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Effective: October 1, 2009 |
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03.45.05ar4 - Emergency Medical Assistance (EMA) (Archive) |
Archived: March 1, 2010 |
Noncitizen applicants or enrollees who are not eligible for federally funded Medical Assistance (MA) or, in some cases, state-funded MA (NMED), may be eligible for Emergency Medical Assistance (EMA) if they have a medical emergency. This includes people in any of the following groups:
l People with an immigration status of undocumented or nonimmigrant .
l People already eligible for state-funded MA (NMED), who then have a medical emergency. Approving EMA for these people enables DHS to claim federal reimbursement for those medical costs.
l Sponsored immigrants who have a medical emergency and are ineligible for MA or NMED because of their sponsors’ income or assets or the sponsor does not respond to the Sponsor Letter (DHS-3453). Sponsored immigrants are not required to provide sponsor information to qualify for EMA.
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 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, three months retroactive eligibility is possible if the chronic condition and need for treatment existed in the retroactive months. All other eligibility factors must also be met.
Renewals (standard guidelines)
For acute emergencies and labor/delivery, EMA will remain open only for the duration of the emergency. There are no renewals unless the EMA is necessary for a chronic condition lasting more than six months.
Note: Follow standard MA guidelines for cases that remain open on EMA due to chronic conditions.
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 the dates of medical services 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 condition is expected to improve.
Determine whether the enrollee is eligible for basic MA prior to closing EMA.
Social Security Number (standard guidelines)
Do not require a Social Security number for people who apply for or enroll in EMA.
Do not require clients to declare or verify their immigration status.
Do not apply sponsor deeming provisions. Follow standard MA guidelines for deeming income and assets.
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 (Prepaid MHCP Manual)
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.
Giving birth qualifies as a medical emergency. EMA covers the labor and delivery costs, but does not cover routine prenatal or postpartum care.
Pregnant noncitizens with a status that does not qualify for FFP may be eligible for
l CHIP-funded MA (program NMED, eligibility type PC) through the birth month, and
l state-funded MA (program NMED, eligibility type PX) for the 60-day postpartum period.
Exception: Pregnant noncitizens who have other insurance are not eligible for CHIP-funded MA for prenatal or postpartum care.
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 ”N”) and TE13.020 (Emergency MA for Program ”N”).
EMA is available for the duration of the medical emergency. People with chronic conditions may be eligible indefinitely if the condition persists.
Determine whether the enrollee is eligible for basic MA prior to closing EMA.
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.