Washington Medicaid Won't Reimburse for "Unnecessary" ER Visits

Starting April 1, Washington's Medicaid program will no longer pay hospitals for any emergency room visit deemed as "unnecessary," according to a Seattle Times report.

The new rules would apply to any adult or child on Medicaid, according to the report. Overall, there are about 500 different conditions that would not justify a Medicaid payment — ranging from obvious non-emergencies such as diaper rash to potential emergencies such as asthma attacks and chest pain.

In November, a Washington county judge ruled the state could not move forward with its previous proposal of limiting Medicaid enrollees to three non-emergency ER visits per year because the state did not go through a formal rulemaking process.  

The Washington State Health Care Authority argued there is significant overuse of ERs that leads to $21 million in excess costs per year, and Medicaid patients need to seek care in primary care medical homes as a first step. However, the Washington State Hospital Association, the Washington State Medical Association and other healthcare provider groups said in a statement (pdf) that many Medicaid patients do not have adequate access to primary care, and self-diagnosing an emergency could lead to unintended consequences.

"What was previously an arbitrary cap on ER visits has now become an outright refusal to cover care HCA believes is unnecessary," the groups wrote. "The problem is that patients do not know what care is an emergency or not."

Related Articles on Washington Medicaid:

Washington Providers Speak Out Against Legislation That Would Harm Patient Safety

Washington State Selects Medicaid Managed Care Provider

Washington Physicians Seek Injunction on New State Law That Limits Medicaid ER Visits

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