Revised Medical Screening Guidelines for Newly Arriving Refugees

TO:   STATE REFUGEE COORDINATORS
         (of State-Administered Programs, Wilson-Fish Programs and Public Private Programs)
         STATE REFUGEE HEALTH COORDINATORS
         NATIONAL VOLUNTARY AGENCIES
          OTHER INTERESTED PARTIES

FROM: Eskinder Negash
             Director
             Office of Refugee Resettlement

SUBJECT: Revised Medical Screening Guidelines for Newly Arriving Refugees

The purpose of this State Letter is to issue revised Medical Screening Guidelines for Newly Arriving Refugees and corresponding reimbursement rates (see attached).  The corresponding reimbursement rates are provided as an administrative tool to assess the reasonableness of a State’s average unit cost for medical screening.  Reasonableness of costs will be determined by comparing a State’s average unit cost with the calculated average unit cost under the reimbursement rates provided in this guidance.   This State Letter does not address administrative costs associated with medical screening.  ORR intends to issue separate guidance on administrative costs.  (This State Letter supersedes ORR State Letters #95-37 and #04-10.)  

Pursuant to section 412(b)(5) of the Immigration and Nationality Act, ORR is authorized to fund States  to cover the costs of providing medical screening to refugees.   Additionally, under 45 CFR 400.107, States are authorized to provide medical screening to refugees in accordance with requirements prescribed by ORR.  This State Letter provides guidelines and reimbursement rates for medical screening activities conducted by the States; these requirements are intended to promote refugee health while safeguarding public health and fiscal responsibility.

In 1995, ORR issued State Letter #95-37, Medical Screening Protocol for Newly Arriving Refugees.  Since then, the Centers for Disease Control and Prevention (CDC) issued a series of 12 subject-based guidelines to assist clinicians, health professionals and public health departments in conducting medical screenings.  These guidelines are formally referred to as Guidelines
for the U.S. Domestic Medical Examination for Newly Arriving Refugees and are available at: http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/domesti... .

The CDC guidelines were developed based on available evidence-based data and a consensus process that included input from subject-matter experts, State Refugee Health Coordinators and a Federal Partners Working Group.  As a member of the Federal Partners Working Group, ORR endorses the CDC guidelines and is revising the 1995 Medical Screening Protocol for Newly Arriving Refugees accordingly.  ORR is also revising its medical screening guidelines to create a minimum standard of care across States and to establish a framework for reimbursement.  The attached checklist of medical screening activities represents the minimum standard of care.  In some instances, a State may need to scale-up its medical screening activities over time to meet this minimum standard.  States that administer medical screening activities beyond what is specified in the attached checklist may continue with those activities, but ORR will limit reimbursement based on a reasonable cost standard as calculated under the reimbursement rates identified in this guidance. 

ORR engaged in a collaborative process to revise its medical screening guidelines and establish a reasonable framework for reimbursement.  ORR collaborated with CDC’s Division of Global Migration and Quarantine for technical input on CDC’s 12 subject-based guidelines, and with the Centers for Medicare and Medicaid Services’ (CMS) Financial Management Group and the Center for Medicare Management to determine the most appropriate reimbursement rates.  ORR also solicited feedback from States in the development of this State Letter.  ORR received comments from 15 States and the Association of Refugee Health Coordinators.  Many of those comments are incorporated in this final guidance.

ORR holds that the purposes for medical screening are as follows:

1. To ensure follow-up with medical issues identified in an overseas medical screening;
2. To identify persons with communicable diseases of potential public health importance;
3. To enable a refugee to successfully resettle by identifying personal health conditions that, if left unidentified, could adversely impact his or her ability to resettle; and
4. To refer refugees to primary care providers for ongoing health care.

Through this State Letter, ORR seeks to provide States with guidance and an instrument with which to review their medical screening programs and to plan for changes or improvements as necessary. States should be ready to implement these guidelines by October 1, 2012.  The attached revised guidelines are presented in a checklist format and include a history and physical exam, testing or presumptive treatment for a variety of medical conditions, immunizations or serology testing for immunity and other screening activities.  The checklist also indicates which medical screening activities should be conducted for all refugee populations, special adult populations only or children only.  If upon review of these guidelines a State determines that there is an additional activity that should be part of a State’s medical screening program, the State may contact its ORR State Analyst.

A critical component of the medical screening is the history and physical exam which should include a review of overseas medical records and a review of all systems to assess refugees’ immediate health needs. As the medical screening is often a refugee’s first encounter with the U.S. health care system, the health care professional may also incorporate orientation to the U.S. health system and general health education within the history and physical exam.  

A review of overseas medical records should include review of the following Department of State (DS) forms:  DS-2053 or DS-2054, Medical Examination for Immigrant or Refugee Applicant; DS-3024 or DS-3030, Chest X-Ray and Classification Worksheet; DS-3025,  Vaccination Documentation Worksheet; and DS-3026,  Medical History of Physical Examination Worksheet;.  The history should also include a review of the UNHCR Medical Assessment Form (MAF), the International Organization for Migration’s Significant Medical Conditions (SMC) form and Pre-Departure Medical Screening (PDMS) form, immunization records and other individually carried documents. 

The physical exam should involve a comprehensive clinical evaluation as well as a head-to-toe review of all systems, including an assessment of refugees’ nutritional well-being, reproductive health, mental health, dental health, hearing and vision.   A gynecological exam may be performed as part of the physical after the health professional informs the refugee woman about the health benefits of this aspect of the assessment and any procedures involved.  The health professional should advise the woman of her choice to opt-out.  During the assessment, the provider should pay special attention to signs of trauma (e.g., childbirth, gender-based violence).    In accordance with CDC’s guidelines, the mental health screening should be incorporated into the history and physical exam.  The purpose of the mental health screening is to assess for acute psychiatric emergencies such as suicidal and homicidal ideation.  In the rare instances where suicidal or homicidal ideation is suspected, States should make expedited referrals for formal psychiatric evaluation. 

ORR will fund medical screening activities that are listed in the attached medical screening guidelines.  This State Letter establishes a framework for reimbursing medical screening costs based on a reasonable cost standard.   After consulting with CMS, ORR determined that the reasonable cost standard should be calculated using Medicare’s Clinical Lab Fee Schedule, which corresponds with most of the medical screening activities in the attached checklist.  (In some instances the Center for Medicare Management calculated reimbursement rates anew because the activity did not exist in any other Medicare fee schedule.  ORR also researched private sector prices to determine reasonable cost for vaccines and medications.)   This methodology is considered ideal, as CMS regularly modifies its Medicare reimbursement rates by taking medical inflation, geographic variances and a survey of industry physicians into account. 

ORR has prepared a list of relevant Current Procedural Terminology (CPT) codes.  This list identifies the CPT codes and specific Medicare reimbursement rate plans that apply to each screening activity.  The list is intended to assist States in the administrative exercise of calculating the average unit cost for medical screening under the Medicare reimbursement rates.  In doing so, a State can determine whether its average unit cost is comparable to the reimbursement framework established in this State Letter (i.e., average unit cost for medical screening under the Medicare reimbursement rates). 

ORR will determine if a State’s medical screening costs are reasonable by comparing them to Medicare reimbursement rates.  If there is a significant difference between the State’s average unit cost and the average unit cost calculated under the Medicare reimbursement rates, ORR will reimburse the State for the lower cost.  For example, if a State’s average unit cost for medical screening is higher than the average unit cost calculated under the Medicare reimbursement rates, ORR will reimburse the State up to the Medicare average unit cost.  If a State’s average unit cost for medical screening is lower, ORR will reimburse the State at the average unit cost reported in its ORR-1. 

States that wish to use Refugee Medical Assistance (RMA) funds for medical screening of any refugees should submit an addendum to the ORR-1 (due August 15, 2012), providing an assurance that the State will comply with these medical screening guidelines and reimbursement framework effective October 1, 2012.  Additionally, States that wish to use RMA funds for medical screening of any refugee, should submit a medical screening plan as part of their State Plan (due October 30, 2012).

Based on feedback from States, ORR understands that approximately 85 percent of States can determine Medicaid eligibility within 45 days from the date of application.  This State Letter does not change existing procedures for requesting written approval to use RMA funds for medical screening performed during the first 90 days after a refugee’s arrival in the U.S.; even in cases where the refugee is subsequently determined eligible for the State Medicaid program.  ORR will review each State’s medical screening plan along with the annual State Plan submission, and will approve or deny the plan in consultation with the State as necessary. 

The medical screening plan should clearly identify the following:

1. A description of existing medical screening services that are covered under Medicaid, State or local public health programs, and/or other non-RMA resources.
2. A budget breakdown (as reflected in the ORR-1) and a description of how the State will use RMA for medical screening (i.e. list of providers, mechanism used for reimbursement, screening locations, activities).

ORR encourages States to adopt the medical screening guidelines and incorporate them into the State’s medical screening plan.  Additionally, for an effective medical screening program, States should ensure:

• A refugee’s access to medical screening by closely coordinating support services (e.g., transportation, interpretation) with reception and placement service providers;
• Maximum utilization of mainstream resources (e.g., State or county immunization programs, Tuberculosis programs);
• Cultural sensitivity of the medical screening providers; and
• Effective data collection and reporting (i.e., the ability to report and track costs that are specific to a State’s plan).

ORR recognizes that in some instances medical screenings may be administered as late as 90 days after a refugee’s arrival, but encourages States to aim for an earlier timeframe.  Ideally, the medical screening should take place within 30 days of a refugee’s arrival to coincide with Reception and Placement services.  Medical screenings should be performed by a qualified licensed health care professional, and an interpreter should be utilized if a refugee does not speak English.  In those States where medical screening is conducted outside of a primary care setting, refugees should be referred or linked to a primary health care facility or provider for on-going follow-up and treatment. Additionally, States should ensure that the primary health care facility or provider receives the results of the domestic medical screenings.  States should also seek to ensure that the primary health care facility or provider receives the results of the overseas medical screening.  

ORR is committed to ensuring that health needs of refugees are properly addressed, and hopes that these guidelines will help State and local partners in working towards improving refugee health.  For further information, please contact the ORR State Analyst or Essey Workie, Refugee Health Team Lead at essey.workie@acf.hhs.gov.

Attachments: 
ORR’s Domestic Medical Screening Guidelines Checklist - 31KB (DOCX)
List of Relevant Current Procedural Terminology (CPT) Codes by Screening Activity - 22KB (XLSX)