Medicaid Releases ED Copay Clarification

July 23, 2020

The Wisconsin Medicaid program now requires an $8 copay for nonemergency visits to the emergency department by certain Medicaid patients. The copay is part of a demonstration waiver approved by the federal Centers for Medicare and Medicaid Services in October 2018 and was included in 2017 Wis. Act 370, which the legislature passed in December 2018.
Although WHA continues to object to the copay policy, believing it does not accomplish the legislature’s goal of reducing the inappropriate use of emergency departments, WHA worked with the Wisconsin Department of Health Services (DHS) to mitigate members’ implementation concerns.
“As we have already done well before this policy was enacted into law, we will continue to work with the legislature and DHS on proven policies, like provider intensive care coordination programs, that actually accomplish the legislature’s intended goal to reduce inappropriate emergency department utilization,” WHA President and CEO Eric Borgerding said.
The $8 copay applies only to Medicaid patients who are considered childless adults, meaning they are between the ages of 19-64, are not pregnant, and they do not have dependent children living at home. There are several exceptions to the copay requirement, including that the Medicaid patient has reached the federal 5% limit on Medicaid cost share amounts.
Acknowledging hospitals’ EMTALA obligations, the Medicaid ED copay applies only when all of the following conditions are met:
  • The $8 copay applies to the member.
  • The member did not meet the prudent layperson standard of a medical emergency.
  • The member sought and received additional post-stabilization care in the emergency department after being informed of the $8 copay and the availability of alternative providers with lesser or no cost share.
There are additional details related to methods for verifying copay eligibility and other implementation issues available in the Medicaid program’s original ForwardHealth Update and in a ForwardHealth Update clarifications released this week. WHA members should contact the HMOs with which they have contracts for details concerning contract issues and other implementation expectations.

This story originally appeared in the July 23, 2020 edition of WHA Newsletter