A new federal program will reimburse physicians and hospitals for emergency and on-call care provided to undocumented immigrants. California will receive about $288 million over four years. The program is being called Section 1011, which is a reference to the section of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 that establishes it.

Through the new program, 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 Emergency Medical Treatment and Labor Act-related emergency services. Payments will be made directly to physicians on a quarterly basis. However, payments may be subject to a pro rata reduction if the state's quarterly allocation is insufficient to provide full reimbursement to all providers submitting claims.

The Centers for Medicare and Medicaid Services has contracted with Dallas-based TrailBlazer Health Enterprises LLC to administer payments nationwide. The company is a subsidiary of BlueCross BlueShield of South Carolina.

TrailBlazer will enroll eligible providers, assist providers with enrollment and billing questions, calculate provider payment amounts, and serve as the compliance contractor. TrailBlazer maintains a dedicated Section 1011 Web site (www.trailblazerhealth.com/section1011) to ensure hospitals, physicians and ambulance providers are kept informed and updated. The TrailBlazer Online Section 1011 Enrollment Application system became available on Aug.15, 2005.

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

Section 1011 is often referred to as the "payer of last resort," which means that 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.

Under 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 uncompensated services is expected to reach $1 billion.

TrailBlazer will begin actual claims adjudication and payment disbursement in February 2006. To contact TrailBlazer Health Enterprises, call 866/860-1011 or visit www.trailblazerhealth.com/Section1011/Enrollment.aspx.


About Section 1011 Applications
Applicants for Section 1011 enrollment must complete and submit both an electronic and signed copy of CMS Form 10115. Hard copy of the electronic application signed by the authorized representative should be mailed to:
TrailBlazer Health
Enterprises LLC
Section 1011
P.O. Box 660529
Dallas, TX 75266-0529