CMS reverses field on ED restrictions
A Centers for Medicare & Medicaid Services (CMS) decision to allow managed care organizations to limit and restrict coverage for emergency services for Medicaid recipients lasted just five weeks and never was implemented by states before the administration reversed field in the face of Congressional pressure and rescinded the provision.
In a Dec. 20, 2002, letter to state Medicaid directors, CMS Medicaid director Dennis Smith said the previous policy for Medicaid recipients had been that states could not limit coverage of emergency services for Medicaid beneficiaries in managed care, even though limits were allowed for those Medicaid recipients in fee-for-service programs. CMS officials say that Alabama, Florida, Idaho, Mississippi, and Wyoming have established limits on emergency services in their fee-for-service program.
The standard for managed care recipients had been that emergency service claims had to be paid if a "prudent layperson" would think that the service was needed. A 1997 law requires that a Medicaid managed care enrollee be allowed to get emergency services immediately at the nearest hospital when the need arises. It also included the prudent layperson provision. Smith’s letter said CMS was removing both of the requirements on managed care organizations.
But opposition was voiced by aides to both Republican and Democratic senators who said that legislation would be introduced if necessary to reverse the CMS guidelines. In a letter to leaders of the Senate Finance Committee, CMS administrator Thomas Scully said the Bush administration wanted to defuse the dispute over what he said was a "rather overblown" issue of emergency department (ED) use by Medicaid recipients at a time when "we are trying to get a lot of stuff done." He told the Washington Post CMS had not been troubled by the policy, but was concerned about the controversy it had caused. "We want to get off to a friendly, happy, bipartisan start of the year, This clearly wasn’t doing it." And he told The New York Times that while the policy was "very defensible" in terms of giving states more flexibility, "we have a busy agenda on other health care issues this year, and it was not worth getting into a controversy over coverage of emergency services."
Florida Democratic Sen. Bob Graham, who had sponsored the 1997 legislation, said returning to the original standard "will not only protect coverage for Medicaid patients; it will save lives. People should not be dissuaded from using emergency services when they need them."
While some state officials have said there were disputes over who should pay for emergency care and have expressed a desire to find ways to move patients into primary care settings when they are more appropriate, it appears they had not asked CMS for this change.
National Association of State Medicaid Directors vice chairman Gregory Vadner, Missouri’s Medicaid director, said the reversal would have little practical effect because states had not begun to restrict ED use based on Smith’s letter. "Really, in the big scheme of things, I don’t think it will be something that all the states will be greatly disappointed about," he told the Post.
In his letter, Scully said CMS wanted to work with Congress to find other ways of discouraging unnecessary use of EDs.
A Centers for Medicare & Medicaid Services (CMS) decision to allow managed care organizations to limit and restrict coverage for emergency services for Medicaid recipients lasted just five weeks and never was implemented by states before the administration reversed field in the face of Congressional pressure and rescinded the provision.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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