[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR438.114]



[Page 224-225]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 438_MANAGED CARE--Table of Contents

 

                Subpart C_Enrollee Rights and Protections

 

Sec.  438.114  Emergency and poststabilization services.



    (a) Definitions. As used in this section--

    Emergency medical condition means a medical condition manifesting 

itself by acute symptoms of sufficient severity (including severe pain) 

that a prudent layperson, who possesses an average knowledge of health 

and medicine, could reasonably expect the absence of immediate medical 

attention to result in the following:

    (1) Placing the health of the individual (or, with respect to a 

pregnant woman, the health of the woman or her unborn child) in serious 

jeopardy.

    (2) Serious impairment to bodily functions.

    (3) Serious dysfunction of any bodily organ or part.

    Emergency services means covered inpatient and outpatient services 

that are as follows:

    (1) Furnished by a provider that is qualified to furnish these 

services under this title.

    (2) Needed to evaluate or stabilize an emergency medical condition.

    Poststabilization care services means covered services, related to 

an emergency medical condition that are provided after an enrollee is 

stabilized in order to maintain the stabilized condition, or, under the 

circumstances described in paragraph (e) of this section, to improve or 

resolve the enrollee's condition.

    (b) Coverage and payment: General rule. The following entities are 

responsible for coverage and payment of emergency services and 

poststabilization care services.

    (1) The MCO, PIHP, or PAHP.

    (2) The PCCM that has a risk contract that covers these services.

    (3) The State, in the case of a PCCM that has a fee-for-service 

contract.

    (c) Coverage and payment: Emergency services. (1) The entities 

identified in paragraph (b) of this section--

    (i) Must cover and pay for emergency services regardless of whether 

the provider that furnishes the services has a contract with the MCO, 

PIHP, PAHP, or PCCM; and

    (ii) May not deny payment for treatment obtained under either of the 

following circumstances:

    (A) An enrollee had an emergency medical condition, including cases 

in which the absence of immediate medical attention would not have had 

the outcomes specified in paragraphs (1), (2), and (3) of the definition 

of emergency medical condition in paragraph (a) of this section.

    (B) A representative of the MCO, PIHP, PAHP, or PCCM instructs the 

enrollee to seek emergency services.

    (2) A PCCM must--

    (i) Allow enrollees to obtain emergency services outside the primary 

care case management system regardless of whether the case manager 

referred the enrollee to the provider that furnishes the services; and

    (ii) Pay for the services if the manager's contract is a risk 

contract that covers those services.

    (d) Additional rules for emergency services. (1) The entities 

specified in paragraph (b) of this section may not--

    (i) Limit what constitutes an emergency medical condition with 

reference to paragraph (a) of this section, on the basis of lists of 

diagnoses or symptoms; and

    (ii) Refuse to cover emergency services based on the emergency room 

provider, hospital, or fiscal agent not notifying the enrollee's primary 

care provider, MCO, PIHP, PAHP or applicable State entity of the 

enrollee's screening and treatment within 10 calendar days of 

presentation for emergency services.



[[Page 225]]



    (2) An enrollee who has an emergency medical condition may not be 

held liable for payment of subsequent screening and treatment needed to 

diagnose the specific condition or stabilize the patient.

    (3) The attending emergency physician, or the provider actually 

treating the enrollee, is responsible for determining when the enrollee 

is sufficiently stabilized for transfer or discharge, and that 

determination is binding on the entities identified in paragraph (b) of 

this section as responsible for coverage and payment.

    (e) Coverage and payment: Poststabilization care services. 

Poststabilization care services are covered and paid for in accordance 

with provisions set forth at Sec.  422.113(c) of this chapter. In 

applying those provisions, reference to ``M+C organization'' must be 

read as reference to the entities responsible for Medicaid payment, as 

specified in paragraph (b) of this section.

    (f) Applicability to PIHPs and PAHPs. To the extent that services 

required to treat an emergency medical condition fall within the scope 

of the services for which the PIHP or PAHP is responsible, the rules 

under this section apply.



[67 FR 41095, June 14, 2002; 67 FR 65505, Oct. 25, 2002]