After sudden onset, the medical condition (including emergency labor and delivery) manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:

  1.  Placing the patient's health in serious jeopardy;
  2.  Serious impairment to bodily functions; or
  3.  Serious dysfunction of any bodily organ or part.

For purposes of this rule, all labor and delivery is considered emergency labor and delivery.

Eligibility for Medicaid for emergency medical care is determined jointly by the county office and the IM Program and Policy Unit.  The county is responsible for taking the appropriate type of application, determining eligibility on all factors except emergency medical condition, and notifying the client.  The IM Program and Policy Unit is responsible for making the final decision on whether client had an emergency medical condition and entering the eligibility into the system.

APPLICATION AND ELIGIBILITY DETERMINATION

An ineligible alien must apply for an existing type of assistance, there is not a separate emergency medical care program.  The type of assistance applied for must be a federally funded Medicaid program, not Blind Pension or General Relief.  Determine eligibility for the program applied for on all factors, including residence, except citizenship/alien status.

If ineligible on a factor other than citizenship/alien status, the caseworker should reject the application.  An ineligible alien cannot be approved prior to the occurrence of the emergency medical condition.  If an ineligible alien who has not received emergency medical care requests to apply, take an application and immediately reject it. 

If eligible on all factors except citizenship/alien status, send a request for emergency medical care coverage to IM Program & Policy with the following information:

• Individual's name, DCN, and alien status;
• The existing program eligibility is based on;
• Statement that individual meets all eligibility requirements except citizenship/alien status;
• Dates of the emergency medical care the individual received;
• Nature of medical condition that required emergency medical care.  If the condition is birth of a child, include the child's date of birth, the mother's dates of admission and discharge, and whether it was a normal delivery or caesarian section.

EMERGENCY MEDICAL CONDITION DETERMINATION

Medical documentation is always needed for all conditions other than birth of a child.  This documentation should include doctor and hospital records, an IM-61 form, and any other information pertaining to the medical condition.

Documentation is only needed on labor and delivery if the hospital stay exceeds one day prior to delivery,  two days after the birth on normal deliveries, or four days on C-Sections.

NOTIFICATION

All eligibility for emergency medical care must be entered into the system by IM Program & Policy.  Entry is made directly to the Medicaid eligibility screen (IXIX) rather than through IMU5.  The caseworker should reject the regular Medicaid application on IMU5.

Once eligibility for emergency medical care is determined, IM Program and Policy will notify the county by E-mail of the decision and eligibility dates.  The client should be sent a rejection letter due to not meeting the citizenship/alien status requirement for the regular Medicaid program for which they applied.  Along with the rejection letter send an approval letter stating they have been approved for Medicaid for Emergency Medical Care, with the eligibility dates.  If applicant is determined ineligible for emergency medical care, send a rejection letter that states the applicant does not have an emergency medical condition; refer to Section 1903 (v) of Social Security Act.

Regular hearing rights and procedures are applicable to requests for emergency medical care.  Ineligible aliens may request a  hearing on the rejection of regular Medicaid, an approval not covering total number of days requested, or a denial due to absence of an emergency medical condition. 

• Review this memorandum with all appropriate staff.

• Immediately begin applying the above policy to determine eligibility for Medicaid coverage for emergency medical care for ineligible aliens.