorizations are rarely used. Connecticut's state comptroller acknowledges the validity of these concerns and emphasizes ongoing efforts to improve plan responsiveness and prior authorization processes, particularly for skilled nursing facilities where approval rates have increased to 92%.

The contract for state retiree health benefits expires in 2027, with negotiations underway involving the State Employee Bargaining Agent Coalition (SEBAC). SEBAC and state officials have recognized the importance of balancing cost savings with access issues and are considering introducing more flexibility in retiree plan options, potentially including traditional Medicare enrollment.

Connecticut remains one of 13 states mandating Medicare Advantage enrollment for state retirees, unlike the majority that offer a choice between Medicare Advantage and traditional Medicare. The state has recently introduced a program allowing enrollees to opt into a Medicare plan under Aetna for critical care providers outside the Medicare Advantage network.

Medicare Advantage plans dominate nationally, covering over half of Medicare beneficiaries. While they offer lower premiums and adequate coverage for many relatively healthy individuals, catastrophic health events can expose coverage limitations, impacting patient experience and outcomes.

Advocates urge awareness among Medicare Advantage enrollees about potential access challenges during acute medical crises. The state reports progress in managing these challenges while maintaining fiscal savings. Future contract negotiations will play a pivotal role in determining plan options and access strategies for Connecticut’s retired workforce.

Regulatory and compliance dynamics around prior authorization and network adequacy remain central to discussions on Medicare Advantage’s suitability in state retiree programs. The Connecticut case reflects broader national debates on balancing cost containment with patient-centered access in government-managed health benefits.