Medicaid Amends Emergency Coverage Rule

Iowa Medicaid provides emergency medical coverage for undocumented immigrants, so long as the patient meets the other eligibility requirements for Medicaid, such as Iowa residency. Applicable law defines an “emergency medical condition” as a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to the patient’s health, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. Labor and delivery is also considered an emergency medical condition.

In the July 5 Iowa Administrative Bulletin, the Department of Human Services published a final rule (ARC 5215B) changing the verification process for emergency Medicaid. Previously, the Iowa Medicaid Manual and corresponding administrative rules provided a list of diagnosis codes that qualified as emergency services, but the list of codes was often out of date, resulting in erroneous denials. The new rule eliminates the list of covered codes and allows the medical provider to verify that the condition was an emergency.

Effective July 1, to verify the presence of an emergency medical condition, the medical provider who treated the emergency medical condition or the provider’s designee must submit verification of the existence of the emergency medical condition on either Form 470-4299, Verification of Emergency Health Care Services, or a signed statement that contains the same information as requested by the form. IHA supports this change because it will substantially reduce the amount of denials and appeals for emergency Medicaid reimbursement.

The Iowa Medicaid program limits payment for emergency Medicaid services to the day treatment is initiated for the emergency medical condition and the following two days. The date the patient first sought treatment is considered as the first day of the emergency, regardless of length of treatment or the condition. Emergency Medicaid will be allowed more than once in a calendar month, but only for an emergency that is unrelated to the previous emergency

CDC Report on ED Care

The CDC released their annual report on emergency department (ED) care in the US. This report is based on 2004 visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS) and the following ED statistics were notable.

Visit frequency
– Over 110 million visits were made in 2004, an increase of 18% over 10 years
– There were 38.2 visits per 100 persons, including one-fifth of all US adults in the past 12 months
– The total number of EDs in the US decreased by 12.4% over 10 years

Acuity measures
– Abdominal pain, chest pain and fever, all high-risk, were the most frequent chief complaints
– Medications were prescribed in three-quarters and procedures were performed in half of patients
– 15% arrived by ambulance
– 13% were admitted
– Of those classified, 15% of visits were emergent, 44% were urgent, 26% were semi-urgent and 15% were non-urgent

Overcrowding indices
– The mean time to see a physician was 47 minutes
– The mean time from arrival to admission or discharge was 3.3 hours
– About 2% left before being seen by a healthcare provider

To see a full copy of the report, go to http://www.cdc.gov/nchs/data/ad/ad372.pdf. For more information about the ED utilization from the National Center for Health Statistics (NCHS) Ambulatory Health Care, go to http://www.cdc.gov/nchs/nhamcs.htm.