Medicaid for the Treatment of an Emergency Medical Condition Fact Sheet

What is Medicaid for the treatment of an emergency medical condition?

Medicaid payment is provided for care and services necessary for the treatment of an emergency medical condition, to otherwise eligible temporary non-immigrants (e.g., certain foreign students, visitors/tourists) and undocumented (illegal) aliens. To be eligible for treatment of an emergency medical condition, an undocumented alien or temporary non-immigrant must meet all eligibility requirements, including proof of identity, income and State residence. Temporary non-immigrants, who have been allowed to enter the United States temporarily for a specific purpose and for a specified period of time, do not have to meet the State residence requirement and are considered "Where Found" for District of Fiscal Responsibility purposes.

Who can receive Medicaid for the treatment of an emergency medical condition?

Undocumented Alien

An individual is here illegally or is undocumented if s/he entered the United States in a manner or in a place so as to avoid inspection, or was admitted on a temporary basis and the period of authorized stay has expired. Undocumented individuals will not have immigration documents.

Temporary Non-Immigrant

Certain immigrants may be lawfully admitted to the United States temporarily for a specific purpose and for a specified period of time. Certain foreign students, visitors, tourists, and some workers are admitted but restricted due to the temporary nature of their admission status. Otherwise eligible non-immigrants who are admitted on a temporary basis and who require immediate medical care which is not otherwise available, may receive Medicaid coverage only for the treatment of an emergency medical condition. Such temporary non-immigrants may receive this coverage, provided they did not enter the State for the purpose of obtaining medical care (e.g., medical visa).

What is an emergency medical condition?

The term "Emergency Medical Condition" is defined as a medical condition (including emergency labor and delivery) that manifests 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:

  • Placing the patient's health in serious jeopardy;
  • Serious impairment to bodily function; or
  • Serious dysfunction of any bodily organ or part.

Care and services related to an organ transplant procedure are not included in this definition.

This definition must be met, after sudden onset of the medical condition, at the time the medical service is provided, or it will not be considered an emergency medical condition and therefore, cannot be covered by Medicaid.

Not all services that are medically necessary meet the definition of an emergency medical condition. Emergency medical conditions do not include debilitating conditions (e.g., heart disease or other medical conditions requiring rehabilitation) resulting from the initial event which later requires ongoing regimented care. The potentially fatal consequence of discontinuing Medicaid coverage care, even if such care is medically necessary, does not transform the condition into an emergency medical condition.

What services do not meet the definition of an emergency medical condition?

Certain types of care provided to chronically ill persons are beyond the intent of the federal and State laws and are not considered "emergency services" for the purpose of payment by Medicaid. Such care includes:

  • Alternate level of care in a hospital;
  • Nursing facility services, home care (including but not limited to personal care services, home health services and private duty nursing); and
  • Rehabilitation services (including physical, speech and occupational therapies).

The above mentioned services do not fall within the definition of an emergency medical condition. Therefore, Medicaid does not cover the cost for the above mentioned services or transportation to these services.

How long is Medicaid coverage for the treatment of an emergency medical condition?

Authorization Period

The initial Authorization Period for the treatment of an emergency medical condition may be up to a maximum of 15 months: three months retroactive from the Application Date and 12 months prospective from the Application Date. The authorization period may be from the first day of the third month prior to the month of application to the last day of the twelfth month prospectively.

A new Medicaid application is not required for subsequent emergencies when a 12 month authorization period is established for the case. Although a new Medicaid application is not required for later emergencies occurring within the established 12 month authorization, the Medicaid claim must indicate that it is for an emergency. The treating physician will determine if the medical conditions meet the definition of an emergency medical condition.