33-32-215. (Effective January 1, 2016) Emergency services. (1) When conducting a utilization review or making a benefit determination for emergency services, a health insurance issuer that provides benefits for services in an emergency department of a hospital shall follow the provisions of this section.
     (2) A health insurance issuer shall cover emergency services that screen and stabilize a covered person:
     (a) without the need for prior authorization of the emergency services if a prudent lay person would have reasonably believed that an emergency medical condition existed even if the emergency services are provided on an out-of-network basis;
     (b) without regard to whether the health care provider furnishing the services is a participating provider with respect to the emergency services;
     (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;
     (d) if the emergency services are provided out-of-network, by complying with the cost-sharing requirements in subsection (4); and
     (e) without regard to any other term or condition of coverage, other than:
     (i) the exclusion of or coordination of benefits;
     (ii) an affiliation or waiting period as permitted under 42 U.S.C. 300gg-19a; or
     (iii) cost-sharing, as provided in subsection (4)(a) or (4)(b), as applicable.
     (3) For in-network emergency services, coverage of emergency services is subject to applicable copayments, coinsurance, and deductibles.
     (4) (a) Except as provided in subsection (4)(b), for out-of-network emergency services, any cost-sharing requirement imposed with respect to a covered person may not exceed the cost-sharing requirement for a covered person if the services were provided in-network.
     (b) A covered person may be required to pay, in addition to the in-network cost-sharing expenses, the excess amount the out-of-network provider charges that exceeds the amount the health insurance issuer is required to pay under this subsection (4).
     (c) A health insurance issuer complies with the requirements 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 and taking into account exceptions in subsections (4)(d) and (4)(e):
     (i) the amount negotiated with in-network providers for emergency services, excluding any in-network cost-sharing imposed with respect to the covered person;
     (ii) 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
     (iii) the amount that would be paid under medicare for the emergency services, excluding any in-network cost-sharing requirements.
     (d) For capitated or other health plans that do not have a negotiated charge for each service for in-network providers, subsection (4)(c)(i) does not apply.
     (e) If a health plan has more than one negotiated amount for in-network providers for a particular emergency service, the amount in subsection (4)(c)(i) is the median of those negotiated amounts.
     (5) Only in-network cost-sharing amounts may be imposed on out-of-network emergency services.
     (6) If prior authorization is required for a postevaluation or poststabilization services review, a health insurance issuer shall provide access to a designated representative 24 hours a day, 7 days a week, to facilitate the review.

     History: En. Sec. 7, Ch. 428, L. 2015.