Each month, this page features selected short items about state
health-care policy digested from newspapers around the country.
Clip File
HCFA asks TennCare to take six "corrective actions" with troubled behavioral health program
NASHVILLE, TN—Under pressure from legislators, Tennessee officials released the results of a Health Care Financing Administration (HCFA) fact-finding mission on the TennCare Partners program, the state’s managed behavioral health program for the Medicaid population and the seriously mentally ill.
Among the documents was a list of six corrective actions HCFA says the state must take. These include reducing inpatient care, ensuring that claims processing, data and payment systems are in place, changing contracts with behavioral health organizations (BHOs) to protect providers from taking too much financial risk, developing a method to monitor that patients are getting the care they need, making sure BHOs are paying providers on a timely basis and separating funding of services to the severely mentally ill from the rest of the population.
HCFA conducted its site visit Feb. 23-28. The state’s documents included financial statements from the two BHOs, showing that Premier Behavioral Systems has received $119.7 million and has paid out $83.7 million for services and that Tennessee Behavioral Health Crop. has received $85.3 million and has paid out $59.9 million to providers. BHOs are allowed a 10% management fee for administration and profits.
The Commercial Appeal, March 20, 1997
Maryland bill would assist consumers in filing HMO appeal, then provide independent review
ANNAPOLIS, MD—Under a broad managed care legislation bill, Maryland consumers who are denied coverage for a procedure or hospital stay by an HMO would be informed that the Health Advocacy Unit of the Attorney General’s Office can assist them in filing an appeal under the insurer’s internal grievance procedures.
If that appeal is unsuccessful, the HMO member would have the right to appeal to the state insurance commissioner who would be authorized to convene an independent panel of health care professionals to hear the case. Significantly, the legislation would put the burden of proof on the insurance carrier to show that its denial was medically justified. The HMO industry says is supports the legislation.
Another measure would require HMOs to explain in their marketing materials how they compensate providers and how each $100 they collect in premiums is allocated.
Baltimore Morning Sun, March 19, 1997
California governor wants to slash 200 services
currently available to undocumented immigrants
SACRAMENTO, CA—Gov. Pete Wilson proposed ending more than 200 state services for undocumented immigrants, a move that would require Californians to show proof of legal residency for a broad range of benefits including state mental health services and prenatal care. Gov. Wilson’s program would require the development of a residency verification system.
Exempted from legal residency requirements would be
critically ill children, such as cancer and cystic fibrosis patients, and severely disabled, aged and critically ill adults already receiving in-home support, long-term care in nursing homes or 24-hour care in state developmental centers.
Gov. Wilson is seeking a federal law change to require the U.S. Justice Department to develop a residency verification procedure for states, said Daniel Kolkey, the governor’s legal affairs secretary.
Once California’s regulations are approved, new applicants for services will have to show that they meet residency requirements. But, verification checks also will have to be conducted for current recipients of services, such as mentally ill patients in state hospitals.
Gov. Wilson’s proposal would prohibit undocumented immigrants from receiving any of 25 state health and mental health
programs.
Sacramento Bee, March 26, 1997
Massachusetts will invite alliances of HMOs and home care agencies to bid for dual eligible program
BOSTON—Massachusetts hopes to award managed care contracts to alliances of HMOs, home care agencies and other health care organizations under Senior Care, a state program that would blend Medicare and Medicaid funds for dual eligibles. About $2.4 billion could be put into one fund for acute and long-term care. About 70 organizations have expressed interest in bidding to provide health care to the 110,000 Massachusetts seniors who would be eligible.
If the initiative wins federal and legislative approval thousands of seniors could get more preventive care and community-based services like Meals on Wheels to help them stay out of nursing homes. They could get acute care in nursing homes to help them stay out of hospitals.
New England’s other states are filing separate plans. The Massachusetts plan could begin operating as soon as July 1998.
Boston Globe, March 14, 1997
Court rules paralyzed woman must repay Medicaid from funds she won in personal injury settlement
NEW YORK—A Suffolk County woman paralyzed in a car accident must pay back Medicaid benefits from a personal-injury settlement, according to a Court of Appeals ruling. In a second case decided by the same court, a Queens mother who won a settlement in a malpractice case against the doctor who delivered her son, must also pay back Medicaid for benefits the state provided for her son’s care.
The Court of Appeals cases could pave the way for counties to collect millions of dollars from Medicaid beneficiaries who win settlements.
The cases centered on different interpretations of a 1993 amendment to the federal Social Services Act, which allows Medicaid recipients to set up Supplemental Needs Trusts with money from friends, relatives and personal injury claims. The trusts cannot be counted as an asset for Medicaid eligibility, but can be used to enhance recipients’ quality of life. New York City and other counties argued for past costs to be recouped before the trust is set up. The other side argued that the federal amendment allows Medicaid to recoup costs only after the recipients’ deaths.
Newsday, March 27, 1997
Missouri governor seeks creation of non-profit
to provide health insurance for 175,000 children
JEFFERSON CITY, MO—Missouri’s governor has proposed that a nonprofit corporation be set up to provide health insurance to uninsured children. All children would be placed in a single risk pool, making them eligible for more favorable health insurance rates. The corporation would seek bids for health insurance packages for these youngsters. The corporation would set the premiums on a sliding scale, based on a family’s income and ability to pay. Public and private contributions would subsidize the premiums for an estimated 175,000 children of working families in Missouri.
St. Louis Post-Dispatch, March 10, 1997
Oxford Health Plans to compile report cards on
surgical procedures for members facing surgery
NORWALK, CT—Oxford Health Plans, Inc. has announced that it will compile report cards on surgical procedures for patients who are facing surgery. The report cards will be compiled from ratings of hospitals, surgeons and nurses who have already had the same type of surgery. Under Oxford’s surgery program, surgeons set up teams of medical professionals to provide services at set fees.
Oxford also unveiled a program to assign each member to a personal service agent—a single person to call whenever they have a question. The person will be responsible for getting them an answer within 24 hours.
Based in Norwalk, Conn., Oxford serves about 1.7 million members nationally.
Philadelphia Inquirer, March 25, 1997
Ohio’s Physician-Health Plan Partnership Act would put physicians in charge of patient-care decisions
COLUMBUS, OH—A bill called the Physician-Health Plan Partnership Act, which would set guidelines for managed care to put physicians in charge of making decisions about patient care, has been introduced in the General Assembly.
The bill would ban gag rules, broaden emergency treatment coverage and set guidelines for experimental treatments. Rep. Dale N. Van Vyven, says the legislation is a joint effort of doctors and managed care organizations.
Columbus Dispatch, Columbus, OH, March 19, 1997
Washington legislation that would restrict access
to insurance clears key committee
OLYMPIA, WA—Washington insurers got the vote they wanted from the Senate Heath and Long-Term Care Committee. Insurers want the state to modify the laws on guaranteed issue, exclusions for pre-existing conditions and other issues. Currently, residents can sign up at any time for health insurance and wait just three months before coverage kicks in for pre-existing conditions.
The Senate Committee approved a bill that would provide guaranteed issue only in July, meaning uninsured residents could be forced to wait for up to 11 months to get affordable insurance. Insurers say the three-month exclusion for coverage of pre-existing conditions is too short and results in "churning" in the market. Opponents of the change are counting on the Democratic governor to veto the bill.
Under the bill, insurers would also be able to turn away applicants in July if the number of applicants exceeded 1.5% of the carrier’s average enrollment in the previous January. Legislators defend the measure by pointing out that it would protect smaller insurers.
The other measures include allowing insurers to drop a plan or product after 90 days’ notice to enrollees, guaranteeing rate increases by putting into statute unacceptable loss ratios that would trigger higher rates and stripping the insurance commissioner of the power to regulate managed care providers.
Seattle Post-Intelligencer, April 2, 1997
Two leading Washington state health insurers win right to impose large rate hikes in individual market
OLYMPIA, WA—After settling nearly two years of litigation with the Washington state insurance commissioner’s office, two of the state’s leading health insurance companies may now go ahead and raise their rates for individual policyholders.
Blue Cross of Washington and Alaska and Pierce County Medical Blue Shield may raise rates on individuals by 11.4% and 16% respectively; they have agreed not to raise the rates again for one year. Insurers cited large losses in the individual market as a result of insurance reforms--some $50 million in losses in 1995--as the reason for needed increases.
Seattle Post-Intelligencer, March 25, 1997
California study says insurance reforms needed
for mid-size firms, to cut costs, improve access
BERKELEY, CA—Insurance reforms are needed to improve access and affordability for mid-size firms with 51-500 employees, says a report on the California insurance market, funded by the California Wellness Foundation.
These mid-size firms need the same protections as small businesses, the report notes, including the use of rating factors and rate bands, price and coverage disclosure, and pre-existing condition limits. A statewide purchasing pool could be established to serve mid-size businesses, recommends the report by the University of California at Berkeley School of Public Health and the UCLA center for Health Policy Research.
Policy Report, UCLA Center for Health Policy Research, Jan. 1997
Each month, this page features selected short items about state
health-care policy digested from newspapers around the country.
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