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Medicaid Coverage Available for Non-Citizens
Federal regulations allow states to reimburse for emergency services provided to Medicaid beneficiaries who are “noncitizens,” also referred to as “aliens,” on a limited basis. Aliens are not eligible for full Medicaid benefits due to their status as non-citizens.
Emergency services are defined as those services required after the sudden onset of a medical condition, manifesting itself by acute symptoms of sufficient severity (including severe pain), such that the absence of immediate medical attention could reasonably result in serious jeopardy to the patient’s health or serious impairment to bodily functions or serious dysfunction of any bodily organ or part. Labor and delivery services to pregnant women and dialysis services are considered emergencies, and therefore, are covered for non-citizens.
Medically necessary services that are not also emergency services are not covered by Medicaid for alien beneficiaries. Medically necessary services are defined as services necessary to palliate or make more bearable the effects of a terminal condition, or to prevent, diagnose, correct, cure, alleviate, or preclude deterioration of a condition that threatens life, causes pain or suffering, or results in illness or infirmity.
Alien claims, except those submitted for payment of labor, delivery, and dialysis services, are subject to medical review. CMS-1500 alien claims with place of service 11 (office setting) or 22 (outpatient hospital) must be submitted to Medicaid with documentation supporting the emergency situation. UB-04 Inpatient alien claims are reviewed and reimbursed up to the point of patient stabilization and are limited to the inpatient 45-day hospital limit.
Alien claims may only be submitted as paper claims. If the service was an emergency, enter a “Y” for “Yes” in field 24C (EMG) of the CMS-1500 claim form and attach medical documentation that describes the medical condition that constituted the emergency and the treatment provided to alleviate or resolve the emergency. For laboratory and radiology reimbursement, a report must be submitted representing each CPT code billed, and the report must have the corresponding date and time. For reimbursement of physician hospital visits, physician progress notes must be submitted with the corresponding date of service. For anesthesia reimbursement, an anesthesia record must be submitted with the start and stop time of the anesthesia clearly indicated. Lack of appropriate documentation will result in a claim denial. Edit 909, Claim Requires Documentation, will post to the denied claim.
All paper alien claims with their medical records must be sent directly to the Medicaid fiscal agent for processing. To reduce claim processing time, submitted claims should be as error-free as possible. Inquiries regarding the status of submitted alien claims must be directed to the fiscal agent or to your local Area Medicaid Office.