2004 APR 19 - (NewsRx.com & NewsRx.net) -- Health maintenance organizations (HMOs) in New York got low grades from state Attorney General Eliot Spitzer for what he said was their reluctance to tell prospective customers what medical treatments and procedures they cover.
Spitzer said members of his staff, posing as prospective enrollees, sent five different letters to 22 HMOs asking what standards they used to determine whether various treatments are 'medically necessary' - the requirement under state law for coverage. According to the state's Managed Care Consumer Bill of Rights, HMOs have to provide 'clinical review criteria' upon request to give consumers a clear idea of how coverage decisions are made.
One letter from Spitzer's staff, for instance, purported to be from a diabetic patient who wanted to know whether an insulin pump would be covered by an HMO. In another, 'patients' asked about coverage for arthroscopic knee surgery.
Half the HMOs either provided insufficient information about their clinical review criteria or, more than a quarter of the time, didn't respond to information requests at all, Spitzer said.
Only one HMO - Empire HealthChoice - responded properly to as many as three of the five letters. No HMO responded properly to either four or five responses.
'The information the companies are obligated to provide to consumers, whether or not they are current clients, is the very information consumers should use to determine which company consumers should subscribe to,' Spitzer said. 'If the companies squeeze that information and don't permit us to get access to it, it will damage us as consumers, it will damage the marketplace, and the whole system will crumble.'
Paul Macielak, president of the New York Health Plan Association, said requests for the information Spitzer's aides sought appear to be rare among consumers. A better gauge of HMOs' compliance with the Managed Care Consumer Bill of Rights, he said, is how they responded under the state's external review process when coverage is denied or annual reports on HMOs prepared by the state health and insurance departments.
'We firmly believe that plans are dedicated to upholding New York's strong healthcare consumer rights laws,' Macielak said.
The Managed Care Consumer Bill of Rights went into effect in 1997. But Spitzer said it is weakened by the lack of any penalties for violators. He is pushing legislation sponsored by the chairmen of the health committees in their respective legislative chambers to create fines ranging from $500 to $5,000 per violation.
Richard Kirsch, executive director of Citizen Action of New York, said 'sharper enforcement teeth' to the consumer bill of rights is needed.
Spitzer said he probably does have the power to fine the HMOs under other provisions of state law, but he said his staff instead will meet with HMO administrators to explain their legal responsibilities. 'We are going to sit down them and say, 'Fellas, get your house in order,'' Spitzer said. 'It's easy stuff.'
Three HMOs had the second-best response rate to Spitzer's survey, with two adequate answering letters: Excellus, Group Health Inc. (GHI)-HMO, and Independent Health.
Seven HMOs had one adequate response, according to Spitzer: Atlantis Health Plan, Capital District Physicians Health Plan, HealthNow New York, MVP Health Plan, Oxford, United Healthcare of New York, and Vytra Health Plans.
Eleven had no responses deemed adequate by Spitzer's office: Aetna US Healthcare, AmeriHealth Health Plan, CIGNA Health Care of New York, Health Insurance Plan (HIP), Health Net, Horizon Healthcare of New York, Magna Health, Managed Health, MDNY Healthcare, Inc., Preferred Care (Rochester), and WellCare of New York.
This article was prepared by Health & Medicine Week editors from staff and other reports. Copyright 2004, Health & Medicine Week via NewsRx.com & NewsRx.net.
