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Washington State limits emergency department visits for Medicaid patients

Washington State will limit Medicaid patients to three non-emergent emergency department visits per year effective Oct. 1. The state says this benefit limit will save $72 million per year in state and federal funds, while opponents say it will endanger some of the state’s most vulnerable citizens.  

As part of this plan, Washington State’s Health Care Authority (HCA), which administers Medicaid, has created a list of 700 diagnoses that will be treated as non-emergent for Medicaid patients, including chest pain, shortness of breath, miscarriage and abdominal pain.

The American College of Emergency Physicians (ACEP) opposes the plan and is urging the Centers for Medicare & Medicaid Services to reject the list, saying it will jeopardize the most vulnerable members of society, including children.
“The list of conditions was generated solely by state Medicaid office over the objections of physician and hospital task force representatives,” said Sandra Schneider, MD, president of ACEP, in a statement. “The use of discharge diagnoses instead of presenting symptoms/conditions is a clear violation of the prudent lay person standard required for Medicaid managed care organizations. With Washington State having close to 60 percent of its Medicaid population enrolled in managed care, how will the state comply with the law? Also, what implications does this have for the millions of people who will be added as Medicaid beneficiaries as part of healthcare reform?”

The prudent layperson standard requires health plans to cover visits to emergency departments based on an average person‘s belief that he or she may be suffering a medical emergency due to the symptoms he or she is experiencing, not a final diagnosis. It is designed to protect patients who experience the symptoms of a medical emergency but who, after a medical examination and testing by a trained professional, are diagnosed with an acute care or non-emergent medical condition, according to ACEP.
ACEP asked CMS to ensure that the Washington State Plan Amendment:

• Requires the state to create a notification system or website so providers will know that an individual has reached his/her third annual “non-emergent” visit
• Requires the state to ensure that patients who reach this status have access to viable primary care services before imposing this policy
• Ensures the state does not apply this policy to managed care patients in violation of federal law
“The symptoms of many of these medical conditions indicate life-threatening emergencies, and people with these symptoms should seek emergency care,” said Stephen Anderson, MD, president of Washington ACEP, in a statement. “Not doing so could lead to severe illness, disability and even death. Including conditions such as congestive heart failure, kidney stones, miscarriage, chest pain and asthma is outrageous and dangerous.”

The Washington State Medical Association also opposed the plan saying that 1.1 million residents covered by Medicaid are children who would be significantly affected by these benefit cuts.

“Limiting Medicaid patients to three emergency department visits poses a significant threat to patient safety,” said Doug Myers, MD, president of the WSMA in a statement.

In a letter sent to Medicaid recipients explaining the benefit change, HCA stated, “Medicaid supports emergency room care for emergencies, but non-emergencies and chronic conditions should be managed by your primary care provider. We want every client to have a primary care provider. Limiting non-emergency use of emergency rooms will support the delivery of care in the most appropriate setting.”

HCA indicated there will be some exceptions to the benefit limit, including services to patients who:

  • Are foster children
  • Have a primary diagnosis of mental health, detox and dental disorders
  • Die on arrival or in the emergency room
  • Are transferred from ambulatory surgery centers
  • Qualify for Alien Emergency Medical
  • Are transferred to another hospital
  • Are admitted, placed in observation beds, or have short stay surgery procedures

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