Ohio Administrative Code
Title 5160:1 - Eligibility
Chapter 5160:1-5 - Medicaid for Other Covered Groups
Section 5160:1-5-06 - Medicaid: non-citizen emergency medical assistance (NCEMA)
Universal Citation: OH Admin Code 5160:1-5-06
Current through all regulations passed and filed through September 16, 2024
(A) 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 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.
(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) Submit an
application for medical assistance .
(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.
(2) Meet eligibility
criteria for a category of medicaid, except that the individual:
(a) Does not meet the medicaid citizenship or
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
:
(i) Social security number; or
(ii)
United
States (U.S.) citizenship or immigration status.
(b) Is not required to apply for social
security administration (SSA) benefits.
(D) 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:
(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
(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.
(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.
(1) Determine the payment
coverage span for routine labor and delivery without submitting medical
documentation to the disability determination area
( DDA)
and enter the payment coverage dates as described in paragraph (D)(2)
of this rule into the electronic eligibility system.
(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.
(3)
Submit medical
documentation to the DDA
for emergency medical conditions other than routine
labor and delivery
and enter the eligibility
span determined by the DDA into the electronic eligibility system.
(4) Upon request, assist the individual
with
obtaining medical documentation to support the 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) DDA responsibilities.
(1)
Make all emergency medical condition determinations except for routine labor
and delivery episodes as
described in paragraph (D)(2) of this rule.
(2) Determine whether the
individual received treatment for an emergency medical condition.
(3) Determine the payment
coverage span for each emergency
medical condition episode.
(4)
Notify the administrative agency of the NCEMA
determination and the payment coverage span via the electronic eligibility
system.
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