U.S. Curbs Medicaid Emergency Care

Poor people on Medicaid seeking emergency care may have a more difficult time getting coverage by managed-care organizations under a new policy by the Bush administration.

The new 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.

The 1997 law allowed states to put participants in Medicaid into cost-cutting health maintenance organizations and other managed-care plans, but it required that these plans include certain patient protections.

Among them: Medicaid HMOs must pay for emergency room visits if a “prudent lay person” would consider the health problem to be an emergency. As a result, HMOs and case managers could not arbitrarily limit the number of visits of Medicaid enrollees to the emergency room.

The policy change allows states to put limits on coverage of emergency services.

White House Press Secretary Ari Fleischer said Friday that the change was not meant to reduce benefits for anyone. “The issue here is to make sure emergency rooms are used for emergencies” and not for primary care, he said.

But Democrats in Congress cried foul.

“Congress enacted the prudent lay person standard so that individuals would not be denied needed emergency care by arbitrary HMO network and prior-authorization restrictions,” Rep. John D. Dingell (D-Mich.) and other Democrats wrote Health and Human Services Secretary Tommy G. Thompson on Friday. The change, they said, “raises questions about these statutory protections for patients, and may actually eviscerate them.”