Purpose: The Alien Emergency Medical (AEM) program 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.
The non-citizens that can receive medical coverage under AEM may be one of the following:
Undocumented;
An unqualified alien; or
A qualified alien who is currently in the five-year ban, so is not eligible for other Medicaid programs.
WAC 388-438-0110
WAC 388-438-0110
Effective April 9, 2007
WAC 388-438-0110 The Alien emergency medical (AEM) program.
The alien emergency medical (AEM) program is a required federally funded program. It is for aliens who are ineligible for other Medicaid programs, due to the citizenship or alien status requirements described in WAC 388-424-0010.
Except for the social security number, citizenship, or alien status requirements, an alien must meet categorical Medicaid eligibility requirements as described in:
When an alien has monthly income that exceeds the CN medical standards, the department will consider AEM medically needy coverage for children or for adults who are age sixty-five or over or who meet SSI disability criteria. See WAC 388-519-0100.
To qualify for the AEM program, the alien must meet one of the criteria described in subsection (2) of this section a qualifying emergency medical condition as described in WAC 388-500-0005.
The alien's date of arrival in the United States is not used when determining eligibility for the AEM program.
The department does not deem a sponsor's income and resources as available to the client when determining eligibility for the AEM program. The department counts only the income and resources a sponsor makes available to the client.
Under the AEM program, covered services are limited to those medical services necessary for treatment of the person's emergency medical condition. The following services are not covered:
Organ transplants and related services;
Prenatal care, except labor and delivery;
School-based services;
Personal care services;
Waiver services;
Nursing facility services, unless they are approved by the department's medical consultant; and
Hospice services, unless they are approved by the department's medical consultant.
The medical service limitations and exclusions described in subsection (7) also apply under the MN program.
A person determined eligible for the AEM program is certified for three months. The number of three-month certification periods is not limited, but, the person must continue to meet eligibility criteria in subsection (2) and (4) of this section.
A person is not eligible for the AEM program if that person entered the state specifically to obtain medical care.
When an alien meets Medicaid program criteria but is ineligible to receive benefits under that program due to alien status, the alien is considered "related to" that Medicaid program. In order to be eligible for the Alien Emergency Medical (AEM) program, a person must:
Have a qualifying emergency medical condition (see the list of qualifying medical conditions in this chapter); and
Be related to one of the following Medicaid programs:
Family medical program (F04);
Children's medical program (F06);
SSI-related medical program (S02);
The Breast and Cervical Cancer Treatment program (S30).
When an alien is eligible for the pregnant women's medical program (P02 or P04), use that program rather than the AEM program because prenatal care is not covered under the AEM program.
When the person's countable income exceeds the standards for one of the CN medical programs in 1, consider Medically Needy (MN) coverage for children (F99) or for adults (S99) who meet the SSI age or disability criteria (S99, L95 or L99 for nursing home clients.). See SPENDDOWN.
WORKER RESPONSIBILITIES
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 person also has a qualifying emergency medical condition, determine eligibility for the AEM program.
The medical care or services for the qualifying emergency medical condition may be provided in a physician’s office or may be hospital or nursing home based.
Hospital-based services include medical care or services provided to a patient in an emergency room, a hospital urgent care center, in a hospital day surgery, or an inpatient setting.
In addition to meeting the categorical criteria for a medical program described in Clarifying Information 1 a. and 1 b. above, coverage for nursing home services requires prior authorization from the MAA Medical consultants.
Clients who are eligible for General Assistance cash will receive GA with state-pay Medical Care Services (MCS) medical. Clients who are aged, blind, or disabled and have an emergency medical condition can choose to not receive cash and receive only S07 CN medical coverage for the emergent condition. Dual program eligibility is not supported for these programs.
CENTRALIZED PROCESSING FOR CSD
Centralized Medical Unit (CMU) staff determine eligibility for non-HCS AEM cases.
Medical only applications received may be routed via DMS to CSO 132 @AEM for processing.
Applications received in the CSO that include requests for other programs are processed by the local office for other programs and by the CMU for AEM.
Set a same date tickler to CSO 132 @AEM for application processing
CMU Contact Information:
Address:
DSHS - CMU
PO Box 34350
Seattle, WA 98124-9511
Phone: (206) 341-7433, or Toll Free (800) 337-1835
REFERRAL AND TRACKING PROCESS FOR AEM
DSHS Form 13-751 has been developed specifically for the AEM program. The form lists the qualifying emergency medical conditions and is completed and signed by the client’s medical provider.
The medical provider may use DSHS Form 13-751 (or other medical documentation) to verify the qualifying emergent medical condition at an application or review for the AEM program.
When the medical provider completes the form and states the client has received medical care in the last 90 days for a qualifying emergent medical condition, you may certify an otherwise eligible client as eligible for AEM. A client can receive up to three months of retroactive medical coverage if the client:
Received care for a qualifying medical condition in a prior retro month; and
Is related to a Medicaid program during that period.
If the DSHS Form 13-751 or other written medical documentation to verify the qualifying emergent medical condition does not accompany an application or review, send the form to the client and request the client have the medical provider complete and sign the form.
If the medical provider indicates on the DSHS Form 13-751 or other written medical documentation that the client was treated for an emergency medical condition that is on the list of qualifying medical conditions, you do not need to refer the case to the Medical Consultant for approval or denial. Nursing home services require prior authorization from the medical consultant. Please see the Nursing Home Services Prior Authorization Section for instructions.
If the medical provider indicates on the DSHS Form 13-751 or on other medical documentation that the client was treated for an emergency medical condition that is not on the list of qualifying medical conditions, refer the case to the Medical Consultant for approval or denial.
To refer the case to Medical Assistance Administration (MAA), complete and FAX Letter #65-08 along with DSHS Form 13-751 or other medical information to the MAA medical consultant for a decision. The medical consultant within seven working days will;
Return DSHS Form 13-751 with a decision of approval or denial of the emergency medical condition; or
Notify the CSO the case was pended by the Medical Consultant for additional medical documentation from the client’s medical provider. Upon receipt of additional medical documentation from the client’s medical provider, within seven working days, the Medical Consultant will send to the CSO:
A decision of approval; or
A decision of denial.
When the medical consultant requests additional medical documentation from the client’s medical provider and the additional medical documents are not received within 30 days, the medical consultant will deny AEM eligibility and notify the CSO worker of that decision on the AEM Referral and Tracking form (DSHS Form 13-751) .
The Medical Consultants can be reached at:
Health & Recovery Services
Division of Medical Management
Program Management and Authorization
MS 45506
Telephone: 1-800 562-3022
FAX: (360) 586-1471
To check on the status of a review, please call 1-800-562-3022.
If the client’s medical provider requests a release of information from the client before discussing the case with the medical consultant, the medical consultant will contact the worker making the initial referral and ask that worker to obtain a release from the client.
HIV positive with complications or opportunistic infections
Hypothermia
Infection, cellulitis, or abscess
Infectious Cholecystitis - acute
Insulin dependent diabetes mellitus
Laceration of artery, nerve or tendon
Laceration or cut requiring sutures, staples, or glue
Liver Failure - Acute
Malignant Hypertension
Meningitis; viral, bacterial, or fungal
Pancreatitis – Acute
Pneumothorax
Poisoning due to food, drugs, or overdose
Post organ transplant care, including
immunosuppressant medication.
Note: organ transplants are not covered under this program.
Pylonephritis – Acute
Renal failure – Acute or requiring dialysis
Respiratory Failure/Breathing Cessation
Sunstroke/Heatstroke
Traumatic Brain Injury
Traumatic injury
Tuberculosis
Ulcer (Peptic or Gastric) with bleeding, perforation and/or obstruction
BEGINNING THE FINANCIAL CERTIFICATION PERIOD FOR AEM
The certification periods for AEM are as described in WAC 388-416-0015 (1) and (7).
DIAGNOSIS-BASED MEDICAL CERTIFICATION PERIODS FOR AEM
The AEM program continues to have a three month review period for financial and categorical eligibility. Most of the qualifying emergency medical conditions also continue to have a medical certification period of three months. Some of the qualifying emergency medical conditions have a medical certification period that may be longer than the three month certification period for a financial review. This means:
The length of an individual person’s medical review period is based on the qualifying emergency medical condition; and
Medical documentation does not have to be reviewed at each application or review for those medical conditions.
At the end of the medical review period, verify current treatment of the previous emergency medical condition or new emergency medical condition before certifying AEM for a new period.
The emergency medical conditions with medical review periods longer than a three month review are:
Post Organ Transplant Care, including anti-rejection (immunosuppressant) medication
12 months
Renal failure-Acute or requiring dialysis
12 months
Traumatic Brain Injury
6 months
Tuberculosis
12 months
NURSING HOME SERVICES PRIOR AUTHORIZATION
Approval for nursing home services requires prior authorization from the medical consultants at MAA for all AEM cases. This approval is in addition to the determination of a qualifying emergency medical condition.
If the client has a qualifying emergency medical condition, send an ACES letter 65-08 to the medical consultants requesting prior authorization for nursing home services. You do not need to duplicate provider or medical information that is already contained within the supporting documents. Send the 65-08 with the following:
A copy of the CARE assessment, and
The completed 13-751. If you are unable to obtain a completed 13-751, other medical documentation verifying the emergency medical condition can be used.
If otherwise eligible, open non-institutional AEM medical pending the outcome of the nursing home authorization. (Do not open L04 or K03 until you have received an approval for the nursing home services from the medical consultant).
If the client’s diagnosis is not on the list of qualifying emergency medical conditions, you will need two authorizations from the medical consultants. Do not open AEM until you have received a response. Send an ACES 65-08 and request the following:
A determination made regarding the emergency medical condition in order to authorize AEM medical. Send the completed 13-751. If you are unable to obtain a completed 13-751, other medical documentation verifying the emergency medical condition can be used; and,
A determination made regarding authorization for nursing home services based on the CARE assessment. Send a copy of the CARE assessment.
If the client has a qualifying medical emergency and the medical consultant authorizes nursing home care:
Open the client on a Long Term Care AEM program if the client has been in the nursing facility or is expected to be there 30 or more days.
If the client was previously opened on a non-Long Term Care program, change to a Long Term Care AEM program if the client has been in the nursing facility or is expected to be there 30 or more days.
If the medical consultant denies nursing home services, advise the client that nursing facility services have been denied. If the client is in a hospital, send a copy of the denial to hospital. Use letter 04-03 for Long Term Care denials. Transfer active AEM only cases to the local CSO.
The Medical Consultants can be reached at:
Client/Provider Notification Unit
Health & Recovery Services
Division of Medical Management
Program Management and Authorization
MS 45506
Telephone: (360) 725-1555
FAX: (360) 586-1471
To check on the status of a review, please call (360) 725-1555.
At the end of the medical review period, verify current treatment of the previous emergency medical condition or new emergency medical condition and obtain prior authorization for nursing home services before certifying AEM for a new period.
EXAMPLE
A client applies for AEM on October 10, 2005. You have determined the person is related to an SSI-related medical program, based on a previous decision from DDDS. The person meets income and resource standards. The DSHS Form 13-751 is completed and signed by the client’s medical provider. The doctor checks the box indicating the client was treated for “Renal failure- Acute or requiring dialysis” on 10/2/05. As noted above, this diagnosis has a 12- month medical review period. On the Remarks screen behind ALAS, document the next medical review of the emergency medical condition is due in September 2006. The client will be required to complete only a review of financial and categorical eligibility in December 2005, March 2006, and June 2006. In September 2006 the review includes a review of financial and categorical relationship and must verify current treatment of the emergency medical condition.
Monitor the diagnosis-based medical certification periods described in 2 by noting the end of the medical review date in the remarks behind the ALAS screen, such as “Renal failure – medical review due in 9/06”.
EXAMPLE
Examples of a Person Eligible for the AEM Program
An undocumented alien child under age 19 is ineligible for children's CN medical (F06) because of the child's alien status. When the family income is under 200% FPL, the child is "related to" the children's CN medical program (F06).
If the child also has an emergency medical condition, AEM can be authorized under the F09 medical coverage group.
When countable income exceeds CN standards, the child may be considered for F99 MN coverage.
An alien family is not eligible for CN Family Medical (F04) because of their alien status. Even though the family is not eligible for aF04 because of their alien status, they remain "related to" a Medicaid program by meeting the categorical requirements including income and resource standards, and a dependent minor child lives in the household. If one or more of the family members has a qualifying emergency medical condition, AEM can be authorized for the person(s) with the qualifying emergency medical condition under the F09 medical coverage group.
NOTE:
If the mother is pregnant, consider the pregnancy medical program (P04) instead of AEM.
EXAMPLE
A Lawful Permanent Resident (LPR) entered the US six months ago and is in the five-year ban period. This person was treated in an ER for an emergency medical condition (a severe laceration requiring sutures), and also appears to be disabled. Do a referral to DDDS to determine if the person meets SSI disability criteria. If DDDS confirms the disability decision, the person becomes "related to" a Medicaid program. AEM can be authorized under the S07 medical coverage group. Should countable income exceed CN standards, the person may be considered for MN coverage. Do not count a sponsor's income or resources when determining eligibility for AEM.
An undocumented alien, age 67, requires nursing facility care. His medical condition is on the list of qualifying emergency medical conditions. Open SSI-Related non-institutional AEM (S07) pending the outcome of the referral. Send a request for nursing home authorization to the medical consultants at MAA. Include in the referral the completed DSHS 13-751 or other medical documentation that verifies the emergency medical condition and the CARE assessment.
A permanent legal resident alien age 70 entered the country one year ago. She does not meet the armed services or veteran’s criteria. She has Alzheimer’s and is in need of nursing home care. She does not have an approved emergency medical condition. Send a request to the MAA medical consultants to review both her emergency medical condition and the need for nursing facility care. With the referral include the completed DSHS 13-751 or other medical documentation that verifies the emergency medical condition and the CARE assessment. Do not open AEM prior to the response from the medical consultants.
An aged person entered the US one year ago and has provided documentation that he has applied for asylum. He indicates he needs both cash and medical coverage because he has cancer. He is eligible for GAU cash and MCS medical, based on his PRUCOL status, age, and medical condition (cancer).
He also meets the criteria for the S07 AEM medical because he is related to a Medicaid program, (Aged), and has a qualifying emergency medical condition (cancer). He can choose to receive GAU cash and the scope of medical care (MCS) provided to GA recipients or he can choose to not receive cash and receive only S07 CN medical coverage for his emergent condition. Dual program eligibility is not supported for these programs.
EXAMPLE
Examples of a Person Ineligible for AEM Program
An undocumented 27 year old woman with no children was hospitalized for an emergency medical condition. She is out of the hospital and is healthy now. She is not related to any Medicaid program. Do not consider the AEM program.
A family applies for medical. The family members are legal immigrants currently in the five-year ban for Medicaid. The family consists of Mom, Dad, and two children. The father's earned income is $1600 per month. The mother has an qualifying emergency medical condition and her doctor wants her to have several medical tests. The family is ineligible for the CN family medical program (F04) because of alien status and family income exceeds the income standards. Do not consider eligibility for AEM.
An immigrant woman 67 years old lives with her daughter who sponsored her US entry two years ago. She is in an immigrant category that has a five year ban and is ineligible for other Medicaid programs. The woman has no income of her own and the AEM program is not subject to sponsor deeming rules. The woman is related to SSI by her age. She provides a DSHS Form 13-751. Her doctor indicated he treats her for angina. Angina is not on the list of emergent medical conditions or on the DSHS Form 13-751. The worker sends the referral to the Medical Consultant at MAA. The Medical Consultant calls the woman’s medical provider and the medical provider states the client’s angina is stable. The medical Consultant returns the DSHS Form 13-751 to the worker denying AEM. Her immigrant status and the sponsor deeming requirements are not an issue for AEM. She is ineligible for AEM because her medical condition is not considered an emergency.
EXAMPLE
Examples of a Person the CSO Worker Cannot Determine as Eligible for AEM Program
A client initially meets all eligibility and emergency medical criteria and is certified for AEM. The client applies again after the three-month certification. The person continues to meet disability criteria and is sick and needs to go to the doctor. The person has not received recent medical services. Do not deny AEM. Send the client Form 13-751 and ask that he have his medical provider complete the form. If the form is not returned, refer this case with any available medical documentation to the Medical Consultant.
A LPR was found eligible for AEM a year ago. She is a sponsored alien and her five-year ban period is over. Because the five-year ban is over, she cannot be considered for AEM. While the sponsor’s income and resources were not considered for the AEM program, they must be considered for other Medicaid programs.
AEM CLIENT RIGHTS TO A FAIR HEARING
Clients applying for or receiving AEM have the same Fair Hearing rights as all other programs. AEM clients will be scheduled on the CSO docket if the decision under appeal was made by the CSO staff. A hearing concerning a decision of MAA staff will be administered by MAA. Those decisions may include, but are not limited to:
Denial that an individual's medical condition meets agency criteria of a qualifying emergent medical condition,
Denial of a medical service;
Restricted use of medical care; or
Denial for nursing home authorization.
An AEM 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. 98504-2489.
