Spitzer Announces Western New York's Top Three Health Care Concerns And Outlines Agenda To Address Them

State Attorney General Spitzer today joined with health care advocates from Western New York 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 that concern residents of Western New York 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 was joined by representatives from Citizen Action of Western New York.

"Most health plans operating in Western New York provide quality 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 the odds are you will win. Very few people denied care actually appeal but those who do win more care or coverage 75% of the time."

"My Health Care Bureau and Citizen Action are here to help Western New York consumers understand an often bewildering array of health care choices and options. We want to ensure that consumers know their rights under state law so that no one who is denied care initially 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 hundreds of consumers from Western New York. 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.

Ellen Kennedy, co-chair of Citizen Action of Western New York, said: "We would like to thank the Attorney General and his Health Care Bureau for addressing the health care concerns of Western New York 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 health care complaints from Western New York 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 many of the people with Medicare in the Western New York 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, Medicare HMOs in Western New York, to the extent they cover prescription drugs at all, typically offer only limited prescription drug coverage and have been scaling back coverage and increasing premiums over the past few years. Thus, people with Medicare in Western New York 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 Western New York 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.

In the absence of such federal legislation, Spitzer said that the New York State Elderly Pharmaceutical Insurance Coverage Program ("EPIC") provides 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 the companies 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 an average of $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 Western New York 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 Access to and Payment for Out-of-Network Providers
HMO members are generally required to receive 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 Western New York want to receive care from specialists and health care facilities in Rochester, Cleveland, Albany and New York City that often do not participate in Western New York HMO networks, access to out-of-network providers is especially important for Western New York 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 pay if the provider were in the network.

Policy Change Needed:
"We have successfully appealed denials of out-of-network care and inadequate payments for that care on behalf of Western New York consumers," said Spitzer. "To protect consumers further, I have proposed legislation 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."

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. Spitzer reiterated that consumers should appeal denials for 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 if the consumer has trouble communicating in English.

3. Denial of Coverage for Medically Necessary Care:
Spitzer said his office has handled many complaints that health plans are denying care ordered by a consumer's doctor because the health plan determines that the care is "not medically necessary." A review of the cases shows that health plans had been refusing to pay for extended hospital stays and recommended care such as inpatient mental health treatment, CAT scans and prescription drugs.

Policy Change Made:
Spitzer noted that he signed agreements with six of the state's largest health insurance plans, including Excellus Health Plan in Western New York, 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 are now 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.

The Attorney General urged any Western New York resident with health care questions to contact his Health Care Bureau Hotline at 800-771-7755 (option 3). The Attorney General's Office also provides, through postings and links on its 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.