April 08, 2020

State to oversee HMO ombudsman

AUGUSTA — Maine residents probably will get some help unraveling the mysteries of managed health care, but the proposed consumer resource will have closer ties to government than originally planned.

The Legislature’s Banking and Insurance Committee held a public hearing Tuesday on LD 1848, An Act to Create the Managed Care Ombudsman Program. The program for consumer education and protection was dropped from Maine’s Health Care Improvement Act passed in 1996.

As proposed in 1996, the ombudsman would have been an independent, nonprofit entity, established to help residents choose HMOs, understand their health plans and appeal managed care decisions.

“Since the first public hearing, it’s been amended so radically it bears little resemblance to the original,” said Rep. Jane Saxl, D-Bangor, the bill’s sponsor. She described the revised version as “toned down.”

The ombudsman bill would, in fact, no longer create an independent agency but a new Consumer Health Care Division within the state Bureau of Insurance. If enacted, Saxl said, the legislation would create three new positions, a director, a nurse and an attorney to assist managed care enrollees.

The new bill earned the approval of Maine managed care companies and doctors. John Doyle, attorney for the Maine HMO Council, called it a “reasonable approach” and offered several “friendly amendments,” including one to prevent the new division from recommending specific health plans.

The Maine Medical Association also endorsed the proposal. “Our members spend an enormous amount of time with patients working through red tape,” Joan Cohen said of the state’s doctors.

Not everyone was happy with the compromise. Leo Delicata, an attorney for Legal Services for the Elderly, blasted the reworked document for its failure to separate the new program from state government.

“The Bureau of Insurance will provide a valuable service … but it won’t be enough, and I tell you, they won’t be independent,” he said. “I’m happy that consumers are going to get more information … but I’m deeply disappointed that the consumers of this state are not going to have someone who can speak truth to power.”

His concerns were echoed by John Marvin, president of the Maine Council of Senior Citizens. Under the proposed structure, the consumer division is “highly dependent” on the insurance bureau and superintendent for money and staff, he said.

So what happens if bureau policy is at the root of someone’s problem?

“How likely is the proposed ombudsman to take on his or her employer over a difference of opinion?” asked Marvin.

The early model for the Managed Care Ombudsman was the Long-term Care Ombudsman, an existing independent Maine agency that serves as an advocate and resource for nursing home residents and their families.

Sally Wagley, an attorney for the older ombudsman program, acknowledged the greater independence enjoyed by her organization but said help for HMO members should be the first concern. “We feel it’s time to overlook these differences and move forward,” she said.

A work session on the bill will begin at 9:30 a.m. next Tuesday before the Banking and Insurance Committee in room 427 at the State House.

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