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Class Action Settlement Affects All Medicare HMOs

Wed, 11/08/2000 - 12:00am — Karen Stevenson
Description: 

On August 9, 2000, a proposed "settlement agreement" was filed with the federal district court in Arizona in Grijalva v. Shalala, a nationwide class action lawsuit brought by Medicare HMO enrollees. This lawsuit involves the type of information beneficiaries receive when their HMO wants to deny, reduce, or terminate services, and their appeal rights if they disagree with your HMO's decision. Everyone who is an enrollee of a Medicare-contracting HMO is a part of the nationwide class represented by the Medicare HMO enrollees who brought this lawsuit.

Under the proposed agreement filed with the court, Medicare would propose to create a new system where a HMO would be required to let beneficiaries know 4 days before it wanted to end home health, nursing home, or certain outpatient rehabilitation care. This advance written notice would explain:

  • Why the HMO thinks that services are either not needed or are not covered
  • How they can go about obtaining a fast appeal of the decision from an independent decision maker outside the HMO if you think the services are covered
  • That payment for the costs of care will continue at least until noon of the day following the decision by the independent decision maker.

Under the proposed settlement, Medicare beneficiaries agree that certain issues would no longer be part of this lawsuit, such as how Medicare HMOs inform them when they want to reduce services. However, this agreement would not prevent anyone from starting another lawsuit about these issues, or about issues concerning whether your HMO covers all of the services that it should. This agreement would settle only the issue of what information they receive and how they appeal when their HMO wants to terminate or deny up-front your services. Beneficiaries would still be able to bring lawsuits appealing individual HMO decisions to terminate or deny services.

On August 9, 2000, a proposed "settlement agreement" was filed with the federal district court in Arizona in Grijalva v. Shalala, a nationwide class action lawsuit brought by Medicare HMO enrollees. This lawsuit involves the type of information beneficiaries receive when their HMO wants to deny, reduce, or terminate services, and their appeal rights if they disagree with your HMO's decision. Everyone who is an enrollee of a Medicare-contracting HMO is a part of the nationwide class represented by the Medicare HMO enrollees who brought this lawsuit.

Under the proposed agreement filed with the court, Medicare would propose to create a new system where a HMO would be required to let beneficiaries know 4 days before it wanted to end home health, nursing home, or certain outpatient rehabilitation care. This advance written notice would explain:

  • Why the HMO thinks that services are either not needed or are not covered
  • How they can go about obtaining a fast appeal of the decision from an independent decision maker outside the HMO if you think the services are covered
  • That payment for the costs of care will continue at least until noon of the day following the decision by the independent decision maker.

Under the proposed settlement, Medicare beneficiaries agree that certain issues would no longer be part of this lawsuit, such as how Medicare HMOs inform them when they want to reduce services. However, this agreement would not prevent anyone from starting another lawsuit about these issues, or about issues concerning whether your HMO covers all of the services that it should. This agreement would settle only the issue of what information they receive and how they appeal when their HMO wants to terminate or deny up-front your services. Beneficiaries would still be able to bring lawsuits appealing individual HMO decisions to terminate or deny services.