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

Attorney General Spitzer today joined health care advocates from the Syracuse area to discuss the region's top health care problems and ways for consumers to deal with those problems.

The Attorney General said that, according to his Health Care Bureau's Helpline, the top three health care problems facing Syracuse area 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 ambulance services.
Spitzer was joined at the event by representatives from the Public Policy and Education Fund and the Cayuga County Office for the Aging.

"Most health plans operating in the Syracuse area provide good care most of the time," said Spitzer. "But consumers still face a bewildering array of health care choices and options and they often need assistance."

"My Health Care Bureau and the Managed Care Consumer Assistance Program in Syracuse can help consumers get the care they expect and deserve."

The Attorney General's Health Care Bureau assisted over 7,100 consumers from across the state last year, including 588 consumers from the Syracuse 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.

Kristin Fiacco, Managed Care Consumer Assistance Program Coordinator of the Public Policy and Education Fund, said, "We would like to thank the Attorney General and his Health Care Bureau for addressing the health care concerns of Syracuse area residents and we look forward to working with him to assist consumers in getting the care they need."

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

1. Lack of Prescription Drug Coverage for People with Medicare:

Spitzer said that 35 percent of the people with Medicare in the Syracuse 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. Further, no Medicare HMOs, which typically offer some prescription drug coverage, are being offered to people with Medicare in the Syracuse area (Onondaga, Cayuga, Cortland, Madison and Oswego counties). Thus, people with Medicare in the Syracuse 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 Syracuse area residents with Medicare who lacked prescription drug coverage.

Policy Change Needed:

Spitzer said that Congress should 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 percent since 1998, 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 approximately $400 annually.

Spitzer also obtained millions of dollars for New York's Medicaid program and the state's consumers by settling a lawsuit against Mylan Laboratories over illegal price increases of clorazapate and lorazapem, generic anti-anxiety drugs. New York also recovered $2 million through Spitzer's settlement of 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 Syracuse 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; and,
  • 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 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 consumers in Syracuse want to receive care from specialists and health care facilities in Rochester, Albany and New York City, which often do not participate in Syracuse area HMO networks, access to out-of-network providers is especially important for Syracuse 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 helped consumers successfully appeal denials of out-of-network care and inadequate payments for that care on behalf of Syracuse consumers," said Spitzer. "To protect consumers further, I will propose legislation this session to allow consumers to request external reviews of denials for 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 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 Syracuse 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; and,
  • How to communicate with the HMO in a language other than 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 covering Syracuse area residents 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 came from consumers whose emergency room care had been covered under the "prudent layperson standard" but who were denied coverage for their ambulance transportation. Under the prudent layperson standard, health plans must 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 must pay for the emergency room services because the patient believed he was suffering a heart attack.

"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 to evaluate both emergency room treatment and ambulance transportation."

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, Syracuse area residents and consumers across the state should have better access to affordable ambulance services," said Spitzer.

Consumer Recourse:

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.

The Attorney General urged any Syracuse area resident with health care questions to contact his Health Care Bureau Hotline at 800-771-7755 (option 3). The Health Care Bureau also provides, 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.