Medicaid Program

House Speaker Casper R. Taylor Jr. unveiled yesterday the outlines of a reform package to bring health insurance to the more than 500,000 Marylanders who don't have coverage. The package calls for expanding income limits for the Medicaid program for the poor, currently about $4,000 a year for an individual, to $13,200; subsidizing coverage on a sliding scale for those making between $13,200 and $22,150; regulating and standardizing individual insurance to make buying policies easier for those who can afford them; and dangling tax incentives to employers for offering affordable health coverage to their workers.

Maryland's Medicaid program violated federal rules when it refused to reimburse Johns Hopkins Hospital for two teen-agers' life-saving liver transplants after the state said the operations were not "appropriate," Maryland's highest court said yesterday. Federal Medicaid guidelines clearly state that only medical necessity - not whether a life-saving procedure is "appropriate" - is the standard that applies to patients under age 21, the Court of Appeals said in a unanimous ruling. The case, which stems from a pair of operations costing a total of $264,000, could affect a range of Medicaid-funded procedures for children that require preauthorization under Maryland regulations, such as other transplants and mental health services, lawyers said.

Responding to a key recommendation of a health department evaluation of Maryland's Medicaid program, the governor yesterday proposed including an extra $25 million in the state budget to increase physician fees. Matched by an equal amount of federal dollars, the new money will be targeted to physician office-visit reimbursements, said Debbie I. Chang, deputy health secretary, and will help assure the program attracts and retains enough participating doctors. While the doctor fee increase is subject to the legislative budget process, Chang said other major recommendations of the evaluation - also released yesterday - can be accomplished by the health department without action by the General Assembly.

When 2-year-old Conor Prochaska dislocated his elbow at his home in Easton, he had to go to Glen Burnie to get it checked out by an orthopedist. And in that drive across the Chesapeake Bay Bridge to see a medical specialist - and other trips like it - lies a problem that could cost the Maryland Medicaid program millions of dollars to fix. The long journey to Conor's orthopedist stems from the fact that many specialists in rural areas refuse to participate...

A state Senate subcommittee was told yesterday that the Medicaid program has failed to achieve its projected budget savings - but also that the program is underfinanced. Senators generally agreed with the latter assertion. Sen. Barbara A. Hoffman, the Baltimore Democrat who heads the Budget and Taxation Committee, said, "I've never seen an agency so poorly funded." David C. Romans, a legislative budget analyst, told the subcommittee on health and human services that when Medicaid shifted more than 300,000 welfare mothers and children in 1997 from fee-for-service coverage to a program operating through HMOs, the state had expected to cut costs by 10 percent.

HMOs don't want to take 40,000 Baltimore Medicaid enrollees who need to find another health plan April 1, officials of three health plans told the state Senate Finance Committee yesterday. The 40,000 are enrolled in FreeState Health Plan, which will leave the Medicaid program April 1. FreeState said the rates the state pays in the Medicaid program, which it calls HealthChoice, are too low. "None of the parties in HealthChoice are willing to absorb these 40,000 enrollees," Eric R. Wagner, MedStar Health's vice president, managed care, testified.

Double-digit inflation is returning in health care - one national study published last month predicted an 11 percent average increase in health premiums for this year - but health care providers say they are caught in a money crunch. Doctors are worried that insurers are not paying them adequate rates. This year, "the big question is whether we start to see physicians telling bottom-dwelling HMOs to take a hike," said T. Michael Preston, executive director of the state medical society.

CareFirst BlueCross Blue- Shield, which announced three months ago that it was pulling out of the Medicaid program in most of Maryland, said yesterday that it was leaving the state program entirely. About 40,000 Medicaid enrollees, almost all in Baltimore, will have to choose new HMOs by April 1, when the CareFirst pullout takes place. Debbie I. Chang, deputy health secretary, said most of the 40,000 would be able to stay with the same doctors by choosing other HMOs with which their doctor participates.

The Maryland Court of Appeals heard arguments yesterday on whether the state's Medicaid program should reimburse Johns Hopkins Hospital for liver transplants that the hospital performed on teen-agers who were refused preauthorization by the state. Despite those refusals, doctors at Hopkins performed the operations in 1996 on Taurus Jackson, now 18, and Jessica Nettles, who has since died. "Hopkins decided to treat first and worry about [the] payment source later," said Marta D. Harting, attorney for the hospital.

Administrative problems in the state's Medicaid program are limiting access to care, according to a report to be released today by Advocates for Children and Youth. Among the problems, the report says, are that there are too few doctors, causing long waits for some services - including one child who, although his condition was not life-threatening, waited six months for an appointment to have a bullet removed from his chest. Also, the report says, children have been assigned to doctors other than their usual pediatrician, and parents have had problems getting care for newborns because the baby does not yet have a membership number for one of the HMOs that provides insurance under HealthChoice, the state's Medicaid program for low-income people, mostly mothers and their children.