Virginia's actions will cripple emergency physicians', staff, and hospitals’ ability to provide quality access to care healthcare.  Patients should never be put in a position where they are expected to self-diagnose and determine whether an emergency condition exists before being seen by a medical professional. This is called the “prudent layperson” standard and it requires care to be provided if the patient believes they are having an emergency. We believe that CMS guidance obligates state Medicaid programs and managed care organizations (MCOs) to reimburse doctors and hospitals for the delivery of such emergency medical care based on presenting symptoms, not using a diagnosis list.