Budget Amendment ID: FY2015-S4-942

EHS 942

Observation Services

Mr. Richard T. Moore and Ms. Creem moved that the proposed new text be amended moved that the bill be amended by inserting, after section xx, the following new sections:-

SECTION X. Section 12 of chapter 118E of the General Laws, as appearing in the 2012 Official Edition, is hereby amended by inserting at the end thereof the following new paragraph:-

The division and its contractors shall classify a medical assistant recipient as requiring or receiving observation services based on the medical judgment of the treating health care provider after due consideration of the recipient’s initial presenting signs and symptoms.  If the treating health care provider anticipates greater than 48 hours diagnostic assessment, the recipient shall be deemed admitted to the facility as an inpatient.  The division and its contractors shall provide the health care provider an opportunity to seek reconsideration of an adverse determination from a clinical peer reviewer should the division or its contractors seek to retroactively reclassify the recipient from an approved inpatient authorization to observation, for either a portion or the entire stay, based upon the division’s clinical review criteria.

SECTION X. Section 12 of chapter 176O, as so appearing, is further amended by inserting the following new subsection:

(g) The carrier and its contractors shall classify an insured as requiring or receiving observation services based on the medical judgment of the treating health care provider after due consideration of the insured’s initial presenting signs and symptoms.  If the treating health care provider anticipates greater than 48 hours diagnostic assessment, the insured shall be deemed admitted to the facility as an inpatient.  The carrier and its contractors shall provide the health care provider an opportunity to seek reconsideration of an adverse determination from a clinical peer reviewer should the carrier or its contractors seek to retroactively reclassify the insured from an approved inpatient authorization to observation, for either a portion or the entire stay, based upon the carrier’s clinical review criteria.

SECTION X.  Notwithstanding the provisions of section 245 of chapter 224 of the acts of 2012, the executive office of health and human services shall seek from the secretary of the United States Department of Health and Human Services a statewide waiver from the Medicare requirement set forth in 42 U.S.C. §1395x(i) that an admission to a skilled nursing facility be preceded by a 3-day inpatient hospital stay.  The secretary shall report within 90 days to the clerks of the house and senate, the joint committee on health care financing and the house and senate committees on ways and means on the status of the waiver sought under this section.