Program offers funds for undocumented aliens’ care
Here’s what providers should know
By Loren Ratner, Nixon Peabody LLP Garden City, NY
The Centers for Medicare & Medicaid Services (CMS) is preparing to implement a new program that will provide funding for emergency health services received by undocumented aliens.
This represents the first time federal funding will be available to hospitals and other providers for services they are required to provide to undocumented aliens under the Emergency Medical Treatment and Labor Act
(EMTALA).
Under Section 1011 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law No. 108-173), a total of $1 billion has been allocated for reimbursement of eligible providers for the four fiscal years beginning FY 2005.
CMS issued a final policy notice May 9, 2005, that provides guidance on implementation of the new program.
Background information and links to the statutory language, applicable forms, and other materials are available from the CMS web site at www.cms.hhs.gov/providers/section1011.
EMTALA, also known as the patient antidumping statute, requires that Medicare-participating hospitals that offer emergency services must provide medical screening examinations and necessary stabilizing treatment or appropriate transfer to individuals who come to a hospital emergency department and request examination or treatment for medical conditions.
The statute applies to all patients, regardless of eligibility for Medicare or any other government-funded health program. EMTALA prohibits any delay in providing required screening or stabilization to inquire about an individual’s payment method or insurance status.
Section 1011 was enacted to provide reimbursement for care provided to undocumented and certain other aliens under EMTALA.
Eligible to receive funding
Funds are available to cover emergency services provided to:
- undocumented aliens;
- aliens who have been paroled into the United States for the purpose of receiving eligible
services; - Mexican citizens permitted to enter the United States for a short period of time under the authority of a biometric machine-readable border crossing identification card (a "laser visa").
The $250 million available per year under Section 1011 will be allocated to each state and the District of Columbia in accordance with two methodologies. Two-thirds of the yearly appropriation, or $167 million, will be divided proportionally among all 50 states and the District of Columbia according to the percentage each state has of all undocumented aliens in the country.
The remaining third of the funds, or $83 million, will be divided among the six states with the highest number of undocumented alien apprehensions.
The money will be divided among the six states according to the percentage of undocumented alien apprehensions in each state compared to the total of those apprehensions for all the states in a designated fiscal year.
The six states with the greatest number of undocumented alien apprehensions for the initial time period used of April 1, 2003, through March 31, 2004, are Arizona, California, Florida, New Mexico, New York, and Texas.
Section 1011 funding is available to hospitals, physicians, and state-licensed ambulance service providers, including Indian Health Service facilities, with the provision that only Medicare-participating hospitals can apply to receive the funds.
The statutory language of Section 1011 requires that eligible services are health care services required under EMTALA and related hospital inpatient and outpatient services and ambulance services.
Payment will be made for covered services that begin when the hospital’s EMTALA obligation begins, such as when an individual arrives at the hospital emergency department and requests examination or treatment for a medical condition.
Coverage will continue until the individual is stabilized. To be considered stable, a patient’s emergency condition must be resolved, even if the underlying medical condition persists.
For example, if a patient presents to the hospital experiencing an acute asthma attack, coverage will end when the hospital’s EMTALA obligation ends — that is, when the patient’s acute respiratory symptoms are alleviated.
Even if the patient is admitted to the hospital for further treatment for asthma, such treatment would not be covered because the patient’s condition had already been stabilized.
| Industry reaction mixed
to Section 1011 funding
Administrative burdens cited New funding for the care of undocumented aliens under Section 1011 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 has drawn mixed reaction from the health care industry, says Loren Ratner, an attorney specializing in health and hospital law in the Health Services Group of Nixon Peabody LLP in Garden City, NY. |
CMS takes the position that most patients are stabilized within two calendar days, and so inpatient admissions that go beyond that time may be reviewed by CMS.
Determination for claims for which stabilization occurs on the first or second day will not
be reviewed. In the event that a claim is reviewed because stabilization occurred later than the
second day of admission, the medical record should document all the reasons for the stabilization determination.
If a determination is not documented properly, stabilization will be deemed to have occurred on the second day of the stay. By limiting coverage through stabilization, rather than discharge, CMS maintains that hospitals will be prevented from seeking Section 1011 funds for services unrelated to the emergency medical condition.
Medically necessary and appropriate services that physicians furnish to patients who receive emergency services required by EMTALA, or related inpatient or outpatient services, through stabilization will be covered.
Similarly, medically necessary air and/or ground ambulance transportation of a patient that is necessary for appropriate transfer under EMTALA will be covered.
Eligible providers must submit a paper enrollment application and an electronic enrollment application prior to submitting a payment request. The provider enrollment application can be found at the CMS web site. Once the web-based enrollment process is established, Medicare providers will be notified. Medicare providers then may submit electronic enrollment applications at any time, but at least 30 days before submitting a claim. If a provider does not have an electronic data interchange agreement in place already with its existing carrier or fiscal intermediary, it must complete such an agreement.
Hospitals can elect to receive payment for eligible physician services provided by its employed or contracted physicians. However, the election requires that the hospital receive payment for all such physicians — that is, hospitals cannot submit claims for eligible services provided by some physicians, leaving other physicians free to submit claims individually. Before submitting claims under Section 1011, providers must seek reimbursement from all available funding sources, including Medicaid, the State Children’s Health Insurance Program, private insurers, HMOs, direct payments from patients, etc.
Providers will be required to use their existing practices and procedures to identify and request reimbursement from such funding sources. When services are covered by other funding sources, providers only will be allowed to submit claims for reimbursement under Section 1011 for any deductible, coinsurance, or copayment not paid by the individual.
Providers are required to document a patient’s eligibility under Section 1011 before submission of claims for that patient. To do so, a Medicaid enrollment application or another established information collection instrument can be used. Alternatively, a collection instrument for provider payment determination information has been developed by CMS.
Regardless of the method used to collect the information, a provider must collect and maintain the same information contained in the CMS instrument. It is important that emergency treatment not be delayed to gather information to determine and document a patient’s eligibility. Providers will be eligible to receive a fraction of the outpatient emergency department care costs for patients who refuse to provide the necessary information to make an affirmative determination of eligibility under Section 1011.
Payments to providers will be made on a quarterly basis using a retrospective payment approach to ensure payments do not exceed the available state allotment and that CMS will not need to make significant adjustments to those payments.
Providers will submit claims for payments on a service-by-service or per-discharge basis.
Payments will be determined based on the information included in the claims. All payment requests will be aggregated at the state level. Each provider within a particular state will receive a payment equal to the lesser of its costs, the Medicare reimbursement rate or, if provider payments exceed the state allotment, a proportional payment of the Medicare reimbursement rate. Services rendered on or after May 10, 2005, will be eligible for reimbursement.
CMS will designate a single contractor for the purpose of enrolling providers, receiving claims, calculating provider payment amounts, and effecting payments. The contract is expected to be awarded shortly.
(Editor’s note: Loren Ratner is an attorney specializing in health and hospital law in the Health Services Group of Nixon Peabody LLP, in its Garden City, NY, office.)
Heres what providers should know By Loren Ratner, Nixon Peabody LLP Garden City, NY The Centers for Medicare & Medicaid Services (CMS) is preparing to implement a new program that will provide funding for emergency health services received by undocumented aliens. This represents the first time federal funding will be available to hospitals and other providers for services they are required to provide to undocumented aliens under the Emergency Medical Treatment and Labor Act (EMTALA).You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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