Emergency Medicaid

I wanted to touch on a topic that I’ve always wanted to learn more about: Emergency Medicaid. As ER docs, I think it’s important to know what resources we have available for our patients. 

Some of this varies by state, so I would recommend quickly familiarizing yourself with the state guidelines. The information provided below is specific to New York state. 

What is Emergency Medicaid?

The federal government requires each state to provide Medicaid coverage for the “care and services necessary for the treatment of an emergency medical condition.”

What services are considered “emergency?”

• “Absence of immediate medical attention could put the patient in serious jeopardy, seriously impair bodily functions, or cause serious dysfunction to an organ or body part.”

• Cancer treatment: chemotherapy, radiation treatment, prescription medications

• Emergency surgeries (not elective)

• Emergency L&D services

So who’s eligible for Emergency Medicaid?

• Undocumented immigrants may apply for Emergency Medicaid.

• There are four criteria for Emergency Medicaid eligibility:

1. The patient is a district resident

2. The patient has an emergency medical condition

3. The patient meets income requirements

4. The patient is not eligible for ongoing Medicaid due to their citizenship or immigration status

For New York Medicaid (not *emergency* Medicaid), here is the criteria for eligibility. As you can see, it doesn’t capture a lot of our patient population. The patient must be:

• NY resident / US citizen, and

• Pregnant, or

• Be responsible for a child </=18 years old, or

• Blind, or

• Have a disability or a family member in the household with a disability, or

• 65+ years old

Some conditions require you to fall below certain income thresholds:

Have a household income (before taxes) that is below 138% of the federal poverty level. For reference, this translates to:

• 1 member household: <$17,131

• 2 member household: <$23,169

• 3 member household: <$29,207

• 4 member household: <$35,245
  

How do I help my patient sign up for it?

Our social work and case management teams are very helpful in facilitating this process. https://nystateofhealth.ny.gov/

How long does it last for?

• If Emergency Medicaid is approved, it will cover future and past costs associated with the medical condition for a maximum of fifteen months.

• Retroactive coverage maximum: 3 months

• Prospective coverage maximum: 12 months

• It can last for up to twelve months or as long as the person is experiencing the emergency, whichever is shorter.

Misc:

• Emergency Medicaid does not affect someone’s ability to apply for legal status

• This is not reported to US Immigration & Customs Enforcement.

References: 

http://www.wnylc.com/health/entry/70/
https://www1.nyc.gov/assets/ochia/downloads/pdf/fly-957-emergency-medicaid-english.pdf
https://dhcf.dc.gov/service/emergency-medicaid
https://www.benefits.gov/benefit/1637  https://www.health.ny.gov/health_care/medicaid/emergency_medical_condition_faq.htm

The Double Set-up

Hi all,

This is going to be a short but important POTD!

I wanted to write about an airway set up technique, colloquially termed “The Double Set Up” that the trauma and northside teams used yesterday during a level 1 trauma.

Without giving any secrets away for a case that will likely be an M&M in the future, for some situational background, the patient was getting progressively hypoxic with vomitus covering the entire airway. It was hard to get visualization of the airway using the Glidescope. The airway options were clear: either tube via DL or crich.

The team smartly employed the double set up technique to secure the airway. 

What does this term mean?

The double set up is when you have simultaneously set up for an orotracheal intubation and for a cricothyroidotomy. The EM/ anesthesia physician is at the head of the bed with the orotracheal airway equipment, while the surgeon is completely prepared for the crich with the scalpel in hand at the neck of the patient. The neck should already be prepped, and the landmarks should be identified.

When should we do the double set up?

Strayer has an amazing blog post about this (see below). Here are some indications where you might want to do the double set-up:

• An unstable maxillofacial trauma patient

• As a last ditch effort to secure the orotracheal tube after a failed attempt

• Rapidly desaturating patient with challenging anatomical features / cannot be successfully bagged

• Concern for an obstructed airway

If the intubator is ultimately unsuccessful, they indicate to the surgical airway physician to proceed. If the orotracheal intubator is successful, then the surgical airway physician can stop.

References:

• Check out Strayer’s excellent post on this: https://emupdates.com/the-emergency-department-double-setup/ 

• https://www.emed.theclinics.com/article/S0733-8627(17)30075-5/pdf 

• http://maryland.ccproject.com/wp-content/uploads/sites/8/2015/09/Leeuwenberg-2015-Airway-Management-of-the-Critically-Ill-Patient-Modifications-of-Traditional-Rapid-Sequence-Induction-and-Intubation.pdf
  

EMS Protocol of the Week - Stroke [Cerebrovascular Accident (CVA)] (Adult and Pediatric)

The bulk of prehospital stroke management has not changed drastically between this year and last. The majority of these calls, like with trauma cases, are handled by BLS units since there are more of them in the city; this increases the likelihood of immediate, rapid transport to a definitive care center, which is ultimately what these patients need.

A few important takeaways:

1.       Any patient with a suspected CVA should be receiving a prehospital glucose measurement, regardless if they’re with a BLS or ALS crew, for the same reason why we check BGM in the ED during stroke codes.

2.       The attached appendix elaborates on the NYC S-LAMS score, which is the go-to prehospital stroke scale in New York City, derived largely from components of the two other major scoring criteria used in the US: The Cincinnati Stroke Scale and the Los Angeles Motor Scale. Look at the attached flowsheet for specifics, but essentially –

a.       if S-LAMS is >= 4 and no exclusion criteria present, the patient has a high concern for acute LVO and should pass potentially closer hospitals to go to the nearest thrombectomy-capable center

b.       if not, the patient should be either brought to a Primary Stroke Center (that can provide medical stroke care, thrombolysis, but not thrombectomy) or a non-stroke center ED, depending on the presentation

c.       you are NOT expected to know which hospitals are Primary Stroke Centers vs Comprehensive (Thrombectomy) Stroke Centers vs general EDs, BUT you should be able to assist crews that call OLMC to determine which TYPE of destination WOULD be appropriate, after which they can work with their own dispatch to determine which hospital to go to; again, refer to the flowsheet for specifics

3.       One NEW feature in this year’s protocol is the addition of metoprolol, 5mg slow IV push, as a Medical Control Option for patients hypertensive to >210/120 (assuming ALS providers are present). As with other MCOs, listen to the crew’s entire presentation, use your discretion, and make sure to utilize great closed-loop communication in your orders.

As always, reach out with questions/comments/concerns, make the most of www.nycremsco.org and the protocol binder, and we’ll see you next week!

Dave