(a)This section applies to post-stabilization
care services provided to an individual enrolled in a Medicaid risk
based managed care program.
(b)The managed care organization through which an individual is
enrolled in a risk based managed care program, is financially
responsible for the following services provided to the enrollee:
(1)Post-stabilization care services that are preapproved by the
managed care organization.
(2)Post-stabilization care services that are not preapproved by the
managed care organization, but that are administered to maintain
the enrollee's stabilized condition within one (1) hour of a request
to the managed care organization for preapproval of further
post-stabilization care services.
(3)Post-stabilization care services provided after an enrollee is
stabilize
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(a) This section applies to post-stabilization
care services provided to an individual enrolled in a Medicaid risk
based managed care program.
(b) The managed care organization through which an individual is
enrolled in a risk based managed care program, is financially
responsible for the following services provided to the enrollee:
(1) Post-stabilization care services that are preapproved by the
managed care organization.
(2) Post-stabilization care services that are not preapproved by the
managed care organization, but that are administered to maintain
the enrollee's stabilized condition within one (1) hour of a request
to the managed care organization for preapproval of further
post-stabilization care services.
(3) Post-stabilization care services provided after an enrollee is
stabilized that are not preapproved by the managed care
organization, but that are administered to maintain, improve, or
resolve the enrollee's stabilized condition if the managed care
organization:
(A) does not respond to a request for preapproval within one (1)
hour;
(B) cannot be contacted; or
(C) cannot reach an agreement with the enrollee's treating
physician concerning the enrollee's care, and a physician
representing the managed care organization is not available for
consultation.
(c) If the conditions described in subsection (b)(3)(C) exist, the
managed care organization shall give the enrollee's treating physician
an opportunity to consult with a physician representing the managed
care organization. The enrollee's treating physician may continue with
care of the enrollee until a physician representing the managed care
organization is reached or until one (1) of the following criteria is met:
(1) A physician:
(A) representing the managed care organization; and
(B) who has privileges at the treating hospital;
assumes responsibility for the enrollee's care.
(2) A physician representing the managed care organization
assumes responsibility for the enrollee's care through transfer.
(3) A representative of the managed care organization and the
treating physician reach an agreement concerning the enrollee's
care.
(4) The enrollee is discharged from the treating hospital.
(d) This subsection applies to post-stabilization care services
provided under subsection (b)(1), (b)(2), and (b)(3) to an individual
enrolled in a Medicaid risk based managed care program by a provider
who has not contracted with the individual's managed care organization
to provide post-stabilization care services under subsection (b)(1),
(b)(2), and (b)(3) to the individual. Payment for post-stabilization care
services provided under subsection (b)(1), (b)(2), and (b)(3) must be
in an amount equal to one hundred percent (100%) of the current
Medicaid fee for service reimbursement rates for such services.
(e) This section does not prohibit a managed care organization from
entering into a subcontract with another managed care organization
providing for the latter managed care organization to assume financial
responsibility for making the payments required under this section.
(f) This section does not limit the ability of the office or the
managed care organization to:
(1) review; and
(2) make a determination of;
the medical necessity of the post-stabilization care services provided
to an enrollee for purposes of determining coverage for such services.