New Program to Pay for Uncompensated Emergency Care to Undocumented Immigrants
[Posted 10/27/05]

The Centers for Medicare & Medicaid Services (CMS) recently launched a new federal program that will reimburse physicians and hospitals for emergency and on-call care provided to undocumented immigrants. The program, Section 1011 of the Medicare Modernization Act of 2003, will provide California with $288 million over four years.

Under the Emergency Medical Treatment and Labor Act (EMTALA), hospitals that maintain an emergency department must provide emergency medical services to anyone regardless of ability to pay. The cost of this care often strains hospital and physician budgets and can threaten a hospital’s ability to keep its emergency room open. This year, the cost of those uncompensated services is expected to reach $1 billion.

Physicians can seek payment for unreimbursed care provided to undocumented patients on or after May 10, 2005. Claims will be paid according to the Medicare fee schedule for EMTALA-related emergency services. Payments will be made directly to physicians on a quarterly basis. Payments may, however, be subject to a pro rata reduction if the state’s quarterly allocation is insufficient to provide full reimbursement to all providers submitting claims. Second-quarter claims (services provided from May 10 to June 1) are due December 27. CMS has contracted with TrailBlazer Health Enterprises to administer payments nationwide. TrailBlazer will begin actual claims adjudication and payment disbursement in February 2006.

To determine a patient’s eligibility, providers are required to ask certain questions that may indirectly reveal the patient’s citizenship or immigration status. CMA is worried, however, that this will intimidate undocumented patients and discourage them from seeking care. CMA continues to urge CMS to adopt a documentation process that would not deter such patients from seeking care.

This federal program is the “payor of last resort.” That means California physicians who provide emergency and on-call care to undocumented immigrants must first bill the Maddy Emergency Medical Services (EMS) fund. The federal program will pay the difference between the amount paid by the EMS fund and the Medicare rate.

Click here for provider enrollment information.

Contact: TrailBlazer Health Services, 866/860-1011.