Patients caught in coverage dispute

ILLINOIS| HEALTHCARE

Tim Rice is in a race against the calendar for his health.

Three years after prostate cancer first upended his life, Rice, 65, learned in May that the disease had returned.

This time, his doctor at Barnes-Jewish Hospital in St. Louis, part of BJC HealthCare, recommended brachytherapy, a form of radiation therapy that places radioactive material inside or near the area being treated.

Rice, who lives in Alto Pass, Illinois, more than 100 miles from the hospital, scheduled the procedure, with the second of two appointments set for Dec. 28.

That plan, however, has changed after news in October that BJC HealthCare is dropping its participation at the end of this year in the Medicare Advantage plans offered by insurers Aetna and Anthem.

That includes TRAIL, the state of Illinois' Aetna-administered Medicare Advantage health insurance program for eligible state, teacher and community college retirees.

Rice, who retired in 2021 after 18 years at the Illinois Department of Children and Family Services, now plans to make six trips to St. Louis beginning in early November to undergo an entirely different form of radiation therapy. He hopes to finish all of the treatments by Thanksgiving.

"The doctor made this decision so that he would have more time to follow up with me," said Rice, eyeing the Dec. 31 deadline. "He knows what's going on. He has a clear idea about my tumor and my cancer."

The Illinois Department of Central Management Services says about 5,000 Illinois retirees who have recently accessed provider or hospital care will be affected when Barnes-Jewish Hospital and WashU Medicine stop accepting Aetna Medicare Advantage plans at the start of 2027.

Many residents of largely rural southern Illinois rely on specialists in the St. Louis area to provide services not available to them locally, but the potential reach extends well beyond state retirees. More than 72,000 people across the 15-county St. Louis metropolitan area are enrolled in Aetna Medicare Advantage plans, according to an analysis of October 2026 enrollment figures from the federal Centers for Medicare and Medicaid Services.

On its website, BJC cited "administrative burden and payment issues" as reasons it would no longer partner with the Aetna and Anthem plans. The disruption doesn't affect commercial or supplemental plan agreements between BJC and Aetna.

Former congressman speaks out

This isn't the first time retirees have found themselves in this predicament. BJC and Aetna reached a last-minute deal on the current one-year contract in December 2025. Facing another year of uncertainty is "so frustrating," said Glenn Poshard, the former U.S. congressman and Southern Illinois University system president.

"I've called everyone I know to call," said Poshard, 81, who with his wife, Jo, relies on services provided at BJC and Washington University. He said he's received upward of 50 calls from concerned friends and colleagues.

"We're just left in a lurch right now," Poshard said. "There are thousands of people in Illinois who go to those hospitals for major things. I don't know where to go from here. I don't know how we get to the bottom of this."

The Illinois Department of Central Management Services, the state agency that oversees the state retiree plans, said in an Oct. 15 memo to participants that BJC HealthCare hospitals would continue providing services after the new year to patients whose care is deemed "medically necessary," although what conditions would warrant that conclusion were not made clear. Cynthia Johnson, a spokesperson for the state agency, did not respond to submitted questions.

Phil Blando, spokesperson for Aetna, said in an emailed statement the company is prepared to provide affected patients with information about continuity of care and its "robust provider network" in the areas affected, including southern Illinois.

Blando said BJC providers would still see certain affected Aetna plan members after the new year under limited circumstances.

"BJC HealthCare/Saint Luke's and Washington University School of Medicine physicians are currently willing to see Aetna Medicare Advantage members for continuity of care and in other limited situations," Blando said.

However, BJC HealthCare qualified that assurance in its own emailed statement.

"Although Aetna has stated that Aetna Medicare Advantage patients can continue to receive care from BJC providers, they have not fully explained that doing so may result in significantly higher costs under out-of-network benefits," said Laura High, media relations director for BJC HealthCare.

Deadline is looming for action

On Oct. 23, a bipartisan group of Illinois legislators wrote a letter to BJC HealthCare, Aetna and CMS, insisting that daily contract negotiations between BJC and Aetna resume immediately. If no agreement is in place by Friday, Nov. 6, the legislators asked to receive a comprehensive briefing from all parties.

"The loss of access to these trusted healthcare providers would have significant consequences for affected retirees and their families," the lawmakers wrote in the letter, signed by five Illinois state senators and nine state representatives. "These individuals dedicated years of service to the State of Illinois and deserve continuity of care and certainty regarding their healthcare coverage."

Pressed on whether negotiations were continuing or how they would respond to the Illinois legislators' demands, the representatives for BJC and Aetna both declined to provide answers.

"We think that both parties have a responsibility to exhaust all avenues of negotiation," said Martha Merrill, director of research and employee benefits for the American Federation of State, County and Municipal Employees Council 31. "We still believe there's time for both parties to act in good faith."

Meanwhile, amid the confusion, retirees in southern Illinois are beginning to make their own choices. Leslie Lloyd, of Murphysboro, retired in 2017 from teaching in the physician assistant program at SIU Carbondale and had her right foot reconstructed by a St. Louis surgeon in December 2024.

She's still receiving follow-up treatments, but a January appointment with her provider has been canceled because of uncertainty about whether the visit will be covered under her existing insurance arrangements.

Lloyd said she worked for the state of Illinois for 22 years, and the anticipated loss of access to her established providers is not what she was promised.

"It's a lifetime benefit for being a public servant," said Lloyd, who added she has been in contact with numerous SIU retirees about the issue. "We paid into the system. I have several physicians, and most of us do, who are being dropped."

Rosemary Rouse of Tunnel Hill retired from the Illinois Department of Corrections in 2002 after working at the Vienna and Shawnee correctional centers. Now dealing with the fallout from a compression fracture in her spine, she has similar questions.

On Oct. 28, Rouse received a letter from the Washington University Division of Bone and Mineral Services informing her an upcoming appointment was being canceled "unless you are switching to a different insurance plan that is contracted with Washington University/BJC."

"I'm worse than disheartened right now," Rouse said.

Rouse said the uncertainty leaves her with few options if she wants to continue with her current provider. She said her best option will be to simply change insurance carriers.

For Rice, still navigating a recurrence of prostate cancer, he began this journey with his doctor in St. Louis, and he is determined to finish there as well, even if he has to pay costs out-of-pocket.

He noted that other expenses pile up as well. Frequently, it makes more sense to get a hotel room in St. Louis, particularly if an appointment is scheduled for early in the morning. Fuel expenses also accumulate — as much as $65 for a round trip, Rice said.

But with his health and emotional well-being on the line, he said he'll do whatever it takes to maintain a relationship with his current doctor.

"I don't want to go to someone who has no idea what's going on," Rice said. "He made it very clear that he would work with us. It's important that I continue with him."

This story was produced by Southern Illinois Source, the Illinois Press Foundation's nonprofit news collaborative serving the bottom third of the state in partnership with the Southern Illinois University Charlotte Thompson Suhler School of Journalism and Advertising.

Distributed by Newsbank, inc.