H06-004 - Procedure

February 2, 2006

TO: / Home and Community Services (HCS) Division Regional Administrators
Division of Developmental Disabilities (DDD) Regional Administrators
Area Agency on Aging (AAA) Directors
FROM: / Bill Moss, Director, Home and Community Services Division
Linda Rolfe, Director, Division of Developmental Disabilities
SUBJECT: /
CHANGES TO ALIEN EMERGENCY MEDICAL (AEM) AND LONG-TERM CARE (LTC) SERVICES
Purpose: / To notify staff of changes and describe the procedures HCS financial and social services staff are to use for new AEM clients applying for, and existing AEM clients receiving, LTC services.
Background: / Alien Emergency Medical (AEM) is a federally-funded medical program for clients who meet all of the eligibility criteria of a regular Medicaid program, but do not qualify due to their alien status. To be eligible for AEM, a non-citizen must have a documented emergency medical condition as defined in WAC 388-500-0005. Medical care, for AEM clients, is limited to those medical services necessary for treatment of the person's emergency medical condition.
What’s new, changed, or
Clarified / Waiver services (COPES, MN waivers, DDD waivers) and personal care services under Medicaid Personal Care (MPC) are not considered medical services necessary for treatment of the person’s medical condition and can’t be paid under the AEM program.
Nursing facility services may be provided, but additional criteria must be met before these services are authorized. In addition to having an emergency medical condition, the department’s medical consultant must approve the NF service as necessary for treatment of the person’s emergency medical condition.
Note: Adult Day Health is not considered an eligible medical service under the AEM program.
ACTION: / Effective Immediately - Financial Staff Actions
New applications
  • Notify the social worker immediately when processing an application if the client will only qualify for the AEM program.
  • Deny waiver and personal care services and determine eligibility for the regular AEM program using the instructions in the E A-Z manual.
The client who meets financial and categorical eligibility requirements may request and receive NF services if the following are met:
  • The client has an approved emergency medical condition;
  • The department’s medical consultant approves NF services before you authorize them;
  • The client meets the NF level of care and institutional status requirements. This will require a CARE assessment for documentation.
If the client has a documented qualifying medical condition identified in the E A-Z manual:
  • Open AEM medical pending the outcome of the NF approval;
  • Use ACES medical coverage group S07 for these cases;
  • FAX the medical documentation to the medical consultant with ACES letter #65-08 and a copy of the CARE assessment;
  • If NF services are approved, change the ACES medical coverage group to L04;
  • Use the diagnosis-based certification periods in the E A-Z manual or the certification period indicated by the department’s medical consultant.
If the client does not have a documented qualifying medical condition identified in the E A-Z manual:
  • Obtain medical documentation to verify the emergent medical condition;
  • FAX a request for determination of a qualifying emergency medical condition and NF approval to the medical consultant on ACES letter #65-08 along with medical documentation and the CARE assessment. Indicate that you need a determination of a qualifying emergency medical condition and NF approval on the ACES letter #65-08. Indicate that you need an expedited decision on the ACES letter #65-08 if the client is in a hospital and requires NF approval before discharge to a NF.
Send cases for review by the Medical Consultants to:
Client/Provider Notification Unit
Health & Recovery Services
Division of Medical Management
MS 45506
Telephone: (360) 725-1720
FAX: (360) 586-1471
  • Use the medical consultant’s decision to approve or deny NF services. The determination from the medical consultant may also include the certification period for the NF approval. Clients will have two types of certification periods:
  1. Financial certification periods for AEM every 3 months;
  2. Diagnosis-based medical certification period that ranges from 3 to 12 months.
If NF services are approved, the emergency medical condition and NF approval must be reviewed and approved by the medical consultant at the end of each diagnosis-based medical certification period before the case can be re-certified.
Clients Currently Receiving Waiver Services and MPC
Financial program managers have received a list of current non-citizen clients in ACES that only qualify for the AEM program. The list includes clients who are currently receiving benefits under the AEM program and clients who are receiving services under a regular CN program in error.
Financial workers must:
  • Review INS status, date of entry, initial entry status and current citizenship status. Initial instructions to obtain information about the client’s current immigration status in order to determine eligibility along with language for a letter to General Assistance client and a flyer that describes eligibility for federal Medicaid for non-citizens was sent out 11/16. Additional instructions with an updated version of the General Assistance letter was sent out 1/13/06 for the AEM clients and clients converted to AEM from CN.
  • Make any corrections necessary on the DEM 2 and ALAS screens in ACES.
  • Correct the ACES workaround for INS status. Replace with the client’s actual status.
  • Do not change the date to the actual entry date. ACES uses the entry date, not the date the client became a qualified alien to determine eligibility. According to federal law, they are eligible for federal benefits 5 years from the date they became a qualified alien (5-year bar). This workaround will be fixed in the next phase of ACES alien changes.
  • For the General Assistance cases that lose eligibility for CN Medicaid, remove the workaround on the ALAS screen and replace it with the client’s actual status. Change the medical coverage group to G01 and notify the social worker that the client is not eligible for waiver or MPC services. Send an ACES general correspondence letter to terminate CN Medicaid and LTC services. Use the attached letter template as a guide. Choose the correct immigration status to put in the reason section.
  • For clients who had their CN benefits (C01 to C04) reinstated and clients who are currently receiving AEM (S07, S95, S99) who are not eligible for regular CN benefits, advise the SW to terminate waiver or personal care services via the ACES letter #065-10 Financial/Social Services Communication. Send a termination letter for COPES and MN waiver clients. The termination letter must have the specific reasons for the termination. Also, give the detailed reason to the SW if they have to send the termination letter for MPC. For those clients who are subject to the 5-year bar, tell the SW and the client when the bar will expire and that they can re-apply for services upon expiration.
  • Determine eligibility for AEM for clients who lost their CN benefits and current AEM clients using the instructions in the E A-Z manual. There is no change for GA clients who are changed to G01.
  • If the client is eligible for AEM only, inform the client that NF services may be an option but will require prior approval and that they need to contact their social worker.
  • If the client, who is no longer eligible for waiver or personal care services requests NF services, follow the “New Applications” procedures established above for determining eligibility for NF services.
  • Transfer the AEM case to the CSO if the client is no longer eligible for long-term care services.
Clients Currently Receiving NF Services
A list of clients currently in nursing facilities will be sent to the Regional Administrators and financial program managers.
Clients currently on AEM in nursing facilities must have their eligibility redetermined based on an emergent medical condition and NF approval by the medical consultant.
Prepare a packet containing medical documentation of the medical condition and the CARE assessment documenting the nursing facility level of care. Give the packet to the financial program manager or their designee for review. The financial program manager will FAX the medical documentation along with the ACES letter #65-08 to HCS HQ, Attention Peggy Rezac (360) 438-8633. Continue NF services until the medical consultant’s decision is received. A process to continue paying for NF care is under development for cases where the medical consultant denies NF services.
You must provide accurate documentation as to how each client was determined ineligible for CN medical and long-term care services. Documentation must be in the case record and recorded in detail in ACES. Record information about the client's immigration status on the remarks behind the ALAS screen in ACES and the steps taken to document the INS status in the Narrative. Also document the client’s response to the veteran question on the DEM2 screen.
Social Service Actions - New Applications
Social service staff must be aware of a client’s alien status. Deny waiver and personal care services.
Non-citizens who do not meet the requirements are:
  1. Undocumented;
  2. An unqualified alien, such as a visitor; or
  3. A qualified alien who is currently in the five-year bar and is not eligible for other Medicaid programs.
Do not open fast track for non-citizens unless you know they will qualify for the regular CN or MN program. Advise clients that they may reapply for services when they meet the 5-year bar or citizenship requirement.
If the client is eligible for GAU, NF and state-funded residential care are options for the client. If the client is eligible for AEM, NF service is the only option, but must be approved by the medical consultant in addition to meeting financial and functional eligibility.
If the client is applying for NF services under AEM, work with the financial worker to obtain medical documentation to verify the emergency medical condition. Provide the financial worker with a copy of the CARE assessment to submit to the medical consultant for approval.
Clients Currently Receiving Waiver Services or MPC
  • Terminate waiver or personal care services for clients who had their CN benefits reinstated and clients who are currently receiving AEM if financial staff have determined they are no longer financially eligible for regular Categorically Needy (CN) or Medically Needy (MN) services.
  • Send a termination letter to MPC clients. The termination letter must have the specific reason for termination and the client’s options.
  • Inform the client that NF services may be an option but will require prior approval.
  • Process the request for NF services the same as a new application.

Related
REFERENCES: /
  • WAC
  • 88-438-0110 – The Alien Emergency Medical (AEM) Program, Emergency filing
  • WAC 388-500-0005, Medical Definitions
  • WAC 388-424-0001 – Citizenship and alien status – Definitions
  • WAC 388-424-0006 Citizenshipand alien status – Date of Entry
  • WAC 388-106-0310Am I eligible for COPES-funded services?
  • WAC 388-106-0210 Am I eligible for MPC-funded services?
  • CSD Region 2 Immigrant Eligibility Training
Resources for Clients:
“When Can I Apply For Citizenship?”
NW Immigrant Rights Project
909 Eighth Ave
Seattle, WA98104
(206) 587-4009

NW Justice Project
401 Second Ave S, Suite 407
Seattle, WA98104
(206) 464-1519

ATTACHMENT(S): / Questions and Answers:

Instructions for General Assistance:

Request for Information letter template for General Assistance:

Eligibility for Medicaid for Non-citizen attachment for letters requesting information:

Instructions for AEM clients and clients converted to AEM from CN

Request for information letter template for AEM clients and clients converted to AEM from CN

Charts from HCS training packet:

ACES chart – Qualified Aliens and Federal Medicaid:

Armed Service and Veteran’s Status Criteria

CONTACT(S): / Mary Lou Percival, Program Mgr. David Armes, Program Mgr.
360-725-2318 360-725-2535

Peggy Rezac Dave Langenes
HCS Financial Trainer DDD Waiver Prog. Mgr.
360-725-2582 360-725-3456

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