12/20/04
Summary:
- Clarifies policy for noncitizens admitted to an inpatient hospital for an emergency service.
- Identifies specific information needed by CAU to make an emergency medical determination.
- Revises Form 3801, Report of Medical Condition.
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.
If a noncitizen who is not eligible for the Medical Programs due solely to immigration status is admitted to a hospital as a result of an emergency medical condition, eligibility for benefits will continue for the length of the medically necessary
acute care hospital stay excluding the discharge date. The Client Assessment Unit (CAU) will determine whether the admission resulted from an emergency medical condition.
Rehabilitation and long term care services are not covered even if the care is provided in an inpatient setting or immediately following admission to an acute care unit for an emergency condition.
CAU will review medical records to determine whether the admission resulted from an emergency condition. CAU will report the length of stay in an acute care unit to the DHS Family Community Resource Center (FCRC) using discharge information provided
by the hospital or attending physician. The FCRC will enroll the noncitizen for the number of days reported by CAU.
EXAMPLE 1: Mr. A is admitted to Adams Hospital on 04/01/04, discharged on 04/05/04. CAU determined he required hospitalization for an emergency condition on 04/01/04 and reports the length of stay to FCRC for Mr. A as 4
days. Authorize benefits for 04/01/04 through 04/04/04. Enter 04/01/04 in Item 77, and 04/04/04 in Item 41.
EXAMPLE 2: Mrs. A is admitted to Adams Hospital on 03/26/04, discharged on 04/05/04. CAU determined she required hospitalization for an emergency condition on 03/26/04, and reports the length of stay to FCRC for Mrs. A
as 10 days. Authorize benefits for 03/26/04 through 04/04/04. Enter 03/26/04 in Item 77, and 04/04/04 in Item 41.
EXAMPLE 3: Mr. C was treated in the emergency room of Adams Hospital on 3/25/04. He was admitted to Adams Hospital on 03/26/04 and discharged on 04/05/04. CAU determined he was treated for an emergent medical condition
on 03/25/04 and admitted as an inpatient for the emergent medical condition on 03/26/04, and reports the number of days to FCRC for Mr. C as 11 days. Authorize benefits for 03/25/04 through 04/04/04. Enter 03/25/04 in Item 77, and 04/04/04 in Item
41.
EXAMPLE 4: Ms. D. is admitted to Adams Hospital on 04/01/04, is transferred to the hospital's rehabilitation unit on 04/15/04, and is discharged from the hospital on 05/14/04. CAU determined she required hospitalization
for an emergency condition on 04/01/04 and reports the length of stay to FCRC for Ms. D as 14 days. Authorize benefits for 04/01/04 through 04/14/04. Enter 04/01/04 in Item 77, and 04/14/04 in Item 41.
To obtain an emergent medical determination related to an acute care inpatient hospital stay, mail or fax to CAU:
- Client Assessment Unit (CAU) Memorandum (Form 183F), located on the Intranet, as a cover sheet for the CAU packet; mark the EMERGENT NEED box;
- a completed Form 3801, Report of Medical Treatment;
- admitting history and physical examination;
- test reports;
- physician's discharge summary; and
- consultation reports.
To obtain an emergent medical determination related to outpatient services, mail or fax to CAU:
- Client Assessment Unit (CAU) Memorandum (Form 183F) as a cover sheet for the CAU packet; mark the EMERGENT NEED box;
- a completed Form 3801;
- doctor's treatment notes;
- test reports; and
- consultation reports.
Submittal of Form 3801 by itself is not enough for CAU to determine whether the person had an emergency medical condition.
If a disability or blind determination is also required, you must:
- mark the box for a disability or blind determination , and
- include the completed Medical Evaluation (Form 183A and Form 183B), progress notes, discharge summary, test results, and any other available medical information.
NOTE: A disability or blind determination is required when the person is between age 19 and 64 and does not have a child under age 19.
Coverage for an emergency medical condition can only be authorized after the services are provided. Eligibility cannot be authorized for a future period. The computer system can not approve the application for a date after the application date.
DPA's hospital utilization review process for determining medical necessity will apply to inpatient stays for noncitizens covered under the Emergency Medical Assistance program.
Form 3801 is revised to reflect these changes.
[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 183A
Form 183B
Form 183F
Form 3801
