Ohio Admin. Code 5160:1-5-06 - Medicaid: non-citizen emergency medical assistance (NCEMA)
(A)
This
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 purposes
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, 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:
(2)(1) Submit an
application for medical assistance for the dates of
a particular emergency medical episode.
(3)(2) Meet eligibility
criteria for a category of medicaid, except that the individual:
(1) Have received treatment for an
emergency medical condition.
(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.
(a) Does not meet the medicaid citizenship or
non-citizen
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
the individual's:
(i) Social security number,
; or
(ii)
Citizenship
United
States (U.S.) 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 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:
(1)(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
(2)(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. The emergency medical condition
episode:
(a) Includes labor and delivery,
but
(b) Does not include ongoing
treatment.
(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.
The administrative agency shall:
(1) Determine the eligibility
payment
coverage span for routine labor and delivery without submitting medical
documentation to the disability determination area
( DDA)
for a
determination, and enter it
the payment coverage dates as described in paragraph (D)(2)
of this rule 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:
the time period for labor
and delivery exceeds the time frames described in paragraph (D)(2) of this
rule.
(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)
Submit medical
documentation to the DDA
For
for emergency medical conditions other than routine
labor and delivery as described in paragraph (E)(1)
of this rule,
and enter the eligibility
span determined by the DDA into the electronic eligibility system.
(4) Upon request, assist the individual
in
with
obtaining medical documentation to support the AEMA
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)
Disability determination area (DDA)
DDA responsibilities. The DDA shall:
(1)
Make all emergency medical condition determinations except for routine labor
and delivery cases
episodes
, as
described in paragraph (E)(1)
(D)(2) of this rule.
(2) Determine if
whether the
individual received treatment for an emergency medical condition.
(3) Determine the eligibility
payment
coverage span for the
each emergency
medical condition episode.
(4)
Notify the administrative agency of the AEMA
NCEMA
determination and the eligibility
payment coverage span via the electronic eligibility
system.
Notes
Promulgated Under: 111.15
Statutory Authority: 5162.031, 5163.02
Rule Amplifies: 5163.02
Prior Effective Dates: 01/01/2014, 08/01/2016
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