Federal Reimbursement of Emergency Health Services Furnished to Undocumented Aliens

To reimburse eligible providers for their otherwise un-reimbursed costs associated with furnishing emergency health services to undocumented and certain other aliens.



Agency - Department of Health and Human Services

The Department of Health and Human Services is the Federal government's principal agency for protecting the health of all Americans and providing essential human services, especially to those who are least able to help themselves.



Program Accomplishments

For the periods FY 2005 and FY 2006, CMS has obligated a total of $266,980,129 of the toatl funding available for those years ($500,000,000) towards the reimbursement of providers for emergency health services furnished to undocumented aliens. Actual payments in FY 2005 and FY 2006 wre $58.1 million and $132.7 million respectively. CMS awarded the national contract for implementation of the Section 1011 program to TrailBlazer Health Enterprises, LLC.

Uses and Use Restrictions

Sections 1866(a)(1)(I), 1866 (a)(1)(N), and 1867 of the Social Security Act (the Act)impose specific obligations on Medicare-participating hospitals that offer emergency services.

These obligations concern individuals who come to a hospital emergency department and request examination or treatment for medical conditions, and apply to all of these individuals, regardless of whether or not they are beneficiaries of any program under the Act.

Section 1867 of the Act sets forth requirements for medical screening examinations of medical conditions, as well as necessary stabilizing treatment or appropriate transfer.

In addition, section 1867(h) of the Act specifically prohibits a delay in providing required screening or stabilization services in order to inquire about the individual's payment method or insurance status.

Eligibility Requirements

Applicant Eligibility

From the allotments made for a State, the Secretary of Health and Human Services shall pay an amount (subject to the total amount available from such allotments) directly to eligible providers located in the State where emergency services were incurred to the extent that the eligible provider was not otherwise reimbursed.

An eligible provider defined under the statute is a hospital, physician, or provider of ambulance services(including an Indian Health Service (IHS) facility whether operated by the IHS or by an Indian tribal or tribal organization).

Beneficiary Eligibility

The amounts of money set aside for each State will be paid directly to hospitals, certain physicians, and ambulance providers for the costs of providing emergency health care required under EMTALA and related hospital inpatient, outpatient, and ambulance services (including those operated by the Indian Health Service and Indian tribes and Tribal organizations) furnished to undocumented aliens, aliens paroled into the United States at a United States port of entry for the purposes of receiving such services, and Mexican citizens permitted temporary entry to the United States with a laser visa.

Credentials/Documentation

Final policy guidance was released on May 9, 2005 regarding the implementation of section 1011 of the MMA. This notice establishes the general framework and procedural rules for submitting an enrollment application and payment requests, establishes general statements of policy, and provides CMS' interpretation of section 1011. It is posted in the "downloads" section of the following web address: http://www.cms.hhs.gov/UndocAliens/02_policy.asp#TopOfPage.

Aplication and Award Process

Preapplication Coordination

This program is excluded from coverage under E.O.

12372.

Application Procedures

On September 1, 2004, the Secretary established a provider enrollment application.

Award Procedures

Official notice of approved claims for emergency health care services will be transmitted to eligible providers pursuant to procedures established prior to September 1, 2004 and published in the Federal Register.

Deadlines

Established when program announcements are published in the Federal Register.

Authorization

Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Public Law 108-73, Section 1011; Medicare Modernization Act (MMA).

Range of Approval/Disapproval Time

None.

Appeals

The final payment methodology will describe the appeals process.

Renewals

None.

Assistance Considerations

Formula and Matching Requirements

No State or local matching funds are required for this activity.

Length and Time Phasing of Assistance

This project is authorized for four years beginning in FY 2005.

Post Assistance Requirements

Reports

Periodic reports are due to CMS in accordance with the timeframes established by CMS.

Audits

All payment transactions identifiable to Federal Reimbursement for Emergency Health Services Furnished to Undocumented Aliens are subject to audit or medical review by the Secretary or his designated agent. In accordance with the provisions of OMB Circular No. A-133 (Revised, June 27, 2003), "Audits of States, Local Governments, and Nonprofit Organizations," nonfederal entities that expend financial assistance of $500,000 or more a year in Federal awards will have a single or a program-specific audit conducted for that year. Nonfederal entities that expend less than $500,000 a year in Federal awards are exempt from federal audit requirements for that year, except as noted in Circular No. A-133.

Records

Financial records, supporting documents, statistical records, and all other records pertinent to the project shall be retained for a period consistent with the information contained in the final payment methodology.

Financial Information

Account Identification

75-0516-0-1-551.

Obigations

FY 07 $219,919,328; FY 08 $225,000,000; and FY 09 est $250,000,000.

Range and Average of Financial Assistance

None.

Regulations, Guidelines, and Literature

CMS intends to provide guidance through a Paperwork Reduction Act (PRA) notice. The PRA package will provide substantive information regarding CMS' final implementation approach.

Information Contacts

Regional or Local Office

None.

Headquarters Office

Program Contact: James Bossenmeyer, CMS, Center for Medicare Management, Hospital and Ambulatory Group, 7500 Security Boulevard, Mail Stop C5-01-14, Baltimore, MD 21244. Telephone: (410) 786-9317.

Criteria for Selecting Proposals

None.



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