Medicaid Copayment, Coming to Your ED February 2020

November 20, 2019 3:30 PM | Sally Winkelman (Administrator)

Lisa Maurer, MD
WACEP Legislative Chair

Wisconsin is one of many states that has received federal approval to change our Medicaid program, called a waiver project, in some substantial ways that will affect our patients in the emergency department. 

There are several characteristics of the changes that will affect our patients.  Namely, there will be a new work requirement for some Medicaid enrollees in order to maintain their eligibility for coverage, new Medicaid coverage for inpatient substance use disorder treatment, and some mandatory screening for substance abuse disorders.  Most impactful for our patients and workflow, the waiver also contains a new potential for copayment for Medicaid patients for ED visits.  As these new laws are implemented in Spring of 2020, it is our responsibility as advocates for our patients to ensure that we maintain protections under the Prudent Layperson Standard. 

This waiver project starts a new $8 copay for ED patients who receive care in the ED for non-emergencies as of February 2020.  This is not a new concept, whereby fourteen other states already charge copays to Medicaid enrollees who receive non-emergent care in the ED.  A minority of states have even gotten federal approval to charge more than the historic maximum of $8 copayment.  The real risk to emergency patients lies in the variance among the states in how they define a “non-emergency,” and what direction Wisconsin moves in this regard.  Scarily, some states’ Medicaid departments chose to define non-emergency based on final diagnosis.  Choosing to define non-emergency in this way is a clear violation of the Prudent Layperson (PLP) Standard as defined by federal law, which protects patients who present with symptoms concerning for emergency, even though ultimately, they might not be diagnosed with a life- or limb-threatening condition. 

Thankfully, the Wisconsin Department of Medicaid has chosen to define emergency (and therefore non-emergency) based on the PLP.  What’s more, this definition of non-emergency is as determined by the physician caring for the patient.  Hence, our judgement is paramount, as it should be, as we are the ones who have the best sense of the patient’s concerns at the time of presentation.  Of note, in Wisconsin, this copayment will be applied to the facility charges, not the professional fee charged by the physician.  Therefore, each hospital system will need to determine what the workflow will be to assess for non-emergency and then somehow alert the registration staff so they can apply the copay to the patient’s cost-sharing responsibilities.  In other states that have implemented a copay for non-emergent services in the ED, actual utilization of the copay by the hospitals has been low.

In the coming months, DHS will be rolling out pre-implementation outreach and communication activities about the program.  Thank you in advance for making sure the implementation of this copay makes sense for emergency physicians and our patients at your hospital.