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

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

Sec. 9. (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.

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