Ohio Admin. Code 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
Notes
Promulgated Under: 111.15
Statutory Authority: 5162.031, 5163.02
Rule Amplifies: 5163.02
Prior Effective Dates: 01/01/2014
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