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 he or she is eligible for Emergency Services. Medicaid providers who have treated non-US citizens for emergency services can provide them with a form verifying that the services provided were to treat an emergency medical condition. The form is “Certification of Emergency for Non-US Citizens (F-01162). Providers are instructed to have the patient present this to the local IM agency when applying for assistance. Note: The F-01162 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 applicationA request for BadgerCare Plus coverage. The request must be on the Department's application or registration form and must contain name, address, and a valid signature. The applicant must submit a signed and completed application form to complete the application process. , his or her eligibility for BadgerCare Plus Emergency Services is determined for the dates of the emergency indicated on the form. If a non-qualifying immigrant does not have the form at the time of application, ask him or her for the dates that he or she 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. 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 39.3 for Emergency Services certification dates for pregnant women.)

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

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 manual certification (F-10110 or DES 3070). See Process Help 81.3. The fiscal agent needs a beginning and end date to process eligibility. In setting the end date, use the last day of the emergency. If that 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. The F-10110 may be submitted to the fiscal agent in the following ways:

Mail: Forward Health iChange

P.O. Box 7636

Madison, WI 53707-7636

Fax: (608) 221-8815

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: 13-02

Release Date: 10/25/13

Effective Date: 10/01/13