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By ROBERT PEAR, NY Times
January 17, 2003
WASHINGTON,
Jan. 16 — In a reversal, the Bush administration has ruled that managed
care organizations can limit and restrict coverage of emergency services
for poor people on Medicaid.
The
new policy, disclosed in a recent letter to state Medicaid directors,
appears to roll back standards established in a 1997 law and in rules
issued by the Clinton administration in January 2001 and by the Bush
administration itself in June 2002.
Under
the 1997 law, states can require Medicaid recipients to enroll in health
maintenance organizations or other types of managed care. But certain
safeguards for patients were built into that law. Congress, for example,
stipulated that managed care organizations had to provide coverage for
Medicaid patients in any situation that a "prudent layperson"
would regard as an emergency.
Now
the Bush administration has decided that states can place certain limits
on coverage of emergency services "to facilitate more appropriate use
of preventive care and primary care," the letter said.
Administration
officials said today that the new policy was consistent with President
Bush's desire to give states greater flexibility in the operation of their
Medicaid programs.
"Some
states felt restricted and constricted by the old policy," said
Gregory A. Vadner, the Missouri Medicaid director, who is also vice
chairman of the National Association of State Medicaid Directors. "In
a time of fiscal stress for states, it's all the more important that we
have discretion to manage programs properly."
States
say they are facing the worst fiscal crisis in more than 50 years and are
desperately looking for ways to control health costs. Many have cut
benefits or restricted eligibility in an effort to hold down Medicaid
costs, which rose 13 percent in the last fiscal year, the biggest increase
in a decade.
But
Cindy Mann, a Medicaid expert at Georgetown University, questioned the
legality of the new policy.
Senator
Bob Graham, Democrat of Florida, a principal author of the 1997 law, said
the new policy "would undermine access to essential emergency
services for low-income Americans," including children, the elderly
and the disabled.
Mr.
Graham said he did not understand how the administration could, by a
letter, make such profound changes in a policy established by statute.
Administration
officials said the basic Medicaid law allowed states to set reasonable
limits on the amount, duration and scope of services.
The
letter was sent to state officials by Dennis G. Smith, the Bush
administration official in charge of Medicaid. Under the old policy, Mr.
Smith said, states could not limit coverage of emergency services for
Medicaid beneficiaries in managed care. "When the prudent layperson
standard is met," the old policy said, "no restriction may be
placed on access to emergency care. Limits on the number of visits are not
allowed." More
than 40 million people are insured through Medicaid. More than 55 percent
of them are in some type of managed care.
The
letter does not specifically say what kind of limits can be imposed, but
state officials have discussed ideas like limits on the number of
emergency room visits that would be covered.
Ben
A. Bearden, the Medicaid director in Louisiana, said his state wanted to
limit Medicaid coverage for adults to three emergency room visits a year.
"Three
emergency visits a year for an adult may sound like a small number, but
it's really not," Mr. Bearden said today in an interview. "I'm
60 years old, and I've been to an emergency room once in my life. The E.R.
is very expensive, and people in this state use it inappropriately. They
go in for a stubbed toe."
Louisiana
used to have a three-visit limit, Mr. Bearden said, but, at the insistence
of federal Medicaid officials, the state ended the restriction for people
in managed care a couple of years ago.
Under
one form of managed care, states pay primary care doctors to coordinate
care for Medicaid recipients.
Mark
D. Trail, the Medicaid director in Georgia, said that prior to 1997, his
state required an emergency room to get authorization from the primary
care doctor before treating a Medicaid patient enrolled in the state's
managed care plan.
Georgia
did away with that requirement because of the 1997 law. "Since
then," Mr. Trail said, "use of hospital emergency rooms has
spiked," and the state is seeking ways to reduce inappropriate use.
Mr.
Vadner, the Missouri official, said states recognized their obligation to
cover emergency care. But there is often a dispute over who should pay and
what services are needed.
Michelle
Mickey, a policy analyst at the National Association of State Medicaid
Directors, said state officials had sought a clarification of federal
policy on emergency care. The new policy, she said, is "above and
beyond what the states ever requested or expected."
Senator
Graham introduced a bill to establish the "prudent layperson"
standard for all insurers in 1997. The standard was included in the
Balanced Budget Act of 1997, as a requirement for managed care plans
serving people in Medicaid or Medicare. The purpose, Mr. Graham said, is
"to allow a person who reasonably believes that he or she is
undergoing an emergency condition to be evaluated, treated and stabilized
in the emergency room without fear that the health plan will later deny
the claim." A
prudent layperson is defined in the law as a person with "an average
knowledge of health and medicine."
Doctors
and hospitals said the prudent layperson standard was needed because
H.M.O.'s had often refused to pay for emergency care after concluding that
there was no real emergency — if, for example, chest pains resulted from
severe indigestion rather than a heart attack.
Under
the law, the managed care plan is supposed to pay for the emergency care,
regardless of whether the patient got "prior authorization." The
patient can go to the nearest hospital, regardless of whether it is in the
health plan's network of providers.
The Bush administration issued rules interpreting the law on June 14, 2002. In a news release at the time, the administration said, "Health plans must pay for a Medicaid beneficiary's emergency room care whenever and wherever the need arises." Copyright
© 2002 Global Action on Aging
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