Emergency Medicaid in NY
Temporary Medicaid, which is known as Emergency Medicaid, is available in New York to assist qualifying undocumented and temporary non-immigrants with paying for medical costs during an emergency. This type of health coverage is colloquially referred to as Emergency Medicaid and it is only available under very specific circumstances to qualifying individuals.
According to Federal law, the emergency Medicaid program can provide coverage only for the “care and services necessary for the treatment of an emergency medical condition” for those immigrants who do NOT meet the specific immigration requirements that must be met in order for them to receive full Medicaid coverage. According to these rules, Immigrants who qualify for emergency Medicaid must not be PRUCOL (must not have Green Cards and must not be permanently residing under color of law).
Since 1996, full Medicaid eligibility has been limited to citizens of the United States and “Qualified Aliens”. Qualified aliens include:
● Individuals who are Lawful Permanent Residents (LPR or “green card” holders). According to eligibility criteria designated by federal law, all but pregnant women and children must go through a 5 year waiting period to qualify for full Medicaid.
● Refugees and Asylees, trafficking victims, and battered persons along with people who have been granted withholding of deportation, people in the military, and immigrants from certain countries that have been granted relief (such as Haitians or Cuban entrants, for example).
Immigrants who fall into the categories above qualify for full Medicaid coverage and will NOT qualify for emergency Medicaid coverage. Only temporary, non-immigrants can qualify for emergency Medicaid coverage.
What is considered emergency Medicaid?
Emergency Medicaid is a Medicaid program that’s provided to cover the care and services needed to treat emergency medical conditions to temporary non-immigrants who would otherwise be ineligible for other Medicaid programs. Temporary non-immigrants include eligible foreign students, visitors or tourists, and undocumented or illegal aliens. Eligibility for emergency Medicaid depends on a number of different factors.
Medicaid for the treatment of an emergency medical condition is provided to non-immigrants who meet specific eligibility requirements. The temporary non-immigrants must have been permitted to enter the United States for a specific purpose and for a limited period of time. It isn’t necessary for them to meet the State residence requirements and in terms of the District of Fiscal Responsibility, they are considered “Where Found”.
The initial duration of the Authorization Period of Medicaid coverage for the treatment of an emergency medical condition may be up to a maximum of 15 months. This initial Authorization Period is calculated from three months before the date the patient applies for coverage to12 months after the application date. The Authorization Period may extend from the first day of the 3rd month before the patient’s application date to the last day of the twelfth month after the application date.
Within the initial 12-month Authorization Period, there is no need for the patient to fill out a new Medicaid application. Within that 12-month period, authorization for emergency Medicaid services has already been established, but although a new application is not required for new emergencies, the Medicaid claim form must indicate that it is for an emergency. Treating physicians are responsible for determining whether the patient’s condition meets the definition for an emergency medical condition and designate that it qualifies for coverage on the proper forms in order for the patient to receive coverage during the initial twelve month Authorization Period.
What does emergency Medicaid cover in New York?
Case laws designating which treatments constitute an emergency and which ones do not are abundant.
According to the state of New York, an “Emergency Medical Condition” is defined as a medical condition that includes acute symptoms that are severe enough that the expected results would place the patient’s health in great danger, result in serious impairment to the patient’s bodily functions, or cause a major dysfunction of a patient’s organs or parts. This definition also regards emergency labor and delivery as a qualifying health issue for temporary non-immigrants. Severe pain also qualifies as an “Emergency Medical Condition” according to this definition.
The specifications for this definition must be met immediately after the medical condition manifests or at the same time that the medical service is provided. If the specifications are not met after manifestation of the medical condition or at the time when medical services are provided, it will not be defined as an “Emergency Medical Condition” and emergency Medicaid will not cover the health condition.
In New York, emergency Medicaid will not cover all health costs. The coverage of certain prescription drugs has been tightening. For example, drugs such as proton pump inhibitors and blood pressure medications that don’t meet the federal government’s definition of emergency care have been under review by the Department of Health. New policies have recommended limiting prescription drug coverage to a limited set of therapeutic classifications that are associated with emergency care, but while certain drugs that are needed by dialysis patients have been added to the list, insulin is not going to be added and drugs that are not on the list will be denied coverage.
Doctors can apply to override claims and in some instances, drugs that are necessary for the treatment of an emergency condition may be paid. Chemotherapy is a drug covered by emergency Medicaid that is paid for using state only funds, but prescribing doctors still need to submit a request for override.
Rather, this program was designed to cover costs for care and services in very specific situations for qualifying individuals. Emergency Medicaid is in place to provide payment for medical services when an individual is in need of immediate medical attention due to a serious health problem. Serious health issues include any of the following:
● Heart attack
● Severe pain that may lead to dangerous health outcomes if medical help isn’t provided.
● Kidney dialysis
● Emergency labor and delivery
Emergency Medicaid may also cover the cost of certain medications that are administered in emergency situations along with certain prescription drugs for cancer treatment. Care and services that pertain to an organ transplant surgery are not included in this definition.
There are a number of medical services that don’t conform to the current definition of an emergency medical condition. Some services are medically necessary, but coverage is not provided. Emergency medical conditions do not include conditions that are debilitating or that require rehabilitation. For example, a patient with heart disease that results from an initial infarction that requires ongoing care will not be covered by Medicaid even if the lack of rehabilitative services end in a potentially fatal event. The likelihood that a patient may die as a result of a lack of rehabilitative services due to a debilitating condition is beyond the domain of emergency Medicaid coverage.
A variety of services and types of care don’t meet the definition of an emergency medical condition according to the state of New York. These services include, for example, those that are provided to patients who are chronically ill. The services needed by these patients is beyond the scope of federal and State laws and as such, they are not viewed as “emergency services”.
Emergency Medicaid does not pay for care and services rendered or transportation to a health facility in the following situations:
● Services provided in nursing or long-term care facilities or home care situations including personal care services, private duty nursing services, and home health services.
● Rehabilitation services such as speech, occupational, or physical therapy
● An alternate level of care in hospitals
Does Medicaid cover emergency surgery?
As a general rule, emergency surgery qualifies for Medicaid coverage except in instances where the surgery is an elective surgery or performed for cosmetic purposes. However, a cosmetic surgery that has been deemed medically necessary may still be approved for coverage.
Who is eligible for emergency Medicaid?
The basic eligibility test for determining whether or not someone qualifies for emergency Medicaid in New York state includes a review of the following:
● Patient Resources
● Low Income
● New York State residency (temporary lawful residents don’t have to meet the State residency requirements)
● Other Insurance
● Disability/medical status
If you meet the eligibility requirements for full Medicaid but you don’t qualify because of your immigration status, then you would likely qualify for emergency Medicaid. If you have a medical emergency and you qualify for emergency Medicaid, all hospitals must treat you even if you don’t have the ability to pay.
If you aren’t sure whether or not you qualify for emergency Medicaid, you can sign up to be pre-approved in advance. By enrolling in advance you can get pre-approved for emergency Medicaid for 12 months. Enrollees under age 65 can enroll online. Those who are 65 years or older or who have a disability must go through a different application process. Call 311 for more information and to learn more about your coverage options.
What documents do I need for emergency Medicaid?
Proof of identity, income and State residence information are all required in order to prove that the temporary non-immigrant qualifies for the program.
Undocumented aliens who entered the United States in a manner that was carried out to avoid inspection, or someone who was admitted temporarily and remained beyond the period of their authorized stay will not have immigration documents. On the other hand a temporary non-immigrant will have immigration documents. Immigration documents are not required to receive emergency Medicaid coverage in NY.
Health providers are required to submit a revised emergency certification form which acts as a HIPAA authorization for disclosure of protected health information. It must be signed by the doctor, the applicant, and/or an authorized representative (in certain situations). Patients can apply on site and be approved on the same day as their appointment. Below are documents are needed to apply:
- Birth certificate (with a notarized translation in English) or Passport
- Valid photo ID (must be issued by the government and not expired)
- Social Security Card (in certain situations)
- Proof of Address (This must be in the patient’s name and dated within 3 months. P.O. Boxes are not accepted.)
- Proof of Income or Proof of Enrollment if the patient is a student under age 21 years.