June 20, 2002
Consumers Union, Southwest Regional Office
on today’s U. S. Supreme Court decision
relating to independent review of denials of care by HMOs
“The Supreme Court’s decision today (Rush Prudential HMO v. Moran) will allow millions of Texas consumers to use the state’s independent review process when denied care by their HMOs. This decision represents a huge gain for insured consumers who are desperately seeking medically necessary care.
“Consumers Union’s recent report on the Texas independent review process revealed that one of the biggest problems was its underuse. Consumers don’t participate because Texans covered by self-funded employer health plans authorized under the federal law — Employees Retirement Income Security Act of 1974 (ERISA) — did not have guaranteed access to the process established by state law. Aetna filed a lawsuit in Texas that took this right away from over four million Texans and their families. According to the Texas Department of Insurance, about half of Texans with health insurance are covered by ERISA plans.
“The Aetna case made its way to the U.S. Supreme Court, but the Court took up a similar case first (Rush Prudential HMO v. Moran). The Court, in a 5-4 decision, ruled that ERISA does not preempt the independent review provisions in the Illinois HMO law, siding with the patient (Moran) whose access to that state’s independent review process was denied.
“We want all Texas consumers covered by health plans to know that they have strong rights when they are denied access to care. If that denial was based on a finding by the health plan that the care is “not medically necessary” they have a right to request a review in which an independent physician or healthcare provider will take a second, unbiased look at their case. If that independent provider determined the care is medically necessary, the health plan must, by law, pay for the care.
“Our research showed that on average, over half of these denials are overturned by the independent reviewers, and when the care being denied is connected to mental health treatment or treatment, the reviewers are overturning the denials 70% of the time. Similar patterns exist for denials of treatment for severe obesity and substance abuse.”
Consumers Union Southwest Office
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