The purpose of this bulletin is to inform Ambulatory Surgical Center providers of the implementation of an updated Enhanced Ambulatory Patient Group (EAPG) grouper version with new weights and statewide base rate for claims payments with dates of service on or after July 1, 2019. DMAS began reimbursing Ambulatory Surgical Centers (ASCs) in accordance with the EAPG reimbursement methodology on claims with dates of service beginning April 5, 2010 (See the March 4, 2010 Medicaid Memorandum entitled, “Enhanced Ambulatory Patient Group (EAPG) for Ambulatory Surgical Centers).”

DMAS is updating the grouper version with new weights and statewide base rate for the EAPG ambulatory surgical services reimbursement methodology. DMAS will be implementing version 3.13 of the EAPG ambulatory surgical services grouper as well as version 3.13 of the national weights developed by 3M. The new statewide base rate of $203.69 should result in total expenditures that are budget neutral to (or the same as) total current expenditures. The new EAPG weights and base rates will be effective for claims with dates of service on or after July 1, 2019.

The EAPG ASC weights and the statewide base rate are available on the DMAS web site at www.dmas.virginia.gov. Click the following links: For Providers, Information for Providers, Rate Setting Information, Ambulatory Surgical Center (located under the Hospital ribbon). To contact 3M for more information about EAPG software, please call 800-367-2447 or use the following link: www.3MHIS.com.

Medicaid Expansion

New adult coverage begins January 1, 2019.  Providers will use the same web portal and enrollment verification processes in place today to verify Medicaid expansion coverage.  In ARS, individuals eligible in the Medicaid expansion covered group will be shown as “MEDICAID EXP.”  If the individual is enrolled in managed care, the “MEDICAID EXP” segment will be shown as well as the managed care segment, “MED4” (Medallion 4.0), or “CCCP” (CCC Plus).  Additional Medicaid expansion resources for providers can be found on the DMAS Medicaid Expansion webpage at:  http://www.dmas.virginia.gov/#/medex.