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Effective: November 1, 2012 |
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03.45.05ar9 - Emergency Medical Assistance (EMA) (Archive) |
Archived: December 1, 2013 |
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 ineligible for federally funded MA due to immigration status or date of entry who meet all other MA program requirements.
l People with an immigration status of undocumented or nonimmigrant.
l People receiving services from the Center for Victims of Torture and on state-funded MA (NMED) without a spenddown, who then have a medical emergency. Approving EMA for the time of the emergency 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 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.
l Noncitizens granted deferred action under the Deferred Action for Childhood Arrivals (DACA) process.
To be eligible for EMA, people must meet all of the following conditions:
l Have an MA basis of eligibility.
l Have an emergency medical condition.
l Meet all other MA eligibility requirements, including state residence.
An emergency medical condition 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.
n For medical conditions that require further care outside of the emergency room or hospital, such as a long-term care facility or a long-term care service through one of the home and community based waiver services, to prevent the condition from becoming an emergency within 48 hours the physician or dentist can submit an Emergency Medical Assistance Care Plan Certification Request (DHS-3642) to DHS' review agents.
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.
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 a care plan certification request is authorized and will last more than six months.
Note: Follow standard MA guidelines for cases that remain open on EMA due to an authorized care plan certification request.
For sudden onset of an emergency medical 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 care plan certification request:
l DHS' medical review agent will contact the MMIS User Services Help Desk upon a decision to authorize care beyond the emergency room or hospital..
l The MMIS User Services Help Desk staff will contact the client's worker who will continue EMA for the client for the authorized time frame or until the next annual renewal..
l If further services are needed the care plan certification request will have to be submitted and authorized at least annually.
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.
When a client's emergency medical condition needs more care beyond the emergency room or hospital the client's physician or dentist may submit a care plan certification request (DHS-3642) to DHS' medical review agents. The physician or dentist needs to identify the need for follow-up care and the services needed to prevent the emergency condition from recurring quickly (typically within 48 hours).
People who receive EMA are excluded from managed care enrollment.
Giving birth qualifies as a medical emergency. EMA covers the inpatient stay related to labor and delivery, but does not cover routine prenatal or postpartum care received before or after the inpatient stay.
Pregnant noncitizens with an undocumented or nonimmigrant status may be eligible for:
l CHIP-funded MA from the month of conception through the 60-day postpartum period.
l EMA for the inpatient stay related to labor and delivery.
Note: For undocumented or nonimmigrant pregnant women who request EMA for labor and delivery costs only, approve EMA for the period from the date of the admission through the discharge date.
For system coding information for EMA, see POLI/TEMP TE13.010 (Major Program ”N”) and TE13.020 (Emergency MA for State-Funded MA Enrollees).
EMA is available for the duration of the medical emergency. People with an authorized care plan certification request 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 and an authorized care plan certification request.
Clients who adjust their immigration status may qualify for additional health care coverage.