Friday, June 08, 2012

MA - undocumented aliens - emergency medical condition - acute symptoms

Spring Creek Management v. DPW - Cmwlth. Court - June 8, 2012

This case presents an issue of first impression for this Court: under what circumstances does an emergency medical condition continue, and when does the emergency end, such that an undocumented alien‟s treatment is no longer eligible for MA pursuant to federal and state law, 55 Pa. Code § 150.11 and Section 1396b(v) of title XIX of the Social Security Act (SSA), 42 U.S.C. § 1396b(v).

The patient in this case suffered a stroke in June 2010, for which she was hospitalized until September 2010. On September 16, 2010, she entered Spring Creek and, on September 29, 2010, Spring Creek submitted, on her behalf, an application for MA/LTC benefits to the CAO. The CAO requested proof of her ‟emergency medical condition" and Spring Creek sent the CAO additional documentation. By notice mailed April 13, 2011, the CAO denied the requested MA/LTC benefits because it determined that no emergency medical condition existed and, therefore, the patient was ineligible for assistance. Spring Creek timely appealed to the Bureau of Hearings and Appeals (BHA), and the ALJ held a hearing, after which he upheld the CAO decision.

After considering the arguments, the plain language of Section 150.11 of the Department‟s regulations and Section 1396b(v) of the SSA, and the existing case law interpreting Section 1396b(v), we, like the other courts that have addressed this issue, believe we must focus on the term "acute." The plain language of Section 1396b(v), which Section 150.11 mirrors, requires an emergency medical condition to manifest itself through acute symptoms, which is defined as "characterized by sharpness or severity . . . having a sudden onset, sharp rise, and short course . . . [as] opposed to chronic.‟

To meet the standard the emergency medical condition must manifest itself through acute symptoms, and the treatment for the emergency medical condition must be immediately necessary to prevent the three statutory outcomes. Here, the Clinical Director testified that the patient suffers from an "aggregate of very severe chronic conditions" and acknowledged that "treatment and care would be for an indefinite period of time. A review of the record reveals that there is no evidence to support the conclusion that the patient is manifesting acute symptoms thereby rendering her condition an emergency medical condition for which she would be eligible for MA/LTC benefits. The fact that, without the treatment she receives , the patient "might [suffer] one of the three adverse consequences listed [in] the statute," Scottsdale, 75 P.3d at 97, does not alter the fact that W.T. currently is not suffering from an emergency medical condition that, without immediate attention, would lead to one of the adverse consequences set forth in Section 150.11 and Section 1396b(v). The "focus must be on the patient‟s current condition and whether that condition satisfies the criteria" of emergency medical condition.

In addition, the court held that, the provisions for ongoing care set forth in the Operations Memo do not mandate that the patient be found eligible for MA/LTC benefits for ongoing treatment for the results of her stroke. The Operations Memo refers to eligibility requirements "if there is a need for emergency medical services involving ongoing treatment."

Before making this case-by-case determination, the following information must be advanced to a CAO: "the nature of the emergency medical condition"; "[t]hat the medical treatment was necessary because of the emergency condition"; and "[t]he approximate duration of the emergency (this includes a treatment plan)." All of these requirements are predicated on the existence of an emergency medical condition for which ongoing treatment is necessary. Here, as stated above, the provider failed to establish that the patient currently is suffering from an emergency medical condition and, therefore, the ongoing treatment provisions explained in the Operations Memo are not applicable.