Medicaid MCO Quality Ratings

https://www.kff.org/medicaid/state-indicator/medicaid-mco-quality-ratings/view/print/?currentTimeframe=0&print=true&sortModel=%7B%22colId%22:%22State%22,%22sort%22:%22asc%22%7D

NOTES

Notes

Data reflect NCQA’s 2019 ratings of Medicaid managed care plans. The plans included in the NCQA data do not always match the MCOs in other tables in the Medicaid Managed Care Market Tracker, or they may appear under different names. Discrepancies may be due to differences across reports and sources, timeframes, and other factors. MCOs not accredited or rated by NCQA may be accredited or rated by other organizations.

The NCQA plan overall rating scale is 0-5 (0 is lower performance, 5 is higher performance). NCQA accreditation is as of June 30, 2018. For more information about how NCQA rates plans, please see NCQA’s methodology.

Sources

NCQA Health Insurance Plan Ratings 2018-2019 – Summary Report (Medicaid). Special Data Request, October 2019.

Definitions

Partial Data Reported: Plans with partial data do not receive a rating, but NCQA lists them in the ratings and shows their scores on the measures they report. A plan is considered to have partial data if it submits HEDIS and CAHPS measure data for public reporting, but has insufficient data for one or more measures, submits HEDIS data for public reporting but does not submit CAHPS data, or vice versa, or earned NCQA Accreditation without HEDIS data (health plan accreditation standards only) and did not submit HEDIS or CAHPS data for public reporting.

No Data Reported: Plans that submit results but do not report data publicly, or plans that report no HEDIS, CAHPS or accreditation information to NCQA, are given a rating status of “No Data Reported”.

Insufficient Data: Plan has “missing values” (i.e., NA or NB) in more than 50 percent of the weight of the measures used in the methodology.

Florida Law Reminder for Early Prescription Refills (Managed Care Plans)

​Tallahassee, Fla. – Following Governor DeSantis’ Executive Orders 21-150 and 21-151 in response to Tropical Storm Elsa, the Florida Office of Insurance Regulation (OIR) issued the following notice to all health insurers, managed care organizations and other health entities licensed by OIR.

Florida Law Reminder for Early Prescription RefillsTuesday,

July 6, 2021

Contact Info:

​(850) 413-2515
press@floir.com

  
Tallahassee, Fla. – Following Governor DeSantis’ Executive Orders 21-150 and 21-151 in response to Tropical Storm Elsa, the Florida Office of Insurance Regulation (OIR) issued the following notice to all health insurers, managed care organizations and other health entities licensed by OIR.

To: All Health Insurers, Managed Care Organizations, and Other Health Entities Authorized to do Business in Florida RE: Tropical Storm Elsa – Notice of Florida Law for Early Prescription Refills 

This notice is a reminder that all health insurers, managed care organizations, and other health entities must comply with must comply with the provisions of section 252.358, Florida Statutes, which allows for early prescription refills in the event that the Governor issues an Executive Order declaring a State of Emergency or when a county Emergency Operations Center (EOC) is activated.This statute has now been triggered due to Tropical Storm Elsa for Alachua, Charlotte, Citrus, Collier, Columbia, Dixie, Franklin, Gilchrist, Hamilton, Hernando, Hillsborough, Jefferson, Lafayette, Lake, Lee, Levy, Madison, Manatee, Marion, Monroe, Pasco, Pinellas, Sarasota, Sumter, Suwanee, Taylor, and Wakulla counties. This mandate remains in effect until the Governor’s Executive Orders are rescinded or expires.

Declaration of Emergency by Governor DeSantisThe Governor’s Executive Orders 21-150, and 21-151 are available here. In accordance with section 252.358, Florida Statutes, Emergency-preparedness prescription medication refills:

  • All health insurers, managed care organizations, and other entities that are licensed by the Office of Insurance Regulation and provide prescription medication coverage as part of a policy or contract shall waive time restrictions on prescription medication refills, which include suspension of electronic “refill too soon” edits to pharmacies, to enable insureds or subscribers to refill prescriptions in advance, if there are authorized refills remaining, and shall authorize payment to pharmacies for at least a 30-day supply of any prescription medication, regardless of the date upon which the prescription had most recently been filled by a pharmacist, when the following conditions occur:
  • (1) The person seeking the prescription medication refill resides in a county that:
    • (a) Is under a hurricane warning issued by the National Weather Service;
    • (b) Is declared to be under a state of emergency in an executive order issued by the Governor; or
    • (c) Has activated its emergency operations center and its emergency management plan.

  • (2) The prescription medication refill is requested within 30 days after the origination date of the conditions stated in this section or until such conditions are terminated by the issuing authority or no longer exist. The time period for the waiver of prescription medication refills may be extended in 15- or 30-day increments by emergency orders issued by the Office of Insurance Regulation.

This section does not excuse or exempt an insured or subscriber from compliance with all other terms of the policy or contract providing prescription medication coverage.

PLEASE BE GOVERNED ACCORDINGLY.

Resources to Pay for Prescription Drugs

Insurance companies regularly update their formularies to classify drugs under certain payment categories. It’s best to ask your doctor to help you find out what payment category your drug is in before you go to the pharmacy to avoid an unpleasant surprise when the bill arrives.

However, many prescription medications for mental health conditions are very expensive and even with health insurance, you can find yourself paying a lot for a prescription.

Help Paying For Medication

The ongoing cost of prescription medications can be a challenge, especially if you are taking more than one prescribed medication.

Some pharmaceutical companies offer prescription assistance programs to individuals and families with financial needs. These programs typically require a doctor’s consent and proof of your financial status. They may also require that you have either no health insurance or no prescription drug benefit through your health insurance.

In addition, there are county, state, and national prescription programs for which you may qualify and special drug discount cards offered by some pharmaceutical companies.

The Partnership for Prescription Assistance can help qualifying patients without prescription drug coverage get the medicines they need through the program that is right for them. Many will get their medications free or nearly free. For more information, visit http://www.pparx.org/ or call 1-888-477-2669.


Cutting Costs

It is important to let your doctor know if you cannot afford your prescriptions. In some cases, they may be able to give you free samples of your medications. Discuss with your doctor if switching to generic drugs or less expensive brand-name prescription drugs is a safe option for you.

When a doctor determines that a brand name medication is medically necessary for you or if you are seeking a generic that is identical to the brand but you have trouble affording the higher cost of the brand name medication, a third option may be available. This third option is an authorized generic. An authorized generic medication is a medication made by the original creator of the drug, using the exact same formula (including inactive ingredients) as the original drug. It is manufactured by the maker of the brand name medication and distributed by a special generics division of the drug company. An authorized generic medication will cost the same as a generic medication. But you may have to specially request it from your pharmacy because they may not keep it in stock. Not all medications are available in authorized generic form, but you can check to see if yours is at www.authorizedgenericmedicines.org/product-finder.

Another way to cut costs is to compare the prices of your prescription drugs at different retail pharmacies (CVS vs Walgreens vs Walmart, etc.). Many retail pharmacies list their prices for commonly prescribed drugs online. You can also call local pharmacies to request prices for your medications.

Consider using a prescription savings card such as FamilyWize as another way to cut costs. FamilyWize, a trusted MHA partner, is a community service partnership focused on enabling everyone, both insured and uninsured, to have access to more affordable medications.  

The FamilyWize Prescription Discount Card: 

  • Is FREE for all
  • Has no eligibility requirements
  • Gives you discounts on your meds, whether you have insurance or not
  • Saves you an average of 54% on mental health medications

FLORIDA: Policing Reforms to Reduce Violence Against Minorities Effective Immediately

House Bill 7051, the package of policing reforms negotiated this spring by members of Florida’s Legislative Black Caucus and Republican leaders, was signed into law late Tuesday by Gov. Ron DeSantis, along with 93 other approved bills. The reforms take effect immediately and would impact not only minorities but other people facing trouble with the law.

House Bill 7051, the package of policing reforms negotiated this spring by members of Florida’s Legislative Black Caucus and Republican leaders, was signed into law late Tuesday by Gov. Ron DeSantis, along with 93 other approved bills. The reforms take effect immediately and would impact not only minorities but other people facing trouble with the law.

Policing reforms to reduce violence against minorities and others take effect immediately

New limits on use of force by police, new training standards, and greater focus on identifying dangerous police practices are now in effect in Florida, though Black legislative leaders say those efforts don’t go far enough.

House Bill 7051, the package of policing reforms negotiated this spring by members of Florida’s Legislative Black Caucus and Republican leaders, was signed into law late Tuesday by Gov. Ron DeSantis, along with 93 other approved bills. The reforms take effect immediately and would impact not only minorities but other people facing trouble with the law.

State Rep. Fentrice Driskell, a key sponsor of the reforms, said they constitute a first step toward safer relations between police and people of color in Florida and that the bipartisan legislative effort is worthy of celebration.

“I’m very glad to see the governor sign this into law. The entire Legislature should be proud of it,” Driskell, a Hillsborough County Democrat, told the Phoenix in a phone interview.

That said, the new policing law doesn’t ban chokeholds and vascular neck restraints but limits the use of them to encounters when an officer “perceives an immediate threat of serious bodily injury or death to himself, herself, or another person.” That kind of restraint was used of by former Minneapolis policeman Derek Chauvin, now convicted of murder, to kill George Floyd, an unarmed, handcuffed suspect in his custody.

The killing of Floyd in May 2020, recorded on video seen around the world, ignited national and international protests against police brutality and inspired a movement for policing reform.

Members of the Black Caucus, led by Rep. Driskell and Sen. Randolph Bracy, an Orlando Democrat, said when the reforms were approved in the final days of the 2021 legislative session, they were considered a good first step for preventing deadly encounters between police and the policed.

The reforms do not include, for instance, requirements that Florida law enforcement officers use bodycams and dashboard cameras to record their activities, as was sought by Black Caucus members and their allies.

“Police reform is long overdue in this state and this country. … People of color are disproportionately affected and in some horrifying cases have cost someone their life,” House Co-leader Bobby DuBose, a Broward Democrat, said in a press statement on Wednesday.  “We will continue having conversations with our communities and law enforcement agencies to propose new legislation at the state and federal levels to ensure there is fair and just policing for all.”

Sen. Bobby Powell, a Palm Beach Democrat and chair of the Florida Legislative Black Caucus, said [This law] acknowledges there is a systemic issue in the hiring, training and accountability of law enforcement and correctional officers. I am hopeful that this is the first step of many towards substantial change.”

On Wednesday, Police Chiefs Association President and Satellite Beach Police Chief Jeff Pearson praised the new law in a statement to the Phoenix:

“In the wake of George Floyd’s murder last year, the Florida Police Chiefs Association established a Subcommittee on Accountability and Social Change that hosted over 23 meetings with community leaders to determine how law enforcement can better serve communities. Their recommendations largely formed the basis for HB 7051.”

Pearson wrote that the new law “approaches reform correctly — factual and balanced, ever mindful of the dedication and sacrifice of law enforcement officers, but equally committed to public safety and accountability.”

Pearson said the subcommittee is working to finalize a detailed report of additional recommendations “that law enforcement and community leaders can use to continue making progress together.”

The new law also:

/Requires an officer who observes another officer engaging or attempting to engage in excessive use of force to intervene;

/Require law enforcement agencies to report quarterly to the Florida Department of Law Enforcement on use-of-force incidents that result in serious bodily injury, death, or the discharge of a firearm at a person;

/Require applicants for law-enforcement, corrections or probation jobs to disclose their history of any pending criminal, civil, or administrative investigation;

/Require a law enforcement or correctional agency to maintain records on why an officer was terminated, resigned or retired;

/Requires the Criminal Justice Standards and Training Commission to establish standards for police training in use of force, and requires agencies to develop policies in proportional use of force and de-escalation techniques;

/Establishes that an officer has a duty to render medical assistance to a person in custody who is injured by an officer’s use of force;

/Requires instruction on recognizing symptoms and characteristics of a person with a substance abuse disorder or mental illness and how to appropriately respond;

/Requires independent reviews of officers’ use of force resulting in a death or the intentional firing of a firearm resulting in injury or death;

/Prohibits children younger than seven from being arrested, except if the child commits a forcible felony.

The Police Chiefs Association is holding its annual summer conference in Plantation. Association President Pearson will step down, and his successor, Stephan Dembinsky, director of the Daytona Beach Shores Public Safety Department, will be installed as the new president tonight, said association spokesman William Stander.

Rep. Driskell was invited to speak at the conference but was unable to attend.

The Florida Sheriffs Association has not yet responded to a request for comment.

Florida Phoenix is part of States Newsroom, a network of news outlets supported by grants and a coalition of donors as a 501c(3) public charity. Florida Phoenix maintains editorial independence. Contact Editor Diane Rado for questions: info@floridaphoenix.com. Follow Florida Phoenix on Facebook and Twitter.

Florida Market Telehealth Rule & Controlled Substances

Rules regarding telehealthcare in Florida.

During the 2019 legislative session, Florida passed Chapter 2019-137, Laws of Florida, which establishes standards of practice for telehealth services, including patient evaluations, record-keeping, and controlled substances prescribing. The law also authorizes out-of-state health care practitioners to perform telehealth services for patients in Florida. Signed by the Governor on June 25, 2019, this law became effective on July 1, 2019.

Out-of-state health care practitioners must be registered with the Florida Department of Health to perform telehealth services for patients in Florida.

Health care providers must be licensed within their scope of practice by the appropriate licensing body to practice telehealth in Florida.

Providers must also use two-way, interactive communication tools, such as live video, instead of email or audio-only communication. If you use Medicaid, your telehealth provider must be registered with the Florida Medicaid program to receive reimbursement for telehealth services. Florida doesn’t require private insurers to cover telehealth, so check with your insurance company to determine if you’re eligible for the service. Some of these regulations may be altered during the COVID-19 pandemic.

In Florida, telehealth providers are permitted to prescribe medications if the medications aren’t listed as controlled substances.

Controlled substances shall not be prescribed through the use of telemedicine except for the treatment of psychiatric disorders. This provision does not preclude physicians from ordering controlled substances through the use of telemedicine for patients hospitalized in a facility licensed pursuant to Chapter 395, F.S.

Telemedicine Rule, Rule 64B8-9.0141, F.A.C.

However, there is one important exception to this rule: If you need a controlled substance to manage a mental health condition, your telehealth provider is allowed to prescribe it.

Before prescribing medication, your telehealth provider must conduct an evaluation and explain the risks and benefits of the medication to you.

Filling out a questionnaire before your telehealth appointment isn’t enough to satisfy the evaluation requirement, so you should expect the provider to ask multiple questions about your symptoms and health history.

CMS Bundled Payments for Care Improvement (BPCI) Initiative: A Discussion on Bundled Payments

There is a large disconnect between what occurs after a patient is discharged from a hospital (acute) and what occurs thereafter. The quality of care is entirely unmanaged, uncontrolled, and unmonitored. Moreover, the patient is placed at greater risk whe

Understanding the CMS Bundled Payments for Care Improvement (BPCI) Initiative

In recent years, healthcare has been undergoing a significant transformation, driven by the need to improve care delivery and reduce costs. One of the key initiatives in this transformation is the Bundled Payments for Care Improvement (BPCI) program, introduced by the Centers for Medicare & Medicaid Services (CMS). The BPCI program is part of a broader effort to move the U.S. healthcare system towards value-based care, focusing on quality outcomes rather than the volume of services.

What is the BPCI Initiative?

The BPCI initiative was launched as part of the Affordable Care Act (ACA), which allowed the establishment of the Center for Medicare and Medicaid Innovation. The goal of this center is to pilot and expand innovative payment models that improve healthcare quality while reducing costs. BPCI is one of the many alternative payment models (APMs) being tested to align financial incentives with the quality of care provided, particularly in the post-acute care (PAC) setting.

The BPCI program focuses on bundled payments, which means that instead of paying for each service separately, healthcare providers receive a single, comprehensive payment for an entire episode of care. This “bundle” covers all services related to a patient’s treatment, including post-hospitalization care, for a specified period (e.g., 30 or 90 days). The goal is to incentivize providers to deliver coordinated, high-quality care that reduces unnecessary services and prevents avoidable readmissions.

Why Focus on Post-Acute Care?

One of the most challenging areas of healthcare to manage, particularly within the Medicare Fee-For-Service (FFS) program, is post-acute care. After patients are discharged from the hospital, they often require further care in settings such as inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), or home health agencies (HHAs). The costs and quality of care in these settings vary significantly across the country, contributing to wide regional disparities in Medicare spending. In fact, 73% of the variation in Medicare spending is attributed to differences in post-acute care settings.

The BPCI initiative specifically targets these post-acute care settings because of the high cost and the potential for improvement. For example, about 20% of Medicare patients are readmitted to the hospital within 30 days of discharge, and research suggests that 75% of these readmissions could be prevented with better care coordination.

The BPCI Models

The BPCI initiative includes four different models, each offering a different approach to bundled payments:

  1. Model 1: Retrospective Acute Care Hospital Stay Only – This model focuses on hospital costs for acute care stays.
  2. Model 2: Retrospective Acute and Post-Acute Care Episode – In this model, hospitals are financially responsible for both the acute care and all post-acute care services provided within 30 or 90 days of discharge.
  3. Model 3: Retrospective Post-Acute Care Only – This model places post-acute care providers (e.g., SNFs, HHAs) at financial risk for the services they provide after a hospital discharge.
  4. Model 4: Prospective Acute Care Hospital Stay Only – In this model, hospitals receive a single, upfront payment for an acute care stay, and they cannot bill for any additional services, even if the patient is readmitted within 30 days.

Model 2 is the most complex and widely adopted model, as it requires hospitals to manage the entire episode of care, including both acute and post-acute services. The financial risk is reconciled retrospectively, meaning that CMS reviews the total cost of care after the episode is complete and compares it to a pre-determined target price. If the costs are lower than the target, the hospital may share in the savings; if the costs are higher, the hospital is responsible for the excess.

Implementation Strategies for Success

To succeed in the BPCI initiative, hospitals and post-acute care providers need to collaborate closely. Many hospitals are implementing strategies such as narrowing their networks to include only high-performing post-acute care providers. This ensures that patients are discharged to facilities with strong track records in quality care and low readmission rates.

Hospitals are also using tools like patient choice letters, which list all available post-acute care providers but highlight those that have been vetted for quality. This approach, known as “soft steerage,” helps guide patients toward the best providers without restricting their choices.

In addition to collaboration, data sharing and technology play a crucial role in the success of BPCI. Hospitals need visibility into the patient’s care journey after discharge, which can be facilitated through electronic health records and other data integration tools. This allows for better coordination and monitoring of patient outcomes across the continuum of care.

Challenges and Opportunities

While the BPCI initiative offers significant opportunities for improving care and reducing costs, it also presents challenges. One major issue is the complexity of managing bundled payments, especially with the retrospective reconciliation process that introduces delays in financial feedback. Hospitals need to track performance in real-time and adjust their strategies based on ongoing data, rather than waiting for quarterly reconciliations from CMS.

Another challenge is managing high-risk patients and outlier cases, which can significantly skew financial outcomes. However, as bundled payment models continue to evolve and expand, hospitals that proactively adapt to these challenges will be better positioned for success in the shifting healthcare landscape.

Conclusion

The BPCI initiative is an important step towards a value-based healthcare system, particularly in managing the costly and often fragmented post-acute care segment. By aligning financial incentives with quality outcomes, the BPCI program encourages providers to deliver more coordinated, efficient care, reducing unnecessary services and preventable readmissions.

As bundled payment models continue to expand, healthcare providers who embrace this shift now will be better prepared for the future. By focusing on collaboration, data integration, and patient-centered care, hospitals can succeed in the BPCI initiative and contribute to a more sustainable healthcare system.

Payer Notice regarding the implementation of Senate Bill 855, Mental Health and Substance Use Disorder Coverage

Carenodes Health Enterprise
Office of the Executive

Dear Health Plan Representative,

Please see attached Notice regarding the implementation of Senate Bill 855, Mental Health and Substance Use Disorder Coverage.



Carenodes Health Enterprise 

Office of the Executive 


Dear Health Plan Representative, 



Please see attached Payer Notice regarding the implementation of Senate Bill 855, Mental Health and Substance Use Disorder Coverage.


 


February 25 , 2021

 

TO:  PAYER PARTNERS

 

 

RE:  DMHC All Plan Letter directing commercial full-service health plans and  specialized health plans offering behavioral health services to demonstrate  compliance with the amended California Mental Health Parity Act (SB 855, 2020).

 

On Jan. 5, the Department of Managed Health Care (DMHC) issued All Plan Letter (APL) 21-002 to all commercial full-service health plans and specialized health plans offering behavioral health services that are regulated by the department. The guidance is designed to ensure health plans comply with amendments made to Senate Bill (SB) 855 (Wiener, D-San Francisco), the mental health and substance use parity law that took effect on Jan. 1.   


SB 855 requires commercial health plans and insurers to provide full coverage for the treatment of all mental health conditions and substance use disorders. It also establishes specific standards for what constitutes medically necessary treatment and criteria for the use of clinical guidelines. The APL outlines filing and compliance requirements of plans, including revised policies and procedures to accommodate new coverage requirements and implementation procedures related to utilization review of covered benefits. 


In addition, the 2020-21 state budget approved strategies to strengthen enforcement of behavioral health parity laws, including focused investigations of commercial health plans regulated by DMHC. These investigations, which are expected to begin in the first quarter of 2021, will help DMHC further evaluate health plan compliance with parity and assess whether enrollees have consistent access to medically necessary behavioral health care services. 





Sincerely,

 




 

A Alex Yarijanian

Chief Executive Officer and Founder

Alex@carenodes.com

(310) 626-0149 (main)

(310) 525-5498 (direct)




Health Care Consumer Assistance

Department of Managed Health Care (DMHC) Help Center
Assistance with problems with health coverage and with health plan grievances and appeals.
http://www.Healthhelp.ca.gov 


California Department of Insurance
Assistance with health insurance problems for non-managed care plans
1-800-927-4357
http://www.insurance.ca.gov 


Health Consumer Alliance
Consumer assistance program to help people with low incomes get the health care they need.
1-888-804-3536
http://www.healthconsumer.org/


HICAP (California Health Insurance Counseling and Advocacy Program)
Information, counseling, and assistance for people who have or will soon have Medicare
1-800-434-0222
http://www.aging.ca.gov/hicap/


MediCaManaged Care Ombudsman
Assistance for people enrolling in or changing Medi-Cal managed care plans
1-888-452-8609
http://www.dhcs.ca.gov/services/medi-cal/Pages/MMCDOfficeoftheOmbudsman.aspx





Payer Notice regarding the implementation of Senate Bill 855, Mental Health and Substance Use Disorder Coverage

Carenodes Health Enterprise
Office of the Executive

Dear Health Plan Representative,

Please see attached Notice regarding the implementation of Senate Bill 855, Mental Health and Substance Use Disorder Coverage.

← Back

Thank you for your response. ✨

 

 

 

 

Carenodes Health Enterprise 

Office of the Executive 

 

Dear Health Plan Representative, 

 

 

Please see attached Payer Notice regarding the implementation of Senate Bill 855, Mental Health and Substance Use Disorder Coverage.

 

 

 

 

 

 

February 25 , 2021

 

TO:  PAYER PARTNERS

 

 

RE:  DMHC All Plan Letter directing commercial full-service health plans and specialized health plans offering behavioral health services to demonstrate compliance with the amended California Mental Health Parity Act (SB 855, 2020).

 

On Jan. 5, the Department of Managed Health Care (DMHC) issued All Plan Letter (APL) 21-002 to all commercial full-service health plans and specialized health plans offering behavioral health services that are regulated by the department. The guidance is designed to ensure health plans comply with amendments made to Senate Bill (SB) 855 (Wiener, D-San Francisco), the mental health and substance use parity law that took effect on Jan. 1.   

 

SB 855 requires commercial health plans and insurers to provide full coverage for the treatment of all mental health conditions and substance use disorders. It also establishes specific standards for what constitutes medically necessary treatment and criteria for the use of clinical guidelines. The APL outlines filing and compliance requirements of plans, including revised policies and procedures to accommodate new coverage requirements and implementation procedures related to utilization review of covered benefits. 

 

In addition, the 2020-21 state budget approved strategies to strengthen enforcement of behavioral health parity laws, including focused investigations of commercial health plans regulated by DMHC. These investigations, which are expected to begin in the first quarter of 2021, will help DMHC further evaluate health plan compliance with parity and assess whether enrollees have consistent access to medically necessary behavioral health care services. 

 

 

 

 

Sincerely,

 

 

 

 

A Alex Yarijanian

Chief Executive Officer and Founder

 

 

 


Health Care Consumer Assistance

Department of Managed Health Care (DMHC) Help Center
Assistance with problems with health coverage and with health plan grievances and appeals.
www.Healthhelp.ca.gov 

 

California Department of Insurance
Assistance with health insurance problems for non-managed care plans
1-800-927-4357
www.insurance.ca.gov 

 

Health Consumer Alliance
Consumer assistance program to help people with low incomes get the health care they need.
1-888-804-3536
www.healthconsumer.org/

 

HICAP (California Health Insurance Counseling and Advocacy Program)
Information, counseling, and assistance for people who have or will soon have Medicare
1-800-434-0222
www.aging.ca.gov/hicap/

 

MediCaManaged Care Ombudsman
Assistance for people enrolling in or changing Medi-Cal managed care plans
1-888-452-8609
www.dhcs.ca.gov/services/medi-cal/Pages/MMCDOfficeoftheOmbudsman.aspx

 

 

 

 

 
 

 

Pandemic Creates Extra Cyber Risk For Health Care Providers

Unfortunately, it is in these times of dogged, urgent focus on patient care that health care organizations may be most vulnerable to another invisible danger: cybercrimes targeting the very hospitals tasked with protecting us.

A recent report estimates that, in 2019 alone, cybercriminals compromised over 41 million patient records, costing the health care industry billions of dollars. (Protenus Inc. & DataBreaches.net, 2020 Breach Barometer (2020); HIPAA Journal, Healthcare Data Breaches Predicted to Cost Industry $4 Billion in 2019 (Nov. 7, 2019).) We also know that health data breaches have increased steadily year over year, and can be expected to increase sharply in times of political or social turmoil.

In short, the global health crisis creates an opportunity for cybercriminals, and health care organizations and hospitals should consider taking steps now to minimize the risk to their systems, their data and, most importantly, their patients.Hospitals as Targets

The health care industry is a favorite target of cybercriminals, and hospitals are particularly vulnerable. There are numerous reasons for this.

Owing to their commendable focus on patient care, many health care organizations have invested less in technology and cybersecurity than other major industries. Recent digitization of patient health records has left many hospitals without robust security infrastructure vulnerable.

In addition, hospitals increasingly are using interconnected medical devices that sometimes have limited security protection. In 2013, these security considerations led doctors for former Vice President Dick Cheney to disable the wireless feature in his pacemaker, for fear that hackers could otherwise access the device. (Dana Ford, Cheney’s defibrillator was modified to prevent hacking, CNN.com (Oct. 24, 2013).)

Further, doctors and nurses on the front lines of patient care sometimes do not receive robust training on cybersecurity measures. Compounding the threat is the enormous value of electronic health records on the black market: Stolen records reportedly can fetch prices of up to $1,000 each. (Mariya Yao, Your Electronic Medical Records Could Be Worth $1000 To Hackers, Forbes (April 14, 2017).)

In short, hospitals and health care organizations are particularly exposed, even in the best of times.Crisis Creates Opportunity

In more challenging times, the picture is darker. In the few short weeks since the World Health Organization declared COVID-19 a global pandemic, cybercriminals already have sought to capitalize on the crisis.

The Wall Street Journal recently reported that hackers targeted two hospital systems, one in the U.S. and another in the Czech Republic — the latter attack compromising the country’s second largest hospital for almost two weeks. (Wall Street Journal, Cybercriminals Sweep In to Take Advantage of Coronavirus (March 24, 2020).)

Although cybercriminals have a number of tools at their disposal, ransomware attacks are perhaps the most concerning in the current climate because they have the potential to lock hospital administrators and staff out of their own systems for lengthy periods of time, compromising patient health. Late last year, for example, a ransomware attack on a cancer center disabled its systems and forced it to halt radiation treatment for cancer patients. (Jessica Davis, Ransomware Attacks Disrupts Patient Care at Hawaii, NJ Hospitals, HealthITSecurity.com (Dec. 16, 2019).) Hospitals often are asked to pay attackers hefty ransoms to resolve such attacks.

The rapidly evolving global health crisis caused by the spread of COVID-19 is also creating new windows of opportunity for cybercrime. The increase in telemedicine and makeshift hospital facilities, in addition to overcrowded conditions in hospitals and emergency rooms across the country, mean that hospital IT systems are at maximum capacity.

Under the circumstances, just one click on an email or attachment by an unsuspecting and exhausted hospital worker could unleash malware that compromises an entire hospital’s financial and clinical information systems, as well as its interconnected medical devices. The global pandemic is a crisis — but without functioning hospital systems and critical care, it could become a disaster.Litigation Risks Abound

Adding to the burdens already faced by health care organizations, cybercrime victimizes health care targets on several fronts, and could lead not only to substantial business costs, but also to potential third-party claims from affected patients.

In one example, a ransomware attack on a Wyoming-based health care company disabled hospital systems, resulting in service disruptions to the organization’s outpatient lab, respiratory therapy and radiological exams. Surgeries were canceled, new patients were turned away, and emergency room patients were transferred to other hospitals. (Jessica Davis, Campbell County Health Ransomware Attack Disrupting Patient Care, HealthITSecurity.com (Sept. 23, 2019).) Plaintiffs lawyers began advertising a potential class action shortly thereafter.

Such lawsuits have become increasingly common in the aftermath of health-care-related cyberattacks. (See, e.g., Aranowitz v. Hackensack Meridian Health Inc., 2:20-CV-01409 (D.N.J. Feb. 10, 2020); Quintero v. Metro Santuce Inc., Case No. 20-1075 (D. Puerto Rico, Feb. 11, 2020); Edwards v. Univ. of Washington, Case No. 19-2-12285-4 (Wash. Super. Ct., Oct. 21, 2019).) Moreover, as cybercriminals become more sophisticated, and the internet of things is extended to include interconnected medical devices, a new wave of product liability lawsuits stemming from malware attacks that compromise patient-worn medical devices or wired devices used for patient care may be on the horizon.

Hospitals and health care organizations are urged think now about how to mitigate the consequences of such attacks, if not prevent them altogether.Critical Care Requires Cybersecurity

The health care industry will require long-term investment, regulatory compliance, and cybersecurity prophylaxis to slow the tide of cyberattacks. But there are several short-term steps all health care organizations can take to protect themselves in this time of crisis.

First, health care companies should consider dusting off their cybersecurity contingency plans and, if necessary, hire outside professionals to update and implement those plans across facilities that are on the front lines of fighting the pandemic.

Second, hospitals should, where possible, provide updated training to emergency personnel on handling electronic health records. This is especially true where patients are being treated remotely or in temporary hospital facilities, where access to core IT systems may not be available.

Third, medical device manufacturers should be mindful of guidance from the U.S. Food and Drug Administration on the post-market cybersecurity in medical devices, particularly as regards updates and patches, and continuously work to improve device security as new technology becomes available. (See FDA, Postmarket Management of Cybersecurity in Medical Devices: Guidance for Industry and Food and Drug Administration Staff (Dec. 2016), available at https://fda.gov/media/95862/download.)

Further, medical device manufacturers and hospitals alike can revisit indemnity provisions in any agreements providing for the sale and distribution of wired medical devices. This will ensure that all parties know who is responsible in the event of a cyberattack affecting those devices.

Finally, all companies operating in the health care space should consider comprehensive cyber-liability insurance. The policies available are not one-size-fits-all, and can be negotiated to include both direct expenses resulting from a cyberattack (e.g., expenses associated with a malware infection, ransomware or business email compromise) as well as expenses resulting from third-party claims (e.g., litigation involving privacy breaches and product liability).

The bottom line is that consistent, reliable patient care requires secure health care systems. Hospitals and health care organizations can take precautions now to prevent cyberattacks from disabling critical systems and compromising patient care as the global health care crisis evolves.

The opinions expressed are those of the author(s) and do not necessarily reflect the views of the firm or any of its or their respective affiliates. This article is for general information purposes and is not intended to be and should not be taken as legal advice.

ALTERNATIVE CARE SETTINGS: TELEMEDICINE AND RETAIL CLINICS

Many firms provide coverage for health services delivered outside typical provider settings. Telemedicine is the delivery of health care services through telecommunications to a patient from a provider who is at a remote location, including video chat and remote monitoring. This generally would not include the mere exchange of information via email, exclusively web-based resources, or online information a plan may make available unless a health professional provides information specific to the enrollee’s condition. We note that during the coronavirus pandemic, some plans have eased their definitions to allow more types of digital communication to be reimbursed.

How alternative settings unlock healthcare access — and eat into hospitals