3.2.3 EMERGENCY SERVICES Medicaid

3.2.3.1  Determination of EMA Eligibility

3.2.3.1.1  MA Deductible

3.2.3.2  Certification of EMA Eligibility
3.2.3.3  Pregnancy
3.2.3.3.1  Eligibility Begin Date

3.2.3.3.2  Eligibility Begin Date for non-qualifying aliens who lose eligibility for the BC Prenatal Program.

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

Note:  Pregnant non-qualifying aliens may be eligible under the BadgerCare Prenatal program 5.7.11.

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

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 MA 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 EMA for eligible non-qualifying aliens.  

The IM agency does not determine if an emergency condition is eligible for EMA coverage.  

The medical provider submits claims for emergency medical services to EDS.  EDS determines if a condition is an emergency medical condition covered by EMA.
 

3.2.3.1   Determination of EMA Eligibility

Certification of EMA is not done by CARES and must be done manually.  EMA 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 s/he is eligible for EMA.  

Note: Determination of BC Prenatal Eligibility is done in CARES.

If a non-qualifying alien provides a “Certification of Emergency for Non-U.S. Citizens” (HCF 1162) at the time of application, determine his/her eligibility for EMA 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 s/he received emergency services.  The HCF 1162 is not required to certify EMA eligibility.  Determine eligibility of a pregnant alien on the date emergency services were provided.  Pregnancy due date is required to determine eligibility for pregnant aliens.  (See 3.2.3.3 and 5.7.11 for EMA certification dates for pregnant women.)

Persons applying for EMA have the same rights and responsibilities as persons applying for regular MA.  S/he must meet the eligibility requirements for his/her type of MA, such as being elderly blind or disabled*, and provide required verifications.  S/he is also entitled to all notice rights and must receive a manual positive or negative notice regarding his/her eligibility.  Positive Notices must provide the dates of eligibility for EMA.  Negative Notices must provide the reasons for the denial or termination.

*If a non-qualifying alien would only qualify for MA if s/he was disabled, follow disability determination procedures (including presumptive disability) before certifying EMA eligibility.

3.2.3.1.1 MA Deductible

Aliens who apply for emergency services may become eligible by way of the MA deductible.  If, on the date s/he applies, s/he is eligible in all respects except income, apply the same deductible policies (4.9.1) to him/her as any other client.

3.2.3.2 Certification of EMA Eligibility

Certification of EMA is not done by CARES and must be done manually.  When an alien is determined eligible for EMA, complete and submit a HCF 10110 ( Formerly DES 3070).  EMA only covers medical services needed for the treatment of an emergency medical condition.  Services related to an organ transplant procedure are not covered by EMA.  EDS 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 HCF 10110 may be submitted to EDS in the following ways:

1. Mail: EDS

P.O. Box 7636

Madison, WI 53707

2. E-mail: eds_3070@dhfs.state.wi.us

3. Fax: (608) 221-8815

An individual eligible for EMA will not receive a Forward card because EMA eligibility ends when the emergency ends.  

However, women determined eligible for the BC Prenatal Program will be issued a Forward Card, which can also be used to access emergency services under EMA after BC ends.

3.2.3.3 Pregnancy

All labor and delivery services are emergency services and are covered under EMA for eligible non-qualifying aliens.  An alien who gives birth and is eligible for EMA is eligible for a 60-day pregnancy extension.  The extension covers emergency MA only.  The emergency does not have to be related to the pregnancy.  Babies born to mothers covered under EMA may be MA eligible as continuously eligible newborns if all other eligibility conditions identified in (5.2.5) are met.

3.2.3.3.1 Eligibility Begin Date

A pregnant non-qualifying alien may apply for emergency services up to one calendar month before her due date (See 3.2.3.3.2 for pregnant non-qualifying aliens who lose eligibility for the BC Prenatal Program).  Certify an eligible pregnant non-qualifying alien from the date of application, if she applies no more than one calendar month prior to her due date, through the end of the month in which the 60th day occurs following her due date.  Adjust the certification period based on the actual pregnancy end date, once it is known.

If a pregnant non-qualifying alien applies prior to the calendar month before her due date and she has not received a service, deny her emergency services eligibility because she has not received a service.

If a woman applies for emergency services within three months after her pregnancy has ended, certify her from the pregnancy end date through the end of the month in which the 60th day occurs.

3.2.3.3.2 Eligibility Begin Date for non-qualifying aliens who lose eligibility for the BC Prenatal Program.

A non-qualifying alien that loses eligibility for the BC Prenatal Program (5.7.11) when her pregnancy ends, or for any reason other than moving out of state, is eligible for EMA from the date she lost BC Prenatal Program eligibility.  Like other pregnant aliens, these women should have EMA coverage through the end of the month in which the 60th day occurs following her due date or the pregnancy end date, if that is known.

Pregnant non-qualifying aliens who are not found eligible for the BC Prenatal Program should have EMA eligibility determined according to the instructions in MEH 3.2.3.3

This page last updated in Release Number: 07-03

Release Date: 04/18/07

Effective Date: 04/18/07