State of Wisconsin Department of Health Services

HISTORY

The policy on this page is from a previous version of the handbook. 

21-01 Version of 34.1 Emergency Services

34.1.1 Emergency Services Eligibility Introduction

Documented and undocumented non-citizens ineligible under regular Medicaid due to alien status can be eligible for Emergency Services, if he or she meets all other eligibility requirements except having or applying for an SSNSocial Security number. Non-citizens may have an SSN and may still qualify for Emergency Services. If a non-citizen would otherwise be eligible for any type of EBD Medicaid, he or she would qualify for Emergency Services.  

An inmate who is a non-qualifying immigrant may be eligible for Emergency Services for the dates they are hospitalized as an inpatient for emergency treatment as long as they meet the rest of the eligibility criteria for Emergency Services.  

Emergency Services only covers medical services needed for the treatment of an emergency medical condition. Services related to organ transplant procedure are not covered by Emergency Services.

An emergency means a medical condition (including labor and delivery) that shows acute symptoms of sufficient severity (including severe pain) such that the lack of immediate Medicaid could result in one or more of the following:

1.  Serious jeopardy to the patient's health.
2.  Serious impairment to bodily functions.
3.  Serious dysfunction of a bodily organ or part.

All labor and delivery services are emergency services and are covered under Emergency Services for eligible non-qualifying aliens.  

The IMincome maintenance agency does not determine if an emergency condition is eligible for Emergency Services coverage.  

The medical provider submits claims for emergency medical services to the fiscal agent. It determines if a condition is an emergency medical condition covered by Emergency Services.

A citizen is not eligible for Medicaid Emergency Services even when he or she cannot produce citizenship and/or identity verification.

Example 1:

Jill applies for Medicaid, declares U.S. citizenship, and is asked to provide documents proving her citizenship and identity. She has a driver license to prove identity but does not have anything to prove her citizenship. Since Emergency Services Medicaid does not require proof of citizenship and identity as an eligibility requirement, she then asks to be considered for this program. However the IM worker cannot process Emergency Services Medicaid eligibility for persons declaring to be U.S. citizens.  Emergency Services Medicaid is reserved for non-qualifying non-citizens.

34.1.2 Determination of Emergency Services Eligibility

Certification of Emergency Services is not done by CARES and must be done manually. Emergency Services coverage lasts from the time of the first treatment for the emergency until the condition is no longer an emergency. Local agencies do not determine if an emergency exists. Local agency responsibility is to determine if the non-qualifying alien meets all other eligibility requirements during the dates of service and to certify if he or she is eligible for Emergency Services.  

If a non-qualifying alien provides a "Certification of Emergency for Non-U.S. Citizens” (F-01162) at the time of application, determine his or her eligibility for Emergency Services for the dates of the emergency indicated on the form. If a non-qualifying alien does not have the form at the time of application, ask him/her for the dates that he or she received emergency services.  The F-01162 is not required to certify Emergency Services eligibility.  

Persons applying for Emergency Services have the same rights and responsibilities as persons applying for regular Medicaid. He or she must meet the eligibility requirements for his or her type of Medicaid, such as being elderlyAnyone 65 years old or older blind or disabled*, and provide required verifications. He or she is also entitled to all notice rights and must receive a manual positive or negative notice regarding his or her eligibility. Positive Notices must provide the dates of eligibility for Emergency Services. Negative Notices must provide the reasons for the denial or termination.

*If a non-qualifying alien would only qualify for Medicaid if he or she was disabled, follow disabilityThe law defines disability for Medicaid as "The inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months." determination procedures (including presumptive disability) before certifying Emergency Services eligibility.  

34.1.2.1 Medicaid Deductible

Aliens who apply for emergency services may become eligible by way of the Medicaid deductible. If, on the date he or she applies, he or she is eligible in all respects except income, apply the same deductible policies (24.2 Medicaid Deductible Introduction) to him or her as any other client.

34.1.3 Certification of Emergency Services Eligibility

Certification of Emergency Services is not done by CARES and must be done manually. When an alien is determined eligible for Emergency Services, complete and submit a Medicaid/BadgerCare Plus Eligibility Certification form (F-10110) (formerly DES 3070). Emergency Services only covers medical services needed for the treatment of an emergency medical condition. Services related to an organ transplant procedure are not covered by Emergency Services. The fiscal agent needs a beginning and end date to process eligibility. In setting the end date, use the last day of the emergency. If that is not known, use the last day of the month in which the emergency is expected to end. Use the AE medical status code.  

The Medicaid/BadgerCare Plus Eligibility Certification form may be submitted to the fiscal agent by fax to 608-221-8815 or by mail to:

ForwardHealth
Eligibility Unit
P.O. Box 7636
Madison, WI 53707

A person eligible for Emergency Services will not receive a ForwardHealth card because Emergency Services eligibility ends when the emergency ends.

34.1.4 BadgerCare Plus Emergency Services

For  Emergency Services for children, parents, caretakers, and pregnant women, see the BadgerCare Plus Handbook Chapter 39.1 Emergency Services and Chapter 41.1 BadgerCare Plus Prenatal Program.

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The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.

Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.

Publication Number: P-10030