Submitted Online (www.townhall.com) and Sent Via Email (Emily.McClellan@dmas.virginia.gov)

September 10, 2020

Emily McClellan

Virginia Department of Medical Assistance Services

600 E. Broad St., Suite 1300

Richmond, VA 23219

Re:       Virginia Hospital & Healthcare Association

Public Comment on Hospital Manual Chapter V

Virginia Hospital & Healthcare Association (“VHHA”) appreciates the opportunity to submit comments to the Virginia Department of Medical Assistance Services (“DMAS”) in response to its General Notice regarding draft Hospital Manual Chapter V posted on August 11, 2020.  The draft changes to Chapter V relate to implementation of reimbursement changes directed by Item 313.AAAAA of HB30 (the “Budget Bill”), which alters Medicaid reimbursements for certain emergency department (“ED”) claims, and Item 313.BBBBB of the Budget Bill, which implements a readmission reimbursement reduction (the “Reimbursement Changes”).

On June 19, 2020, VHHA submitted public comments in response to the DMAS Notices of Intent to Amend the Virginia State Plan for Medical Assistance posted on May 20, 2020, for the purpose of implementing the Reimbursement Changes.  In its public comments in response to that notice, VHHA expressed its opposition to the Reimbursement Changes and related State Plan Amendment.  Because this General Notice relates to the same subject matter as the proposed State Plan Amendments, VHHA is opposed to the draft changes to Hospital Manual Chapter V for the same reasons stated in our public comments on June 19, 2020.   

For your reference, please find enclosed copies of the public comments submitted on June 19, 2020, expressing our opposition to the Reimbursement Changes. 

https://townhall.virginia.gov/l/viewcomments.cfm?commentid=80911

https://townhall.virginia.gov/l/viewcomments.cfm?commentid=80915

To summarize the reasons for our opposition as it relates to the Reimbursement Changes and the draft Hospital Manual Chapter V:

• DMAS’ planned implementation of the Reimbursement Changes will significantly undermine our partnership with the state on COVID-19 response and Medicaid Expansion and further erode hospitals’ ability to provide access to essential health care for Medicaid enrollees.  Furthermore, the proposed reimbursement changes stand to disproportionately impact facilities that treat a high percentage of Medicaid patients, penalizing them for providing access to care for medically underserved and vulnerable patient populations who do not have adequate alternatives, further contributing to inequity and historical disparities in access to care. 
• Aside from these critical access and health equity concerns, implementation of Item 313.AAAAA will violate federal Medicaid regulations, conflict with the well-established “prudent layperson” (“PLP”) standard, raise constitutional concerns, and ultimately fail to reduce avoidable and unnecessary ED utilization.  For these reasons, as set forth in more detail below, VHHA opposes DMAS’ proposed reimbursement changes.
• DMAS’ planned implementation of Item 313.BBBBB is noticeably absent of any attempt at risk stratification or adjustments for community differences in the social determinants of health, virtually insuring that this misguided policy will further weaken urban and rural communities who are already medically underserved and exacerbate racial, ethnic, and geographic disparities in care. 
• Aside from these broader health equity and policy concerns, Item 313.BBBBB is draconian and differs significantly from the Centers for Medicare and Medicaid Services (“CMS”) Hospital Readmissions Reduction Program (“HRRP”) in several fundamental ways that make it inappropriate for use with Medicaid enrollees. 

For all of the reasons stated in our June 19, 2020, public comments and restated herein, VHHA is opposed to the draft Hospital Manual Chapter V.  Furthermore, to our knowledge the State Plan Amendments for the Reimbursement Changes have not yet been approved by the Centers for Medicare & Medicaid Services.  Accordingly, it may be premature to amend the Hospital Manual at this time. 

Thank you again for this opportunity to comment.  If you have any questions or require clarifications of our comments, please feel free to contact me at brawlings@vhha.com.

Sincerely,

R. Brent Rawlings
Senior Vice President & General Counsel

Enclosures

Submitted Online (www.townhall.com) and Sent Via Email (Emily.McClellan@dmas.virginia.gov)

September 10, 2020

Emily McClellan

Virginia Department of Medical Assistance Services

600 E. Broad St., Suite 1300

Richmond, VA 23219

Re:       Virginia Hospital & Healthcare Association

Public Comment on Physician Manual Chapters IV, V

Virginia Hospital & Healthcare Association (“VHHA”) appreciates the opportunity to submit comments to the Virginia Department of Medical Assistance Services (“DMAS”) in response to its General Notice regarding draft Physician Manual Chapters IV, V posted on August 11, 2020.  The draft changes to Chapters IV, V relate to implementation of reimbursement changes directed by Item 313.AAAAA of HB30 (the “Budget Bill”), which alters Medicaid reimbursements for certain emergency department (“ED”) claims (the “Reimbursement Change”).

On June 19, 2020, VHHA submitted public comment in response to the DMAS Notice of Intent to Amend the Virginia State Plan for Medical Assistance posted on May 20, 2020, for the purpose of implementing the Reimbursement Change.  In its public comment in response to that notice, VHHA expressed its opposition to the Reimbursement Change and related State Plan Amendment.  Because this General Notice relates to the same subject matter as the proposed State Plan Amendment, VHHA is opposed to the draft changes to Physician Manual Chapters IV, V for the same reasons stated in our public comment on June 19, 2020.   

For your reference, please find enclosed a copy of the public comment submitted on June 19, 2020, expressing our opposition to the Reimbursement Change. 

https://townhall.virginia.gov/l/viewcomments.cfm?commentid=80911

To summarize the reasons for our opposition as it relates to the Reimbursement Change and the draft Physician Manual Chapters IV, V:

• DMAS’ planned implementation of the Reimbursement Change will significantly undermine our partnership with the state on COVID-19 response and Medicaid Expansion and further erode hospitals’ ability to provide access to essential health care for Medicaid enrollees.  Furthermore, the proposed reimbursement changes stand to disproportionately impact facilities that treat a high percentage of Medicaid patients, penalizing them for providing access to care for medically underserved and vulnerable patient populations who do not have adequate alternatives, further contributing to inequity and historical disparities in access to care. 
• Aside from these critical access and health equity concerns, implementation of Item 313.AAAAA will violate federal Medicaid regulations, conflict with the well-established “prudent layperson” (“PLP”) standard, raise constitutional concerns, and ultimately fail to reduce avoidable and unnecessary ED utilization.  For these reasons, as set forth in more detail below, VHHA opposes DMAS’ proposed reimbursement changes.

For all of the reasons stated in our June 19, 2020, public comment and restated herein, VHHA is opposed to the draft Physician Manual Chapters IV, V.  Furthermore, to our knowledge the State Plan Amendments for the Reimbursement Change have not yet been approved by the Centers for Medicare & Medicaid Services.  Accordingly, it may be premature to amend the Physician Manual at this time. 

Thank you again for this opportunity to comment.  If you have any questions or require clarifications of our comments, please feel free to contact me at brawlings@vhha.com.

Sincerely,

R. Brent Rawlings
Senior Vice President & General Counsel

Enclosure

Submitted Online (www.townhall.com) and Sent Via Email (Emily.McClellan@dmas.virginia.gov)

September 10, 2020

Emily McClellan

Virginia Department of Medical Assistance Services

600 E. Broad St., Suite 1300

Richmond, VA 23219 

Re:       Virginia College of Emergency Physicians’ Public Comment on Physician Manual Chapters IV, V

The Virginia College of Emergency Physicians (VACEP) appreciates the opportunity to submit comments to the Virginia Department of Medical Assistance Services (DMAS) in response to its General Notice regarding draft Physician Manual Chapters IV, V posted on August 11, 2020.  The draft changes to Chapters IV, V reflect the implementation of reimbursement changes directed by Item 313.AAAAA of HB30, which alters Medicaid reimbursements for level 2, 3 and 4 emergency department claims solely if they are on a “preventable” ER visit list. 

On June 18, 2020, VACEP submitted public comment in response to the DMAS Notice of Intent to Amend the Virginia State Plan for Medical Assistance posted on May 20, 2020, for the purpose of implementing the automatic downcoding.  In our public comments, we clearly expressed our opposition to the implementation of the ER Utilization program.  Because this General Notice relates to the same subject matter as the proposed State Plan Amendment, VACEP is opposed to the draft changes to Physician Manual Chapters IV, V for the same reasons stated in our public comment on June 18, 2020.   

For your reference, please find enclosed a copy of the public comment submitted on June 18, 2020, expressing our opposition to the implementation of the ER Utilization program.  To summarize, we believe the ER Utilization program to be inconsistent with the federal and state prudent layperson standard and CMS policy against paying for emergency care based solely on a diagnosis list.

To that end, we therefore oppose amending the Physician Manual Chapters IV, V.  Furthermore, it is our understanding that DMAs has yet to even submit their State Plan Amendments for the ER Utilization program to CMS for approval.  Therefore, we believe it to be premature to amend the Physician Manual at this time.  

Thank you again for this opportunity to comment.  If you have any questions or require clarifications of our comments, please feel free to contact us.  

Sincerely,  

K. Scott Hickey, MD, FACEP

President