Hiking boots, parks fees, other perks were covered by health insurer. That’s over.

Now, Aetna is rolling back its promises.

New instructions from federal regulators said insurers couldn't reimburse for such items, the company said in memos issued to insurance brokers in recent weeks.

And industry executives are suggesting more changes may be coming next year to seniors' Medicare Advantage plans — the private insurance alternative to traditional Medicare.

Since the federal government announced lower-than-expected 2025 reimbursement rates last month, many in the industry now believe Medicare Advantage carriers will approach next year with an eye toward profitability rather than expansion, said Julie Utterback, senior equity analyst at Morningstar Research Services.

"They can exit unprofitable counties," Utterback said. "They can reduce some of the extra benefits. They can share more costs with their members, up to a certain level."

The Medicare Advantage industry has grown expansively for decades. It crossed a threshold last year when, for the first time ever, more than half of all eligible Medicare beneficiaries were enrolled in Medicare Advantage plans. That's up from 2007, when fewer than 1 in 5 were, according to KFF. Plus, the baby boomer generation has been aging into Medicare, creating a wider pool of potential members.

But indeed, the finalized reimbursement rates for 2025 show a 0.2% fall in average payment, according to Reuters.

That led Aetna executives and their competitors to suggest during recent conference calls they may have to cut benefits or slim provider networks.

Karen Lynch, chief executive of Aetna parent CVS, called the rates "insufficient" and said they will result in "added disruption" to benefits and choice. Humana CEO Bruce Dale Broussard said he expects "benefit levels, plan stability and choice for seniors to be negatively impacted." Centene CEO Sarah London also called the 2025 reimbursement rates "insufficient" and said the Medicare Advantage landscape "remains challenging."

Barry Streit, senior vice president of growth at Essence, a company that sells Medicare Advantage plans primarily in the St. Louis area, said there will be hard choices ahead for insurers.

"Where do you adjust?" asked Streit. "Where do you put those extra costs?"

The past 20 years have been the "golden days" for Medicare Advantage, said Streit, whose company is affiliated with Maryland Heights-based health care company Lumeris.

It's still an excellent business, he said, "but it's not going to be operated like it has been for the last 15 or 20 years."

No more fishing rods, hiking poles

In memos to insurance brokers, Aetna attributed the change to its fitness benefits to guidance from the federal agency that oversees Medicare. The company told brokers it could no longer reimburse for athletic shoes, camping tents, fishing rods, hiking poles, and state and national park fees due to "a recent clarification" from the U.S. Centers for Medicare and Medicaid Services, or CMS.

A CMS spokesperson did not directly address the change to Aetna's plans. But the spokesperson said in an email that the agency issued a memo noting that sneakers, athletic clothing, sporting goods or fees, social programs and parks passes don't meet the criteria for benefits, which must be "primarily" health-related. The spokesperson added that Medicare Advantage carriers can offer items like sneakers to patients who are chronically ill — if the companies provide research showing that such items will improve patients' health or overall function.

Aetna did not comment in time for publication of this story.

Fitness benefits have long been included in Medicare Advantage plans. Many seniors have gym memberships through the popular SilverSneakers program, which has existed since 1992. But the additions Aetna made for 2024 were "pretty mind-boggling," said Colton Rector, an insurance agent at O'Fallon, Missouri-based Denny & Associates, who focuses on Medicare plans.

Rector said he had never seen any benefits like them in Medicare Advantage plans.

"It looked really good for 2024," Rector said.

Rector said he had cautioned members ahead of time that the benefits were brand new, and there may be hiccups. If someone planned to buy a new item on the assumption their insurance would cover it, he advised them to keep it in the box until they actually received the reimbursement.

Since the change was announced, clients have generally been understanding, he said, after hearing that the change was imposed by CMS. And, Rector said, if he helped someone sign up for an Aetna plan, it wasn't because of a pair of sneakers. It was because the plan was the best fit for their needs. It had the patient's doctors in network. It covered their medications at the best available rate. And it offered the lowest overall out-of-pocket costs.

"Even if Aetna did not cover tennis shoes from the beginning — every person I signed up would still be signed up for that plan," he said.

'They baited us'

Still, the move rankled some because the change was announced after plans were largely locked in for the year.

Open enrollment, the federal window when people can sign up for, drop or switch Medicare Advantage plans, runs from mid-October through early December. Members can switch between plans from January through March. It's rare for insurers to make changes after that period, said Nathan Toal, an insurance agent at Allraya in St. Louis County, who focuses on Medicare and Affordable Care Act plans.

Daniel Himes, a longtime cyclist from Clovis, California, switched to Aetna's plan weeks before the change was announced. Himes, 68, said he chose the Aetna plan because it covered his doctors and seemed to impose fewer hoops to make appointments.

The fitness perks were "just icing on the cake," Himes said in an email. He and his wife, Marilyn, are hikers, snowshoers and cyclists and were looking forward to using the benefits.

They found out about the change after Aetna denied a claim for a cycling helmet and felt deceived. He has since started a Facebook page for disgruntled Aetna members.

"They baited us into this program with these benefits and then didn't follow up on it," said Marilyn Himes, 65.

___

(c)2024 the St. Louis Post-Dispatch

Visit the St. Louis Post-Dispatch at www.stltoday.com

Distributed by Tribune Content Agency, LLC.