Lawriter - OAC - 5160:1-5-06 Medicaid: alien emergency medical assistance (AEMA).

5160:1-5-06 Medicaid: alien emergency medical assistance (AEMA).

(A) This rule describes eligibility criteria for coverage of 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 purposes 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;

(b) Serious impairment to bodily functions; or

(c) Serious dysfunction of any bodily organ or part;

(2) Including labor and delivery, but

(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) Have received treatment for an emergency medical condition.

(2) Submit an application for medical assistance for the dates of a particular emergency medical episode.

(3) Meet eligibility criteria for a category of medicaid, except that the individual:

(a) Does not meet the medicaid citizenship or non-citizen 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 the individual's:

(i) Social security number, or

(ii) Citizenship or immigration status.

(b) Is not required to apply for social security administration (SSA) benefits.If the individual is otherwise eligible for a category of medicaid that requires a disability determination, the administrative agency shall submit a disability determination packet to the disability determination area (DDA) in accordance with rule 5160:1-3-02.9 of the Administrative Code.

(D) Eligibility span. Coverage for an individual who meets the criteria in paragraph (C) of this rule:

(1) 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

(2) 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. The emergency medical condition episode:

(a) Includes labor and delivery, but

(b) Does not include ongoing treatment.

(E) Administrative agency responsibilities. The administrative agency shall:

(1) Determine the eligibility span for routine labor and delivery without submitting medical documentation to the DDA for a determination, and enter it into the electronic eligibility system in accordance with the following policy:

(a) The eligibility span begins on the date of admission for labor, and ends at midnight of the day in which one of the following time periods falls:

(i) A maximum of two days (forty-eight hours) following a vaginal delivery; and

(ii) A maximum of four days (ninety-six hours) following a caesarian section delivery.

(b) The time period beginning on the date of admission for labor and ending on the date of delivery shall not exceed two days (forty-eight hours).

(2) Submit medical documentation to the DDA for a determination of the covered dates of service when:

(a) The time period beginning on the date of admission for labor and ending on the date of delivery is greater than two days (forty-eight hours); or

(b) The labor and delivery episode from admission through discharge exceeds the timeframes described in paragraph (E)(1)(a) of this rule.

(3) For emergency medical conditions other than routine labor and delivery as described in paragraph (E)(1) of this rule, enter the eligibility span determined by the DDA into the electronic eligibility system.

(4) Upon request, assist the individual in obtaining medical documentation to support the AEMA claim.

(F) Disability determination area (DDA) responsibilities. The DDA shall:

(1) Make all emergency medical condition determinations except for routine labor and delivery cases, as described in paragraph (E)(1) of this rule.

(2) Determine if the individual received treatment for an emergency medical condition.

(3) Determine the eligibility span for the emergency medical condition episode.

(4) Notify the administrative agency of the AEMA determination and the eligibility span via the electronic eligibility system.

Replaces: 5160:1-1-91

Effective: 8/1/2016
Five Year Review (FYR) Dates: 08/01/2021
Promulgated Under: 111.15
Statutory Authority: 5162.031, 5163.02
Rule Amplifies: 5163.02
Prior Effective Dates: 01/01/2014