405 Ind. Admin. Code 14-6-12

Current through October 9, 2024

Section 405 IAC 14-6-12 - Emergency and poststabilization care services

Authority: IC 12-15-1-10

Affected: IC 12-15-5; IC 12-15-12-17

Sec. 12.

(a) An MCO shall cover emergency services as follows:

(1) The MCO shall not require prior authorization for the service.

(2) The MCO shall not require the emergency care provider to be contracted with the MCO.

(3) Services are available to members twenty-four (24) hours a day, seven (7) days a week.

(4) Services must comply with the requirements under IC 12-15-12, including applying the prudent layperson standard for applying emergency and poststabilization care services policy outlined in this section.

(b) An MCO shall include urgent care clinics in the MCO's contracted provider networks, which are made available to members not less than eleven (11) hours each day, Monday through Friday, and not less than five (5) hours each day on weekends.

(c) An MCO shall cover the medical screening examination, as defined by the Emergency Medical Treatment and Active Labor Act regulations at 42 CFR 489.24, given to a member who presents to an emergency department with an emergency medical condition.

(d) Non-physician emergency care providers who do not have a contract with the MCO are reimbursed at not more than one hundred percent (100%) of the Medicaid fee schedule rate set by the state under 405 IAC 1-8-3, unless other payment arrangements are made, while physician services are reimbursed at one hundred percent (100%) of prior year Medicare rates.

(e) The MCO shall pay the contracted or fee schedule rate for an observation stay, regardless of whether a related emergency department visit was determined emergent.

(f) The MCO may choose to use a list of diagnosis codes to initially determine whether a service may be an emergency but shall, at least, use the emergency department autopay list developed by the office.

(g) An MCO shall cover poststabilization care services for members under federal requirements at 42 CFR 438.114(e) and 42 CFR 422.113(c), and state law at IC 12-15-12-17.

405 IAC 14-6-12

Office of the Secretary of Family and Social Services; 405 IAC 14-6-12; filed 8/30/2024, 11:42 a.m.: 20240925-IR-405240180FRA