Rule 5160:1-5-06 | Medicaid: non-citizen emergency medical assistance (NCEMA).
(A) In accordance with 42 U.S.C. 1396b(v), this rule describes eligibility criteria for coverage of the treatment of an emergency medical condition for certain individuals who do not meet the medicaid citizenship or satisfactory immigration status requirements described in rule 5160:1-2-11 or 5160:1-2-12 of the Administrative Code.
(B) Definition. "Emergency medical condition," for the purpose of this rule, means a medical condition with a sudden onset:
(1) Manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
(a) Placing the patient's health in serious jeopardy; or
(b) Serious impairment to bodily functions; or
(c) Serious dysfunction of any bodily organ or part.
(2) Including labor and delivery.
(3) Not including either:
(a) Routine prenatal or postpartum care; or
(b) Care and services related to an organ transplant procedure.
(C) Eligibility criteria. The individual must:
(1) Submit an application for medical assistance.
(a) Once approved for NCEMA, the eligibility span shall remain open for twelve months beginning with the month of application.
(b) Only emergency medical condition episodes will be eligible for payment of services.
(c) A new application is not needed for subsequent emergency medical condition episodes during the twelve-month span; however, the individual is responsible for reporting all emergency medical condition episodes to the administrative agency when they occur.
(2) Meet eligibility criteria for a category of medicaid, except that the individual:
(a) Does not meet the medicaid citizenship or satisfactory immigration status requirements set forth in rules 5160:1-2-11 and 5160:1-2-12 of the Administrative Code. The individual is not required to verify:
(i) Social security number; or
(ii) United States (U.S.) citizenship or immigration status.
(b) Is not required to apply for social security administration (SSA) benefits.
(D) Coverage for payment of NCEMA services for an individual who meets the criteria identified in paragraph (C) of this rule.
(1) Payment of services for an episode other than routine labor and delivery:
(a) Begins on the day on which the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part; and
(b) Ends on the day on which the absence of immediate medical attention could no longer reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
(2) Payment of services for routine labor and delivery:
(a) Begins on the date of admission for labor; and
(b) Ends at midnight on the day in which one of the following time periods falls:
(i) A maximum of two days (forty-eight hours) following a vaginal delivery; or
(ii) A maximum of four days (ninety-six hours) following a caesarean section delivery.
(E) Administrative agency responsibilities.
(1) Determine the payment coverage span for routine labor and delivery without submitting medical documentation to the disability determination area (DDA) and enter the payment coverage dates as described in paragraph (D)(2) of this rule into the electronic eligibility system.
(2) Submit medical documentation to the DDA for a determination of the covered dates of service when the time period for labor and delivery exceeds the time frames described in paragraph (D)(2) of this rule.
(3) Submit medical documentation to the DDA for emergency medical conditions other than routine labor and delivery and enter the eligibility span determined by the DDA into the electronic eligibility system.
(4) Upon request, assist the individual with obtaining medical documentation to support the NCEMA claim.
(5) Upon notification of an individual's subsequent emergency medical condition episode during his or her twelve-month eligibility period, obtain medical documentation to determine the new NCEMA payment coverage span and submit to DDA in accordance with paragraphs (E)(2) and (E)(3) of this rule.
(F) DDA responsibilities.
(1) Make all emergency medical condition determinations except for routine labor and delivery episodes as described in paragraph (D)(2) of this rule.
(2) Determine whether the individual received treatment for an emergency medical condition.
(3) Determine the payment coverage span for each emergency medical condition episode.
(4) Notify the administrative agency of the NCEMA determination and the payment coverage span via the electronic eligibility system.
Last updated December 1, 2023 at 9:39 AM
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