Health Plan Agrees To Revise Improper Id Cards

Attorney General Spitzer today announced an agreement with Blue-Cross Blue-Shield of Western New York and Blue Shield of Northeastern New York, divisions of HealthNow, to remove language from member identification cards that failed to properly inform consumers of their rights to obtain emergency care.

"State law expressly mandates that health plans cover the cost of treating any emergency condition that meets the prudent layperson standard, and bars health plans from requiring preauthorization for such treatment," Spitzer said. "This agreement will help consumers avoid being misled about their rights to coverage for emergency room claims."

Spitzer's office investigated complaints about Blue Cross member ID cards and found that many, of the cards contained misleading language. For example, HealthNow Flex ID cards instructed members to "contact your Primary Care Physician (PCP)" in the case of an emergency, and only "if not possible" to first contact your PCP, "proceed to the nearest urgent care center or emergency room . . . ." This language amounted to a preauthorization requirement for emergency care, which is strictly prohibited under New York law.

Other Blue Cross member ID cards contained language that instructed: "In a life-threatening emergency, go to the nearest emergency room . . . ." However, New York law requires health plans to cover emergency claims when the individual has symptoms that an ordinary, prudent layperson would believe pose a serious health risk, whether or not the ultimate diagnosis is "life-threatening."

"Consumers are entitled to coverage for claims that meet the prudent layperson standard even if the final diagnosis is not as severe as the patient originally thought," said Spitzer. "For example, if a patient with chest pains has an ultimate diagnosis of indigestion, the health plan generally must pay for the emergency room services."

Under the terms of the agreement, Blue Cross has issued new cards with improved language. Blue Cross will also submit to the New York State Departments of Health and Insurance revised subscriber contracts to correct inaccurate language regarding emergency care found in those documents. In addition, Blue Cross will review emergency claims it denied between April 1997 and June 2002. Blue Cross will then reimburse any consumers who were erroneously denied emergency room claims that should have been covered.

"Many consumers are simply not aware of their rights under the Managed Care Consumer Bill of Rights," said Spitzer. "And, none of these rights are more basic than the consumer's right to obtain emergency care."

Spitzer commended Blue Cross for working with his office to promptly resolve this matter.

The Blue Cross matter is the latest in a series of cases in which the Attorney General's office has held health plans accountable under the Managed Care Consumer Bill of Rights. Last year, the office reached agreement with Blue Cross in Rochester for the review of more than 25,000 emergency claims where the health plan failed to review patients' symptoms upon arrival at the emergency room prior to denying claims. The office also settled a case with GHI last year for improperly processing emergency room claims. Previously, the Attorney General settled separate cases with HIP, Kaiser Permanente and Vytra for violating the state ban on prior authorization of claims for emergency services that meet the prudent layperson standard.

The investigation was handled by Health Care Bureau Albany Section Chief Troy Oechsner under the direction of Bureau Chief Joe Baker. Consumers may contact the Health Care Bureau's toll-free hotline at (800) 771-7755 (option #3 on the automated voice menu).