Emergency Assistance - Alien Medical Program (AMP)
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Emergency Assistance - Alien Medical Program (AMP)


Revised April 29, 2013



Purpose: The Alien Medical Program (AMP) is for non-citizens who: Have a qualifying emergent medical condition; Would be eligible for Medicaid if he/she were a citizen; and Are ineligible for a full-scope Medicaid program due to immigrant status.

WAC 182-507-0110Alien medical programs.
WAC 182-507-0115Alien emergency medical program (AEM).
WAC 182-507-0120Alien medical for dialysis and cancer treatment.
WAC 182-507-0125State-funded long-term care services program.

NOTE:

A non-citizen that can receive medical coverage under AMP may be one of the following:

  1. Undocumented;
  2. An unqualified alien; or
  3. A qualified alien who is currently in the five-year ban, so is not eligible for other Medicaid programs.

WAC 182-507-0110

WAC 182-507-0110

Effective October 1, 2013

WAC 182-507-0110 Washington apple health -- Alien medical programs.



(1) To qualify for an alien medical program (AMP) a person must:

(a) Be ineligible for federally funded Washington apple health (WAH) programs due to the citizenship/alien status requirements described in WAC 182-503-0535;

(b) Meet the requirements described in WAC 182-507-0115, 182-507-0120, or 182-507-0125; and

(c) Meet all categorical and financial eligibility criteria for one of the following programs, except for the Social Security number or citizenship/alien status requirements:

(i) An SSI-related medical program described in chapters 182-511 and 182-512 WAC;

(ii) A MAGI-based program referred to in WAC 182-503-0510; or

(iii) The breast and cervical cancer treatment program for women described in WAC 182-505-0120; or

(iv) A medical extension described in WAC 182-523-0100.

(2) AMP medically needy (MN) health care coverage is available only for children, pregnant women and persons who meet SSI-related criteria. See WAC 182-519-0100 for MN eligibility and WAC 182-519-0110 for spending down excess income under the MN program.

(3) The agency or its designee does not consider a person's date of arrival in the United States when determining eligibility for AMP.

(4) For non-MAGI-based programs, the agency or its designee does not consider a sponsor's income and resources when determining eligibility for AMP, unless the sponsor makes the income or resources available. Sponsor deeming does not apply to MAGI-based programs.

(5) A person is not eligible for AMP if that person entered the state specifically to obtain medical care.

(6) A person who the agency or its designee determines is eligible for AMP may be eligible for retroactive coverage as described in WAC 182-504-0005.

(7) Once the agency or its designee determines financial and categorical eligibility for AMP, the agency or its designee then determines whether a person meets the requirements described in WAC 182-507-0115, 182-507-0120, or 182-507-0125.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-507-0115

WAC 182-507-0115

Effective December 30, 2012

WAC 182-507-0115 Alien emergency medical program (AEM).

1.  A person nineteen years of age or older who is not pregnant and meets the eligibility criteria under WAC 182-507-0110 is eligible for the alien emergency medical program's scope of covered services described in this section if the person meets (a) and (b) or (c) of this subsection:

a. The medicaid agency determines that the primary condition requiring treatment meets the definition of an emergency medical condition as defined in WAC 182-500-0030, and the condition is confirmed through review of clinical records; and

b.  The person's qualifying emergency medical condition is treated in one of the following hospital settings:

i. Inpatient;

ii. Outpatient surgery;

iii. Emergency room services, which must include an evaluation and management (E&M) visit by a physician; or

c. InvoluntaryTreatment Act (ITA) and voluntary inpatient admissions to a hospital psychiatric setting that are authorized by the agency's inpatient mental health designee (see subsection (5) of this section).

2. If a person meets the criteria in subsection (1) of this section, the agency will cover and pay for all related medically necessary health care services and professional services provided:

     a.  By physicians in their office or in a clinic setting immediately prior to the transfer to the hospital, resulting in a direct admission to the hospital; and

      b. During the specific emergency room visit, outpatient surgery or inpatient admission.  These services include, but are not limited to:

i. Medications;

ii. Laboratory, x-ray, and other diagnostics and the professional interpretations;

iii.  Medical equipment and supplies;

iv.  Anesthesia, surgical, and recovery services;

v. Physician consultation, treatment, surgery, or evaluation services;

vi. Therapy services;

vii. Emergency medical transportation; and

viii. Non-emergency ambulance transportation to transfer the person from a hospital to a long term acute care (LTAC) or an inpatient physical medicine and rehabilitation (PM&R) unit, if that admission is prior authorized by the agency or its designee as described in subsection (3) of this section.

3. The agency will cover admissions to an LTAC facility or an inpatient PM&R unit if:

a. The original admission to the hospital meets the criteria as described in subsection (1) of this section;

b.  The person is transferred directly to this facility from the community hospital; and

c. The admission is prior authorized according to LTAC and PM&R program rules (see WAC 182-550-2590 for LTAC and WAC 182-550-2561 for PM&R).

4. The agency does not cover any services, regardless of setting, once the person is discharged from the hospital after being treated for a qualifying emergency medical condition authorized by the agency and its designee under this program.  Exception: Pharmacy services, drugs, devices, and drug-related supplies listed in WAC 182-530-2000, prescribed on the same day and associated with the qualifying visit or service (as described in subsection (1) of this section) will be covered for a one-time fill and retrospectively reimbursed according to pharmacy program rules.

5. Medical necessity of inpatient psychiatric care in the hospital setting must be determined, and any admission must be authorized by the agency's inpatient mental health designee according to the requirements in WAC 182-550-2600.

6.  There is no precertification or prior authorization for eligibility under this program.  Eligibility for the AEM program does not have to be established before an individual begins receiving emergency treatment.

7. Under this program, certification is only valid for the period of time the person is receiving services under the criteria described in subsection (1) of this section.  The exception for pharmacy services is also applicable as described in subsection (4) of this section.

a. For inpatient care, the period of eligibility is only for the period of time the person is in the hospital, LTAC, or PM&R facility - the admission date through the discharge date.  Upon discharge the person is no longer eligible for coverage.

b. For an outpatient surgery or emergency room services the period of eligibility is only for the date of service.  If the person is in the hospital overnight, the eligibility period will be the admission date through the discharge date.  Upon release form the hospital, the person is no longer eligible for coverage.

8.  Under this program, any visit or service not meeting the criteria described in subsection (1) of this section is considered not within the scope of covered services as described in WAC 182-501-0060.  This includes, but is not limited to:

a. Hospital services, care, surgeries, or inpatient admissions to treat any condition which is not considered by the agency to be a qualifying emergency medical condition, including but not limited to:

i. Laboratory, x-ray, or other diagnostic procedures;

ii. Physical, occupational, speech therapy, or audiology services;

iii. Hospital clinic services; or

iv. Emergency room visits, surgery, or hospital admissions.

b. Any services provided during a hospital admission or visit (meeting the criteria described in subsection (1) of this section), which are not related to the treatment of the qualifying emergency medical condition;

c. Organ transplants, including pre-evaluations, post-operative care, and anti-rejection medication;

d. Services provided outside the hospital settings described in subsection (1) of this section including, but not limited to:

i. Office or clinic-based services rendered by a physician, an ARNP, or any other licensed practitioner;

ii. Prenatal care, except labor and delivery;

iii. Laboratory, radiology, and any other diagnostic testing;

iv. School-based services;

v. Personal care services;

vi. Physical, respiratory, occupational, and speech therapy services;

vii. Waiver services;

viii. Nursing facility services;

ix. Home health services;

x. Hospice services;

xi. Vision services;

xii. Hearing services;

xiii. Dental services;

xiv. Durable and non durable medical supplies;

xv. Non-emergency medical transportation;

xvi. Interpreter services; and

xvii. Pharmacy services, except as described in subsection (4) of this section.

9. The services listed in subsection (8) of this section are not within the scope of service categories for this program and therefore the exception to rule process is not available.

10. Providers must not bill the agency for visits or services that do not meet the qualifying criteria described in this section.  The agency will identify and recover payment for claims paid in error.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-507-0120

WAC 182-507-0120

Effective December 30, 2012

WAC 182-507-0120 Alien medical for dialysis and cancer treatment.

In addition to the provisions for emergency care described in WAC 182-507-0115, the medicaid agency also considers the conditions in this section as an emergency, as defined in WAC 182-500-0030.

1. A person nineteen years of age or older who is not pregnant and meets the eligibility criteria under WAC 182-507-0110  may be eligible for the scope of covered services under this program if the condition requires:

a. Surgery, chemotherapy, and/or radiation therapy to treat cancer;

b. Dialysis to treat acute renal failure or end stage renal disease (ESRD); or

c. Anti-rejection medication, if the person has had an organ transplant.

2. When related to treating the qualifying medical condition, covered services include but are not limited to:

a.  Physician and ARNP services, except when providing a service that is not within the scope of this medical program (as described in subsection (7) of this section);

b. Inpatient and outpatient hospital care;

c. Dialysis;

d. Surgical procedures and care;

e. Office or clinic based care;

f. Pharmacy services;

g. Laboratory, x-ray, or other diagnostic studies;

h. Oxygen services;

i. Respiratory and intravenous (IV) therapy;

j. Anesthesia services;

k. Hospice services;

l. Home health services, limited to two visits;

m. Durable and non durable medical equipment;

 n. Non-emergency transportation; and

o. Interpreter services.

3. All hospice, home health, durable and non durable medical equipment, oxygen and respiratory, IV therapy, and dialysis for acute renal disease services require prior authorization.  Any prior authorization requirements applicable to the other services listed above must also be met according to specific program rules.

4. To be qualified and eligible for coverage for cancer treatment under this program, the diagnosis must be already established or confirmed. There is no coverage for cancer screening or diagnostics for a workup to establish the presence of cancer.

5. Coverage for dialysis under this program starts the date the person begins dialysis treatment, which may include fistula placement. and other required access.   There is no coverage for pre-dialysis intervention, such as surgery for fistula placement anticipating the need for dialysis, or any services related to preparing for dialysis.

6. Certification for eligibility will range between one to twelve months depending on the qualifying condition, the proposed treatment plan, and whether the client is required to meet a spenddown liability.

7. The following are not within the scope of service categories for this program:

a. Cancer screening or work-ups to detect or diagnose the presence of cancer;

b. Fistula placement while the person waits to see if dialysis will be required;

c. Services by any healthcare professional provided to treat a condition not related to, or medically necessary to, treat the qualifying condition;

d. Organ transplants, including pre-evaluations and post operative care;

e. Health department services;

f. School-based services;

g. Personal care services;

h. Physical, occupational, and speech therapy services;

i. Audiology services;

j. Neurodevelopmental services;

k. Waiver services;

l. Nursing facility services;

m. Home health services, more than two visits;

n. Vision services;

o. Hearing services;

p. Dental services, unless prior authorized and directly related to dialysis or cancer treatment;

q. Mental health services;

r. Podiatry services;

s. Substance abuse services; and

t. Smoking cessation services.

8. The services listed in subsection (7) of this section are not within the scope of service categories for this program.  The exception to rule process is not available.

9. Providers must not bill the agency for visits or services that do not meet the qualifying criteria described in this section. 

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-507-0125

WAC 182-507-0125

Effective October 1, 2013

WAC 182-507-0125 State-funded long-term care services program.

Emergency WAC effective 1-1-2014

  1. The state-funded long-term care services program is subject to caseload limits determined by legislative funding.  Services cannot be authorized for eligible persons prior to a determination by the aging and long-term supports administration (ALTSA) that caseload limits will not be exceeded as a result of the authorization.
  2. Long-term care services are defined in this section as services provided in one of the following settings:

a.  In a person's own home, as described in WAC 388-106-0010;

b.  Nursing facility, as defined in WAC 388-97-0001;

c.  Adult family home, as defined in RCW 70.128.010;

d.  Assisted living facility, as described in WAC 182-513-1301;

e.  Enhanced adult residential care facility, as described in WAC 182-513-1301;

f.  Adult residential care facility, as described in WAC 182-513-1301.

3.  Long-term care services will be provided in one of the facilities listed in subsection (2) (b) through (2)(f) of this section unless nursing facility care is required to sustain life. 

4.  To be eligible for the state-funded long-term care services program described in this section, an adult nineteen years of age or older must meet all of the following conditions:

a.  Meet the general eligibility requirements for medical programs described in WAC 182-503-0505 (2) and (3) with the exception of subsection (3) (c) and (d) of this section

b.  Reside in one of the settings described in subsection (2) of this section;

c.  Attain institutional status as described in WAC 182-513-1320;

d.  Meet the functional eligibility described in WAC 388-106-0355  for nursing facility level of care;

e.  Not have a penalty period due to a transfer of assets as described in WAC 182-513-1363, 182-513-1364, or 182-513-1365;

f.  Not have equity interest in a primary residence more than the amount described in WAC 182-513-1350; and

g.  Any annuities owned by the adult or spouse must meet the requirements described in chapter182-516 WAC.

5.  An adult who is related to the supplemental security income (SSI) program as described in WAC182-512-0050  (1), (2), and (3) must meet the financial requirements described in WAC 182-513-1315.

6.  An adult who does not meet the SSI-related criteria in subsection (2) of this section may be eligible under the family institutional medical program rules described in WAC 182-514-0230

7.  An adult who is not eligible for the state-funded long-term care services program under categorically needy (CN) rules may qualify under medically needy (MN) rules described in:

a. WAC 182-513-1395  for adults related to SSI; or

b. WAC 182-514-0255 for adults up to age twenty-one related to family institutional medical.

8.  All adults qualifying for the state-funded long-term care program will receive CN scope of medical coverage described in WAC 182-500-0020.

9.  The department determines how much an individual is required to pay toward the cost of care using the following rules:

a.  For an SSI-related individual residing in a nursing home, see rules described in WAC 182-513-1380

b.  For an SSI-related individual residing in one of the other settings described in subsection (2) of this section, see rules described in WAC 182-515-1505.

c.  For an individual eligible under the family institutional program, see WAC 182-514-0265. 

10.  A person is not eligible for state-funded long-term care services if that person entered the state specifically to obtain medical care.

11.  A person eligible for the state-funded long-term care services program is certified for a twelve month period.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WORKER RESPONSIBILITIES

Specialized Medical Unit (SMU) staff determines eligibility for non-HCS AMP cases.

  1. Medical only applications and renewals received must be routed via DMS to CSO 157@AEM for processing.
  2. Applications received in the CSO that include requests for other programs are processed by the local office for other programs and by the SMU for AMP.

a.  Set a same-date tickler to CSO 157@AEM for application processing

b.  SMU Contact Information:

DSHS-Customer Service Center

PO Box 11699

Tacoma, WA 98411-6699

Toll Free (877) 501-2233


CMU AMP APPLICATION PROCESS

All reviews received from an alien on AMP are treated as applications with a new certification period established.

  1. Ask yourself if the alien would be eligible for Medicaid if the alien were a citizen.  If the answer is YES, the person is "related to" a Medicaid program.  If the alien is not related to a Medicaid program, deny the application.
  2. Has the alien received treatment in a hospital setting (inpatient or outpatient)?  Are they currently receiving cancer or dialysis treatment or anti-rejection medication for post-organ transplant?
  3. If the alien does not meet a condition in 2 above, ACES will deny the AU with reason code 276 - No Medical Emergency,  with auto text reading:  Your medical condition doesn't meet the emergency requirements.

You will need to add the following free-form text:

We have reviewed your case and you are not eligible for any HCA/DSHS medical program.  We also reviewed your eligibility for the Alien Medical Program and you do not meet the following:

  • Have not had surgery to treat cancer, and are not receiving chemotherapy and/or radiation therapy to treat cancer; or
  • Are not immediately starting or receiving dialysis to treat acute renal failure or end-stage renal disease; or
  • Are not receiving anti-rejection medication for an organ transplant.

         4.  If the alien meets 1 and 2 above, complete Alien Medical Referral/Checklist

a.  If not already provided, send a request for information letter to client for required documents on referral/checklist.

b.  If client is still hospitalized at time of application and after contact with the hospital, the discharge date cannot be determined, refer to HCA medical consultant with the following:

i.  Admission History and Physical (signed by the admission doctor);

ii.  The most recent physician notes; and

iii.  Note from the worker that the client is still inpatient.

c.  Once all documents are provided, forward referral/checklist and documents to the HCA medical consultant through the Barcode AMP Referral system.

d.  AMP requests cannot be opened until a prior authorization approval has been received from the HCA medical consultant.


NOTE:

Referrals without all required documentation will be considered incomplete and not accepted.  They will be returned and will need to be resubmitted.  Incomplete requests will not be pended by the medical consultant for completed documents.


NOTE:

Separate medical AUs need to be established for eligible individuals when there are different approval begin and end dates for two or more individuals.  Alien medical AUs with two or more persons on the same AU, and both recipients, can be on the same AU when the recipients have the same approval begin and end dates. 

It is recommended that separate medical AUs for each eligible individual always be established when an AU has more than one eligible individual.

Separate AMP Barcode referrals are needed for each individual if applying at the same time.


5.  Once the AMP referral is returned by the medical consultant, update the Approval Source field under ALIEN Medical on the ALAS screen in ACES with one of the following codes:

  • A - ADSA Headquarters Approved
  • H - HCA Med Consultant Approved
  • N - Not Approved

NOTE:

Leaving the Approval Source field blank will result in the AU being denied.  This field should only be left blank for applications being denied when a Barcode referral to the HCA medical consultant is not appropriate.


6.  If approved by the HCA medical consultant and the client has been hospitalized for over 30 days, open L04 (K03 if under age 21) using institutional rules.

7.  Certification periods for AEM:

  • Cannot be more than 12 months for non-spenddown AUs
  • Cannot be less than 1 month and no more than 6 months for spenddown AUs
  • Won't be synchronized with other related AUs
  • Won't continue beyond the end date when a review is initiated or received but not completed

NOTE:

During review completion, the system won't auto-extend the review period in order to sync up review cycles.  No review generates if the review cycle is missed.


  • If the approval dates span more than one calendar month, the certification period includes all months within the approval period.

For Example: 

  • Approval period is 6/5/xx - 7/12/xx.  The certification period is 6/1/xx - 7/31/xx; however, eligibility is only established from 6/5/xx - 7/12/xx.
  • If this is a spenddown AU, the AU begin date would be the date spenddown is met, which could be no earlier than 6/5/xx.

EXAMPLE

An undocumented client applies for AMP on December 10th.  You have determined the person is related to the F04 medical program and meets income and resource Standards.  The client was treated in the hospital for a stroke from 11/02/XX through 11/15/XX.  Request hospital documents listed on the referral/checklist under Inpatient admission if not already provided.  Once received, refer to HCA medical consultant.  If approved by HCA medical consultant, AEM is authorized for November only to cover hospital stay.  Update the Alien Medical fields on the ALAS screen in ACES with the following :  Approv Source: H; Approv Begin: 11/02/XX; Approv End: 11/15/XX.


NOTE:

Once the HCA medical consultant end date has expired, a new application, referral checklist, and medical documentation are required.


8.  If denied by the HCA medical consultant, update the approval source field under Alien Medical on the ALAS screen in ACES with N and ACES will deny the AU with reason code 276 - No Medical Emergency with auto text reading:  Your medical condition doesn't meet the emergency requirements.

You will need to add the following fee form text:

We have reviewed your case and you are not eligible for any HCA/DSHS medical program.  We also reviewed your eligibility for the Alien Medical program and you do not meet the following:

  • Have not had surgery to treat cancer, and are not receiving chemotherapy and/or radiation therapy to treat cancer; or
  • Are not immediately starting or receiving dialysis to treat acute renal failure or end-stage renal disease; or
  • Are not receiving anti-rejection medication for an organ transplant.

9.  AMP cannot be approved without prior authorization from HCA medical consultants.  They can be contacted at:

Health Care Authority

Health Care Benefits and Utilization Management

MS 45506

Telephone:  1-800-562-3022    FAX:  (360) 586-1471

All communication pertaining to an AMP referral should be made through the Barcode AMP Referral system.


AMP CLIENT RIGHTS TO AN ADMINISTRATIVE HEARING

1.  Clients applying for, or receiving, AMP have the same administrative hearing rights as all other programs.  AMP clients will be scheduled on the CSO docket if the decision under appeal was made by the CSO staff.

2.  A hearing concerning a decision by HCA staff will be administered by HCA.  Those decisions may include, but are not limited to:

a.  Denial that an individual's medical condition meets agency criteria of a qualifying emergent medical condition

b.  Denial of a medical service, or

c.  Restricted use of medical care

3.  An AMP client may request the hearing at the CSO or they may send the request directly to:

Office of Administrative Hearings

PO Box 42489

Olympia, WA  98506-2489

Clearly mark the request with:

  • AMP (CSO)
  • AMP (HCS), or
  • AMP (HCA)
Modification Date: April 29, 2013