Medicaid would judge emergency care payments by patients' initial symptoms

State Medicaid officials and Medicaid health plans would judge emergency care by the patient's symptoms and condition when seeking care. These rules would cover services Medicaid patients receive in emergency departments. An emergency would mean symptoms that an average person could reasonably expect to cause serious harm without immediate care. Payment decisions could not rely on the final diagnosis, discharge code, or conditions identified after the required medical screening. Officials and plans could not use tools based on final diagnoses to classify emergencies or cut emergency payments by labeling the care nonemergency.

State Medicaid officials and Medicaid health plans would pay for emergency services at least at Medicaid's fee-for-service rate, its payment amount for each service. The minimum would cover emergency services that hospitals or emergency care providers give Medicaid patients. State officials and health plans could negotiate higher rates with providers. The minimum payment would use the Medicaid fee-for-service rate in effect when the services were provided.

Medicaid would recognize a formal hospital admission for inpatient payment when the admitting doctor or other qualified clinician expects care to span at least two consecutive midnights. These rules would cover Medicaid patients formally admitted by a doctor or other qualified clinician. The two midnights could occur at different facilities. The clinician ordering admission would need permission to admit patients at that hospital and knowledge of the patient's care and condition. Medical reasons supporting the expected stay would have to appear in the patient's record. Unexpected shorter stays could receive inpatient payment under Medicare rules. Planned shorter stays could qualify based on the clinician's medical judgment and the patient's record.