Current through Register Vol. 24-18, September 15, 2024
(1) A person nineteen years of age or older
who is not pregnant and meets the eligibility criteria under WAC
182-507-0110 is eligible for the
alien emergency medical program's scope of covered services described in this
section if the person meets (a) and (b) or (c) of this subsection:
(a) The medicaid agency determines that the
primary condition requiring treatment meets the definition of an emergency
medical condition as defined in WAC
182-500-0030, and the condition
is confirmed through review of clinical records; and
(b) The person's qualifying emergency medical
condition is treated in one of the following hospital settings:
(i) Inpatient;
(ii) Outpatient surgery;
(iii) Emergency room services, which must
include an evaluation and management (E&M) visit by a physician;
or
(c) Involuntary
Treatment Act (ITA) and voluntary inpatient admissions to a hospital
psychiatric setting that are authorized by the agency's inpatient mental health
designee (see subsection (5) of this section).
(2) If a person meets the criteria in
subsection (1) of this section, the agency will cover and pay for all related
medically necessary health care services and professional services provided:
(a) By physicians in their office or in a
clinic setting immediately prior to the transfer to the hospital, resulting in
a direct admission to the hospital; and
(b) During the specific emergency room visit,
outpatient surgery or inpatient admission. These services include, but are not
limited to:
(i) Medications;
(ii) Laboratory, X ray, and other diagnostics
and the professional interpretations;
(iii) Medical equipment and
supplies;
(iv) Anesthesia,
surgical, and recovery services;
(v) Physician consultation, treatment,
surgery, or evaluation services;
(vi) Therapy services;
(vii) Emergency medical transportation;
and
(viii) Nonemergency ambulance
transportation to transfer the person from a hospital to a long term acute care
(LTAC) or an inpatient physical medicine and rehabilitation (PM&R) unit, if
that admission is prior authorized by the agency or its designee as described
in subsection (3) of this section.
(3) The agency will cover admissions to an
LTAC facility or an inpatient PM&R unit if:
(a) The original admission to the hospital
meets the criteria as described in subsection (1) of this section;
(b) The person is transferred directly to
this facility from the hospital; and
(c) The admission is prior authorized
according to LTAC and PM&R program rules (see WAC
182-550-2590 for LTAC and WAC
182-550-2561 for
PM&R).
(4) The
agency does not cover any services, regardless of setting, once the person is
discharged from the hospital after being treated for a qualifying emergency
medical condition authorized by the agency or its designee under this program.
Exception: Pharmacy services, drugs, devices, and drug-related supplies listed
in WAC 182-530-2000, prescribed on the
same day and associated with the qualifying visit or service (as described in
subsection (1) of this section) will be covered for a one-time fill and
retrospectively reimbursed according to pharmacy program rules.
(5) Medical necessity of inpatient
psychiatric care in the hospital setting must be determined, and any admission
must be authorized by the agency's inpatient mental health designee according
to the requirements in WAC
182-550-2600.
(6) There is no precertification or prior
authorization for eligibility under this program. Eligibility for the AEM
program does not have to be established before an individual begins receiving
emergency treatment.
(7) Under this
program, certification is only valid for the period of time the person is
receiving services under the criteria described in subsection (1) of this
section. The exception for pharmacy services is also applicable as described in
subsection (4) of this section.
(a) For
inpatient care, the certification is only for the period of time the person is
in the hospital, LTAC, or PM&R facility - The admission date through the
discharge date. Upon discharge the person is no longer eligible for
coverage.
(b) For an outpatient
surgery or emergency room service the certification is only for the date of
service. If the person is in the hospital overnight, the certification will be
the admission date through the discharge date. Upon release from the hospital,
the person is no longer eligible for coverage.
(8) Under this program, any visit or service
not meeting the criteria described in subsection (1) of this section is
considered not within the scope of service categories as described in WAC
182-501-0060. This includes, but
is not limited to:
(a) Hospital services,
care, surgeries, or inpatient admissions to treat any condition which is not
considered by the agency to be a qualifying emergency medical condition,
including but not limited to:
(i) Laboratory
X ray, or other diagnostic procedures;
(ii) Physical, occupational, speech therapy,
or audiology services;
(iii)
Hospital clinic services; or
(iv)
Emergency room visits, surgery, or hospital admissions.
(b) Any services provided during a hospital
admission or visit (meeting the criteria described in subsection (1) of this
section), which are not related to the treatment of the qualifying emergency
medical condition;
(c) Organ
transplants, including preevaluations, post operative care, and anti-rejection
medication;
(d) Services provided
outside the hospital settings described in subsection (1) of this section
including, but not limited to:
(i) Office or
clinic-based services rendered by a physician, an ARNP, or any other licensed
practitioner;
(ii) Prenatal care,
except labor and delivery;
(iii)
Laboratory, radiology, and any other diagnostic testing;
(iv) School-based services;
(v) Personal care services;
(vi) Physical, respiratory, occupational, and
speech therapy services;
(vii)
Waiver services;
(viii) Nursing
facility services;
(ix) Home health
services;
(x) Hospice
services;
(xi) Vision
services;
(xii) Hearing
services;
(xiii) Dental
services;
(xiv) Durable and
nondurable medical supplies;
(xv)
Nonemergency medical transportation;
(xvi) Interpreter services; and
(xvii) Pharmacy services, except as described
in subsection (4) of this section.
(9) The services listed in subsection (8) of
this section are not within the scope of service categories for this program
and therefore the exception to rule process is not available.
(10) Providers must not bill the agency for
visits or services that do not meet the qualifying criteria described in this
section. The agency will identify and recover payment for claims paid in
error.
Statutory Authority:
RCW
41.05.021. 12-24-038, §182-507-0115,
filed 11/29/12, effective 12/30/12. 12-13-056, recodified as WAC 182-507-0115,
filed 6/15/12, effective 7/1/12. Statutory Authority:
RCW
74.04.050,
74.08.090, and
2009 c
564
§§
1109,
201,
209. 10-19-085, §
388-438-0115, filed 9/17/10, effective
10/18/10.
