Spitzer Announces Rochester Area's Top Three Health Care Concerns And Outlines Agenda To Address Them

State Attorney General Spitzer today joined with health care advocates from the Rochester area to discuss the region's top health care concerns and ways consumers 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 Rochester area residents are:

  • Lack of prescription drug coverage for people with Medicare,
  • Denial of payment for emergency room visits, and
  • Denial of coverage for ambulance services.

Spitzer was joined by representatives from Monroe County Legal Assistance Corporation..

"Most health plans operating in the Rochester area provide good care most of the time," said Spitzer. "But when they deny care that doctors and patients think is necessary, our experience has shown that the best advice is to appeal because, if you do, odds are you will win. Very few people denied care actually appeal but those who do win more care or coverage for care 75% of the time."

"My Health Care Bureau and the Managed Care Consumer Assistance Program in Rochester are here to help Rochester area consumers understand an often bewildering array of health care choices and options. I want to make sure that consumers know their rights under state law so that no one who is denied care is intimidated or afraid to appeal."

The Attorney General's Health Care Bureau assisted over 7,100 consumers from across the state last year, including 455 consumers from the Rochester area. The Bureau operates a Health Care Helpline that assists 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 to thank the Attorney General and his Health Care Bureau for addressing the health care concerns of Rochester area residents and we look forward to working with him to assist consumers in getting the care they need," said Anne Erickson, Executive Director of the Greater Upstate Law Project.

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


1. Lack of Prescription Drug Coverage for People with Medicare:
Spitzer said that 38% of the people with Medicare in the Rochester area who called his Health Care Helpline had no coverage for prescription drugs and, consequently, were looking for coverage for their prescription drug costs. Medicare does not provide coverage for most outpatient prescription drugs.

Because Medicare HMOs in Monroe, Livingston, Ontario, and Wayne counties offer no prescription drug coverage and those in Genesee and Orleans counties offer only limited coverage, people with Medicare in the Rochester area have fewer prescription drug coverage options than residents in other metropolitan areas of the state. Spitzer noted that his Health Care Helpline also received calls from under-65, disabled Rochester area residents with Medicare who lacked prescription drug coverage.

Policy Change Needed:
Spitzer said that Congress must add a comprehensive, affordable prescription drug benefit to Medicare to ensure that people with Medicare have reliable access to life-saving prescription drugs.

Until Congress acts, Spitzer said that the New York State Elderly Pharmaceutical Insurance Coverage Program ("EPIC") has provided valuable coverage to people with Medicare who are 65 years of age or older and who have an annual income of $35,000 or less if single, or $50,000 or less if married. EPIC enrollment recently reached 250,000, an increase of more than 250% since 1998 and an all-time high. Spitzer recommended that consideration be given to expanding EPIC to cover people with disabilities on Medicare who are under 65 years of age and who meet the financial eligibility guidelines.

Spitzer has also been at the forefront of efforts to make prescription drugs more affordable. In May 2001, Spitzer instituted a $100 million lawsuit against Aventis and Andrx alleging that they kept a cheaper generic version of a popular heart medication, Cardizem CD, off the market. It'sestimated that the generic form of the drug would have saved individual consumers approximately $400 annually.

Spitzer also settled with Mylan Laboratories over illegal price increases of clorazaate and lorazapem, generic anti-anxiety drugs. He settled a lawsuit against BASF, Inc. over its attempt to prevent publication of a study showing that some generic drugs were equivalent to Synthroid, the most commonly prescribed synthetic thyroid hormone replacement medication, in treating thyroid disorders.

Consumer Recourse:
Until a comprehensive, affordable prescription drug benefit is added to Medicare, Spitzer recommends that people with Medicare in the Rochester area look into the following programs:

  • EPIC (for those 65 and older on Medicare who meet financial eligibility guidelines) at 1-800-332-3742
  • TRICARE at 877-363-6337 and the Veterans Health Benefits Service Center at 877-222-8387 offer prescription coverage to military retirees and veterans, respectively
  • Pharmaceutical Company Patient Assistance Programs (PhRMA) at 202-835-3400 offer free or discounted prescriptions for a limited period to those who meet guidelines.

2. Denial of Payment for Emergency Room Visits
Spitzer’s Health Care Bureau began an investigation of Blue Cross and Blue Shield of the Rochester area after receiving complaints about coverage denials for emergency room visits. Blue Cross’ denial notices stated that the claims were rejected for lack of a physician’s referral and that the "member is liable." Area hospitals subsequently billed the patients for the cost of the emergency room visit.

Under the New York State Managed Care Bill of Rights, however, it is illegal to deny an emergency claim for lack of a physician referral where the presenting symptoms meet the "prudent layperson" standard. This law requires health plans to cover emergency room claims when the patient has symptoms that an ordinary, prudent person without medical training would consider a serious health risk.

Spitzer said that 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. For example, even if a patient with severe chest pains has an ultimate diagnosis of indigestion, the health plan still must pay for the emergency room services.

Under the terms of its agreement, Blue Cross is currently reviewing more than 25,000 emergency claims it denied between April 1997 and November 2000 and will reimburse Rochester area consumers and hospitals for claims that meet the prudent layperson standard, plus interest.

Policy Change Needed:
"We successfully settled with Blue Cross to ensure that Rochester area residents have access to coverage for emergency room care. I am glad to report that the Department of Health and Department of Insurance issued opinion letters in November 2001 and January 2002, respectively, which track the outlines of our settlement with Blue Cross and basically apply its terms to health plans across the state and clarify that consumers have the right to request external reviews of denials of emergency room coverage," said Spitzer.

Consumer Recourse:
Spitzer noted that health plans may, in some circumstances, still deny coverage for emergency care and advised consumers to read all notices carefully, including provisions of the Managed Care Bill of Rights, which guarantee their right to emergency care coverage and their right to appeal denials of care, and a host of other rights. Consumers should work with their doctors and emergency providers to make sure their requests for emergency care coverage are fully documented. If a consumer is confused or does not get a denial notice with proper instructions, Spitzer recommended that the consumer call his Health Care Bureau’s Helpline or the Rochester Managed Care Consumer Assistance Program.

Spitzer reiterated that consumers should appeal denials of emergency care. 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 coverage for emergency care, it must send the consumer a notice that includes information about:

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

3. Denial of Coverage for Ambulance Services:
Before the recent enactment of a law mandating that health plans provide coverage for ambulance services, many health plans did not offer such coverage. Additionally, those plans that did offer ambulance benefits frequently second-guessed patients about whether they had experienced a true emergency that required transportation by ambulance.

Many complaints to the Health Care Helpline involved consumers whose emergency room care had been covered under the prudent layperson standard but whose ambulance transportation was denied.

"Consumers were confused and angry to find themselves held responsible for paying a large bill from an ambulance company when their emergency room care was covered under the prudent layperson standard," said Spitzer. "It didn’t make sense to them and it was irrational and inequitable not to use the same standard, the prudent layperson standard, to evaluate both claims."

Policy Change Made:
A new law, effective as plans are issued or renewed after January 1, 2002, now mandates that all health plans subject to state regulation provide coverage for ambulance services and that the plans use the prudent layperson standard in evaluating ambulance services claims.

"With the enactment of the ambulance coverage mandate and the application of the prudent layperson standard to ambulance claims, Rochester area residents and consumers across the state should have better access to affordable ambulance services," said Spitzer.

Consumer Recourse:
Once again, Spitzer encouraged consumers who are denied coverage for ambulance services to use their appeal rights, which are guaranteed under the Managed Care Bill of Rights. As mentioned in the previous section, health plans are required to send consumers a notice with information on how to file an appeal.

The Attorney General urged any Rochester area resident with health care questions to contact his Health Care Bureau Hotline at 800-771-7755 (option 3). Spitzer also provided, through posting and links on his website at www.ag.ny.gov, the following information for consumers:

  • a tip sheet for consumers on how to appeal denials of care,
  • answers to frequently asked questions about the Elderly Pharmaceutical Insurance Coverage (EPIC) at www.health.ny.gov

The Attorney General’s Health Care Bureau is headed by Bureau Chief Joseph Baker.


**Once again, Spitzer encouraged consumers who are denied coverage for ambulance services to use their appeal rights, which are guaranteed under the Managed Care Bill of Rights. As mentioned in the previous section, health plans are required to send consumers a notice with information on how to file an appeal.

The Attorney General urged any Rochester area resident with health care questions to contact his Health Care Bureau Hotline at 800-771-7755 (option 3). Spitzer also provided, through posting and links on his website at www.ag.ny.gov, the following information for consumers:

  • a tip sheet for consumers on how to appeal denials of care,
  • answers to frequently asked questions about the Elderly Pharmaceutical Insurance Coverage (EPIC) at www.health.ny.gov

The Attorney General’s Health Care Bureau is headed by Bureau Chief Joseph Baker.


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