Spitzer Announces Long Island's Top Three Health Care Concerns And Outlines Agenda To Address Them

State Attorney General Spitzer today joined with health care advocates from Long Island to discuss the region's top health care concerns and ways Long Islanders can get assistance in dealing with their health care problems.

The Attorney General said that, according to his Health Care Bureau's Helpline, the top three major health care problems facing Long Islanders are:

  • Medicare HMO withdrawals,
  • denial of payment for out-of-network providers, and
  • denial of coverage for breast cancer treatment.

"There's nothing more fundamental in our lives than basic health care," Spitzer said. "The needs are clear, but meeting those needs can be very difficult. It requires consumers to understand an often bewildering array of health care choices and options. Long Island consumers especially need to educate themselves on how the health care market operates, on their rights under state law to obtain care and on the various forms of assistance that are already available."

Spitzer said that most health plans operating on Long Island provide reasonable access to health care most of the time. However, when necessary care is denied, consumers should always appeal, because consumers win appeals about 75 percent of the time.

The Attorney General's Health Care Bureau assisted over 7,100 consumers from across the state last year, including 1,314 consumers from Long Island. The Bureau operates a Health Care Helpline that assists thousands of New Yorkers with individual problems, investigates and takes law enforcement action to address systemic problems in the operation of health care networks, and proposes legislation to enhance overall heath care quality in the state.

"We would like the to thank the Attorney General and his Health Care Bureau for addressing the health care concerns of Long Islanders and we look forward to working with him to assist Long Islanders in getting the care they need," said Judy Pannullo, Executive Director of the Long Island Progressive Coalition.

The Attorney General gave the following overview of the three top complaint areas from Long Island residents, along with his agenda for addressing those issues. Spitzer also outlined steps that consumers themselves could take to obtain the care they need.

1. Medicare HMO Withdrawals:
For the third year in a row, Medicare Health Maintenance Organizations ("HMOs") have increased premiums and co-pays for Long Island consumers and, even worse, terminated certain plans. In December 2001, Oxford pulled out of Nassau County, leaving 13,000 residents without Medicare HMO coverage. Many seniors who relied on Medicare HMOs feel abandoned, and have not been able to find comparable coverage, especially for prescription drugs.

Policy Change Needed:
Spitzer said that Congress needs to adjust reimbursement rates for Medicare HMOs on Long Island to encourage HMOs to return and offer plans with lower premiums and better benefits, like plans available in Queens and other boroughs of New York City. Consumer Recourse:
Until Congress acts, Spitzer recommends that seniors evaluate and apply for, if appropriate, the New York State Elderly Pharmaceutical Insurance Coverage Program ("EPIC") and the Medicare Payment Programs. As enhanced in 2001, EPIC provides drug coverage to seniors who have an income of $35,000 or less if single, or $50,000 or less if married. The Medicare Payment Programs help pay for Medicare premiums and other costs for those who qualify.
2. Denial of Access to and Payment for Out-of-Network Providers
HMO members are generally required to get care only from in-network providers unless they first obtain authorization for an out-of-network referral. Many consumers want to go out-of-network for a second opinion or to get medically necessary care. Because many specialists on Long Island do not participate in HMO networks, access to out-of-network providers is especially important for Long Island consumers.
Spitzer noted that the New York State Managed Care Bill of Rights guarantees that HMO members have the right to obtain out-of-network care if they have a condition that requires an uncommon medical service or a provider with unusual training and expertise, not available in the HMO network. In some plans, even when the out-of-network care has been approved, disputes frequently arise about the amount of payment the plan makes to the provider. Typically, when consumers use an out-of-network specialist, they are surprised that the usual and customary rate ("UCR") that their health plan pays is much less than what the doctor actually charges - leaving the consumers responsible for a significant part of the bill. Policy Change Needed:
"We have successfully appealed denials of out-of-network care and inadequate payments for that care on behalf of Long Island consumers. To protect consumers further, I will prppose legislation this session to allow consumers to request external reviews of denials of out-of-network care. With external review, consumers can be sure that a third party, not the health plan that originally denied them, is objectively determining whether the out-of-network care they seek is medically necessary," Spitzer said.
Spitzer noted that his Health Care Bureau is currently conducting an investigation to determine whether or not the UCR used by health plans constitutes a deceptive business practice and whether legislation might be necessary to further protect consumers in this area.Consumer Recourse:
Spitzer advised consumers to read all notices carefully, including provisions of the Managed Care Bill of Rights, which guarantees their right to have access to out-of-network specialists, the right to appeal denials of care, and a host of other rights. Consumers should work with their doctors to make sure their requests for out-of-network care are fully documented. If a consumer is confused or does not get a notice with proper instructions, Spitzer recommended that the consumer call his Health Care Bureau's Helpline or the Long Island Managed Care Consumer Assistance Program. Spitzer reiterated that consumers should appeal denials of out-of-network care and low reimbursement rates. In the past, such appeals have resulted in more care being approved or additional reimbursement being paid by the health plan.Under the Managed Care Bill of Rights, every time an HMO denies a request for a referral to either an in-network specialist or an out-of-network provider, it must send the consumer a notice that includes information about:

  • how to file a grievance
  • how long it will take the HMO to review the grievance
  • the consumer's right to pick someone to help submit a grievance
  • how to communicate with the HMO if the consumer has trouble communicating in English.

Spitzer described the case of a Melville woman with cancer located on her optic nerve who was treated with proton radiation by a Harvard specialist, one of only two doctors in the country who could perform this procedure. The specialist from whom she had sought a second opinion stated that this treatment was her best chance for recovery. Before treatment, the health plan assured the consumer that she would be "covered," even though the Harvard specialist did not participate in the health plan. After receiving the specialist's bill in excess of $7,500, however, the health plan said the "usual and customary rate" due under the consumer's contract amounted to only approximately $2,000. The consumer appealed and, with assistance from the Health Care Bureau and the specialist, succeeded in securing an additional payment of nearly $3,000 from the health plan. 3. Breast Cancer:
Long Island has one of the highest incidences of breast cancer in New York. Yet, some health care plans are denying coverage for critical services for at-risk patients, denying access to out-of-network doctors and denying access to life-saving prescription drugs. Policy Change Needed:
Spitzer said his office has handled dozens of consumer complaints concerning breast cancer care denials, and voiced his support for legislation that would mandate coverage of mammograms. He also called for speedy implementation of the CDC Treatment bill, which the Governor signed recently to help those who get free mammograms through the state's Healthy Women Partnership obtain Medicaid coverage for follow-up treatment.
"The sooner the Department of Health implements this program, the sooner hundreds of New York women will be able to get the affordable breast cancer treatment that they need so desperately," said Spitzer.Consumer Recourse:*** Spitzer encouraged women with breast cancer to use their appeal rights, especially their right to an external appeal, which is guaranteed under the Managed Care Bill of Rights when their health plan denies care because the plan determines:

  • the care is not "medically necessary"
  • the care is investigational or experimental, or
  • the benefit is part of a clinical trial.

As mentioned in the previous section, HMOs are required to send consumers a notice with information on how to file a grievance for that appeal.

By way of example, Spitzer recounted the case of a Riverhead woman who called his Health Care Bureau Helpline. Diagnosed with Stage IV (advanced) cancer, she received a radical mastectomy and aggressive chemotherapy upon a recommendation from her specialist. Her health plan denied coverage on the ground that, because her cancer was so advanced, the procedure was not likely to succeed and, therefore, was not medically necessary. The health plan denied the consumer's first appeal, again stating that the treatment was not medically necessary. The Health Care Bureau intervened, submitting documentation from the treating physician demonstrating that the type of cancer, combined with the consumer's relative youth, made her a reasonable candidate for the course of treatment. The health plan reversed its denial and covered the treatment.

Spitzer was joined at the news briefing by breast cancer survivors who urged women to seek preventive care.

Hilary Rutter, Executive Director of the Adelphi New York State Breast Cancer Hotline said: "Many of our clients and volunteers are living proof that mammograms help catch breast cancer at a treatable stage. Until we have an even better test, I urge women to continue to get mammograms in accordance with their physician's advice."

The Attorney General urged any Long Islander with health care questions to contact his Health Care Bureau Hotline at 800-771-7755 (option 3). Spitzer also provided a tip sheet for consumers on how to appeal denials of care, which is also posted on the AG's website at www.ag.ny.gov. The Attorney General's Health Care Bureau is headed by Bureau Chief Joseph Baker.

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