2022 Session

Budget Amendments - HB30 (Member Request)

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Chief Patron: Sickles
Policy on Non-emergent Use of Hospital Emergency Depts. (language only)

Item 304 #57h

Item 304 #57h

Health and Human Resources
Department of Medical Assistance Services


Page 340, after line 10, insert:

"PPPP.1.  For the first visit of a Medicaid patient to the hospital emergency department (ED) for non-emergent care that should have been provided in another, more appropriate and less intensive setting, the Medicaid rate for services rendered shall be reimbursed to the hospital without down coding the services. On the second visit of the same patient to any hospital ED for reasons similar to the first visit, the reimbursement rate will be reduced, unless the Commissioner of Health certifies that 95 percent of all of Virginia's hospitals are fully participating and using the Commonwealth's Emergency Department Care Coordination system to provide real-time ED and hospital encounter information to improve the quality of patient care services and share information on common high-risk patients.

2. Each record of a Medicaid patient visit to a hospital ED shall be reported to the appropriate Medicaid Managed Care Organization (MCO). The Medicaid MCO shall consult with the patient on the proper use of an ED services and ensure the patient has access to a primary care provider. If the patient returns to any hospital ED, full payment to providers will be made subject to the certification of hospital participation in the EDCC as noted."  


(This amendment adds language setting forth a policy for Medicaid reimbursement of hospital emergency departments (EDs) for non-emergent care that could have been provided in a more appropriate, less intensive outpatient setting. It also requires that 95 percent of Virginia hospitals must be fully participating in the Commonwealth's Emergency Department Care Coordination (EDCC) system in order to receive an unreduced Medicaid rate for the second visit by a Medicaid patient for non-emergent care in the hospital ED. The EDCC system is a single, statewide real-time communication and collaboration program among healthcare providers, clinical and care management personnel for patients receiving ED services in Virginia for the purpose of improving the quality of patient care services and providing better management of high-risk patients. It also integrates the state’s Prescription Monitoring Program and the Advance Healthcare Directive Registry. The EDCC system was launched in July 2018.)