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Effective: December 1, 2006 |
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03.45.05ar1 - Emergency Medical Assistance (EMA) (Archive) |
Archived: December 1, 2008 |
Noncitizen applicants or enrollees who are not eligible for federally funded Medical Assistance (MA) or, in some cases, state-funded MA (program NM), may be eligible for Emergency Medical Assistance (program EH) if they have a medical emergency. This includes people in any of the following groups:
l Have an immigration status of undocumented or nonimmigrant .
l Are already eligible for state-funded MA (program NM), then have a medical emergency. Approving EMA for these people enables DHS to claim federal reimbursement for those medical costs.
l Are sponsored immigrants who have a medical emergency and are ineligible for MA or NM because of their sponsors’ income and/or assets.
To be eligible for EMA, people must meet all of the following conditions:
l Have an MA basis of eligibility.
l Have a medical emergency.
l Be ineligible for MA solely due to their immigration status or deeming of sponsor income and assets. They must meet all other MA eligibility requirements, including state residence.
A medical emergency for EMA purposes occurs when a person:
l Has a sudden onset of a physical or mental condition which causes acute symptoms, including severe pain, where the absence of immediate medical attention could reasonably be expected to do any of the following:
n Place the person's health in serious jeopardy.
n Cause serious impairment to bodily functions.
n Cause serious dysfunction of any bodily organ or part.
Note: Examples of such conditions include, but are not limited to, stroke, heart attack, abscessed teeth, broken bones, ear infections, and kidney failure.
l Has a chronic medical condition which, if left untreated, could reasonably be expected to do any of the following:
n Place the person's health in serious jeopardy.
n Cause serious impairment to bodily functions.
n Cause serious dysfunction of any bodily organ or part.
Note: Examples of such conditions include, but are not limited to, diabetes requiring treatment, HIV positive with complications, cancer, kidney disease, and tuberculosis.
l Gives birth. See Other Requirements for further information on pregnant women and EMA.
Eligibility factors and links to standard program guidelines are provided below.
Citizenship/Immigration Status.
Insurance and Benefit Recovery.
Relationship to Other Groups/Bases.
Application Process (standard guidelines)
Follow standard MA guidelines.
The earliest date of eligibility for EMA is the date the medical emergency begins.
Note: For chronic conditions, retroactive eligibility is possible if the chronic condition and need for treatment (along with meeting all other eligibility factors) existed in the retroactive months.
Renewals (standard guidelines)
For acute emergencies and labor/delivery, EMA will remain open only for the duration of the emergency. There are no renewals.
Note: For cases left open on an ongoing basis due to chronic conditions, follow standard MA guidelines.
For sudden onset of a condition which causes acute symptoms:
l Accept the client's statement that the client was in severe pain at the time of treatment.
l Verify medical service dates and open EMA only from the date the medical emergency begins until the medical emergency ends.
For a chronic medical condition:
l Verify with a physician's statement that confirms both the condition and the consequences if left untreated.
l Open EMA for as long as the chronic condition persists.
l Re-verify the condition and consequences of not receiving medical treatment at each renewal, or sooner if the client's health is expected to improve.
Social Security Number (standard guidelines)
Undocumented people and nonimmigrants who are applying for or enrolled in EMA are not required to provide SSNs.
Do not require sponsor information or apply sponsor deeming provisions for sponsors who are not members of the EMA client's household.
Do not use the Systematic Alien Verification for Entitlements (SAVE) system for EMA clients.
Residency (standard guidelines)
Follow standard MA guidelines.
Follow standard MA guidelines.
Household Composition (standard guidelines)
Follow standard MA guidelines.
Use the method associated with the client's MA basis of eligibility.
Asset Guidelines (standard guidelines)
Follow the asset guidelines associated with the client's MA basis of eligibility.
Follow the income guidelines associated with the client's MA basis of eligibility.
Deductions/Disregards (standard guidelines)
Apply the deductions and disregards associated with the client's MA basis of eligibility.
Follow the spenddown guidelines associated with the client's MA basis of eligibility.
Covered Services (standard guidelines)
EMA does not cover preventive care, organ transplants, or home- and community-based waiver services. See the MHCP Provider Manual for more information on covered services.
People who receive EMA are excluded from managed care enrollment.
While giving birth qualifies as a medical emergency, EMA will not cover prenatal or postpartum care. Instead:
l Pregnant women who are ineligible for MA solely due to their immigration status (for example, undocumented or nonimmigrant) are eligible for state-funded MA (program NM) for the duration of the pregnancy and the 60-day postpartum period.
l EMA will cover the labor and delivery costs; MMIS will identify these costs and automatically seek federal reimbursement through EMA.
l It is not necessary to change pregnant women’s eligibility from program NM to EH for labor and delivery.
Note: For pregnant women who are requesting EMA for labor and delivery costs only, approve EMA for the period from the onset of labor through delivery.
For system coding information for EMA, see POLI/TEMP TE13.010 (Major Program ”r;N”) and TE13.020 (Emergency MA for Program ”r;N”).
EMA is available for the duration of the medical emergency. People with chronic conditions may be eligible indefinitely if the condition persists.
Children who are ineligible for MA due to immigration status may receive EMA under the TEFRA option if they have a medical emergency.
Clients who adjust their immigration status may qualify for additional health care coverage.