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Previous Policy
A. Definition
Emergency Medicaid is not a separate type of Medicaid. Emergency Medicaid is temporary coverage only for emergency services to individuals who meet all the requirements for a Medicaid program but are not U.S. citizens and do not meet the eligible qualified non-citizen or lawfully present child ( 205-2.1 ) status requirements for full Medicaid coverage. It is not an ongoing Medicaid program. See section 205-1 and 205-2 . It is available to both MAGI-based groups and non-MAGI-based groups.
B. Who May Be Eligible?
Any non-citizen who does not meet the non-citizen status requirements for full Medicaid coverage may be eligible for Emergency Medicaid. See section 205 . This includes:
1. Undocumented non-citizens.
2. non-citizens who are in the country legally but are not qualified non-citizens as described in section 205-2 , No. 1.
3. Qualified non-citizens who are barred from full Medicaid coverage for 5 years as described in section 205-2 .
4. Deferred Action for Childhood Arrivals (DACA) individuals.
C. Eligibility Requirements
1. State Residency
To qualify for Medicaid for emergency services, the applicant has to be a resident of Utah. See Sec. 207 for residency requirements.
2. Verification of Citizenship or non-citizen Status
If an individual says that he or she does not meet U.S. citizenship or qualified non-citizen status, accept the client's statement. The individual must sign the application, which certifies that the questions about citizenship/non-citizen status were answered correctly.
3. Social Security Number
An undocumented non-citizen does not have to provide a Social Security number nor apply to receive one.
4. Program eligibility
The individual must meet the eligibility requirements for a Medicaid program. For example, eligibility for Disabled Medicaid requires that the individual meets disability requirements. The Disability Review Committee can decide if the person is disabled. Emergency Services are not available under the 4-month Extended Medicaid, 12-Month Transitional Medicaid, Targeted Adult Medicaid, Nursing Home, HCB Waivers, QMB, SLMB, or QI programs. Use MAGI-based methodologies for MAGI groups, and non-MAGI-based methodologies for non-MAGI groups. The only difference is that the individual does not have to meet the citizenship/non-citizen status requirements.
D. Receipt of Emergency Medical Services
Except for coverage for a pregnant member, Emergency Medicaid coverage will be for retroactive months or the application month. This is because emergency services are unplanned events.
1. To be eligible for Emergency Medicaid, the individual must indicate that he or she received medical services in the application month or retro period which the individual believes were for a serious enough situation that it was an emergency.
o The eligibility worker does not need to determine if the services will be covered by Emergency Medicaid.
2. A pregnant individual may apply in the month before the expected due date because labor and delivery of the baby is considered an emergency service.
o Keep the case open until the end of the month the pregnancy ends.
o If the member owes a spenddown, she will usually only meet it for the month of delivery and may choose to use medical bills to meet the spenddown.
3. Other types of medical services that an individual needs are not emergency services if the services are or can be scheduled in the future.
o Emergency Medicaid does not cover long-term nursing home or HCB waiver services.
o It is not for routine care, scheduled services, or treatment of chronic conditions. For dialysis treatments, see E.4. below.
4. All claims for Emergency Medicaid cases are reviewed by Medicaid Operations to determine if the service meets the criteria for emergency services.
o Tell individuals that receipt of Emergency Medicaid is not a guarantee that any or all services will be paid by Medicaid.
5. Do not deny emergency Medicaid eligibility because you suspect the services the applicant received do not qualify as emergency services.
o If the individual says they received medical services for a serious or emergency situation, determine eligibility for Medicaid.
E. Other Considerations
1. Pregnant Woman Medicaid . Pregnant individuals who qualify for Pregnant Woman Emergency Medicaid may be eligible for emergency services at any time during their pregnancy if they have an emergency need.
o If the emergency need occurs two or more months before the expected month of delivery, close the case at the end of that month, unless the emergency situation spanned into the next month.
o The pregnant individual can reapply and have a new eligibility decision made one month before the due date, or if a subsequent emergency occurs.
o Coverage for the delivery can begin in the month before the month of the expected date of delivery. The emergency need will be labor and delivery. Keep the case open until after the delivery. If the delivery date is at the end of one month, and the member is still in the hospital on the first of the next month, continue coverage into that next month.
o The unborn (single or multiple unborn children) will be counted in the member's household size. Once the infant is born, open the child on MAGI Child Under One Medicaid because the child is a U.S. citizen and cannot be open under an emergency program. The newborn automatically qualifies for Child 0-1 coverage until the child turns age 1. See sec. 347 .
o 12-Month Coverage . A pregnant member who received Emergency Medicaid in the month of the birth does NOT qualify for coverage during the 12 month postpartum period. However, if the individual experiences a new emergency during the postpartum period, she could reapply to address that issue.
2. Family Coverage (Parent/Caretaker Relative or Medically Needy Family) - If a parent has had an emergency medical need and requests Emergency Medicaid coverage, they must have a dependent child in the home per policy found at 345 , 345-1 , 345-2 . The child does not also have to claim having had an emergency medical need for the parent to get coverage. The entire family may be approved for a family program when only one family member had the emergency need. The child may or may not meet citizenship or non-citizen status requirements.
3. Spenddown . Spenddown is allowed if the applicant qualifies for a category of Medicaid that allows Spenddown. This includes the Medically Needy Pregnant Woman program. (See Section 441-3 ) If an applicant qualifies for Emergency Medicaid and has a spenddown, it will usually be in the applicant’s best interest to use incurred medical bills (See Section 461-5 ) to satisfy the spenddown requirement. This is because in most cases the applicant cannot be assured that the medical service meets Medicaid’s emergency criteria. It is possible that the service will not be paid (one service that always meets emergency criteria is labor and delivery for pregnant women.)
4. Duration of Coverage . An applicant can receive Emergency Medicaid for each retroactive month and the application month if the applicant says that he or she has received emergency services in such months.
Emergency Medicaid is not an on-going medical program. Close the case at the end of the application month, except in the following circumstances:
· Pregnant women: Open the case only for the retro or application month during which the member received medical services.
· Individuals with renal failure requiring dialysis: These individuals will remain open until their next scheduled review, provided they continue to meet all eligibility requirements.
Do not continue the coverage into the month after the application month unless you know that the member received medical services near the end of the application month and into the following month. In that case, close the case at the end of the month after the application month.
Do not leave the case open for future months. If the member has another emergency situation in a future month, the member can reapply in that month or within the 90 days after receiving the emergency services.
The approval and closure notices should tell members that they may reapply whenever they have received emergency services for which they want Medicaid coverage.
If a member is eligible for Medicare and workers leave the emergency Medicaid case open, the state will continue paying the Medicare premiums creating an overpayment for the member. Do Not Leave Emergency Medicaid open like an ongoing case .
If the member's condition has resulted in multiple emergency episodes within a 12 month period, the agency may contact DHHS to request the program remain open until the next review, provided they continue to meet all eligibility requirements.
5. Retroactive Period Coverage .
o Follow the rules in Section 705 to decide what the retroactive period is based on the application date.
o See Sec. 703-2 to decide the application date.
o If a spenddown is owed for retroactive coverage, review Section 461-8 to decide how to apply medical bills the applicant may have incurred before or during the retroactive period.
o Close the emergency Medicaid case at the end of either the retroactive period or the end of the application month.