Medicaid May Restrict Emergency Care
A new Bush administration policy gives states the right to restrict emergency room access for poor people enrolled in managed care Medicaid programs.
The administration says the proposal is designed to give cash-strapped states more flexibility to manage their Medicaid programs, which are jointly funded by federal and state governments.
It is likely to be just the first in a number of significant changes the White House will propose for health programs. The Bush administration is also planning to offer a prescription drug benefit for Medicare subscribers, if Congress allows more private competition in the program.
The new Medicaid guidelines, outlined in a recent letter to state Medicaid directors, narrows standards set out in a 1997 law and in rules issued by the Clinton administration and more recently, by the Bush administration in June 2002.
The 1997 law requires that a Medicaid managed care enrollee be allowed to get emergency services immediately at the nearest provider when the need arises.
It also says that as long as a person's medical condition would appear to be an emergency to a "prudent layperson," no restriction may be placed on that person's access to emergency care. Managed care organizations and primary care case managers could not place visit limitations on Medicaid enrollees to the emergency room.
The change of policy, reported Friday by The New York Times, says states can place certain limits on coverage of emergency services.
In a letter to state officials last month, Dennis Smith, director of the Center for Medicaid and State Operations at the Department of Health & Human Services, said that it was removing both of the requirements on managed care organizations, primary care case managers, prepaid inpatient health plans and prepaid ambulatory health plans.
Smith said that the limitations on amount, duration and scope having to do with emergency services in the state plan will apply to managed care enrollees as well as all other beneficiaries.
States occasionally amend their state plans to place limits on coverage of emergency services, to the extent appropriate, he said, "to allow for more appropriate use of preventive and primary care in outpatient settings."
But under the 1997 law and subsequent regulations, states and managed care organizations were required to cover inpatient days for emergency services for managed care enrollees beyond any state plan-defined limits.
It was not clear from the letter what kind of changes would be allowed. A Louisiana health official said his state would seek to limit adult Medicaid patients to three emergency room visits a year.
The newspaper reported Bush administration officials said that the new policy was consistent with the president's desire to give states greater flexibility in the operation of their Medicaid programs.
States are struggling with the worst fiscal crisis in more than 50 years and are seeking looking for ways to control health costs. Health care costs represent one-third of most state budgets, and they are growing faster than tax revenues, rising 13 percent in the last fiscal year.
Emergency room care is particularly expensive, and some health care experts feel people tend to use the ER for problems that a less expensive doctor's appointment could solve.
However, the Times reports, the 1997 law sought to guarantee emergency room access because some managed care organizations were discouraging emergency room visits even if patients were having symptoms like chest pains.
Sen. Bob Graham, D-Fla., told the newspaper the new policy "would undermine access to essential emergency services for low-income Americans," and questioned its legality.
Some 40 million people are insured through Medicaid with more than 55 percent of them are in some type of managed care.