EMERGENCY HEALTH SERVICES FOR UNDOCUMENTED ALIENS:

Overview: Undocumented aliens’ use of medical services has been a long-standing issue for hospitals, particularly among those located along the U.S.-Mexican border. As required by  federal law (The Emergency Medical Treatment and Labor Act or EMTALA), hospitals participating in Medicare must medically screen all persons seeking emergency care and provide the treatment necessary to stabilize those who have an emergency condition, regardless of payment method or insurance status. 

In an effort to assist hospitals and other providers with their uncompensated care costs, Congress included a provision in the Medicare Modernization Act (MMA)—Section 1011—to set aside $1 billion through 2008 to help hospitals and other emergency providers recoup some of the expenses of providing this critical care.

Today, CMS is issuing its final guidance regarding the implementation of Section 1011.  The Federal Register notice and related information collection instruments can be found at http://www.cms.hhs.gov/providers/section1011.

Section 1011 Summary

• This section appropriates $250 million per year in FY 2005 – 2008.   Two-thirds ($167 million) will be allotted in all 50 states and the District of Columbia , based on their relative percentages of the total number of undocumented aliens.  The remaining one-third ($83 million) will be allotted to the six states with the largest number of undocumented alien apprehensions for each fiscal year.
• The Secretary must directly pay hospitals, certain physicians, and ambulance providers (including Indian Health Service and Tribal organizations) for their otherwise unreimbursed costs of providing services under EMTALA to undocumented immigrants.  This includes related hospital inpatient, outpatient, and ambulance services furnished to undocumented aliens, aliens paroled into the United States at a U.S. port of entry for the purpose of receiving such services, and Mexican citizens permitted temporary entry to the U.S.
• Payment will be made from the allotment amounts for the state where the providers are located.  Provider payments are subject to a pro-rata reduction if the state allocation is insufficient to provide full reimbursement under the formula established by HHS.
• The six states receiving additional funding in FY 2005 based on the highest number of undocumented alien apprehensions are: Arizona , Texas , California , New Mexico , Florida , and New York .
• The states receiving the highest funding allocations in FY 2005 are:

1. California - $70.8 million
2. Texas - $46.0 million
3. Arizona - $45.0 million
4. New York - $12.25 million
5. Illinois - $10.3 million
6. Florida  - $8.7 million

In addition, New Mexico , one of the six states receiving additional funding based on the number of alien apprehensions, will receive $5.1 million in a FY 2005.

Policy Positions

• In this final policy notice, CMS has adopted an indirect approach to determine whether a provider can seek payment for an eligible patient.   CMS will not require hospital staff to ask patients directly about their citizenship or immigration status.
• Under the new policy, payment will be made for covered services that would begin when the hospital’s EMTALA obligation begins.  Typically this is when the individual arrives at the hospital emergency department.  Section 1011 coverage would continue until the individual is stabilized, notwithstanding any inpatient admission. To be considered stable, a patient’s emergency medical condition must be resolved, even though the underlying medical condition may persist.  In general, we believe that most patients will be stabilized within 2 calendar days.
• According to the MMA, Section 1011 funds can be used to cover all medically necessary and appropriate services which physicians furnish to a hospital inpatient or outpatient patients who receive emergency services required by section 1867 (EMTALA) and related hospital inpatient and outpatient services and ambulance services.
• CMS will designate a single contractor for the purposes of enrolling providers, receiving claims, calculating provider payment amounts, and effectuating payments.   The agency determined that a single claims processing contractor would best facilitate the effective administration of this provision of MMA.  CMS will award the contract shortly.
• Providers can claim payment for emergency services furnished to eligible patients beginning May 10.
• CMS’ designated contractor will notify enrolled providers when and how claims may be filed.
• All claims be filed electronically with CMS’ designated contractor.   In addition, providers will be required to file a claim within 180 days of the end of the federal fiscal quarter in which the service was provided.
• CMS is adopting an informal appeals process to resolve payment disputes.