State limits Medicaid coverage of non-emergency visits to ER

OLYMPIA — Medicaid has begun notifying clients that it is changing coverage for some health care services as a consequence of budget reductions for the 2011-13 biennium, including a legislatively mandated limit on non-emergency visits to hospital emergency rooms.

Beginning Oct. 1, Medicaid will pay for only three non-emergency visits to an emergency room per client per year. Any subsequent non-emergency visits will not be covered by Medicaid, and hospitals will be permitted to bill clients for those services.

“This is not just another budget cut in hard times — this is a realistic strategy to change clients’ and providers’ behavior,” said Doug Porter, director of the Health Care Authority. “Non-emergency issues and chronic conditions should be treated by a primary care provider, not by an expensive visit to hospital emergency rooms.”

The first three-visit count will run through June 30, 2012, and restart July 1. Clients who reach their third visit limit will be notified by letter and warned that additional non-emergency visits will be the client’s responsibility.

The Health Care Authority spent nearly $98 million on a total of 327,965 hospital emergency room visits last year. The Legislature estimated that the state could save $34 million a year, about a third of that, with the new limit on non-emergency visits.

The three-visit limit would not apply to certain specific circumstances:

• Children placed by the department in out-of-home care with foster parents, relatives, or other caregivers

• Visits for mental health diagnoses or for clients seeking detoxification services

• Visits that result in an inpatient admission, emergency surgery, or admission for observation

Porter said the Health Care Authority has been working with hospital administrations and providers to find ways to refer non-emergencies to more appropriate providers.

A letter sent to clients this month also details legislative changes in the way Medicaid covers comprehensive dental services for adults. Effective July 1, these services were restored for several groups of Medicaid adults:

• Women who are pregnant, including a 60-day postpartum period

• Residents of nursing homes, including nursing home wings of State Veterans Hospitals

• Residents of privately operated Intermediate Care Facilities for the Intellectually Disabled or state-operated Residential Habilitation Centers

• Adults enrolled in 1915 (c) Home and Community-Based Waiver Programs or participating in the Roads to Community Living Grants

The Legislature also ruled that another group of clients would no longer be eligible for comprehensive dental coverage, effective Oct. 1. This group includes adult clients whose care is managed by the Department of Social and Health Services (DSHS) Division of Developmental Disabilities, but who do not fit in the categories above.

However, Medicaid will honor any prior authorization approvals for dental services.

Clients who are unsure whether they fit into one of these groups should work with their dental provider, who will be able to clarify their status with Medicaid.

Clients who do not have a dental provider or a primary care provider can receive help on the agency’s website at:

You can also contact the Health Care Authority by submitting an online request form at to find a provider in your area.

— Information from Health Care Authority

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