State of Wisconsin Department of Health Services

HISTORY

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

23-04 Version of 34.1 Emergency Services

34.1.1 Emergency Services Eligibility Introduction

Emergency Services Medicaid is a limited benefit for immigrants who do not qualify for other forms of Medicaid because of their immigration status.

An immigrant who is ineligible for Medicaid because of their immigration status is eligible for Emergency Services Medicaid coverage if they:

• Have a qualifying emergency medical condition.
• Meet all the eligibility requirements of any Medicaid category under the state plan except
  • U.S. citizenship or qualifying immigrant status.
  • Having or applying for an SSN.

See BadgerCare Plus Handbook, SECTION 39.1 EMERGENCY SERVICES INTRODUCTION for information about Emergency Services for non-qualifying immigrants who are not elderly, blind, or disabled.

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.

A person can be eligible for Emergency Services for an emergency that occurred within the three months prior to the application month as long as the person met the eligibility requirements for Emergency Services during the month(s) in which the emergency occurred.

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 U.S. citizen is not eligible for Medicaid Emergency Services even when they 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 for adults or the end of a 12-month period for children under age 19. 

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 they are 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 their eligibility for Emergency Services for the dates of the emergency indicated on the form (unless a child under age 19). If a non-qualifying alien does not have the form at the time of application, ask them for the dates that they 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. They must meet the eligibility requirements for their type of Medicaid, such as being elderlyAnyone 65 years old or older blind or disabled*, and provide required verifications. The IM agency must provide a manual positive or negative notice regarding the applicant’s eligibility. Positive notices must provide the dates of eligibility for Emergency Services. Negative notices must provide the reason(s) for the denial or termination.

*If a non-qualifying immigrant would only qualify for Medicaid if they were disabled, the normal 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) are followed before Emergency Services eligibility is certified.  

34.1.2.1 Medicaid Deductible

Individuals may become eligible for Emergency Services by meeting the Medicaid deductible. If, on the date they apply, they are otherwise eligible except for excess income, normal deductible policies (see Section 24.2 Medicaid Deductible Introduction) are applicable.

34.1.3 Certification of Emergency Services Eligibility

Individuals enrolled in Emergency Services will be eligible until: 

• For adults age 19 and older, the last day of the emergency. 
• For children under age 19, the end of a 12-month period.
• For a child who is turning 19 in the next 12-month period, the last day of the emergency or the last day or the month the child turns 19, whichever is later.

For adults age 19 and older, if the last day of the emergency is not known, they are eligible through the last day of the month in which the emergency is expected to end. 

For information on manually processing applications, see Process Help, Section 9.3 Health Care (BC+ and MA) Emergency Services Manual Application Processing.

A person eligible for Emergency Services will not receive a ForwardHealth card because Emergency Services eligibility typically 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.

34.1.5 Emergency Services and Public Charge

Emergency Services is not considered in public charge determinations (see Section 7.3.4 Public Charge).

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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