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 10/11/2023

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 — 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 Jimeequa Williams, DMAS, 600 Broad Street, Suite 1300, Richmond, VA  23219, or via e-mail at: Jimeequa.Williams@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 Jimeequa Williams 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 (https://townhall.virginia.gov) on the General Notices page, found at:  https://townhall.virginia.gov/L/generalnotice.cfm

Methods & Standards for Establishing Payment Rates-Other Types of Care (12 VAC 30-80)

Item 313.AAAAA of the 2020 Appropriations Act required DMAS to allow the pending, reviewing, and the reducing of fees for avoidable emergency room (ER) claims for codes 99282, 99283 and 99284, both physician and facility. The Department utilized the avoidable ER diagnosis code list currently used for Managed Care Organization (MCO) clinical efficiency rate adjustments. If the ER claim was identified as a preventable ER diagnosis, the Department directed the MCO to default to the payment amount for code 99281, commensurate with the acuity of the visit. (This also applied to fee-for-service.)    

However, pursuant to a federal court order, dated April 27, 2023, (Va. Hosp. & Healthcare Assoc. et al. v. Roberts et al., No. 3:20-cv-00587-HEH), DMAS must repeal/remove the state plan language that fulfilled the 2020 General Assembly mandate, and can no longer enforce the fee adjustments for avoidable ER claims for codes 99282, 99283 and 99284, for both physicians and facilities.

The expected increase in annual aggregate fee-for-service expenditures is $62,024 in state general funds, $8,251 in special funds, and $141,666 in federal funds in federal fiscal year 2024, and $62,024 in state general funds, $8,251 in special funds, and $141,666 in federal funds in federal fiscal year 2025.