2020 Session

Budget Amendments - HB30 (Member Request)

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Chief Patron: Carr
Medicaid Avoidable ER Utilization Program (language only)

Item 313 #18h

Item 313 #18h

Health and Human Resources
Department of Medical Assistance Services


Page 313, strike lines 22 through 26 and insert:

"YY.  The Department of Medical Assistance Services shall amend the State Plan for Medical Assistance Services to allow the pending, reviewing and reducing of fees for avoidable emergency room claims, both physician and facility. The department shall utilize the avoidable emergency room diagnosis code list currently used for managed care organization clinical efficiency rate adjustments. If the emergency room claim is identified as a preventable emergency room diagnosis, the department shall direct the managed care organizations to default to a payment level 1, commiserate with the acuity of the visit. The department shall have the authority to implement this reimbursement change effective July 1, 2020, and prior to the completion of any regulatory process undertaken in order to effect such change."


(This amendment adds language creating a provider integrity program for avoidable emergency room utilization by Virginia Medicaid beneficiaries. This program completes the 2017 General Assembly efforts that resulted in the development and utilization of a Medicaid Avoidable Emergency Room Diagnosis Code List; adjustments in Medicaid Managed Care Organization (MCO) capitation rates for Medicaid member avoidable emergency room utilization based on this code list; and the creation of the Emergency Department Care Coordination Program (EDCCP) that arms physicians and hospitals with access to real-time clinical information to help inform clinical decisions, including the appropriateness of the emergency room visit. It eliminates language which prohibits the agency from implementing such a program.)