Medicaid Emergency Services Only (ESO) Coverage for the Treatment of an Emergency Medical Condition Fact Sheet
What is Medicaid ESO coverage for the treatment of an emergency medical condition?
Medicaid ESO coverage is available for care and services necessary for the treatment of an emergency medical condition as defined in federal regulation 42 CFR 440.255 and section 1903(v)(3) of the Social Security Act to certain temporary non-immigrants (e.g., certain foreign students, visitors/tourists) and undocumented non-citizens, if otherwise eligible. An undocumented non-citizen must meet all eligibility requirements, including proof of identity, income, and State residency to be eligible for Medicaid ESO coverage of an emergency medical condition. Temporary non-immigrants, who have been allowed to enter the United States for a specific purpose and for a specified period of time and who meet all other eligibility requirements, do not have to meet the State residency requirement to receive coverage for the treatment of an emergency medical condition and are considered "Where Found" for District of Fiscal Responsibility purposes.
Who can receive Medicaid ESO coverage for the treatment of an emergency medical condition?
Undocumented Non-Citizen
An individual who is not lawfully present is considered undocumented if they entered the United States in a manner or in a place so as to avoid inspection or was admitted on a temporary basis and the period of authorized stay has expired. Undocumented individuals will not have valid/unexpired immigration documents.
Temporary Non-Immigrant
Non-immigrants are lawfully admitted to the U.S. temporarily for a specific purpose and for a specified period of time. Otherwise eligible non-immigrants, who are not New York State residents and who require immediate medical care may receive Medicaid ESO coverage for the treatment of an emergency medical condition. Such temporary non-immigrants may receive this coverage, provided they did not enter the State for the purpose of obtaining medical care (e.g. with a medical visa).
Temporary non-immigrants who are New York State residents (e.g., own or rent a home, work in New York State) may be eligible for Essential Plan (EP) or Medicaid. These non-immigrants are given the New York State residency review. If they "pass" residency review, they may be eligible for either EP or full Medicaid.
What is an emergency medical condition?
The term "Emergency Medical Condition" is defined as, after sudden onset, a medical condition (including emergency labor and delivery) that manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
- Placing the patient's health in serious jeopardy;
- Serious impairment to bodily function; or
- Serious dysfunction of any bodily organ or part.
Care and services related to an organ transplant procedure are not included in this definition as stipulated in section 1903(v)(2)(c) of the Social Security Act.
This definition must be met, after sudden onset of the medical condition, at the time the medical service is provided, or it will not be considered an emergency medical condition and therefore, cannot be covered by Medicaid ESO.
Not all services that are medically necessary for the treatment of a medical condition are entitled to reimbursement under ESO coverage. Emergency medical conditions do not include debilitating conditions (e.g., heart disease or other medical conditions requiring rehabilitation) resulting from the initial event which later require ongoing regimented care. The potentially fatal consequence of discontinuing Medicaid ESO covered care, even if such care is medically necessary, does not transform the condition into an emergency medical condition.
What services do not meet the definition of an emergency medical condition?
Certain types of care provided to chronically ill persons are beyond the intent of the federal and State laws and are not considered "emergency services" for the purpose of payment by Medicaid. Such care includes:
- Alternate level of care in a hospital;
- Nursing facility services;
- Home care (including but not limited to personal care services, home health services and private duty nursing); and
- Rehabilitation services (including physical, speech and occupational therapies).
The above-mentioned services are not considered emergency medical services. Therefore, Medicaid does not cover the cost for the above-mentioned services or transportation to these services.
How long is Medicaid coverage for the treatment of an emergency medical condition?
Authorization Period
The initial authorization period for the treatment of an emergency medical condition may be up to a maximum of 15 months: three (3) months retroactive coverage from the application date and up to 12 months prospective coverage from the application date. The authorization period may be from the first day of the third month prior to the month of application to the last day of the twelfth month prospectively. As of February 2026, individuals with ESO coverage must have a paid claim in the previous six (6) months in order to maintain coverage.
A new Medicaid application is not required for each emergency medical condition. However, if an individual's ESO coverage is ended because there has not been a paid claim in the previous six (6) months, a new Medicaid application will be needed to reauthorize additional ESO coverage. Claims paid with ESO coverage must indicate that it is for an emergency. The treating physician will determine if the medical condition meets the definition of an emergency medical condition.
