Apple Health Alien Emergency Medical

Worker Responsibilities

Both HCA and DSHS process AEM applications, depending on whether the AEM is relatable to a MAGI-based Apple Health program or Classic Apple Health (aged, blind, or disabled) program.

1. HCA processes AEM MAGI-based Apple Health applications for:
   1. Applicants between ages 19 – 64 who are not entitled to Medicare.
2. DSHS processes AEM Classic Apple Health applications for:
   1. Applicants age 65 or older and not a caretaker for a child under age 19,
   2. Applicants receiving Medicare, and
   3. Applicants seeking long-term care services that are not relatable to a MAGI-based program.

MAGI-Based Apple Health

Processing the Application:

1. Review the individual's immigration status to ensure they are not eligible for any other MAGI programs. AEM is a program of last resort and only available to the following:
   1. Undocumented individuals;
   2. Qualified aliens who have not met the 5-year bar and are not exempt from the 5-year bar; and
   3. Nonpregnant nonqualified aliens
2. Review supporting medical documents to ensure the individual:
   1. Received treatment in a hospital setting (inpatient or outpatient); or
   2. Is receiving cancer treatment, dialysis, or antirejection medication following an postorgan transplant
      1. If yes, the individual received medical services that may be eligible for AEM. Continue processing.
      2. If no, deny the application by force closing the application in the Washington Healthplanfinder. Proceed to step 9 below.
3. Input the information from the paper application into the Healthplanfinder.
4. Is the individual seeking or receiving long-term care services?
   1. If yes, refer to the Aging and Long-Term Support Administration (ALTSA). Send an email to Sandy Spiegelberg at HCS indicating the name, client ID, type of LTC services needed, and dates services are needed. Depending on where the individual resides, copy one of the following program managers at ALTSA on the email:
      Region 1: Dan Rees (reesdr@dshs.wa.gov)
      Region 2 King County: Michelle Joseph (BeetsMe2@dshs.wa.gov)
      Region 2 North: Wendy Wendell (HealeWS@dshs.wa.gov)
      Region 3: Ian Horlor (Horloit@dshs.wa.gov)
      LTC Specialty Unit: Marcell Birdsall (BirdsMM@dshs.wa.gov)
      Continue processing the AEM request for medical assistance pending the result of the ALTSA prior authorization request. The HCS program manager will ensure the LTC request is followed up on if a slot is approved on the state-funded program. There is no need to forward documents in DMS to HCS or to the LTC Specialty Team
   2. If No, continue processing.
5. Complete the AEM Referral/Checklist in Barcode as follows:
   1. If not already provided, send a request for information letter HCA 12-361 to the individual for required documents on referral/checklist.
   2. If the individual is still hospitalized at time of application and after contact with the hospital, the discharge date cannot be determined, refer to HCA medical consultant with the following:
      1. Admission History and Physical (signed by the admission doctor);
      2. The most recent physician notes; and
      3. Note from the worker that the individual is still inpatient.
   3. Once all documents are provided, forward the referral/checklist and documents to the HCA medical consultant through the Barcode AEM Referral system.
   4. AEM applications cannot be approved until the HCA medical consultant has approved the AEM Referral. The HCA medical consultant can be contacted at:

      Health Care Authority
      Health Care Benefits and Utilization Management
      MS 45506
      Telephone: 800-562-3022 FAX: 360-586-1471

      All communication pertaining to an AEM referral should be made through the Barcode AEM Referral system.

6. Once the AEM referral is returned by the medical consultant, update the Alien Medical section of the Client Demographics screen in ACES Online with one of the following Approval Source Codes:
   1. A–ADSA Headquarters Approved
   2. H–HCA Med Consultant Approved
   3. N–Not Approved
      Update the Approval Begin Date and Approval End Date fields with the appropriate dates.
      From the individual's dashboard in the Washington Healthplanfinder, click on the My Household tab to report a change to ensure the 2015 tax filing status has been completed for all household members; e-sign the application. This action will authorize N21/N25.
7. Approval and denial letters must be manually generated out of the Washington Healthplanfinder.
   1. Add the following free-from text to approval letters:
      1. (Individual's name) has been approved Washington Apple Health, Alien Emergency Medical from (date) to (date).
   2. Add the following WAC and free-form text to denial letters:
      1. WAC 182-507-0110 - We have reviewed your case and you are not eligible for any HCA/DSHS medical program. We also reviewed your eligibility for the Alien Emergency Medical program and you do not meet the following:
         1. Have not had surgery to treat cancer, and are not receiving chemotherapy and/or radiation therapy to treat cancer; or
         2. Are not immediately starting or receiving dialysis to treat acute renal failure or end-stage renal disease; or
         3. Are not receiving antirejection medication for a postorgan transplant.
         4. Do not have a qualifying emergency condition
8. ACES Online calculates the certification period.
9. If an AEM application is denied without having to make a referral to the HCA medical consultant, force close the application in the Washington Healthplanfinder with a 535 code and add the following WAC and free-form text:
   WAC 182-507-0110 We have reviewed your case and you are not eligible for any HCA/DSHS medical program. We also reviewed your eligibility for the Alien Medical program and you do not meet the following:
   1. Have not had surgery to treat cancer, and are not receiving chemotherapy and/or radiation therapy to treat cancer; or
   2. Are not immediately starting or receiving dialysis to treat acute renal failure or end-stage renal disease; or
   3. Are not receiving antirejection medication for a postorgan transplant.
   4. Do not have a qualifying emergency condition

Classic Apple Health (Medicaid)

Note: Referrals to the HCA Medical Consultant team without all required documentation will be considered incomplete and not accepted. They will be returned and will need to be resubmitted. Incomplete requests will not be pended by the medical consultant for completed documents.

Note: Separate medical AUs for each eligible individual should always be established even when an AU could have more than one eligible individual.

Note: Separate AMP Barcode referrals are needed for each individual.

Classic Apple Health (Medicaid)

Processing

1. Ensure that the AEM application is relatable to a Classic Medicaid program. These would typically include:
   1. Individuals age 65 or older and not a caretaker for a child under age 19;
   2. Individuals eligible for Medicare;
2. Review supporting medical documents to ensure the individual:
   1. Received treatment in a hospital setting (inpatient or outpatient); or
   2. Is receiving cancer treatment, dialysis, or antirejection medication following a postorgan transplant
      1. If Yes, the individual received medical services that may be eligible for AEM. Continue processing.
      2. If No, process the application by leaving the ALAS screen blank and proceed to step 6 below.
3. Complete the AEM Referral/ Checklist in Barcode as follows:
   1. If not already provided, send a request for information letter to the individual for the required supporting medical documents on referral/checklist.
   2. If the individual is still hospitalized at time of application and after contact with the hospital, the discharge date cannot be determined, refer to HCA medical consultant with the following:
      1. Admission History and Physical (signed by the admission doctor);
      2. The most recent physician notes; and
      3. Note from the worker that the individual is still inpatient.
   3. Once all documents are provided, forward the referral/checklist and documents to the HCA medical consultant through the Barcode AEM Referral system.
   4. AEM applications cannot be approved until the HCA medical consultant has approved the AEM Referral. The HCA medical consultant can be contacted at:
      Health Care Authority
      Health Care Benefits and Utilization Management
      MS 45506 Telephone: 800-562-3022 FAX: (360) 586-1471 All communication pertaining to an AMP referral should be made through the Barcode AEM Referral system.

      Note: Referrals to the HCA Medical Consultant team without all required documentation will be considered incomplete and not accepted. They will be returned and will need to be resubmitted. Incomplete requests will not be pended by the medical consultant for completed documents.

      Note: Separate AEM medical AUs for each eligible individual should always be established even when an AU could have more than one eligible individual. This ensures correct coverage periods for each individual.

      Note: Separate AEM Barcode referrals are needed for each individual.

4. Once the AEM referral is returned by the medical consultant, update the Approval Source field under ALIEN Medical on the ALAS screen in ACES with one of the following codes:
   1. H - HCA Med Consultant Approved
   2. N - Not Approved

      Note: Leaving the Approval Source field blank will result in the AU being denied. This field should only be left blank for applications being denied when a Barcode referral to the HCA medical consultant is not appropriate.

      Note: Noncitizen children are eligible for full-scope CN coverage through MAGI through the end of the month in which they turn 19. Young adults age 19-21 who are hospitalized over 30 days may be eligible for either MAGI based new adult coverage OR Institutional Family coverage using K03. If the individual meets these criteria and is NOT eligible for MAGI-based new adult coverage, refer to the LTC Specialty Unit for a K03 eligibility determination. The individual will still have to meet the criteria in Section 2 above. Send an email to K01Applications@dshs.wa.gov indicating the individual needs AEM under the K03 program.

5. ACES calculates a certification period for the individual. Verify the certification period and adjust in ACES accordingly, using the coverage end date given by the HCA medical consultant. Certification periods for AEM:
   1. Cannot be more than 12 months for non-spenddown AUs;
   2. Cannot be less than 1 month or more than 6 months for spenddown AUs;
   3. Won't be synchronized with other related AUs; and
   4. Won't continue beyond the end date when a renewal request (for instance, in the case of dialysis or cancer treatment) is initiated or received but not completed.

      Note: During renewal processing, the system won't auto-extend the certification period in order to sync up renewal cycles. For certification periods less than 60 days, ACES does not send out renewal forms or notices because the renewal cycle is not triggered.

      Note: If the approval dates span more than one calendar month, the certification period shown in ACES includes all months within the approval period. However, the certification period in ACES for AEM does not show the actual approval period in ProviderOne. Coverage in ProviderOne will be for the actual dates approved.

      Example: Approval period is 6/5/xx - 7/12/xx. The certification period is 6/1/xx - 7/31/xx; however, eligibility is only established from 6/5/xx - 7/12/xx.
      If this is a spenddown AU, the AU begin date would be the date spenddown is met, which could be no earlier than 6/5/xx.

      Note: Once the HCA medical consultant-approved coverage period has expired, a new application, referral checklist, and medical documentation are required.

6. If an AEM application is denied, update the approval source field under Alien Medical on the ALAS screen in ACES with "N".
   1. ACES will deny the AU with reason code 276 - No Medical Emergency, with auto text reading: "Your medical condition doesn't meet the emergency requirements."
   2. You will need to add the following free-form text:

      We have reviewed your application and you are not eligible for any HCA/DSHS medical program. You are not eligible for the Alien Emergency Medical Program because you did not receive medically necessary treatment for a qualifying emergency medical condition.

Referrals for prior authorization to the ALTSA State-funded nursing facility program manager

If it is determined that the individual needs LTC services either at home, in a residential setting or in a nursing facility while processing the AMP request, a prior authorization request must be made to the ALTSA state-funded nursing facility program manager. Since the program is very limited and currently full, long-term care services cannot be authorized without receiving confirmation that a slot is available for the individual.

For CSD or HCA staff who are processing an application which also includes a request for LTC services, send an email referral to Sandy Spiegelberg indicating the name, client ID, type of LTC services needed, and dates services are needed. Depending on where the individual resides, copy one of the following program managers at ALTSA on the email:

Region 1: Dan Rees(reesdr@dshs.wa.gov)
Region 2 King County: Michelle Joseph (BeetsMe2@dshs.wa.gov)
Region 2 North: Wendy Wendell (HealeWS@dshs.wa.gov)
Region 3: Ian Horlor (Horloit@dshs.wa.gov)
LTC Specialty Unit: Marcell Birdsall (BirdsMM@dshs.wa.gov)

Continue processing the AEM request for medical assistance pending the result of the ALTSA prior authorization request. If the HCA medical consultant:

1. Approves medical condition for AEM coverage, process the noninstitutional medical coverage using coverage group S07.
2. Denies medical condition. Deny the S07 and mark all documents complete.
3. The HCS program manager will ensure the LTC request is followed up on if a slot is approved on the state-funded program. There is no need to forward documents in DMS to HCS or to the LTC Specialty Team.