Tuesday, May 25, 2010

Who gets to decide medical necessity in Hawaii: NOT the insurance companies

Yesterday's story about Hawaii's Medicaid program for the elderly and disabled quoted the regional president for Hawaii at Wellcare as saying "we approve all medically necessary care to members."  A UnitedHealth spokesperson was quoted saying their health plan is "required to...assure that members receive medically necessary services."

When Erik Sorensen's home care services were cut by Wellcare, his appeal ended up at the Hawaii State Insurance Commission.  The decision, released on February 25, clearly stated that, in imposing the cuts in services, Wellcare "made a coverage decision without undertaking the required statutory medical necessity analysis."

There are currently several other cases pending at the state insurance commissioner, all alleging that cuts in services by both Wellcare and UnitedHealth have not met "the required statutory medical necessity analysis."

Yesterday's story in the Honolulu Advertiser omitted any mention of the cases pending against Wellcare and UnitedHealth at the state Insurance Commission.  It not mention the February 25 decision of the Insurance Commission against Wellcare, which directly contradicts the official company statement which was cited in the article.

In fact, the decision referred to Wellcare's concept of "medical necessity" as "an absurd statutory construction." 

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About Me

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I'm the mom of a child with disabilities. Hannah's first neurologist said she might never develop beyond the level of a 2 month old infant, and there wasn't anything I could do about it. The brain damage was just too severe. Nine years later, she walks, uses a touchscreen computer and I've just been shown she can learn to construct sentences and do simple math with the right piece of technology. Along the way, I discovered I needed to teach myself what Hannah's rights to services really were. Learning about early intervention services led to reading about IDEA and then to EPSDT. I've been waiting for the Obama administration to realize the power and potential of EPSDT for the medical rights - including the right to stay at home with their families - of children with disabilities. The health reform people talk about long term care, and the disability people talk about education and employment, but nobody is talking about EPSDT. So I am.