The Division of Medical Services presented a proposed Medicaid rule to a legislative public‑health subcommittee that would allow limited urgent‑care visits without a primary‑care provider (PCP) referral and drew questions from lawmakers about access, enrollment and hospital reimbursement.

The rule, as described by Elizabeth Pittman, Division of Medical Services, allows two urgent‑care visits for beneficiaries who already have an assigned PCP and four visits for beneficiaries without an assigned PCP. “The rule itself was designed to help create better access to urgent care for for people that were really being forced to go to the ER when they otherwise didn't want to,” Pittman said during the subcommittee discussion.

Why it matters: Lawmakers said the rule addresses access gaps where primary‑care offices are unavailable for same‑day care, but they pressed the Department of Health and Human Services for data on how many Medicaid enrollees lack PCPs, where urgent‑care clinics operate, and the financial effects on rural hospitals and existing care‑coordination programs.

At the meeting, Nell Smith, deputy director for the Division of Medical Services, said about 145,000 Medicaid beneficiaries who are required to have an assigned PCP do not currently have one; the agency also noted total Medicaid enrollment of roughly 800,000 beneficiaries. Smith described existing operational steps for beneficiaries without a PCP: hospitals may call the Connect Care line to request assignment and the department pays about $15 to hospitals for that assignment call.

Lawmakers repeatedly raised rural access and service‑type questions. Matt Gilmore of the Department of Health said the state does not license “urgent care” as a separate facility type and therefore lacks a registry of urgent‑care clinics: “We don't have a licensure process for urgent care clinics, facilities, whatever you wanna call them.” Committee members said they were concerned that many rural areas lack urgent‑care clinics and that the emergency department often is the only available after‑hours option.

Committee members asked for several follow‑up items the department agreed to provide: demographics and duration of enrollment for beneficiaries lacking PCPs; count and geographic distribution of urgent‑care providers if possible; denial rates and review practices by AFMC for emergency‑department claims evaluated under the prudent‑layperson standard; and a clear comparison of reimbursement levels for nonemergent care delivered in emergency departments versus urgent‑care settings.

Officials described current payment and care‑coordination details that lawmakers said need clarifying: the state’s primary‑care case‑management (PCCM) program pays approximately $3 per member per month to PCPs, and the agency has discussed auto‑assignment of beneficiaries to PCPs but has not implemented it because of cost and program implications. Officials said a hospital can be paid roughly $15 to call Connect Care and help assign a PCP when a beneficiary lacks one.

Lawmakers also sought more detail about how hospitals are reimbursed for emergency‑department visits that AFMC later finds nonemergent. Pittman and Smith described the review process: if a beneficiary has an assigned PCP and no referral was obtained, AFMC may review the claim under the prudent‑layperson standard and may deny payment for nonemergent visits; if no PCP is assigned, the state currently reimburses the visit but requires efforts to help the beneficiary obtain a PCP.

Representative Lee Johnson, who pressed for follow‑up data during the meeting, said he supported the rule in principle but asked the department to consider changes — for example, shortening the number of allowed visits before requiring PCP assignment — and to return with detailed metrics. “I support this idea,” Johnson said during questioning.

Outcome: The committee agreed to hold further action and to schedule a follow‑up meeting to review the requested data and options. Representative Johnson had prepared a motion to recommend approval but agreed to withdraw it while the department supplies additional information. Committee members noted that substantial drafting changes to the rule would require restarting the public‑comment process, while minor clarifying edits likely would not.

Next steps: The department committed to provide the requested metrics and to work with the subcommittee to schedule a follow‑up hearing. Lawmakers said they intend to examine the PCCM and PCMH programs, AFMC denial patterns and the possibility of targeted reimbursements or parity payments for nonemergent care delivered at rural emergency departments if urgent‑care capacity is lacking.

Ending: Committee leaders said they expect further interim work with the Department of Health and Human Services and planned at least one additional subcommittee meeting to consider the rule and the data requested by lawmakers.