Emergency and Urgent Care Services. (1) Contractor shall establish written policies and procedures and monitoring systems that provide for Emergency Services including post-stabilization care services, and Urgent Services for all Members on a 24-hour, 7-day-a-week basis consistent with OAR 410- 141-3140 and 42 CFR 438.114. The emergency response system must include the necessary array of services to respond to mental health crises, that may include crisis hotline, mobile crisis team, walk-in/drop- off crisis center, crisis apartment/respite and short-term stabilization unit capabilities. Contractor’s policies and procedures shall include an emergency response system that provides an immediate, initial and/or limited duration response for potential mental health emergency situations or emergency situations that may include mental health conditions, which consist of: screening to determine the nature of the situation and the person’s immediate need for Covered Services; capacity to conduct the elements of a Mental Health Assessment that are needed to determine the interventions necessary to begin stabilizing the crisis situation; development of a written initial services plan at the conclusion of the Mental Health Assessment; provision of Covered Services and Outreach needed to address the urgent or emergency situation; and linkage with the public sector crisis services, such as pre-commitment.

Emergency and Urgent Care Services. An emergency can be any medical or behavioral condition that would lead you to believe that the condition, sickness, or injury is of such a nature that failure to obtain immediate medical care could result in placing your health in serious jeopardy. You are not required to get prior approval from MetroPlus Managed Long Term Care to be treated for emergency medical conditions. If you need Emergency Services, call 911 right away or visit the nearest hospital or emergency room. Wherever you have an emergency or urgent situation, get the care first, and then contact your Care Manager as soon as you are able to. It’s important that you, a family member or a friend call your Care Manager as soon as possible at 1- 855-355-MLTC (6582) after an emergency or urgent care service. TTY users can call 711 Your Care Manager can reschedule any planned services you might miss during that time, and start to make any needed changes to your Care Plan. He or she will help you avoid any unnecessary gaps in the services you might need. If you have Medicare and/or Medicare supplemental coverage and benefits and/or Medicaid, your emergency care will be covered by them and by your MLTC plan. Non-Covered Services You can still receive the following services listed below. Medicare and/or Medicaid may cover these services on a fee-for-service basis from a provider who accepts Medicare and/or Medicaid. These Are Some Examples of Non-Covered Services:  Inpatient and Outpatient Hospital Services  Primary Care and Specialty Doctor Services  Outpatient Clinic Services  Laboratory Services  X-Ray and other Radiology Services  Chiropractic Services  Chronic Renal Dialysis  Emergency Transportation  Emergency Room (ER) visits  Non Medical Transportation  Cosmetic surgery if not medically needed  Personal and Comfort items  Infertility Treatment  Services of providers that are not part of the plan (unless MetroPlus MLTC refers you to that provider)  Mental Health and Substance Abuse Services  Prescription and Non-Prescription Drugs  Assisted Living Program  Family Planning Services  Office of Mental Retardation and Developmental Disabilities (OMRDD) Services Our Network Providers Members are required to use our Network Providers for all covered services. Your Care Manager will also coordinate any services you may require that are not covered by MetroPlus Managed Long Term Care. Your Care Manager will work with your doctor and other providers involved in your care to make thi...

Emergency and Urgent Care Services. Members experiencing an Emergency Medical Condition, may call 911 (where available) or go to the nearest emergency department. Emergency Services do not need prior authorization. Emergency Services for Emergency Medical Conditions are covered when provided by Physicians and medical practitioners other than Physicians anywhere in the world, as long as the Services would have been covered under this section S (subject to the Exclusions and Limitations section of this Service Agreement) if received from Physicians. Emergency Services are available from Health Plan emergency departments 24 hours a day, seven days a week.

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Urgent Care Services All Medically Necessary Covered Services received in Urgent Care Centers, Retail Clinics or your Primary Care Physician’s office after-hours to treat an Urgent Medical Condition will be covered by AvMed. Any request for reimbursement of payment made by a Member for services received must be filed within 90 days or as soon as reasonably possible but not later than one year unless the Member was legally incapacitated. If Urgent Medical Services and Care are required while outside the continental United States, Alaska or Hawaii, it is the Member’s responsibility to pay for such services at the time they are received. For information on filing a Claim for such services, see Part XIII. REVIEW PROCEDURES AND HOW TO APPEAL A CLAIM (BENEFIT) DENIAL.
Emergency Care Services If you experience a medical emergency while traveling outside our service area, go to the nearest emergency or urgent care facility. When you receive Out-of-Area covered healthcare services outside our service area and the claim is processed through the BlueCard Program, the amount you pay for the Out-of-Area Covered healthcare services, if not a flat dollar copayment, is calculated based on the lower of: • the billed charges for your Out-of-Area covered healthcare services; or • the negotiated price that the Host Blue makes available to us. Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to your healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settlements, incentive payments and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price. Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims, as noted above. However, such adjustments will not affect the price we have used for your claim because they will not be applied after a claim has already been paid. Negotiated (non–BlueCard Program) Arrangements With respect to one or more Host Blues, in certain instances, instead of using the BlueCard Program, we may process your claims for covered healthcare services through Negotiated Arrangements for National Accounts. The amount you pay for covered healthcare services under this arrangement will be calculated based on the negotiated price (refer to the description of negotiated price in the BlueCard® Program section above) made available to us by the Host Blue.
Emergency and urgently needed care outside the service area Professional services of a physician, emergency room treatment, and inpatient hospital services are covered at eighty percent (80%) of the first two thousand dollars ($2,000) of the charges incurred per insurance year, and one-hundred percent (100%) thereafter. The maximum eligible out-of-pocket expense per individual per year for this benefit is four hundred dollars ($400). This benefit is not available when the member’s condition permits him or her to receive care within the network of the plan in which the individual is enrolled.
Outpatient emergency and urgicenter services within the service area The emergency room copay applies to all outpatient emergency visits that do not result in hospital admission within twenty-four (24) hours. The urgicenter copay is the same as the primary care clinic office visit copay.
Emergency Medical Services The City’s Fire Department and MedStar (or other entity engaged by the City after the Effective Date) will provide emergency medical services.
Urgent Care This plan covers services received at an urgent care center. For other services, such as surgery or diagnostic tests, the amount that you pay is based on the type of service being provided. See Summary of Medical Benefits for details. Follow-up care (such as suture removal or wound care) should be obtained from your primary care provider or specialist.
Prevention Care Services and Early Detection Services See Prevention and Early Detection Services section for details. 0% Not Covered Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible Not Covered
Emergency Medical Care a. How to appropriately use Emergency Services and facilities, including a description of the services offered by the Member Services Call Center;
Office Visits (other than Preventive Care Services) This plan covers office and clinic visits to diagnose or treat a sickness or injury. Office visit copayments differ depending on the type of provider you see. This plan covers physician visits in your home if you have an injury or illness that: • confines you to your home; or • requires special transportation; and • because of this injury or illness, you are physically unable to travel to the provider’s
Covered Health Care Services We agree to provide coverage for medically necessary covered health care services listed in this agreement. If a service or category of service is not specifically listed as covered, it is not covered under this agreement. Only services that we have reviewed and determined are eligible for coverage under this agreement are covered. All other services are not covered. See Section 1.4 for how we identify new services and our guidelines for reviewing and making coverage determinations. We only cover a service listed in this agreement if it is medically necessary. We review medical necessity in accordance with our medical policies and related guidelines. The term medically necessary is defined in Section 8.0 - Glossary. It does not include all medically appropriate services. The amount of coverage we provide for each health care service differs according to whether or not the service is received: • as an inpatient; • as an outpatient; • in your home; • in a doctor’s office; or • from a pharmacy. Also coverage differs depending on whether: • the health care provider is a network provider or non-network provider; • deductibles (if any), copayments, or maximum benefit apply; • you have reached your plan year maximum out-of-pocket expense; • there are any exclusions from coverage that apply; or • our allowance for a covered health care service is less than the amount of your copayment and deductible (if any). In this case, you will be responsible to pay up to our allowance when services are rendered by a network provider. Please see the Summary of Medical Benefits to determine the benefit limits and amount that you pay for the covered health care services listed below. Please see the Summary of Pharmacy Benefits to determine the benefit limits and amount that you pay for prescription drug and diabetic equipment and supplies purchased at a pharmacy.

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