39.2 Determining if an Emergency Exists

39.2.1 Determining Eligibility
39.2.2 Providing Manual Positive or Negative Notice

It is not the responsibility of the IM agency to determine if the applicant’s condition is or was an emergency condition and reimbursable under BadgerCare Plus Emergency Services. The medical provider submits claims for emergency medical services to the fiscal agent . The fiscal agent then determines if a condition is an emergency medical condition covered by BadgerCare Plus Emergency Services.

39.2.1 Determining Eligibility

It is the IM agency’s responsibility to manually determine if the non-qualifying immigrant meets all eligibility requirements during the dates of service and to certify if they are eligible for Emergency Services.

Medicaid providers who have treated non-US citizens for emergency services can provide them the Certification of Emergency for Non-U.S. Citizens form (F-01162) to verify that the services provided were to treat an emergency medical condition. Providers are instructed to have the patient present this to the local IM agency when applying for assistance.

Note	The Certification of Emergency for Non-U.S. Citizens form is not required to certify Emergency Services eligibility.

If a non-qualifying immigrant provides a “Certification of Emergency for Non-U.S. Citizens” at the time of application, their eligibility for BadgerCare Plus Emergency Services is determined for the dates of the emergency indicated on the form. A child under age 19 must remain eligible for 12 months.

If a non-qualifying immigrant does not have the form at the time of application, ask them for the dates that they received emergency services.

Emergency Services coverage begins at the time of the first treatment for the emergency and ends when the condition is no longer an emergency for adults, or at the end of a 12-month period for children under age 19.

Determine eligibility of a pregnant immigrant on the date emergency services were provided. The pregnancy due date is required to determine eligibility for pregnant immigrants (see Section 39.3 Emergency for Pregnant Members).

If a non-qualifying immigrant would only qualify for BadgerCare Plus if they were disabled, follow disability determination procedures (including presumptive disability) before certifying Emergency Services eligibility.

Note	Emergency Services has the same policies on referrals to child support agencies (CSA) and cooperation as BadgerCare Plus. See Chapter 5 Medical Support and Third-Party Liability..

Certification of Emergency Services is not done through CARESThis system supports the Income Maintenance operations for DHS and DCF. CARES is used to determine eligibility, issue benefits, track premium payments, and manage support for BadgerCare Plus, EBD Medicaid, W-2, Child Care, and Work Programs. and must be done manually. However, all applications should be processed through CARES to determine BadgerCare Plus eligibility. If the immigrant does not have an SSNSocial Security number, CARES will assign a pseudo SSN. That pseudo SSN should be used when submitting the manual certification. When an immigrant is determined eligible for Emergency Services, complete and submit a Medicaid/BadgerCare Plus Eligibility Certification form (F-10110) (see Process Help, Section 24.21.3 Manual F-10110). The fiscal agent needs a beginning and end date to process eligibility. In setting the end date,

For adults, use the last day of the emergency.
For children under age 19, use the end of a 12-month period.
For a child who is turning 19 in the next 12-month period, use the last day of the emergency or the last day of the month the child turns 19, whichever is later.

If the last day of the emergency is not known, use the last day of the month in which the emergency is expected to end. Use the AE medical status code.

Note	The Federally Facilitated Marketplace will send accounts to state consortia and tribal agencies for individuals who have been assessed as potentially eligible for BadgerCare Plus Emergency Services.

Submit completed Medicaid/BadgerCare Plus Eligibility Certification forms by fax to 608-221-8815 or by mail to:

ForwardHealth

Eligibility Unit

P.O. Box 7636

Madison, WI 53707-7636

An individual eligible for BadgerCare Plus Emergency Services will not receive a ForwardHealth card because BadgerCare Plus Emergency Services eligibility ends when the emergency ends.

However, women determined eligible for the BadgerCare Plus Prenatal Program will be issued a ForwardHealth Card, which can also be used to access emergency services under the Emergency Services coverage group after the BadgerCare Plus Prenatal Program coverage ends.

39.2.2 Providing Manual Positive or Negative Notice

The IM agency must provide a manual positive or negative notice regarding the applicant’s eligibility. Positive notices must provide the dates of eligibility for BadgerCare Plus Emergency Services. Negative notices must provide the reason(s) for the denial or termination.

This page last updated in Release Number: 24-02
Release Date: 08/22/2024
Effective Date: 08/22/2024