§ 31-2802 — Covered services.

(1) All health insurers, hospitals or medical services corporations, and health maintenance organizations shall reimburse for emergency services that are due to a medical emergency.

(2) Reimbursement for pre-hospital medical care and transport delivered pursuant to paragraph (1) of this subsection by the Fire and Emergency Medical Services Department ("Department") or a third party contracted by the District to provide such services pursuant to § 5-401(b) , shall be at the fee rate authorized by the Council pursuant to § 5-416(a) .

(3) This subsection shall not apply to any group health plan or multiple employer welfare arrangement to the extent the plan or arrangement is not subject to state insurance regulation under section 514 of the Employee Retirement Income Security Act of 1974, approved September 2, 1974 (88 Stat. 897; 29 U.S.C. § 1144).

(b) A hospital emergency department or emergency medical service transporter shall provide a health insurer, hospital or medical services corporation, or health maintenance organization with any claim for reimbursement of services, and information on the presenting symptoms of the insured as well as the services provided.

(c) A health insurer, hospital or medical services corporation, or health maintenance organization shall consider both the presenting symptoms and the services provided in processing a claim for reimbursement of emergency services.

(d) A health insurer, hospital or medical services corporation, or health maintenance organization may not deny reimbursement, except for co-payments, deductibles, and co-insurance, for the provision of emergency services that are due to a medical emergency solely because the member failed to obtain pre-authorization for emergency services from the health insurer, hospital or medical services corporation, or health maintenance organization.

Legislative History

Sept. 11, 1998, D.C. Law 12-145, § 3, 45 DCR 3785