Bulletin Details

4082 : January 8, 2012

Medicaid ER Visit Limit: A New Approach

Background:  During its 2011 session, the Washington State Legislature enacted a budget proviso limiting Medicaid payment to three "non-emergency" visits to emergency departments each year per patient.  The Washington Chapter of the American College of Emergency Physicians, the Washington State Medical Association, the Washington State Hospital Association, and Seattle Children’s sued the Washington State Health Care Authority (HCA) over this plan.  The hospitals and physicians won the first hearing and the October 1, 2011 implementation date was lifted.  HCA put its plans on hold in order to begin a rulemaking process as instructed by the court. 

New Proposal:  The HCA is in the process of rolling out a significant change to the way it pays for emergency care for Medicaid patients in order to reach their budget goals.  HCA plans to stop paying for all Medicaid hospital emergency room visits when it deems those visits “not medically necessary”.  This reduction in payment will occur regardless of an alternative setting being available.  The specific criteria HCA will be using for “medically necessary” is not clear at this time.  HCA will continue to pay for all visits to the emergency room that it deems medical emergencies.  This standard means that in order for the condition to be considered an “emergency,” the ER must be the medically necessary setting for the delivery of care.

If the HCA decides the care should have been rendered in a primary care provider’s office – whether or not the patient actually has access to a primary care provider’s office – HCA will not pay for the emergency room visit.  Hospitals and physicians will not be reimbursed even if the primary care provider is not available or advises the patient to go to the emergency room.  HCA says it plans to deny payment for “non-emergent” visits for all Medicaid beneficiaries – this would include people with disabilities, newborns, foster children, pregnant women, and other vulnerable patients.
Now Considered Emergencies:  One of WSHA’s main concerns with the prior approach was the list of conditions considered “non-emergent.”  While there is no static list of codes with this approach, a number of serious conditions included on the previous list – chest pain, for example – have been deleted as HCA agrees they should be covered as emergency services.

Approval of the New Plan:  The Health Care Authority believes this approach does not require approval.  Typical approval paths would be a State Plan Amendment from the Centers for Medicaid & Medicare Services, a change to state statute, or a state rule-making process.  HCA states it has the authority to pay for only medically necessary care, including emergency room visits, so does not need to utilize these processes. 

Timing and Funding:  HCA is planning for an effective date of April 1, 2012.  It projects a total savings (state and federal funds) of $51 million for the current biennium (through June 2013).  This is less than the original projected savings of $72 million, which is a positive development.

Next Steps:  WSHA has significant concerns about this new approach.  WSHA does not believe the emergency room is the place to provide primary care but there needs to be access to care in the community.  Currently, primary care capacity is inadequate to serve the state's Medicaid beneficiaries in an office or clinic setting.  WSHA is working to identify grant opportunities to create community partnerships to address emergency room overuse. 

We worked with the Health Care Authority to devise a list of questions and answers (click here to download) about the new benefit limit.  We and our physician partners will continue to meet with Health Care Authority representatives over the coming days, and will fully analyze the proposal and determine appropriate next steps.

For additional information, please contact:
Carol Wagner, Senior Vice President Patient Safety, carolw@wsha.org
Cassie Sauer, Vice President Public Affairs, cassies@wsha.org

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