§ 27-13-36-9 — Coverage and reimbursement for expenses for care obtained in an emergency

Indiana § 27-13-36-9

• Jurisdiction: Indiana
• Title 27: INSURANCE
• Art. 13: HEALTH MAINTENANCE ORGANIZATIONS
• Ch. 36: Patient Protection; Clinical Decision Making; Access

Text

(a) As used in this section, "care obtained in
an emergency" means, with respect to an enrollee, covered services that
are:
(1) furnished by a provider within the scope of the provider's
license and as otherwise authorized under law; and
(2) needed to evaluate or stabilize an individual in an emergency.
(b) As used in this section, "stabilize" means to provide medical
treatment to an individual in an emergency as may be necessary to
assure, within reasonable medical probability, that material
deterioration of the individual's condition is not likely to result from or
during any of the following:
(1) The discharge of the individual from an emergency
department or other care setting where emergency services are
provided to the individual.
(2) The transfer of the individual from an emergency department
or other care setting where emergency services are provided to the
individual to another health care facility.
(3) The transfer of the individual from a hospital emergency
department or other hospital care setting where emergency
services are provided to the individual to the hospital's inpatient
setting.
(c) As described in subsection (d), each health maintenance
organization shall cover and reimburse expenses for care obtained in
an emergency by an enrollee without:
(1) prior authorization; or
(2) regard to the contractual relationship between:
(A) the provider who provided health care services to the
enrollee in an emergency; and
(B) the health maintenance organization;
in a situation where a prudent lay person could reasonably believe that
the enrollee's condition required immediate medical attention. The
emergency care obtained by an enrollee under this section includes
care for the alleviation of severe pain, which is a symptom of an
emergency as provided in IC 27-13-1-11.7.
(d) Each health maintenance organization shall cover and reimburse
expenses for emergency services at a rate equal to the lesser of the
following:
(1) The usual, customary, and reasonable charge in the health
maintenance organization's service area for health care services
provided during the emergency.
(2) An amount agreed to between the health maintenance
organization and the out of network provider.
A provider that provides emergency services to an enrollee under this
section may not charge the enrollee except for an applicable copayment
or deductible. Care and treatment provided to an enrollee once the
enrollee is stabilized is not care obtained in an emergency.

Legislative History

As added by P.L.69-1998, SEC.14.