Section 17-134d-86 - Medicaid payment for general hospital outpatient emergency and non-emergency visits to a hospital emergency room and outpatient clinic visits(a)Definitions(1) "Department" means The State of Connecticut Department of Income Maintenance or its agent.(2) "Emergency room" means that part of a general hospital that is designed, organized, equipped, and staffed to provide initial diagnosis and treatment of patients requiring immediate physician, dental, or allied services.(3) "Emergency visit" means an urgent encounter requiring the immediate decision-making and medically necessary action to prevent death or any further disability for patients in health crises (including labor and delivery). Such medical conditions are manifested by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. In order to be considered urgent, the encounter must occur within seventy-two (72) hours from the onset of the presenting medical condition.(4) "General hospital" means a short-term hospital having facilities, medical staff and all necessary personnel to provide diagnosis, care and treatment of a wide range of acute conditions, including injuries, and shall include a children's general hospital which means a short-term hospital having facilities, medical staff and all necessary personnel to provide diagnosis, care and treatment of a wide range of acute conditions among children, including injuries.(5) "Medically necessary" means medical care provided to:(A) Correct or diminish the adverse effects of a medical condition;(B) Assist an individual in attaining or maintaining an optimal level of well being;(C) Diagnose a condition; or(D) Prevent a medical condition from occurring.(6) "Non-emergency visit" means a medically necessary non-urgent encounter presenting a medical condition which does not meet the requirements for an emergency visit as defined in this section but, rather, requires a routine level of ambulatory health care. Such conditions may be characterized by the fact that they may also be treated in an alternate health care setting, such as: community-based physician's office, walk-in clinic, comprehensive health center, neighborhood health center and other free-standing primary health care clinics because such medical conditions do not require the skills, resources and equipment of a hospital emergency room. Such visits may include primary health care or the initial diagnosis and treatment of routine acute or chronic illnesses whether on a scheduled or unscheduled basis.(7) "Outpatient" means a patient of an organized medical facility, or distinct part of that facility who is expected by the facility to receive and who does not receive professional services for less than a 24-hour period regardless of the hour of admission, whether or not a bed is used, or whether or not the patient remains in the facility past midnight.(8) "Outpatient clinic visit rate" means the rate set by the Department using the methodology as required by subsection 17-312(d) of the General Statutes of the State of Connecticut.(b)Payment(1) The Department shall pay general hospitals for each outpatient clinic visit at the outpatient clinic visit rate not to exceed the charges made by such hospital for comparable services to the general public.(2) The Department shall pay all non-emergency visits to a general hospital emergency room at the hospital's outpatient clinic visit rate but not to exceed the charges made by such hospital for comparable services to the general public.(3) There is no payment for emergency room services provided on the same day as an inpatient admission for the same recipient.(4) Emergency Room Visit Rate(A) The rate for an emergency room visit is calculated by the Department effective July 1st of each year.(B) Payment for emergency visits to the emergency room shall be calculated as follows: Hospital emergency room costs must be submitted in writing under oath by each hospital by June 1st annually on forms acceptable to the Department. Each hospital's cost is adjusted by the lesser of: (i) the percent of change in its own emergency room costs over the last four years; or (ii) the percent of change in the emergency room costs for all hospitals for the same period. The rate authorized by the Department shall be the lower of the hospital's adjusted cost, as set forth above, or the rate calculated at the 66? percentile of the statewide adjusted cost for all hospitals, ranked in ascending order.(C) A hospital emergency room visit includes a facility cost component and a professional cost component.(D) Each hospital may annually elect to have the rate for its facility component and professional component determined separately or with the components combined. Said election shall be made at the time the emergency room costs are filed with the Department in accordance with subsection (b) (4) (A) and (B) of this regulation.(5) The Department shall pay general hospitals for each emergency room visit at the rate authorized herein not to exceed the charges made by such hospital for comparable services to the general public.Conn. Agencies Regs. § 17-134d-86
Effective September 25, 1990