03/21/03

Summary:

  • Clarifies coverage for persons who qualify only for emergency services.
  • Clarifies policy as to what is, and what is not, an emergency medical condition, and provides that the Client Assessment Unit makes the determination.
  • Limits the time period emergency medical can be authorized.
  • Introduces new Form 3801, Report of Medical Condition.
  • Introduces a new Item 74 code to identify noncitizens requiring End Stage Renal Disease (ESRD) services.
  • Changes the term "ineligible noncitizen" to noncitizen not meeting immigration status.
  1. EMERGENCY MEDICAL CONDITION
  2. REPORT OF MEDICAL TREATMENT
  3. AUTHORIZING EMERGENCY MEDICAL (Except for ESRD)
  4. NONCITIZENS WITH ESRD
  5. ESRD PATIENT RECEIVES OTHER EMERGENCY MEDICAL SERVICES
  6. MEDIPLAN CARD
  7. SYSTEM CHANGES

This memorandum was prepared by the Department of Public Aid. DPA administers the Medicaid and KidCare Programs. These programs provide medical benefits to families with children and other persons. This information is to be used by staff of the Illinois Department of Human Services when determining eligibility and authorizing medical benefits for these persons on behalf of DPA.

There are three different policies and procedures for authorizing medical benefits to noncitizens who do not meet immigration status requirements depending on their individual circumstances.

  • The policy and procedures for pregnant women are covered in a separate Policy Memorandum, Medical Coverage for Noncitizen Pregnant Women.
  • The policy and procedures for persons with End Stage Renal Disease (ESRD) are covered in this Policy Memorandum.
  • The policy and procedures for all other noncitizens who do not meet immigration status requirements are also covered in this Policy Memorandum.

DPA pays for medical services furnished to these persons only if:

  • the person meets all other medical assistance eligibility requirements including Illinois residence; and
  • the services are necessary for the treatment of an emergency medical condition.

Organ transplants and related services, such as anti-rejection drugs are not covered under this program.

EMERGENCY MEDICAL CONDITION

An emergency medical condition:

  • occurs suddenly and unexpectedly,
  • is caused by injury or illness, and
  • requires immediate medical attention to prevent:
    • serious jeopardy to patient's health, or
    • serious impairment to bodily functions or parts.

Chronic conditions and terminal illness do not meet the requirement for emergency medical coverage. Need for long term care services does not qualify the person for emergency medical coverage. The person must also have an emergency medical condition as defined above.

The following instructions do not apply to persons with End Stage Renal Disease (ESRD). Instructions for these cases are on page 3.

Coverage for an emergency medical condition is very limited. Only medical care that is strictly of an emergency nature, such as treatment in an emergency room, or treatment in a critical care unit or intensive care unit, meets this requirement. Eligibility for payment of services lasts only until the emergency condition is stabilized. The period of time for which services are authorized cannot be more than 30 consecutive days.

In those rare situations where the emergency medical condition extends beyond 30 consecutive days, contact the Illinois Department of Public Aid, Bureau of Medical Eligibility Policy, at 217-557-7158 for guidance.

Coverage for an emergency medical condition can only be authorized after the services are provided. Eligibility cannot be authorized for a future period.

REPORT OF MEDICAL TREATMENT

To assist providers and DHS local offices in identifying emergency medical conditions, we have developed Report of Medical Treatment (Form 3801). If a noncitizen who does not meet immigration status requirements applies and the person states they have received emergency services:

  • Send Form 3801 to the person's attending physician.
  • The attending physician must specify on Form 3801 the diagnosis, or condition requiring treatment, the onset date, and the date the patient was stabilized.
  • If the attending physician does not complete Form 3801 or does not provide all the needed information, deny the application, TA 05/TAR 43. Reports from nonmedical sources such as billing companies or agents are not acceptable.
  • Send the completed Form 3801 along with any available hospital records or treatment notes to the Client Assessment Unit (CAU) for review.
  • Submittal of Form 3801 does not guarantee payment. CAU makes the determination as to whether the person received emergency services on Form 183C, Medical Evaluation Client Assessment Unit (CAU) Decision.
  • If CAU determines that the person received treatment for an emergency medical condition, and the person meets all other eligibility requirements, approve the case.
  • If CAU determines that the person did not receive treatment for an emergency medical condition, deny the application, TA 05/TAR 43.

AUTHORIZING EMERGENCY MEDICAL (Except for ESRD)

Only one person can be approved in an emergency medical case. If more than one family member received emergency medical care, set up separate cases.

Authorize emergency medical as follows:

  • Item 3 - Enter TA 10 (approve and cancel).
  • Item 33 - Enter B8.
  • Item 41 - Enter the date the emergency condition was stabilized.
  • Item 74 - Enter Code 36.
  • Item 77 - Enter the date the emergency condition started.

If the emergency condition only lasted one day, enter the day following the emergency in Item 41. The date in Item 41 cannot be more than 30 days from the date in Item 77. Do not authorize coverage beginning on the first day of the month unless the person received emergency services on that date.

Example 1: The application date for Mr. A. is 04/02/03. He received emergency medical services on 03/24/03 for a broken leg. Enter 03/24/03 in Item 77 and 03/25/03 in Item 41.

Example 2: The application date for Ms. A. is 04/03/03. She received emergency medical services for acute appendicitis at Adam's Hospital from 03/29/03 to 04/02/03. Enter 03/29/03 in Item 77 and 04/02/03 in Item 41.

NONCITIZENS WITH ESRD

ESRD is considered an emergency medical condition. However, coverage is limited to renal dialysis services and the case can be approved on an ongoing basis. Form 3801 is not required to approve an ESRD case for renal dialysis services. A statement from the attending physician that the person is receiving ESRD services is sufficient.

A new question has been added to AIS, Screen 8B: "Is anyone receiving services for End Stage Renal Disease?"

Authorize ESRD coverage as follows:

  • Item 3 - Enter TA 11 or 12.
  • Item 33 - Enter the appropriate TAR.
  • Item 41 - No entry is required.
  • Item 74 - Enter new code 50 - receives ESRD services.
  • Item 77 - Enter the beginning medical eligibility date.

ESRD PATIENT RECEIVES OTHER EMERGENCY MEDICAL SERVICES

If a person receiving ESRD services receives treatment for another emergency medical condition, the client must sign Application for Payment of Emergency Medical Services (Form 2378NC). To authorize coverage for the other emergency:

  • Form 3801 is required.
  • Register a new application with a different basic number.
  • The ESRD case remains active.
  • If CAU determines that the person received treatment for another emergency condition, authorize emergency medical according to the instructions in the prior section, Authorizing Emergency Medical. Be sure to use the same Recipient Identification Number (RIN).

Example 3: Ms. B has an active 93 case because she is disabled and receives ESRD services. She is in an automobile accident on 05/26/03 and receives treatment in the emergency room. She signs Form 2378NC and her physician completes Form 3801. CAU determines that she received treatment for an emergency medical condition.

Leave the original case active and set up a new 93 case with a different basic number using the same RIN. Use a TA 10/TAR B8 transaction and enter Code 36 in Item 74. Enter 05/26/03 in Item 77 and 05/27/03 in Item 41.

MEDIPLAN CARD

The message on the MediPlan Card (except for ESRD cases) now reads:

"Only emergency services are covered. Organ transplants and related services are not covered."

For End Stage Renal Disease cases, the message now reads:

"Only End Stage Renal Disease services are covered. Organ transplants and other related services are not covered."

SYSTEM CHANGES

  1. Use TA 10/TAR B8 to authorize emergency medical except for ESRD cases.
  2. Use new Item 74 Code 50 when authorizing ESRD coverage.
  3. Medical eligibility for noncitizens who do not meet immigration status (except for ESRD cases) is shown in MMIS under the MANG P segment as "NE EMG".
  4. Medical eligibility for ESRD cases is shown in MMIS under the MANG P segment as "NC RNL".
  5. The following edits have been created:
    • A person coded 36 in Item 74 cannot be added to an active 94 or 96 case unless the person is coded with an EDD date in Item 60.
    • A person coded 50 in Item 74 cannot be added to an active 94 or 96 case.
    • Item 74 cannot be changed on an active case to Code 36 unless the person is pregnant or a payee only and not receiving benefits.
    • No more than one noncitizen can receive benefits on the same case. To delete someone from an emergency medical request in AIS, use new TA 05/TAR A3. TA 05/TAR A3 does not generate a notice.

[signed copy on file]

CAROL L. ADAMS, Ph.D.
Secretary, Illinois Department of Human Services

BARRY S. MARAM
Director, Illinois Department of Public Aid

Forms referenced:
Form 183C
Form 2378NC
Form 3801