5160:1-5-20 Medicaid: alien emergency medical assistance (AEMA).

(A) Alien emergency medical assistance (AEMA) is a category of medicaid that provides coverage for the treatment of an emergency medical condition for certain individuals who do not meet the medicaid citizenship requirements outlined in rule 5101:1-38-02.3 of the Administrative Code.

(B) Definitions.

(1) "Administrative agency" is the county department of job and family services (CDJFS), Ohio department of job and family services (ODJFS) or other entity that determines eligibility for a medical assistance program.

(2) "Covered dates of service" is the term used by the county medical services (CMS) unit for the time period of the emergency medical condition episode.

(3) "Eligibility span" is the time period of eligibility within the covered dates of service.

(4) "Emergency medical condition" means after sudden onset, a medical condition, including labor and delivery, 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 placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. An emergency medical condition does not include care and services related to either an organ transplant procedure or routine prenatal or postpartum care.

(5) "Emergency medical condition episode" is defined as the period of time that starts with 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 stops 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 includes labor and delivery, but does not include ongoing treatment.

(6) "Individual" is the applicant or recipient of a medical assistance program.

(7) "Non-qualified alien" as defined in rule 5101:1-38-02.3 of the Administrative Code.

(8) "Optional qualified alien" is an alien who has completed the five-year period of ineligibility for medicaid. Optional-qualified aliens are not eligible for medicaid in accordance with rule 5101:1-38-02.3 of the Administrative Code.

(9) "Qualified alien within the five-year period of ineligibility for medicaid", as outlined in rule 5101:1-38-02.3 of the Administrative Code.

(10) "Resident of Ohio" as defined in rule 5101:1-39-54 of the Administrative Code.

(C) Eligibility criteria.

(1) The individual must have received treatment for an emergency medical condition.

(2) The individual must submit an application for medical assistance. A new medical assistance application is required for each emergency medical assistance episode.

(3) The individual must be otherwise eligible for a category of medicaid. If the individual would be eligible for a category of medicaid that requires a disability determination, the administrative agency shall submit a CMS packet to the CMS unit in accordance with rule 5101:1-39-03 of the Administrative Code.

(4) The individual must be one of the following:

(a) Non-qualified alien;

(b) Optional qualified alien; or

(c) Qualified alien within the five-year period of ineligibility for medicaid.

(5) The individual must be a resident of Ohio.

(D) Exceptions to eligibility criteria.

(1) The individual is not required to meet the medicaid citizenship requirements in accordance with rule 5101:1-38-02.3 of the Administrative Code.

(2) If the individual would be eligible for a category of medicaid that requires a disability determination, the individual is not required to apply for social security administration (SSA) benefits.

(3) The individual is not required to participate in a face-to-face interview in accordance with rule 5101:1-38-01.2 of the Administrative Code.

(4) The individual is not subject to alien-sponsor deeming provisions.

(5) The individual is not required to provide verification of a social security number in accordance with rule 5101:1-38-02 of the Administrative Code.

(6) The individual is not required to provide verification of immigration/alien status.

(E) Administrative agency responsibilities.

(1) The administrative agency shall determine medicaid eligibility in accordance with the eligibility rules contained in Chapters 5101:1-37 to 5101:1-42 of the Administrative Code.

(2) The administrative agency shall determine eligibility for AEMA as identified in paragraphs (C) and (D) of this rule.

(3) Upon request, the administrative agency shall assist the individual in obtaining medical documentation to support the AEMA claim. When assistance is requested, the administrative agency shall request from the medical provider, medical documentation to support the emergent nature of the AEMA claim including physician progress notes and discharge summary. The administrative agency shall then forward the medical documentation to the CMS unit.

(4) The administrative agency shall determine the eligibility span for labor and delivery 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 includes:

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

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

(b) The time period from date of admission for labor until delivery shall not exceed two days or forty-eight hours.

(c) The eligibility span ends at midnight on the last day in which the forty-eight or ninety-six hour time-period following delivery falls. If the labor and delivery episode exceeds the timeframes as outlined in paragraph (E)(4), the administrative agency shall forward the medical documentation to the CMS unit for the determination of the covered dates of service.

(5) The administrative agency shall enter the eligibility span into the electronic eligibility system for the emergency medical condition episode within the covered dates of service as determined by the CMS unit.

(6) The administrative agency shall issue proper notice and hearing rights as outlined in division level designation 5101:6 of the Administrative Code.

(F) County medical services (CMS) unit responsibilities.

(1) The CMS unit shall make all emergency medical condition determinations, except for labor and delivery, as outlined in paragraph (E) of this rule.

(2) The CMS unit shall determine if the individual received treatment for an emergency medical condition.

(3) The CMS unit shall determine covered dates of service for the emergency medical condition episode.

(4) The CMS unit shall notify the administrative agency of the AEMA determination and the covered dates of service via the electronic eligibility system.

Eff 3-1-05
Replaces: 5101:1-42-02
Rule promulgated under: RC 111.15
Rule authorized by: RC 5111.01
Rule amplifies: RC 5111.01 , 5111.012
Prior Effective Dates: 3-1-88 (Emer.), 5-15-88, 3-1-94 (Emer.), 4-18-94, 3-1-98 (Emer.), 5-1-98, 10-1-01 (Emer.), 12-29-01, 12-1-03, 12-1-04 (Emer.).
R.C. 119.032 review dates: 03/01/2010