White House approves limits on emergency coverage

Friday, January 17th 2003, 12:00 am

By: News On 6

WASHINGTON (AP) _ 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 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 when the ``prudent layperson'' standard is met, no restriction may be placed on 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 MCOs, PCCMs, 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.''

Previously, states and managed care organizations were required to cover inpatient days for emergency services for managed care enrollees beyond any state plan-defined limits.

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.

Some 40 million people are insured through Medicaid with more than 55 percent of them are in some type of managed care.