W. Va. Code R. § 114-95-9

Current through Register Vol. XLI, No. 45, November 8, 2024

Section 114-95-9 - Emergency Services

9.1. When conducting utilization review or making a benefit determination for emergency services, an issuer that provides benefits for services in an emergency department of a hospital shall follow the provisions of this section.

9.2. An issuer shall cover emergency services to screen and stabilize a covered person in the following manner:

9.2.a. Without the need for prior authorization of such services if a prudent layperson would have reasonably believed that an emergency medical condition existed even if the emergency services are provided on an out-of-network basis;

9.2.b. Shall cover emergency services whether the health care provider furnishing the services is a participating provider with respect to such services;

9.2.c. If the emergency services are provided out-of-network, without imposing any administrative requirement or limitation on coverage that is more restrictive than the requirements or limitations that apply to emergency services received from network providers;

9.2.d. If the emergency services are provided out-of-network, by complying with the cost-sharing requirements of subdivision 9.3.b; and

9.2.e. Without regard to any other term or condition of coverage, other than:

9.2.e.1. The exclusion of or coordination of benefits;

9.2.e.2. An affiliation or waiting period as permitted under section 2704 of the Public Health Service Act (PHSA); or

9.2.e.3. Applicable cost-sharing, as provided in subdivisions 9.3.a or 9.3.b.

9.3. For in-network emergency services, coverage of emergency services shall be subject to applicable co-payments, coinsurance and deductibles.

9.3.a. For out-of-network emergency services, any cost-sharing requirement expressed as a copayment amount or coinsurance rate imposed with respect to a covered person cannot exceed the cost-sharing requirement imposed with respect to a covered person if the services were provided in-network.

9.3.b. Notwithstanding subdivision 9.3.a, 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 the issuer is required to pay under this paragraph.

9.3.c. An issuer complies with the requirements of this subsection if it provides payment of emergency services provided by an out-of-network provider in an amount not less than the greatest of the following:

9.3.c.1. The amount negotiated with in-network providers for emergency services, excluding any in-network copayment or coinsurance imposed with respect to the covered person;

9.3.c.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

9.3.c.3. The amount that would be paid under Medicare for the emergency services, excluding any in-network copayment or coinsurance requirements.

9.3.d. For capitated or other health benefit plans that do not have a negotiated per-service amount for in-network providers, paragraph 9.3.C.1 does not apply. If a health benefit plan has more than one negotiated amount for in-network providers for a particular emergency service, the amount in paragraph 9.3.C.1 is the median of these negotiated amounts.

9.3.d.1. Any cost-sharing requirement other than a copayment or coinsurance requirement, such as a deductible or out-of-pocket maximum, may be imposed with respect to emergency services provided out-of-network if the cost-sharing requirement generally applies to out-of-network benefits.

9.3.d.2. A deductible may be imposed with respect to out-of-network emergency services only as part of a deductible that generally applies to out-of-network benefits.

9.3.d.3. If an out-of-pocket maximum generally applies to out-of-network benefits, that out-of-network maximum must apply to out-of-network emergency services.

9.4. For immediately required post-evaluation or post-stabilization services, an issuer shall provide access to designated representative twenty-four hours a day, seven days a week, to facilitate review.

W. Va. Code R. § 114-95-9