Plans to build new medical rehabilitation facilities in Montgomery and Prince George's counties have drawn fire from the region's largest health insurer on the grounds that they may be too costly and duplicate services already provided in the District.

Six suburban Maryland health care organizations have applied to the state for permission to build rehabilitation facilities under provisions of the state's health plan. The plan calls for 61 additional beds each in Montgomery County and southern Maryland, which includes Prince George's County. The state has cited a lack of adequate rehabilitation facilities to serve Maryland residents in those regions.

However, Blue Cross and Blue Shield of the National Capital Area, which provides coverage for many residents of suburban Maryland, is arguing that the state has not adequately taken into account the extent to which state residents use the new National Rehabilitation Hospital in downtown Washington or other regional facilities.

"We don't have evidence that rehabilitation services are not available to people in the region, or that people have to leave the area to get it," Barry P. Wilson, vice president for public affairs at the insurance carrier, said last week. Wilson said the state's plan raises the potential for "unnecessary services and unnecessary expenditures . . . that will continue the upward spiral of health costs."

Wilson said Blue Cross and Blue Shield, which often takes an active role in health planning issues, objects not so much to the number of new beds being proposed but to the manner in which the state is approaching the issue.

The insurer has won some support for its view from the planning agencies in Montgomery County and southern Maryland, which make recommendations to the state on new facility applications. The two agencies said last week that they are preparing a letter to state officials asking for permission to jointly review the rehabilitation applications in the context of the needs of the overall Washington region. Such a joint review, while not unprecedented, is unusual, officials said

"The state's health plan is okay as far as it goes," said John Osborne, executive director of the Montgomery County Health Planning Commission. But he added, "The state's methodology is only based on our residents' use of Maryland facilities {not D.C. facilities.} . . . . We want to make sure the facilities we do develop are not duplicative."

Susan Panek, a spokeswoman for the Maryland Health Resources Planning Commission, which drew up the state plan and must approve the requests to build new facilities, said planners considered the fact the people "migrate" to other jurisdictions to seek care when planners came up with the projected need of 122 new rehabilitation beds in suburban Maryland.

Panek said the numbers were not "engraved in stone," and that the commission could reconsider if presented with compelling evidence to the contrary. But she said the commission is going ahead with its consideration of the pending applications.

"This has been the product of a lot of cooperation with the {hospital} industry," she said.

The Blue Cross and Blue Shield action is only the latest step in a long-brewing political debate among area health care officials over the need for rehabilitation services -- an expensive but growing part of the medical industry. As doctors have become more adept at saving the lives of victims of strokes, car crashes and other catastrophic accidents, some health experts say there has been a growing need for facilities that specialize in the physical therapy, psychology and other areas that enable patients to resume a productive life.

While there have long been some rehabilitation services provided by a few area hospitals, a controversy erupted in the early 1980s over efforts to build a facility devoted exclusively to rehabilitation, with some health officials claiming there wasn't a need. However, that facility, the National Rehabilitation Hospital, opened last year and -- with 120 beds now in operation -- is almost 90 percent full, a spokesman said.

Now, as Maryland health officials begin preparing to allow hospitals to expand their rehabilitation capabilities, a similar debate is emerging again.

It is complicated this time, however, by a number of factors. One is jurisdictional jealousies. Maryland officials say residents need their own facilities for convenience, while others, like those at Blue Cross and Blue Shield, say much of the needs can be met by District facilities.

In addition, several of the facilities that have applied to build rehabilitation facilities are under separate orders by the state to reduce the number of beds at their facilities as part of an effort to save health care costs. Thus the opportunity to build rehabilitation beds offers a chance to convert beds that would otherwise have to close.

"The purpose for which many of these units are being applied for is economic -- survival," said Edward Eckenhoff, president of the National Rehabilitation Hospital. "You get the feeling that people don't pay attention to systems across state lines. It's a pity."

Eckenhoff, a prominent administrator who was lured from the celebrated Rehabilitation Hospital of Chicago just a few years ago, said he doesn't "have fault with the view that more rehabilitation beds are needed." But he said the state did little to take into account the services offered by his hospital in its planning. But he said since its plan was adopted, he has been talking with several Maryland hospitals about assisting or cooperating with their proposed facilities.

Several officials with the state and suburban hospitals took issue with the view that the added rehabilitation beds may not be needed, pointing out that demographic trends such as the aging of the population suggest an urgent need for more facilities.

"I think that it was a very flawed decision of the District of Columbia to approve {the National Rehabilitation Hospital} with the assumption that it would take care of Maryland residents," said Michel Augsburger, a vice president of an Adventists health group, which is proposing to build 30 rehabilitation beds in a facility adjacent to Shady Grove Adventist Hospital in Montgomery County.

"The state of Maryland is mandated to provide services for residents of the state of Maryland," Augsburger said, adding that the District facilities were often inconvenient for patients and their families.

Barry Passett, president of the Greater Southeast Community Hospital Foundation, whose Parkwood facility in Clinton is proposing rehabilitation beds, said Maryland hospitals who don't apply now risk losing the chance to build rehabilitation beds. "We would have preferred a longer time frame, but we weren't given that luxury," he said.

Noting that the National Rehabilitation Hospital is now virtually full, Passett added: "{Eckenhoff} is now in a position to prove his original case -- that there's far more demand for rehabilitation services than any of the health planners ever believed.

"We may be looking at another one of these cases where what used to be perceived as care that could only be delivered in an acute-care hospital is better delivered in a specialty setting," Passett said.

The other groups submitting applications to build beds are: Montgomery General Hospital, Suburban Hospital, the Prince George's Hospital Center, and the Prince George's Center for Continuing Care.