33-32-215. (Temporary) 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.

Terms Used In Montana Code 33-32-215

  • Authorized representative: means :

    (a)a person to whom a covered person has given express written consent to represent the covered person;

    (b)a person authorized by law to provided substituted consent for a covered person; or

    (c)a family member of the covered person, or the covered person's treating health care provider, only if the covered person is unable to provide consent. See Montana Code 33-32-102

  • benefits: means those health care services to which a covered person is entitled under the terms of a health plan. See Montana Code 33-32-102
  • Covered person: means a policyholder, a certificate holder, a member, a subscriber, an enrollee, or another individual participating in a health plan. See Montana Code 33-32-102
  • Emergency medical condition: has the meaning provided in 33-36-103. See Montana Code 33-32-102
  • Emergency services: has the meaning provided in 33-36-103. See Montana Code 33-32-102
  • Health insurance issuer: has the meaning provided in 33-22-140. See Montana Code 33-32-102
  • Network: means the group of participating providers providing services to a managed care plan. See Montana Code 33-32-102
  • Participating provider: means a health care provider who, under a contract with a health insurance issuer or with its contractor or subcontractor, has agreed to provide health care services to covered persons with the expectation of receiving payment, other than coinsurance, copayments, or deductibles, directly or indirectly from the health insurance issuer. See Montana Code 33-32-102
  • Person: means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, or any similar entity or combination of entities in this subsection. See Montana Code 33-32-102
  • provider: means a person, corporation, facility, or institution licensed by the state to provide, or otherwise lawfully providing, health care services, including but not limited to:

    (a)a physician, physician assistant, advanced practice registered nurse, health care facility as defined in 50-5-101, osteopath, dentist, nurse, optometrist, chiropractor, podiatrist, physical therapist, psychologist, licensed social worker, speech pathologist, audiologist, licensed addiction counselor, or licensed professional counselor; and

    (b)an officer, employee, or agent of a person described in subsection (18)(a) acting in the course and scope of employment. See Montana Code 33-32-102

  • Stabilize: means , with respect to an emergency condition, to ensure that no material deterioration of the condition is, within a reasonable medical probability, likely to result from or occur during the transfer of the individual from a facility. See Montana Code 33-32-102
  • Utilization review: means a set of formal techniques designed to monitor the use of or to evaluate the clinical necessity, appropriateness, efficacy, or efficiency of health care services, procedures, or settings. See Montana Code 33-32-102

(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)A health insurance issuer shall allow a covered person, the person’s authorized representative, and the person’s health care provider at least 24 hours following an emergency admission or the provision of emergency services to notify the health insurance issuer of the admission or provision of emergency services. If the admission or the emergency services occur on a holiday or weekend, a health insurance issuer shall allow notification no later than by the next business day following the admission or provision of emergency services.

(7)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.

(8)A health insurance issuer may not impose prior authorization or step therapy requirements for an oral therapy prescription used to treat opioid use disorder.

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