Ruling Expands Medicare Patients’ Rights

Rejecting the government’s arguments, a federal judge has issued new rules that will significantly expand the rights of Medicare beneficiaries in HMOs to receive speedy hearings in disputes over the denial of medical treatment.

The ruling comes in a 3-year-old class-action lawsuit in Arizona brought by health-care advocates on behalf of Medicare recipients who complained of improper denials of medical care by health maintenance organizations and roadblocks they faced when contesting those decisions.

The decision would affect about 4 million Medicare recipients belonging to HMOs nationwide. Membership in Medicare HMOs has been growing rapidly, with more than 50,000 people age 65 and over joining such plans each month.

The decision was issued last week by U.S. District Judge Alfredo C. Marquez in Tucson but not made public until Tuesday. Marquez’s ruling would require the U.S. Department of Health and Human Services, which oversees Medicare, to revamp its rules to provide immediate hearings--and broader rights--for Medicare patients whenever medical services are denied. His order requires the government to make the changes by early July.

Marquez’s decision follows his rejection in October of government arguments that his court lacked jurisdiction over the matter. The government also argued that the current appeals process for Medicare beneficiaries met federal rules.

At the time, Marquez called on attorneys for the government and consumer advocates to jointly develop a plan to expand appeal rights for Medicare HMOs. The sides were unable to agree on a plan, so Marquez last week largely accepted the recommendations of consumer advocates.

“This decision means that patients and consumers will at least have a fair shot at getting the services they need, when they need them, before it’s too late,” said Lenore Gerard, an attorney at Legal Assistance to the Elderly in San Francisco, who represented plaintiffs in the lawsuit.

In his decision, Marquez, among other things, orders the federal government to require Medicare HMOs to:

* Provide written notice of coverage decisions within five working days after a patient’s complaint, or one day before an ongoing medical treatment is reduced or stopped.

* Issue written notices in “clear, readable” form in large typeface and explain the particular policy in layman’s language.

* Allow patients to contest denials of medical coverage in person or by telephone with whoever was responsible for making their coverage decisions.

The federal government has 60 days to appeal the ruling.

Federal officials were not immediately available for comment.