Friday, April 22, 2011

State is sweetening contracts with Evercare and Ohana with SB 1274

SB 1274 is the only way that Hawaii's Medicaid bureaucracy can help their insurance buddies get rid of a lot of nasty legal costs from people appealing their decisions.

Hawaii's external medical decision review panels are a mandated part of Hawaii's contract with CMS (the Centers for Medicare & Medicaid) for the 1115 waiver. As a result, they are also a mandated part of Hawaii's contracts with both UnitedHealth and Wellcare, the only companies who hold provider contracts under that waiver.

Presumably, the feds would never give Hawaii written permission to delete an entire section of the contract dealing with consumer appeal rights. The only way to get UnitedHealth and Wellcare out from under that burden would be a law that repeals the law creating the reviews in the first place:

S.B. 1274 is repealing H.R.S. 432E-6, the law that defines the external review process.

Rafael del Castillo has had thirty cases go through the insurance commission reviews over the past decade, and has eleven cases sitting there now. Ten of them are appeals against UnitedHealth. That seems to imply that the problem isn't the review system, it's UnitedHealth's medical decision making process.

There was a funny rumor going around in January that state employees were working on how to make the contracts with Evercare and Ohana "above federal law." Specific sections of the contract, dealing with appeals and grievances, were being focused on. I provided the information to CMS in mid-January.

Checking my notes, the rumor had to do with the same part of the contract that will be invalidated once SB 1274 goes through.

What a coincidence?

In fact, Evercare was put under a Corrective Action Plan by the state a year ago, for ongoing violations of federal regulations. By and large, these were federal regulations related to mandated procedures for appeals of insurance decisions, grievances, and complaints.

CMS has been receiving documentation of Evercare's ongoing violations of multiple federal regulations for months. CMS has also been receiving documentation of the state's failure to provide the required oversight of Evercare's operations. Letters from Dr. Ken Fink, Hawaii state Medicaid Director, just echo UnitedHealth's corporate line. I reported earlier that Fink's salary is more than twice that of his predecessor, and have not heard that Governor Abercrombie has taken any steps to reduce it.

The agreement between the state and CMS clearly gives federal regulators the ability to step in if the waiver program is no longer in the public interest or there is on-going non-compliance.

Both conditions seem met, which means only federal regulators or attorneys can step in to help us if SB 1274 is passed.

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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.