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Virginia Regulatory Town Hall
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Department of Medical Assistance Services
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Board of Medical Assistance Services

General Notice
Public Notice - Intent to Amend the State Plan - Avoidable ER Claims and Hospital Readmissions
Date Posted: 5/20/2020
Expiration Date: 7/31/2020
Submitted to Registrar for publication: YES
30 Day Comment Forum is underway. Began on 5/20/2020 and will end on 6/19/2020

LEGAL NOTICE

COMMONWEALTH OF VIRGINIA

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

NOTICE OF INTENT TO AMEND

 

(Pursuant to §1902(a)(13) of the Act (U.S.C. 1396a(a)(13))

 

THE VIRGINIA STATE PLAN FOR MEDICAL ASSISTANCE

 

This Notice was posted on May 20, 2020

 

The Virginia Department of Medical Assistance Services (DMAS) hereby affords the public notice of its intention to amend the Virginia State Plan for Medical Assistance to provide for changes to the Methods and Standards for Establishing Payment Rates — Inpatient Hospital Services (12VAC 30-70 and Methods and Standards for Establishing Payment Rates - Other Types of Care (12 VAC 30-80).  

This notice is intended to satisfy the requirements of 42 C.F.R. § 447.205 and of § 1902(a)(13) of the Social Security Act, 42 U.S.C. § 1396a(a)(13).  A copy of this notice is available for public review from Emily McClellan, DMAS, 600 Broad Street, Suite 1300, Richmond, VA  23219, or via e-mail at:  Emily.McClellan@dmas.virginia.gov

 

DMAS is specifically soliciting input from stakeholders, providers and beneficiaries, on the potential impact of the proposed changes discussed in this notice.  Comments or inquiries may be submitted, in writing, within 30 days of this notice publication to Emily McClellan and such comments are available for review at the same address.  Comments may also be submitted, in writing, on the Town Hall public comment forum attached to this notice.

 

This notice is available for public review on the Regulatory Town Hall (www.townhall.com), on the General Notices page, found at:  https://townhall.virginia.gov/L/generalnotice.cfm

 

Reimbursement Changes Affecting Inpatient Hospital Services (12VAC 30-70), effective July 1, 2020

 

Pursuant to the General Assembly mandate in bill HB30, Item 313.BBBBB, DMAS will amend the State Plan for Medical Assistance Services to modify the definition of readmissions to include cases when patients are readmitted to a hospital for the same or a similar diagnosis within 30 days of discharge, excluding planned readmissions, obstetrical readmissions, admissions to critical access hospitals, or in any case where the patient was originally discharged against medical advice. If the patient is readmitted to the same hospital for a potentially preventable readmission then the payment for such cases shall be paid at 50 percent of the normal rate, except that a readmission within five days of discharge shall be considered a continuation of the same stay and shall not be treated as a new case. Similar diagnoses shall be defined as ICD diagnosis codes possessing the same first three digits.

 

The total decrease in annual expenditures, including the managed care impact, as a result of these changes is expected to be $14,786,952 in state fiscal year 2021.

 

 

Reimbursement Changes Affecting Other Types of Care (12VAC 30-80), effective July 1, 2020

 

Pursuant to the General Assembly mandate in bill HB30, Item 313.AAAAA, DMAS will amend the State Plan for Medical Assistance Services to allow the pending, reviewing and the reducing of fees for avoidable emergency room claims for codes 99282, 99283 and 99284.  Claims for these emergency room procedure codes with diagnoses on the avoidable emergency room diagnosis code list shall default to 99281 for both physician and facility reimbursement.

 

The total decrease in annual expenditures, including the managed care impact, as a result of these changes is expected to be $40,441,596 in state fiscal year 2021.

 


Contact Information
Name / Title: Emily McClellan  / Regulatory Manager
Address: Division of Policy and Research
600 E. Broad St., Suite 1300
Richmond, 23219
Email Address: Emily.McClellan@dmas.virginia.gov
Telephone: (804)371-4300    FAX: (804)786-1680    TDD: (800)343-0634