§ 15-1A-14
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/md/insurance/15-1a-14A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
§15–1A–14.
(1)In this section the following words have the meanings indicated.
(2)“Emergency medical condition” means a medical condition, including a mental health condition or substance use disorder, that manifests itself by acute symptoms of such severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson, who possesses an average knowledge of health and medicine, to result in a condition described in § 1867(e)(1) of the Social Security Act.
(i)“Emergency services” means, with respect to an emergency medical condition:
1. a medical screening examination that is within the capability of the emergency department of a hospital or freestanding medical facility, including ancillary services routinely available to the emergency department to evaluate an emergency medical condition;
2. any other examination or treatment within the capabilities of the staff and facilities available at the hospital or freestanding medical facility that is necessary to stabilize the patient, regardless of the department of the hospital in which the examination or treatment is furnished; or
3. except as provided in subparagraph
(iii)of this paragraph, additional covered items and services furnished by a health care provider of emergency services that does not have a contractual relationship with the carrier after the patient is stabilized and as part of outpatient observation or an inpatient or outpatient stay with respect to the visit in which the services described in items 1 and 2 of this subparagraph are furnished.
(ii)“Emergency services” includes services described in subparagraph
(i)of this paragraph that are provided in specialized facilities that are staffed by behavioral health providers trained to provide crisis services.
(iii)Subject to § 14–205.2 of this article and § 19–710(p) of the Health – General Article, “emergency services” does not include items and services described in subparagraph (i)3 of this paragraph if all of the conditions in 45 C.F.R. § 149.410(b) are met.
(b)If a carrier provides or covers any benefits for emergency services in an emergency department of a hospital or freestanding medical facility, the carrier:
(1)may not require prior authorization for the emergency services;
(2)shall provide coverage for the emergency services regardless of whether the health care provider providing the emergency services has a contractual relationship with the carrier to furnish emergency services;
(3)may not limit what constitutes an emergency medical condition solely on the basis of diagnosis codes; and
(4)may not impose any other term or condition on the coverage for emergency services, except for:
(i)the exclusion or coordination of benefits;
(ii)a waiting period; and
(iii)applicable cost–sharing.
(c)If a health care provider of emergency services does not have a contractual relationship with the carrier to provide emergency services, the carrier:
(1)may not impose any administrative requirement or limitation on coverage that would be more restrictive than administrative requirements or limitations imposed on coverage for emergency services furnished by a health care provider with a contractual relationship with the carrier;
(2)subject to § 14–205.2 of this article and § 19–710.1 of the Health – General Article, may not impose any cost–sharing amount greater than the amount imposed for emergency services furnished by a health care provider with a contractual relationship with the carrier;
(3)shall calculate and apply the cost–sharing amounts in accordance with the requirements of 45 C.F.R. § 149.110(b)(3)(iii) and (v); and
(4)except as provided in § 14–205.2 of this article and § 19–710.1 of the Health – General Article, shall reimburse the health care provider in accordance with the requirements of 45 C.F.R. § 149.110(b)(3)(iv).