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MEDICAL SERVICES POLICY MANUAL, SECTION B

B 500 Emergency Health Care Services for Aliens

To qualify as an emergency, the medical conditionmust be acute. It must have a sudden onset, a sharp rise and last a short time. If the individual’s condition is chronic (ongoing), including without limitation, cancer, AIDS, and end-stage renal disease, it is not considered acute and does not meet the definition of an emergency. If the chronic condition worsens, it is still not acute and does not qualify for emergency services. Federal policy specifically identifies care and services related to an organ transplant procedure as not qualifying under emergency services. Before eligibility can be determined, the existence of an emergency medical condition must be verified by a physician’s statement that the alien met the conditions shown above. A physician’s statement that the individual will die without medical treatment does not in and of itself, constitute an emergency. The eligibility determinationmust include a determination of whether the condition is acute or chronic. Verification that medical expenses were incurred for treatment of the condition must also be presented. Payment for emergency services is limited to the day treatment was initiated and the following period of time in which the necessity for emergency services existed. The date the alien first sought treatment is considered the first day of the emergency, regardless of the length of time the condition exists. The period of eligibility will be a fixed retroactive period, with the Health Care begin, and end dates entered in the system. Emergency services are defined as services provided in a hospital, clinic, office or other facility equipped to furnish the required care after the onset of an emergency medical condition. Labor and delivery services are covered, including normal deliveries. To determine if an applicant’s doctor visit, emergency room visit or hospital stay was considered an emergency, the discharge summary for the medical visit will be sent to OPPD for an emergency medical determination.