[Congressional Record Volume 144, Number 135 (Thursday, October 1, 1998)]
[Extensions of Remarks]
[Page E1870]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




            MEDICARE+CHOICE MEDICAL NECESSITY PROTECTION ACT

                                 ______
                                 

                        HON. FORTNEY PETE STARK

                             of california

                    in the house of representatives

                       Thursday, October 1, 1998

  Mr. STARK. Mr. Speaker, I rise to introduce the Medicare+Choice 
Medical Necessity Protection Act. With passage of the Balanced Budget 
Act, Congress has opened the Medicare program to a host of private 
insurance companies that will be competing with each other to get the 
most Medicare patients while spending the least amount of money. One of 
the cost-saving mechanisms commonly used to managed care plans today is 
to interpret ``medical necessity'' on their own terms. In this manner, 
health plans can avoid paying for services that would be considered 
normal and appropriate based on the standard medical practice of the 
day. Using such means, health plans can and do override the medical 
decisions of treating physicians.
  The clearest examples of this type of health plan behavior have also 
been areas where Congress has recently considered specific legislation. 
In the last Congress, we passed a law to prohibit health plans from 
requiring a mother who had just given birth to leave the hospital in 
less than 48 hours after birth. This year, Congress has been 
considering similar legislation with respect to a two-day stay for 
women who have undergone mastectomies.
  It is not good legislative policy to pass such case-by-case fixes to 
health plan behavior that we find abhorrent. Standard medical practices 
change on a continual basis. Having requirements for length-of-stay in 
federal law could become problematic if that medical standard changes. 
These decisions are best left in the hands of medical professionals. 
Unfortunately, with the growth of managed care in our country, it is 
often not medical professionals who are making such treatment 
decisions. These cases are becoming so blatantly arbitrary and without 
medical merit that Congress has been forced into action by public 
outcries. Rather than continue such case-by-case legislating, I support 
the creation of a medical necessity standard that would eliminate 
health plans' abilities to manipulate the standard.
  Under this proposal, medical necessity would be defined as ``a 
service or a benefit which is consistent with generally accepted 
principles of professional medical practice.'' This definition was part 
of the Democratic Patients' Bill of Rights (HR 3605), which created 
federal consumer protection standards for managed care plans in the 
private sector. It is also the common definition of medical necessity 
which has been established in case law over the past century.
  The Medicare+Choice Medical Necessity Protection Act would add that 
same definition of medical necessity to the Medicare+Choice program. 
This change would help ensure that seniors' who join any of the new 
Medicare+Choice health plan options in Medicare would have the 
protection of knowing that their private health plan could not 
manipulate the rules in order to avoid coverage and payment for 
appropriate medical services. It would put medical decision-making back 
in the hands of doctors where it belongs--not under the control health 
plan bureaucrats.
  Let me emphasize that this amendment would not mean that a health 
plan would ever be required to cover a service that is clearly not 
covered by the plan's contract. It only applies to covered services. 
So, if a health plan does not provide coverage for hearing aids, 
inclusion of this definition would never require the health plan to 
make an exception and cover a hearing aid for a particular person.
  The Medicare+Choice Medical Necessity Protection Act is a simple, 
sensible bill. It would ensure that all Medicare+Choice plans are 
playing under a uniform set of rules for coverage determinations and 
would end the practice of health plans arbitrarily overriding doctors' 
judgments. Our Medicare beneficiaries deserve no less. I urge my 
colleagues to join me in support of this important legislation.

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