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R-15-98E

CRITERIA FOR EMERGENCY AND PREGNANCY-RELATED SERVICES
 FOR PERSONS ENTITLED TO RESTRICTED BENEFITS ONLY

The following criteria are presented to clarify the provisions contained in Section 14007.5 of the Welfare and Institutions Code and in related State and federal laws. The approach adopted in these criteria is to set forth the parameters of what constitutes an emergency medical condition, and have these parameters applied to the circumstances of individual cases based on the medical judgment of professionals capable of applying them. These criteria do not spell out every condition and circumstance under which services provided to an individual covered under this provision would end. To attempt to do so would constrain the exercise of medical judgment by trained professionals. Accordingly, each Treatment Authorization Request (TAR) will be evaluated on the documentation presented after emergency services are rendered, applying the guidance set for in the criteria. These criteria make no changes in existing TAR procedures.

Pursuant to provisions of state and federal law, undocumented aliens and specified classes of amnesty aliens are eligible for restricted benefits only. Aliens entitled to restricted benefits have Medi-Cal cards with the appropriate restricted aid code.

Depending on the alien's status, restricted benefits may include (1) care and services that are necessary for the treatment of an emergency medical condition (including renal dialysis services, but not related to an organ transplant procedure) and medical care directly related to emergency, as defined in federal law, and (2) long term care. Acute, ongoing, and maintenance renal dialysis services are covered as emergency services. These criteria make no changes in the scope of renal dialysis services previously available.

 The following criteria apply only to emergency services and pregnancy-related services.

I. Emergency and Pregnancy-Related Services

Any alien who is otherwise eligible for Medi-Cal services, and who is not a lawful permanent resident or permanently residing in the United States under color of law (PRUCOL), shall only be eligible for care and services that are necessary for the treatment of an emergency medical condition (not related to any organ transplant procedure but including renal dialysis services and emergency labor and deliver) and medical care directly related to the emergency, as defined in federal law, and for medically necessary pregnancy-related services.

For purposes of applying these criteria, "medical care directly related to the emergency" includes only such care and services that are necessary for the treatment of an emergency medical condition as defined in paragraphs I.A and I.B below.

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A. Definition in Federal Statue (42 U.S.C. Section 130b (v))

The term "emergency medical condition" is defined in federal statute to mean a medical condition (including emergency labor and delivery) manifesting itself by acute symptoms of sufficient severity, including sever pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following:

1. Placing the patient's health in serious jeopardy;
2. Serious impairment to bodily functions;
3. Serious dysfunction of any bodily organ or part.

B. Definition in Federal Regulations (42 C.F.R. Section 440.255)

"Emergency medical condition" is defined in federal regulations to mean that the alien has, after sudden onset a medical condition (including emergency labor and delivery) manifesting 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:

1. Placing the patient's health in serious jeopardy;
2. Serious impairment to bodily functions; or
3. Serious dysfunction of any bodily organ or part.

C. Additional Criteria and Interpretative Guidelines

1. Services provided to aliens must be medically necessary. Medically necessary services are those services which are reasonably and necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness or injury.

2. Medi-Cal includes as a benefit to an otherwise eligible alien care and services necessary for the treatment of the emergency medical condition and medical care directly related to the emergency, as defined in federal law. That is, Medi-Cal coverage for individuals whose eligibility is limited to emergency services begins at the point described in paragraph A above and ends when the patient is stablized so that the conditions described in paragraphs I.A and I.B no longe apply.

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3. If an eligible individual receives treatment for an emergency medical condition and continues to receive care after the emergency ends (that is, when the conditions described in paragraphs I.A and I.B no longer exist), treatment after the emergency ends is not covered by Medi-Cal.

4. Medi-Cal is available for care and services necessary for the treatment of the emergency medical condition and medical care directly related to the emergency, as defined in federal law. Medi-Cal coverage is not available for continuing or follow-up care that may be necessary to restore the patient to health.

5. The federal definition (set forth in paragraphs I.A and I.B) defines an emergency medical condition. Without implying any limitation on the definitions in paragraphs I.A and I.B, the terms "acute"," "sufficient severity," and "imediate medical attention" help to define the parameters within which Medi-Cal can cover services for the treatment of emergency medical conditions.

D. Pregnancy-Related Medical Services

Medi-Cal coverage for pregnancy-related services is available to all aliens who meet all other Medi-Cal eligibility requirements. Routine prenatal care, labor and delivery, routine post-partum care, and family planning are classified as pregnancy-related services. Medi-Cal also covers the treatment of conditions which complicate the pregnancy or delivery (such as hypertension, diabetes, and urinary tract infection). Routine post-partum care extends for the 60-day period beginning on the last day of the pregnancy and ending on the last day of the month in which the 60th day occurs. All Medi-Cal family planning services are available to recipients of restricted benefits. All services would still need to meet the criteria of medical necessity.

II. Continuing Care/Follow-Up Care

Care and services that are necessary for the treatment of the emergency medical condition and medical care directly related to the emergency, as defined in federal law, are covered. "Medical care directly related to the emergency" includes only such care and services that are necessary for the treatment of an emergency medical condition as defined in paragraphs I.A and I.B above.

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Accordingly, continuation of medically necessary inpatient hospital services and follow-up care after the emergency has resolved shall not be authorized or reimbursed for aliens eligible for restricted benefits only. This means that treatment aimed at a cure or long-term solution to the problem, such as transplantation or elective surgery, related to the underlying chronic condition shall not be authorized or reimbursed by the Medi-Cal program.

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Manual of Criteria, Emergency Pregnancy Related Services