Emergency Medicaid Federal law requires that state Medicaid programs cover emergency medical services for ineligible immigrants, when these individuals otherwise meet the categorical and financial criteria for Medicaid. Approval of an Emergency Medicaid application only provides coverage for a single episode of care (the same patient may qualify for Emergency Medicaid for separate episodes of care, provided that they are not for ongoing, routine care). Furthermore, the coverage is limited to the length of time required to stabilize the emergent episode and only the services involved in the emergency itself will be reimbursed. There are four requirements to determine if the service qualifies for Emergency Medicaid reimbursement: 1. The patient is an undocumented or ineligible immigrants; AND 2. The care meets the standard of emergency care ; AND 3. The patient s condition meets the sudden onset requirement; AND 4. The patient is otherwise categorically and financially eligible for Medicaid. An undocumented immigrant is a person who is not a citizen of the United States and has not been lawfully admitted for permanent residence. Undocumented immigrants were either never legally admitted to the United States for any period of time or were admitted for a limited period of time and did not leave the United States when that period of time expired. An ineligible immigrant is not a citizen of the United States and their status prevents them from qualifying for Medicaid. Examples include the following: Certain qualified immigrants arriving on or after August 22, 1996, who may have been lawfully admitted to the United States but who are prohibited from acquiring Medicaid during the first five years of their residence in this country. This period of time is referred to as the "five-year bar." Immigrants who are not permanently residing in the United States, such as foreign students and tourists, who may be in a satisfactory status with the Bureau of Citizenship and Immigration Services (BCIS), but who are admitted for only a specified period of time. They cannot qualify for Medicaid during that specified period of time. Definition of Emergency Services An emergency medical condition is the sudden onset of a medical condition, with acute symptoms that are severe enough such that the absence of immediate medical attention could be expected to result in any one of the following: 1. Placing the patient s health in serious jeopardy; 2. Serious impairment of bodily functions; OR 3. Serious dysfunction of any bodily organ or part.
The Sudden Onset Requirement The phrase sudden onset is a further qualifier that specifically excludes services for individuals who need ongoing routine care (e.g. dialysis, chemotherapy) for conditions that could become emergency medical conditions in the future. All labor and delivery service IS considered an emergency medical condition; Care and services related to an organ transplant procedure for aliens not lawfully admitted for permanent residence are NOT a covered emergency benefit. Acceptable Medical Records Requirement Submitting an application alone is not enough. Providers must also send documentation of the medical condition and treatment to TennCare where the Bureau s Medical Director will review the medical records submitted with the application to determine whether the services satisfy the definition of emergency. When submitting medical records, TennCare directs providers to write EMS APPLICATION on every page. According to TennCare, acceptable medical records include: Emergency department s triage notes; Emergency department s physician notes; Laboratory notes; Histories and physicals; AND/OR Hospital discharge summaries. Medical records should be faxed with a copy of the FFM application to Tennessee Health Connections (TNHC). Additional records may be sent after the original application has been faxed to establish length of stay, laboratory notes, billing, etc. (See Steps for Submitting Subsequent Documentation, below.) Applying for Emergency Medicaid Below you will find the steps to apply for Emergency Medicaid that will increase the likelihood of a patient s treatment being covered by the program. These steps are a combination of the procedural steps outlined in the TennCare Policy Manual and the Delay Application Appeals Desk Guide (dated 4/27/2015), as well as experiences navigating the application and eligibility determination process of the FFM and the TennCare Bureau. Lastly, it is highly recommended that you maintain a log or report of all pending applications for Emergency Medicaid.
Step 1 Step 2 Step 3 Step 4 Step5 Step 6 Step 7 Step 8 Download and print a paper application from: https://marketplace.cms.gov/applications-and-forms/marketplace-applicationfor-family.pdf. Complete the paper application and have the patient or family member to sign it. Send by express delivery, Certified Mail Return Receipt requested, to: Health Insurance Marketplace 465 Industrial Blvd. London, KY 40750-0061 Complete TennCare s Authorization of Representative Organization form, and have the patient sign it. This form lets the provider act on behalf of the patient when applying for medical benefits. Since Emergency Medicaid is limited to a single episode of care, it is in the provider s interest to act on behalf of the patient. Using TennCare s Emergency Medical Services form, fax copies of the FFM paper application (including proof of mailing from step 2) and the medical records to document the existence of an emergency pursuant to the definitions above to Tennessee Health Connection at 1-855-315-0669. Remember to write the words, EMS APPLICATION on the top of every page submitted to Tennessee Health Connection (TNHC). With the exception of labor and delivery, note the very specific nature of the emergency, and that it could not have been foreseen. Failure to do so (as well as advance requests for coverage) will result in the application being denied for failure to meet the "sudden onset" requirement. Proof of income should also be provided, if available. Place copies of the application and proof of fax (including the date and time this was done) and mailing in the patient's record. If proof of income was not submitted with the application to TNHC, provide the applicant with TJC s TennCare Income Verification handout. Have the patient provide copies of paystubs (if any) or proof of other income from all household members for the last 8 weeks. Chances are the patient will be required to provide this information within 10 days. Once received from the patient, fax copies to TNHC as outlined in the Steps for Submitting Subsequent Documentation section (see below). You should not wait for an official request from TennCare before faxing to TNHC. Calculate and record the date 45 calendar days from the application date in the patient s file. This is the deadline imposed by federal regulations within which the state must ordinarily decide whether to approve the application. Have the patient sign TennCare s Release form. Add the form to the patient file. You may need this form in the future.
Step 9 Step 10 Step 11 Step 12 Step 13 Step 14 Follow-up with the patient on the date that marks the end of the 45 day time period for an eligibility determination. Also, inform the patient to notify you of any requests for information, denials, etc, and record in the patient's file. If after 45 days a decision has not been rendered on the application, complete the TennCare Eligibility Appeal form, and attach the following: a. EMS Application Cover Sheet b. Application and proof of the application date (fax and certified mail receipts); c. Medical Records establishing the sudden onset of an emergency medical condition; d. Medical bills associated with the medical services. Fax the appeal to TNHC at 1-855-315-0669. Place copies of the fax receipt in the patient file. Obtain a proof mailing or the fax receipt as proof and record in the patient s file. Record patient information in the log/report of pending Emergency Medicaid appeals and dispositions for your entity. If the application is denied, or if it is approved but with a coverage date later than the date on which the application was mailed to the FFM in London, KY, file an appeal with TennCare through TNHC by completing and faxing the TennCare Eligibility Appeal form to 1-855-315-0669. Submit proof that the application was filed on an earlier date. Submit documentation of the patient s household composition and income, as well as proof of the emergency nature of the medical care. Also send the TennCare Release and Authorization of Representative Organization to TNHC and ask for the hospital to be copied on any communications related to the appeal. Try to contact the patient and ask him/her to respond promptly to any requests for information regarding the appeal, and to notify hospital staff whenever he/she receives a communication from TennCare or the FFM. Steps for Submitting Subsequent Documentation After the original application has been mailed to the FFM and faxed to TNHC, chances are additional documentation will be created that supports the application. This could be additional physician notes, laboratory notes, billing, income verification, etc. Follow the steps below in order to increase the chances of complete reimbursement for medical services. Step 1 Step 2 Use Emergency Medical Services (EMS) Cover Sheet for Application/Verifications when faxing information to TNHC. Write EMS APPLICATION at the top of every page faxed to TNHC.
Step 3 Whenever faxing additional information to TNHC, please include the original FFM application, proof of mailing to the FFM AND original fax confirmation page along with any other documents that were previously faxed to THC.* * NOTE: TJC recommends faxing ALL documents related to the request for EMS Medical Services in the event prior documentation relating to the patient cannot be found by TennCare. In other words, TennCare should able to render a decision based solely on the last set of documents that were faxed. Please do not assume TennCare will be able to locate and consider previously submitted documentation and/or applications. Mailing Addresses & Fax Numbers HCFA (Eligibility Delay Appeals) PO Box 23650 Nashville, TN 37202 FAX: 1-844-563-1728 Tennessee Health Connections PO Box 305240 Nashville, TN 37202 FAX: 1-855-315-0669 Health Insurance Marketplace 465 Industrial Blvd London, KY 40750-0061 Want more information or still have questions? Contact the Tennessee Justice Center at 615-255-0331. For a copy of the TJC s full Emergency Medicaid Toolkit or for copies of any of the documents mentioned above, please contact Rob Watkins at rwatkins@tnjustice.org.