Nursing Home and Alien Emergent Medical (AEM)

Revised November 17, 2008

Medical Assistance EAZ manual material with WAC on AEM

Once you have opened the link above, scroll down to the clarifying information for complete instructions regarding AEM and nursing facility clients. The section is called nursing home prior authorization.

Always consider the possibility of General Assistance Unemployable

Other programs should always be considered before AEM.

Many non-citizens who are in a five year medicaid bar or considered PRUCOL can receive medical and nursing facility services through the General Assistance Unemployable program.

They must meet income and resource criteria for GAU and be assessed as nursing facility level of care (NFLOC).

Clarifying Information-AEM in NF

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 AEM medical program using the instructions in the AEM chapter.

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 AEM chapter:

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 EAZ 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 AEM chapter:

Obtain medical documentation to verify the emergent medical condition;
FAX a request for determination of both 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 both 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:

Financial certification periods for AEM every 3 months;
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.

NOTE:

The AEM NF authorization often does not match the eligibility review certification period. Make sure an alert or tickler is set well in advance of when a new NF authorization is needed from the medical consultant. The HCS SW must perform a new assessment for additional nursing facility authorizations and this must be forwarded to the medical consultant along with any additional medical records with the ACES letter 65-08.

Nursing Home under State Funds (AEM denied)

Aging and Disability Services Administration has a limited amount of state funding available for client who have been denied or terminated from AEM coverage by the medical consultant and are in need of nursing facility care.

Funding priority will be given to clients who are initially approved for AEM coverage and are denied at review but still require nursing facility care.

Always consider GAU first.

IMPORTANT

The state funded program is not supported by ACES. An L04 is used in ACES. For this reason ADSA headquarters must track each case using the state funds to pay for nursing facility services.

For AEM nursing home denials and terminations contact David Armes, Financial Policy Manager at ADSA headquarters via e mail.

Any new admits.
Any reviews where there is a gap of approved coverage by the medical consultant. Include the dates of the state funded coverage.
Any reviews where AEM was initially approved, but the medical consultant denies AEM for current period. Make sure the date of denial by the medical consultant is included in the e mail to ADSA headquarters and the dates of the state fund opening.
If a state funded client's medical condition causes re-hospitalization, re-refer to the medical consultant for AEM to see if federal coverage can be obtain. E-mail David Armes on the referral and if approved for federal coverage. (AEM approved).

EXAMPLE

#1.

Joe Smith is approved for 6 months through 10/31/2008 under the federal AEM program. The financial worker does not receive a new assessment until 11/10/2008. The referral is received by the medical consultant on 11/15/2008 and approved for a new time period of 11/15/2008 to 5/31/2009. The period from 11/1/2008 through 11/14/2008 must be paid out of state funds. E-mail David Armes at ADSA HQ to inform him of the dates of the state funded coverage.

EXAMPLE

Jane Smith has been in a hospital for six months. All options for alternative settings have been explored by the hospital. The medical consultant denies AEM coverage because the client does not have a condition that meets the federal emergent criteria. However the client has many severe chronic conditions. She must either remain in the hospital indefinately or be placed in a nursing home.

She is assessed by the HCS social worker and meets NFLOC. A local nursing facility will admit Jane if state funding can be provided.

If financially and resource eligible, refer case to ADSA HQ, David Armes.

EXAMPLE

#3.

Jayna Smith is a legally admitted alien in the 5 year bar. Jayna is exempt from sponsored deeming because she has no income. (income less than 130% of the FPL).

Jayna has been hospitalized and is in need of nursing home care due to a stroke. She has been assessed by the HCS SW and meets NFLOC.

Jayna can be opened on general assistance unemployable. There is no need to refer for AEM or state funded nursing home program. GAU covers nursing facility coverage.

*If Jayna were to be release from the nursing home, the department continues GAU for 90 days, but cannot offer personal care coverage at home.

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