Sec. 3 AAC 28.914 - Emergency services
§ 3 AAC 28.914. Emergency services
(a) A health care insurer shall follow the provisions of this section when conducting a utilization review or making a benefit determination for emergency services.
(b) A health care insurer shall cover emergency services to screen and stabilize a covered person
(1) without the need for prior authorization of emergency services if a prudent person would reasonably believe that an emergency medical condition exists even if the emergency services are provided on an out-of-net work basis;
(2) without regard to whether the health care provider furnishing the services is a participating provider with respect to the services;
(3) if the emergency services are provided out-of-network, without imposing an administrative requirement or limitation on coverage that is more restrictive than the requirements or limitations that apply to emergency services received from network providers;
(4) if the emergency services are provided out-of-network, by complying with the cost-sharing requirements of (d) - (h) of this section; and
(5) without regard to another term or condition of coverage, other than
(A) the exclusion of, or coordination of, benefits;
(C) applicable cost-sharing, under (c) - (h) of this section.
(c) For in-network emergency services, coverage of emergency services is subject to applicable copayments, coinsurance, and deductibles.
(d) Except under (e) of this section, for out-of-network emergency services, a cost-sharing requirement expressed as a copayment amount or coinsurance rate imposed with respect to a covered person may not exceed the cost-sharing requirement imposed with respect to a covered person if the services were provided in-network.
(e) A covered person may be required to pay, in addition to the in-network cost-sharing, the excess of the amount the out-of-network provider charges over the amount a health care insurer is required to pay under (d) of this section.
(f) A health care insurer complies with the requirements of (d) and (e) of this section by paying for emergency services provided by an out-of-network provider in an amount not less than the greatest of the following, taking into account the exceptions under (g) and (h) of this section:
(1) the amount negotiated with in-network providers for emergency services, excluding an in-network copayment or coinsurance imposed with respect to the covered person;
(2) the amount of the emergency service calculated using the same method the plan uses to determine payments for out-of-network services, but using the in-network cost-sharing provisions instead of the out-of-network cost-sharing provisions; or
(3) the amount that would be paid under Medicare for the emergency services, excluding an in-network copayment or coinsurance requirements.
(g) For capitated or other health care insurance policies that do not have a negotiated charge for each service for in-network providers, (f)(1) of this section does not apply.
(h) If a health plan has more than one negotiated amount for in-network providers for a particular emergency service, the amount in (f)(1) of this section is the median of those negotiated amounts.
(i) A health care insurer may impose only in-network cost-sharing amounts on out-of-network emergency services.
(j) If prior authorization is required for a post-evaluation or post-stabilization services review, a health care insurer shall provide access to a designated representative 24 hours a day. seven days a week, to facilitate the review.(Eff. 3/15/2018,Register 225, April 2018)
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