Apple Health Alien Emergency Medical

Revised Date: 
December 16, 2014

Purpose: To explain the Alien Medical Programs (commonly referred to as AEM) available to Washington State residents who are "Qualified Aliens" who have not met their 5-year bar, "Nonqualified Aliens", or undocumented individuals.

WAC 182-507-0110 Washington apple health -- Alien medical programs.

Effective March 31, 2014.

  1. To qualify for an alien medical program (AMP) a person must:
    1. Be ineligible for federally funded Washington apple health (WAH) programs due to the citizenship/alien status requirements described in WAC 182-503-0535;
    2. Meet the requirements described in WAC 182-507-0115, 182-507-0120, or 182-507-0125; and
    3. Meet all categorical and financial eligibility criteria for one of the following programs, except for the Social Security number or citizenship/alien status requirements:
      1. An SSI-related medical program described in chapters 182-511 and 182-512 WAC;
      2. A MAGI-based program referred to in WAC 182-503-0510; or
      3. The breast and cervical cancer treatment program for women described in WAC 182-505-0120; or
      4. A medical extension described in WAC 182-523-0100.
  2. AMP medically needy (MN) health care coverage is available only for children, pregnant women and persons who meet SSI-related criteria. See WAC 182-519-0100 for MN eligibility and WAC 182-519-0110 for spending down excess income under the MN program.
  3. The agency or its designee does not consider a person's date of arrival in the United States when determining eligibility for AMP.
  4. For non-MAGI-based programs, the agency or its designee does not consider a sponsor's income and resources when determining eligibility for AMP, unless the sponsor makes the income or resources available. Sponsor deeming does not apply to MAGI-based programs.
  5. A person is not eligible for AMP if that person entered the state specifically to obtain medical care.
  6. A person who the agency or its designee determines is eligible for AMP may be eligible for retroactive coverage as described in WAC 182-504-0005.
  7. Once the agency or its designee determines financial and categorical eligibility for AMP, the agency or its designee then determines whether a person meets the requirements described in WAC 182-507-0115, 182-507-0120, or 182-507-0125.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-507-0115 Alien emergency medical program (AEM).

Effective December 30, 2012

  1. A person nineteen years of age or older who is not pregnant and meets the eligibility criteria under WAC 182-507-0110 is eligible for the alien emergency medical program's scope of covered services described in this section if the person meets (a) and (b) or (c) of this subsection:
    1. The medicaid agency determines that the primary condition requiring treatment meets the definition of an emergency medical condition as defined in WAC 182-500-0030, and the condition is confirmed through review of clinical records; and
    2. The person's qualifying emergency medical condition is treated in one of the following hospital settings:
      1. Inpatient;
      2. Outpatient surgery;
      3. Emergency room services, which must include an evaluation and management (E&M) visit by a physician; or
    3. Involuntary Treatment Act (ITA) and voluntary inpatient admissions to a hospital psychiatric setting that are authorized by the agency's inpatient mental health designee (see subsection (5) of this section).
  2. If a person meets the criteria in subsection (1) of this section, the agency will cover and pay for all related medically necessary health care services and professional services provided:
    1. By physicians in their office or in a clinic setting immediately prior to the transfer to the hospital, resulting in a direct admission to the hospital; and
    2. During the specific emergency room visit, outpatient surgery or inpatient admission. These services include, but are not limited to:
      1. Medications;
      2. Laboratory, x-ray, and other diagnostics and the professional interpretations;
      3. Medical equipment and supplies;
      4. Anesthesia, surgical, and recovery services;
      5. Physician consultation, treatment, surgery, or evaluation services;
      6. Therapy services;
      7. Emergency medical transportation; and
      8. Nonemergency ambulance transportation to transfer the person from a hospital to a long term acute care (LTAC) or an inpatient physical medicine and rehabilitation (PM&R) unit, if that admission is prior authorized by the agency or its designee as described in subsection (3) of this section.
  3. The agency will cover admissions to an LTAC facility or an inpatient PM&R unit if:
    1. The original admission to the hospital meets the criteria as described in subsection (1) of this section;
    2. The person is transferred directly to this facility from the community hospital; and
    3. The admission is prior authorized according to LTAC and PM&R program rules (see WAC 182-550-2590 for LTAC and WAC 182-550-2561 for PM&R).
  4. The agency does not cover any services, regardless of setting, once the person is discharged from the hospital after being treated for a qualifying emergency medical condition authorized by the agency and its designee under this program. Exception: Pharmacy services, drugs, devices, and drug-related supplies listed in WAC 182-530-2000, prescribed on the same day and associated with the qualifying visit or service (as described in subsection (1) of this section) will be covered for a one-time fill and retrospectively reimbursed according to pharmacy program rules.
  5. Medical necessity of inpatient psychiatric care in the hospital setting must be determined, and any admission must be authorized by the agency's inpatient mental health designee according to the requirements in WAC 182-550-2600.
  6. There is no precertification or prior authorization for eligibility under this program. Eligibility for the AEM program does not have to be established before an individual begins receiving emergency treatment.
  7. Under this program, certification is only valid for the period of time the person is receiving services under the criteria described in subsection (1) of this section. The exception for pharmacy services is also applicable as described in subsection (4) of this section.
    1. For inpatient care, the period of eligibility is only for the period of time the person is in the hospital, LTAC, or PM&R facility the admission date through the discharge date. Upon discharge the person is no longer eligible for coverage.
    2. For an outpatient surgery or emergency room services the period of eligibility is only for the date of service. If the person is in the hospital overnight, the eligibility period will be the admission date through the discharge date. Upon release form the hospital, the person is no longer eligible for coverage.
  8. Under this program, any visit or service not meeting the criteria described in subsection (1) of this section is considered not within the scope of covered services as described in WAC 182-501-0060. This includes, but is not limited to:
    1. Hospital services, care, surgeries, or inpatient admissions to treat any condition which is not considered by the agency to be a qualifying emergency medical condition, including but not limited to:
      1. Laboratory, x-ray, or other diagnostic procedures;
      2. Physical, occupational, speech therapy, or audiology services;
      3. Hospital clinic services; or
      4. Emergency room visits, surgery, or hospital admissions.
    2. Any services provided during a hospital admission or visit (meeting the criteria described in subsection (1) of this section), which are not related to the treatment of the qualifying emergency medical condition;
    3. Organ transplants, including preevaluations, postoperative care, and antirejection medication;
    4. Services provided outside the hospital settings described in subsection (1) of this section including, but not limited to:
      1. Office or clinic-based services rendered by a physician, an ARNP, or any other licensed practitioner;
      2. Prenatal care, except labor and delivery;
      3. Laboratory, radiology, and any other diagnostic testing;
      4. School-based services;
      5. Personal care services;
      6. Physical, respiratory, occupational, and speech therapy services;
      7. Waiver services;
      8. Nursing facility services;
      9. Home health services;
      10. Hospice services;
      11. Vision services;
      12. Hearing services;
      13. Dental services;
      14. Durable and non durable medical supplies;
      15. Nonemergency medical transportation;
      16. Interpreter services; and
      17. Pharmacy services, except as described in subsection (4) of this section.
  9. The services listed in subsection (8) of this section are not within the scope of service categories for this program and therefore the exception to rule process is not available.
  10. Providers must not bill the agency for visits or services that do not meet the qualifying criteria described in this section. The agency will identify and recover payment for claims paid in error.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

WAC 182-507-0120 Alien medical for dialysis and cancer treatment, and treatment of life-threatening benign tumors.

Effective March 8, 2015 

In addition to the provisions for emergency care described in WAC 182-507-0115, the medicaid agency also considers the conditions in this section as an emergency, as defined in WAC 182-500-0030.

  1. A person nineteen years of age or older who is not pregnant and meets the eligibility criteria under WAC 182-507-0110 may be eligible for the scope of service categories under this program if the condition requires:
    1. Surgery, chemotherapy, and/or radiation therapy to treat cancer or life-threatening benign tumors;
    2. Dialysis to treat acute renal failure or end stage renal disease (ESRD); or
    3. Antirejection medication, if the person has had an organ transplant.
  2. When related to treating the qualifying medical condition, covered services include but are not limited to:
    1. Physician and ARNP services, except when providing a service that is not within the scope of this medical program (as described in subsection (7) of this section);
    2. Inpatient and outpatient hospital care;
    3. Dialysis;
    4. Surgical procedures and care;
    5. Office or clinic based care;
    6. Pharmacy services;
    7. Laboratory, X ray, or other diagnostic studies;
    8. Oxygen services;
    9. Respiratory and intravenous (IV) therapy;
    10. Anesthesia services;
    11. Hospice services;
    12. Home health services, limited to two visits;
    13. Durable and nondurable medical equipment;
    14. Nonemergency transportation; and
    15. Interpreter services.
  3. All hospice, home health, durable and nondurable medical equipment, oxygen and respiratory, IV therapy, and dialysis for acute renal disease services require prior authorization.  Any prior authorization requirements applicable to the other services listed above must also be met according to specific program rules.
  4. To be qualified and eligible for coverage for cancer treatment or treatment of life-threatening benign tumors under this program, the diagnosis must be already established or confirmed.  There is no coverage for cancer screening or diagnostics for a workup to establish the presence of cancer or life-threatening benign tumors.
  5. Coverage for dialysis under this program starts the date the person begins dialysis treatment, which includes fistula placement and other required access.  There is no coverage for diagnostics or predialysis intervention, such as surgery for fistula placement anticipating the need for dialysis, or any services related to preparing for dialysis.
  6. Certification for eligibility will range between one to twelve months depending on the qualifying condition, the proposed treatment plan, and whether the client if required to meet a spenddown liability.
  7. The following are not within the scope of service categories for this program:
    1. Cancer screening or work-ups to detect or diagnose the presence of cancer or life-threatening benign tumors;
    2. Fistula placement while the person waits to see if dialysis will be required;
    3. Services provided by any health care professional to treat a condition not related to, or medically necessary to, treat the qualifying condition;
    4. Organ transplants, including preevaluations and post operative care;
    5. Health department services;
    6. School-based services;
    7. Personal care services;
    8. Physical, occupational, and speech therapy services;
    9. Audiology services;
    10. Neurodevelopmental services;
    11. Waiver services;
    12. Nursing facility services;
    13. Home health services, more than two visits;
    14. Vision services;
    15. Hearing services;
    16. Dental services, unless prior authorized and directly related to dialysis or cancer treatment;
    17. Mental health services;
    18. Podiatry services;
    19. Substance abuse services; and
    20. Smoking cessation services.
  8. The services listed in subsection (7) of this section are not within the scope of service categories for this program.  The exception to rule process is not available.
  9. Providers must not bill the agency for visits or services that do not meet the qualifying criteria described in this section.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

The Alien Medical Programs (AMP) includes:

  • The federally-funded Alien Emergency Medicaid (AEM) (WAC 182-507-0110); and
  • The state-funded Long-Term Care (LTC) program (WAC 182-507-0125).

Note: AEM applications are ONLY processed by DSHS and HCA specialty staff.
AMPs have the following program codes: K03, L04, L24, N21, N25, and S07.

AEM is for individuals who have a qualifying medical emergency and do not qualify for any other Apple Health program due to citizenship/immigration requirements under WAC 182-503-0535. This includes qualified aliens who have not met the 5-year and are not exempt from the 5-year bar, nonpregnant nonqualified aliens, and undocumented individuals.

To qualify for AEM, an individual must have or need at least one of the following:

  • A qualifying emergent medical condition such as emergency room care, inpatient admission, or outpatient surgery;
  • A cancer treatment plan;
  • Dialysis treatment;
  • Antirejection medication for a postorgan transplant; or on long-term care services (LTC)*

*LTC applications are coordinated and processed by ALTSA. Contact Sandy Spiegelberg for all LTC applications and referrals. LTC includes the following tracks: K03, L04, and L24.

Note: The state-funded long-term care program has limited slots due to funding restrictions. A slot must be available in order for this program to be considered. It covers nursing facility, in-home personal care, or residential services in an alternate living facility. All applications for state-funded long-term care services are coordinated and processed by ALTSA and require prior authorization from the ALTSA program manager. Specific instructions are in the clarifying information for the state-funded long-term care program for noncitizens.

The DSHS Specialized Medical Unit (SMU) or HCA MEDS Specialized Staff process applications as outlined below:

DSHS-Classic Medicaid

DSHS processes AEM cases under Classic Apple Health when:

  • Individual is age 65 or older and is not a caretaker for a child under age 19;
  • Individual is eligible for Medicare; or
  • Individual is receiving long-term care services and not relatable to a MAGI program.

HCA – MAGI Medicaid

HCA processes AEM applications under MAGI Medicaid when:

  • Individual is age 19 through 64
  • Individual is not eligible for Medicare; and
  • Follows MAGI rules established through the Healthplanfinder.

Submitting an Application

DSHS Classic Medicaid:

Applications must be submitted through Washington Connection or by completing a Washington Apple Health Application for ABD / LTC (18-005). Follow the instructions on the 18-005 form for submitting the application.

HCA MAGI-based AEM

Apply online at www.wahealthplanfinder.org; or by 

Submitting a paper application (HCA 18-001):

  • Write "AEM" on the top of the application
  • Write the date coverage needs to begin; and
  • Fax the completed application to: 1-866-841-2267

Routing Misdirected Applications (For internal HCA and DSHS AEM specialty staff only):

  1. If the CSO, HCS or HCA receives a Form HCA 18-005 for AMP (non LTC):
    Route the application via DMS to CSO 157@AEM for processing.
  2. If the CSO, HCS or HCA receives a Form HCA18-001 for AMP (non LTC):
    Route the application via DMS to @AEM076.

Supporting Medical Documents:

Both HCA MAGI-based and DSHS Classic AEM require the following supporting documents based on emergent condition:

  1. Emergency Room Care:
    1. Emergency room treatment page(s)
    2. Copy of the completed hospital claim form (UB04)
  2. Outpatient Surgery Care:
    1. Operative notes (description of procedure completed)
    2. Copy of the completed hospital Claim form (UB04)
  3. Inpatient Admission:
    1. History and Physical
    2. Hospital discharge summary
    3. Copy of the completed hospital claim form (UB04)
  4. Cancer Treatment:
    1. Cancer treatment plan
  5. Dialysis Treatment:
    1. Current dialysis flow charts from dialysis center;
    2. Treatment plan from the attending physician
  6. Antirejection Treatment for a postorgan transplant
    1. Treatment plan from the attending physician or provider

HCA Medical Consultant Approval:

AEM applications cannot be approved without prior authorization from an HCA Medical Consultant.

The specialized eligibility worker makes the referral to the HCA medical consultant team via the AMP barcode referral system when:

  • Financial eligibility has been determined;
  • The required supported medical documents have been received; and
  • A NGMA approval has been received when required (only applies to DSHS Classic).

View a AEM process PDF.

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.