Spitzer Announces Southern Tier's Top Three Health Care Concerns And Outlines Agenda To Address Them
Attorney General Spitzer today joined health care advocates from the Southern Tier 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 three major health care problems facing Southern Tier residents are:
- Lack of prescription drug coverage for people with Medicare,
- Denial of access to and payment for out-of-network providers, and
- Denial of coverage for medically necessary care.
Spitzer said that many of the people with Medicare in the Southern Tier 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. Further, no Medicare HMOs, which typically offer some prescription drug coverage, are being offered to people with Medicare in most counties of the Southern Tier (Broome, Chenango, Chemung, Schuyler, Steuben, Tioga and Tompkins counties). In Alleghany County, Medicare HMOs are available but generally only cover up to $500 a year in prescription drug costs. Thus, people with Medicare in the Southern Tier area have fewer prescription drug coverage options than residents in some other areas of the state. Spitzer noted that his Health Care Helpline also received calls from under-65, disabled Southern Tier residents with Medicare who lacked prescription drug coverage. Policy Change Needed:
Noting that Congress recently adjourned after failing to enact legislation that would add a prescription drug benefit to Medicare, Spitzer said that Congress must act when it resumes this year's session to 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 has increased more than 250% since 1998 and is at 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 is estimated that the generic form of the drug would have saved individual consumers who take Cardizem CD approximately $400 annually. Spitzer also settled with Mylan Laboratories over illegal price increases of clorazapate 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 Southern Tier 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.
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 consumers in Southern Tier want to receive care from specialists and health care facilities in Rochester, Syracuse, Albany and New York City, which often do not participate in Southern Tier HMO networks, access to out-of-network providers is especially important for Southern Tier 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. When an HMO approves out-of-network care in such a situation, the member pays the same amount for the care as he or she would if the provider had been in the network. In other plans, such as Preferred Provider Organizations (PPOs),where consumer can usually seek out-of-network care without prior approval, 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 Southern Tier consumers. To protect consumers further, I have proposed legislation 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.
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 said his office has handled many complaints from consumers that health plans are denying care ordered by the consumer's doctor because the health plan determines that the care is "not medically necessary." A review of the cases shows that health plans were refusing to pay for extended hospital stays and recommended care such as MRIs and prescription drugs.
Policy Change Made:
Spitzer noted that he signed agreements with six of the state's largest health insurance plans, including Excellus, Aetna and GHI health plans that operate in the Southern Tier, which requires health plans to spell out the specific reasons for denying a treatment deemed "not medically necessary." As a result of the agreement, plans have been providing more specific information about the reasons and clinical rationale used in denying care so that if consumers and their doctors disagree with the rationale used to deny coverage, they can appeal the plan's decision more effectively.
Once again, Spitzer encouraged consumers who are denied coverage for medically necessary care to use their appeal rights, especially their right to an external appeal, which is 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.
- 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