Tip for State-specific (e.g., Form 520)

Emergency Medicaid is available to individuals who would qualify for Medicaid but for their immigration status

Tip for State-specific (e.g., Form 520)

Coverage is limited to emergency medical conditions — it does not cover preventive or routine care

Tip for State-specific (e.g., Form 520)

Ask the hospital's financial counselor to help with the application before discharge

Medicaidhard

Emergency Medicaid Application

State-specific (e.g., Form 520) · State Medicaid Agencies

Application for Emergency Medical Assistance for individuals meeting all Medicaid requirements except citizenship/immigration status. Must have received emergency services.

Form Details

Total fields: 70
Auto-fillable: 30 (43%)
Time without BeneFill: 60 minutes
Time with BeneFill: 15 minutes
Time saved: 45 minutes
Filled by: patient
Frequency: per incident
State-specific: Yes — form may vary by state

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Where to Submit This Form

🏢

Apply at the hospital or through your state Medicaid office

Most hospitals have financial counselors or Medicaid enrollment specialists who can help you apply.

🌐

Apply through your state Medicaid agency's website

Some states allow online Emergency Medicaid applications.

🌐

Call your state Medicaid office

Find your state's Medicaid contact at Medicaid.gov.

Filing Deadline

Apply as soon as possible — ideally during or immediately after the emergency. Many states allow retroactive coverage for up to 3 months prior to the application date.

Required Attachments

📎 Completed Medicaid application
📎 Proof of identity
📎 Proof of income (if applicable)
📎 Medical records documenting the emergency condition
📎 Hospital bills and explanation of benefits (EOB)

Processing Time

Emergency Medicaid applications are typically expedited — 1-2 weeks in most states. Some states provide presumptive eligibility for hospital stays.

What Happens Next

If approved, Emergency Medicaid covers the emergency treatment. Coverage is typically limited to the emergency condition and does not include ongoing care.

Tips for This Form

✓ Emergency Medicaid is available to individuals who would qualify for Medicaid but for their immigration status
✓ Coverage is limited to emergency medical conditions — it does not cover preventive or routine care
✓ Ask the hospital's financial counselor to help with the application before discharge
✓ Retroactive coverage can apply — apply even if the emergency has already occurred

More Medicaid Forms

Medicaid Application

State-specific · State Medicaid Agencies / CMS via HealthCare.gov

Unified application for Medicaid, CHIP, and Marketplace coverage under ACA. Uses MAGI for financial eligibility. Available online, by mail, phone, or in person.

HealthCare.gov Marketplace Application

Federal Marketplace Application · CMS / Federal Marketplace

Federal marketplace application that also screens for Medicaid/CHIP eligibility and refers to state agencies when the applicant qualifies.

Presumptive Eligibility Determination

State-specific PE form · State Medicaid Agencies / Qualified Entities

Temporary Medicaid coverage granted by qualified entities (hospitals, clinics) based on preliminary income assessment. Covers services until full application is processed.

Medicaid Renewal / Redetermination

State-specific (e.g., CA MC 210 RV) · State Medicaid Agencies

Annual renewal verifying continued Medicaid eligibility. Includes income, expenses, and household composition. Failure to complete results in disenrollment.

Medicaid Spend-Down Documentation

State-specific · State Medicaid Agencies

Documents medical expenses applied toward meeting the spend-down amount. Once the difference between income and the medically needy income level is met, Medicaid covers remaining expenses.

QMB / Medicare Savings Program Application

State-specific MSP/QMB form · State Medicaid Agencies

Application for Medicare Savings Programs (QMB, SLMB, QI) that help pay Medicare premiums, deductibles, and copays for low-income Medicare beneficiaries.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the State Medicaid Agencies or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.