Common use of Emergency Care Clause in Contracts

Emergency Care. MCO policy and procedures, covered Medicaid services, claims adjudication methodology, and reimbursement performance for emergency care services must comply with all applicable state and federal laws, rules, and regulations, including 42 CFR §438.114, whether the provider is in the MCO’s network or out-of-network. The MCO must cover and pay for all medical, behavioral, inpatient pharmacy, dental services, and emergency transportation described in Contract Appendix A that may be required on an emergency basis twenty-four (24) hours each day, seven (7) days a week, either in the MCO’s facilities or through arrangements approved by BMS.3 The terms “Emergency Care,” “Urgent Care,” “Emergency Medical Conditions,” and “Emergency Dental Condition” are defined in Article II of this Contract. Reimbursement for emergency services provided in-network and out-of-network must be equal to the Medicaid prevailing FFS reimbursement level for emergency services, less any payments for direct costs of medical education and direct costs of graduate medical education included in the FFS reimbursement rate. In emergency situations, no preauthorization is required to provide necessary medical care and enrollees may seek care from non-participating providers. The MCO must reimburse for emergency transportation at a rate of at least one hundred percent (100%) of the Medicaid fee schedule for emergency ground transportation and emergency air transportation. The MCO is required to inform enrollees regarding their rights of access to and coverage of emergency services, both inside and outside of the plan’s network. Coverage of emergency services by the MCO will be determined under the “prudent layperson” standard. That standard considers the symptoms (including severe pain) of the presenting enrollee. The MCO may not limit what constitutes an Emergency Medical or Behavioral Health Condition on the basis of lists of diagnoses or symptoms. The MCO may not deny payment for treatment obtained when an enrollee had an emergency medical or dental condition in which the absence of immediate medical attention would have placed the health of the individual, or in the case of a pregnant women, the woman or her unborn child, in serious jeopardy; resulted in serious impairment to bodily functions; or resulted in 3 Qualified medical personnel must be accessible twenty-four (24) hours each day, seven (7) days a week, to provide direction to patients in need of urgent or emergency care. Such medical personnel include, but are not limited to, physicians, physicians on-call, licensed practical nurses, or registered nurses. serious dysfunction of any bodily organ or part. The MCO may not deny payment for treatment when a representative of the MCO instructs the enrollee to seek emergency care. The MCO may not retroactively deny a claim for an emergency screening examination because the condition, which appeared to be an emergency medical condition under the prudent layperson standard (as defined above), turned out to be non-emergency in nature. Hospitals are required to evaluate each enrollee presenting for services in the emergency room and must be reimbursed for this evaluation. If emergency room care is later deemed non-emergency, the MCO is not permitted to bill the Medicaid patient; the MCO and the hospital must determine who pays for this care, except for the applicable non-emergency copays paid by the enrollee. The MCO may not require prior authorization for emergency services. This applies to out-of- network as well as to in-network services which an enrollee seeks in an emergency. Placement in an IMD is considered an emergency service and as such, the MCO cannot require a prior authorization for placement in the IMD the first forty-eight (48) hours. A medical screening examination needed to diagnose an enrollee’s emergency medical condition must be provided in a hospital-based emergency department that meets the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 CFR §489.20, §489.24 and §438.114(b)&(c)). The MCO must pay for the enrollee’s emergency medical screening examination, as required by 42 U.S.C. §1395dd. The MCO must reimburse providers for both the physician's services and the hospital's emergency services, including the emergency room and its ancillary services, so long as the “prudent layperson” standard (as defined above) has been met.

Emergency Care. MCO policy and procedures, covered Medicaid and WVCHIP services, claims adjudication methodology, and reimbursement performance for emergency care services must comply with all applicable state and federal laws, rules, and regulations, including 42 CFR §438.114, whether the provider is in the MCO’s network or out-of-network. The MCO must cover and pay for all medical, behavioral, inpatient pharmacy, dental services, and emergency transportation described in Contract Appendix A that may be required on an emergency basis twenty-four (24) hours each day, seven (7) days a week, either in the MCO’s facilities or through arrangements approved by BMS.3 The terms “Emergency Care,” “Urgent Care,” “Emergency Medical Conditions,” and “Emergency Dental Condition” are defined in Article II of this Contract. Reimbursement for emergency services provided in-network and out-of-network must be equal to the Medicaid prevailing FFS reimbursement level for emergency services, less any payments for direct costs of medical education and direct costs of graduate medical education included in the FFS reimbursement rate. In emergency situations, no preauthorization is required to provide necessary medical care and enrollees may seek care from non-participating providers. The MCO must reimburse for emergency transportation at a rate of at least one hundred percent (100%) of the Medicaid fee schedule for emergency ground transportation and emergency air transportation. The MCO is required to inform enrollees regarding their rights of access to and coverage of emergency services, both inside and outside of the plan’s network. Coverage of emergency services by the MCO will be determined under the “prudent layperson” standard. That standard considers the symptoms (including severe pain) of the presenting enrollee. The MCO may not limit what constitutes an Emergency Medical or Behavioral Health Condition on the basis of lists of diagnoses or symptoms. The MCO may not deny payment for treatment obtained when an enrollee had an emergency medical or dental condition in which the absence of immediate medical attention would have placed the health of the individual, or in the case of a pregnant women, the woman or her unborn child, in serious jeopardy; resulted in serious impairment to bodily functions; or resulted in 3 Qualified medical personnel must be accessible twenty-four (24) hours each day, seven (7) days a week, to provide direction to patients in need of urgent or emergency care. Such medical personnel include, but are not limited to, physicians, physicians on-call, licensed practical nurses, or registered nurses. serious dysfunction of any bodily organ or part. The MCO may not deny payment for treatment when a representative of the MCO instructs the enrollee to seek emergency care. The MCO may not retroactively deny a claim for an emergency screening examination because the condition, which appeared to be an emergency medical condition under the prudent layperson standard (as defined above), turned out to be non-emergency in nature. Hospitals are required to evaluate each enrollee presenting for services in the emergency room and must be reimbursed for this evaluation. If emergency room care is later deemed non-emergency, the MCO is not permitted to bill the Medicaid patient; the MCO and the hospital must determine who pays for this care, except for the applicable non-emergency copays paid by the enrollee. The MCO may not require prior authorization for emergency services. This applies to out-of- network as well as to in-network services which an enrollee seeks in an emergency. Placement in an IMD is considered an emergency service and as such, the MCO cannot require a prior authorization for placement in the IMD the first forty-eight (48) hours. A medical screening examination needed to diagnose an enrollee’s emergency medical condition must be provided in a hospital-based emergency department that meets the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 CFR §489.20, §489.24 and §438.114(b)&(c)). The MCO must pay for the enrollee’s emergency medical screening examination, as required by 42 U.S.C. §1395dd. The MCO must reimburse providers for both the physician's services and the hospital's emergency services, including the emergency room and its ancillary services, so long as the “prudent layperson” standard (as defined above) has been met.

Emergency Care. MCO policy and procedures, covered Medicaid services, claims adjudication methodology, and reimbursement performance for emergency care services must comply with all applicable state and federal laws, rules, and regulations, including 42 CFR §438.114, whether the provider is in the MCO’s network or out-of-network. The MCO must cover and pay for all medical, behavioral, inpatient pharmacy, and dental services, and emergency transportation services described in Contract Appendix A that may be required on an emergency basis twenty-four (24) hours each day, seven (7) days a week, either in the MCO’s facilities or through arrangements approved by BMS.3 BMS.2 The terms “Emergency Care,” “Urgent Care,” “Emergency Medical Conditions,” and “Emergency Dental Condition” are defined in Article II of this Contract. Reimbursement for emergency services provided in-network and out-of-network must be equal to the Medicaid prevailing FFS fee-for-service (FFS) reimbursement level for emergency services, less any payments for direct costs of medical education and direct costs of graduate medical education included in the FFS reimbursement rate. In emergency situations, no preauthorization pre-authorization is required to provide necessary medical care and enrollees may seek care from non-participating providers. The MCO must reimburse for emergency transportation at a rate of at least one hundred percent (100%) of the Medicaid fee schedule for emergency ground transportation and emergency air transportation. The MCO is required to inform enrollees regarding their rights of access to and coverage of emergency services, both inside and outside of the plan’s network. Coverage of emergency services by the MCO will be determined under the “prudent layperson” standard. That standard considers the symptoms (including severe pain) of the presenting enrollee. The MCO may cannot limit what constitutes an Emergency Medical or Behavioral Health Condition on the basis of lists of diagnoses or symptoms. The MCO may not deny payment for treatment obtained when an enrollee had an emergency medical or dental condition in which the absence of immediate medical attention would have placed the health of the individual, or in the case of a pregnant women, the woman or her unborn child, in serious jeopardy; resulted in serious impairment to bodily functions; or resulted in 3 Qualified medical personnel must be accessible twenty-four (24) hours each day, seven (7) days a week, to provide direction to patients in need of urgent or emergency care. Such medical personnel include, but are not limited to, physicians, physicians on-call, licensed practical nurses, or registered nurses. serious dysfunction of any bodily organ or part. The MCO may not deny payment for treatment when a representative of the MCO instructs the enrollee to seek emergency care. The MCO may not retroactively deny a claim for an emergency screening examination because the condition, which appeared to be an emergency medical condition under the prudent layperson standard (as defined above), turned out to be non-emergency in nature. Hospitals are required to evaluate each enrollee presenting for services in the emergency room and must be reimbursed for this evaluation. If emergency room care is later deemed non-emergency, the MCO is not permitted to bill the Medicaid patient; the MCO and the hospital must determine who pays for this care, except for the applicable non-emergency copays paid by the enrollee. The MCO may not require prior authorization for emergency services. This applies to out-of- network as well as to in-network services which an enrollee seeks in an emergency. Placement in an IMD is considered an emergency service and as such, the MCO cannot require a prior authorization for placement in the IMD the first forty-eight (48) hours. A medical screening examination needed to diagnose an enrollee’s emergency medical condition must be provided in a hospital-based emergency department that meets the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 CFR §489.20, §489.24 and §438.114(b)&(c)). The MCO must pay for the enrollee’s emergency medical screening examination, as required by 42 U.S.C. §1395dd. The MCO must reimburse providers for both the physician's services and the hospital's emergency services, including the emergency room and its ancillary services, so long as the “prudent layperson” standard (as defined above) has been met.

Emergency Care. MCO policy and procedures, covered Medicaid services, claims adjudication methodology, and reimbursement performance for emergency care services must comply with all applicable state and federal laws, rules, and regulations, including 42 CFR §438.114, whether the provider is in the MCO’s network or out-of-network. The MCO must cover and pay for all medical, behavioral, inpatient pharmacy, dental services, and emergency transportation described in Contract Appendix A that may be required on an emergency basis twenty-four (24) hours each day, seven (7) days a week, either in the MCO’s facilities or through arrangements approved by BMS.3 The terms “Emergency Care,” “Urgent Care,” “Emergency Medical Conditions,” and “Emergency Dental Condition” are defined in Article II of this Contract. Reimbursement for emergency services provided in-network and out-of-network must be equal to the Medicaid prevailing FFS reimbursement level for emergency services, less any payments for direct costs of medical education and direct costs of graduate medical education included in the FFS reimbursement rate. In emergency situations, no preauthorization is required to provide necessary medical care and enrollees may seek care from non-participating providers. The MCO must reimburse for emergency transportation at a rate of at least one one-hundred percent (100%) of the Medicaid fee schedule for emergency ground transportation and emergency air transportation. The MCO is required to inform enrollees regarding their rights of access to and coverage of emergency services, both inside and outside of the plan’s network. Coverage of emergency services by the MCO will be determined under the “prudent layperson” standard. That standard considers the symptoms (including severe pain) of the presenting enrollee. The MCO may not limit what constitutes an Emergency Medical or Behavioral Health Condition on the basis of lists of diagnoses or symptoms. The MCO may not deny payment for treatment obtained when an enrollee had an emergency medical or dental condition in which the absence of immediate medical attention would have placed the health of the individual, or in the case of a pregnant women, the woman or her unborn child, in serious jeopardy; resulted in serious impairment to bodily functions; or resulted in 3 Qualified medical personnel must be accessible twenty-four (24) hours each day, seven (7) days a week, to provide direction to patients in need of urgent or emergency care. Such medical personnel include, but are not limited to, physicians, physicians on-call, licensed practical nurses, or registered nurses. serious dysfunction of any bodily organ or part. The MCO may not deny payment for treatment when a representative of the MCO instructs the enrollee to seek emergency care. The MCO may not retroactively deny a claim for an emergency screening examination because the condition, which appeared to be an emergency medical condition under the prudent layperson standard (as defined above), turned out to be non-emergency in nature. Hospitals are required to evaluate each enrollee presenting for services in the emergency room and must be reimbursed for this evaluation. If emergency room care is later deemed non-emergency, the MCO is not permitted to bill the Medicaid patient; the MCO and the hospital must determine who pays for this care, except for the applicable non-emergency copays paid by the enrollee. The MCO may not require prior authorization for emergency services. This applies to out-of- network as well as to in-network services which an enrollee seeks in an emergency. Placement in an IMD is considered an emergency service and as such, the MCO cannot require a prior authorization for placement in the IMD the first forty-eight (48) hours. A medical screening examination needed to diagnose an enrollee’s emergency medical condition must be provided in a hospital-based emergency department that meets the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 CFR §489.20, §489.24 and §438.114(b)&(c)). The MCO must pay for the enrollee’s emergency medical screening examination, as required by 42 U.S.C. §1395dd. The MCO must reimburse providers for both the physician's services and the hospital's emergency services, including the emergency room and its ancillary services, so long as the “prudent layperson” standard (as defined above) has been met.

Emergency Care. MCO policy and procedures, covered Medicaid services, claims adjudication methodology, and reimbursement performance for emergency care services must comply with all applicable state and federal laws, rules, and regulations, including 42 CFR §438.114, whether the provider is in the MCO’s network or out-of-network. The MCO must cover and pay for all medical, behavioral, inpatient pharmacy, dental services, and emergency transportation described in Contract Appendix A that may be required on an emergency basis twenty-four (24) hours each day, seven (7) days a week, either in the MCO’s facilities or through arrangements approved by BMS.3 DHHR.2 The terms “Emergency Care,” “Urgent Care,” “Emergency Medical Conditions,” and “Emergency Dental Condition” are defined in Article II of this Contract. Reimbursement for emergency services provided in-network and out-of-network must be equal to the Medicaid prevailing FFS reimbursement level for emergency services, less any payments for direct costs of medical education and direct costs of graduate medical education included in the FFS reimbursement rate. In emergency situations, no preauthorization pre-authorization is required to provide necessary medical care and enrollees may seek care from non-participating providers. The MCO must reimburse for Medcaid emergency transportation at a rate of at least one one-hundred percent (100%) of the Medicaid fee schedule for emergency ground transportation and emergency air transportation. The MCO is required to inform enrollees or their representatives regarding their rights of access to and coverage of emergency services, both inside and outside of the plan’s network. Coverage of emergency services by the MCO will be determined under the “prudent layperson” standard. That standard considers the symptoms (including severe pain) of the presenting enrollee. The MCO may not limit what constitutes an Emergency Medical or Behavioral Health Condition on the basis of lists of diagnoses or symptoms. The MCO may not deny payment for treatment obtained when an enrollee had an emergency medical or dental condition in which the absence of immediate medical attention would have placed the health of the individual, or in the case of a pregnant women, the woman or her unborn child, in serious jeopardy; resulted in serious impairment to bodily functions; or resulted in 3 Qualified medical personnel must be accessible twenty-four (24) hours each day, seven (7) days a week, to provide direction to patients in need of urgent or emergency care. Such medical personnel include, but are not limited to, physicians, physicians on-call, licensed practical nurses, or registered nurses. serious dysfunction of any bodily organ or part. The MCO may not deny payment for treatment when a representative of the MCO instructs the enrollee to seek emergency care. The MCO may not retroactively deny a claim for an emergency screening examination because the condition, which appeared to be an emergency medical condition under the prudent layperson standard (as defined above), turned out to be non-emergency in nature. Hospitals are required to evaluate each enrollee presenting for services in the emergency room and must be reimbursed for this evaluation. If emergency room care is later deemed non-emergency, the MCO is not permitted to bill the Medicaid patient; the MCO and the hospital must should determine who pays for this care, except for the applicable non-emergency copays paid by the enrollee. The MCO may not require prior authorization for emergency services. This applies to out-of- network as well as to in-network services which an enrollee seeks in an emergency. Placement in 2 Qualified medical personnel must be accessible twenty-four (24) hours each day, seven (7) days a week, to provide direction to patients in need of urgent or emergency care. Such medical personnel include, but are not limited to, physicians, physicians on-call, licensed practical nurses, or registered nurses. an IMD is considered an emergency service services and as such, the MCO cannot require a prior authorization for placement in the IMD the first forty-eight (48) hours. A medical screening examination needed to diagnose an enrollee’s emergency medical condition must be provided in a hospital-based emergency department that meets the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 CFR §489.20, §489.24 and §438.114(b)&(c)). The MCO must pay for the enrollee’s emergency medical screening examination, as required by 42 U.S.C. §1395dd. The MCO must reimburse the providers for both the physician's services and the hospital's emergency services, including the emergency room and its ancillary services, so long as the “prudent layperson” standard (as defined above) has been met.

Emergency Care. MCO policy and procedures, covered Medicaid services, claims adjudication methodology, and reimbursement performance for emergency care services must comply with all applicable state and federal laws, rules, and regulations, including 42 CFR §438.114, whether the provider is in the MCO’s network or out-of-network. The MCO must cover and pay for all medical, behavioral, inpatient pharmacy, dental services, and emergency transportation described in Contract Appendix A that may be required on an emergency basis twenty-four (24) hours each day, seven (7) days a week, either in the MCO’s facilities or through arrangements approved by BMS.3 the Department.2 The terms “Emergency Care,” “Urgent Care,” “Emergency Medical Conditions,” and “Emergency Dental Condition” are defined in Article II of this Contract. 2 Qualified medical personnel must be accessible twenty-four (24) hours each day, seven (7) days a week, to provide direction to patients in need of urgent or emergency care. Such medical personnel include, but are not limited to, physicians, physicians on-call, licensed practical nurses, or registered nurses. Reimbursement for emergency services provided in-network and out-of-network must be equal to the Medicaid prevailing FFS reimbursement level for emergency services, less any payments for direct costs of medical education and direct costs of graduate medical education included in the FFS reimbursement rate. In emergency situations, no preauthorization pre-authorization is required to provide necessary medical care and enrollees may seek care from non-participating providers. The MCO must reimburse for Medicaid emergency transportation at a rate of at least one one- hundred percent (100%) of the Medicaid fee schedule for emergency ground transportation and emergency air transportation. Upon BMS notification to the MCO of any changes to the emergency transportation reimbursement rates, the MCO must update payment rates to emergency transportation providers to the effective date in the notification by BMS. If payment was already made for a claim within the current SFY with a date of service on or after the effective date of the rate change, the MCO must reprocess the claim to reimburse at the new rate. Claims reprocessing at the new rate includes those claims with dates of service in a prior SFY if the payment had been made in the current SFY. The new payment rate must be loaded into the MCO’s claims payment system within thirty (30) calendar days of notification of the payment rate change. The MCO is required to inform enrollees or their representatives regarding their rights of access to and coverage of emergency services, both inside and outside of the plan’s network. Coverage of emergency services by the MCO will be determined under the “prudent layperson” standard. That standard considers the symptoms (including severe pain) of the presenting enrollee. The MCO may not limit what constitutes an Emergency Medical or Behavioral Health Condition on the basis of lists of diagnoses or symptoms. The MCO may not deny payment for treatment obtained when an enrollee had an emergency medical or dental condition in which the absence of immediate medical attention would have placed the health of the individual, or in the case of a pregnant women, the woman or her unborn child, in serious jeopardy; resulted in serious impairment to bodily functions; or resulted in 3 Qualified medical personnel must be accessible twenty-four (24) hours each day, seven (7) days a week, to provide direction to patients in need of urgent or emergency care. Such medical personnel include, but are not limited to, physicians, physicians on-call, licensed practical nurses, or registered nurses. serious dysfunction of any bodily organ or part. The MCO may not deny payment for treatment when a representative of the MCO instructs the enrollee to seek emergency care. The MCO may not retroactively deny a claim for an emergency screening examination because the condition, which appeared to be an emergency medical condition under the prudent layperson standard (as defined above), turned out to be non-emergency in nature. Hospitals are required to evaluate each enrollee presenting for services in the emergency room and must be reimbursed for this evaluation. If emergency room care is later deemed non-emergency, the MCO is not permitted to bill the Medicaid patient; the MCO and the hospital must determine who pays for this care, except for the applicable non-emergency copays paid by the enrollee. The MCO may not require prior authorization for emergency services. This applies to out-of- network as well as to in-network services which an enrollee seeks in an emergency. Placement in an IMD is considered an emergency service and as such, the MCO cannot require a prior authorization for placement in the IMD the first forty-eight (48) hours. A medical screening examination needed to diagnose an enrollee’s emergency medical condition must be provided in a hospital-based emergency department that meets the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 CFR §489.20, §489.24 and §438.114(b)&(c)). The MCO must pay for the enrollee’s emergency medical screening examination, as required by 42 U.S.C. §1395dd. The MCO must reimburse providers for both the physician's services and the hospital's emergency services, including the emergency room and its ancillary services, so long as the “prudent layperson” standard (as defined above) has been met.

Emergency Care. MCO policy and procedures, covered Medicaid services, claims adjudication methodology, and reimbursement performance for emergency care services must comply with all applicable state and federal laws, rules, and regulations, including 42 CFR §438.114, whether the provider is in the MCO’s network or out-of-network. The MCO must cover and pay for all medical, behavioral, inpatient pharmacy, dental services, and emergency transportation described in Contract Appendix A that may be required on an emergency basis twenty-four (24) hours each day, seven (7) days a week, either in the MCO’s facilities or through arrangements approved by BMS.3 DHHR.2 The terms “Emergency Care,” “Urgent Care,” “Emergency Medical Conditions,” and “Emergency Dental Condition” are defined in Article II of this Contract. Reimbursement for emergency services provided in-network and out-of-network must be equal to the Medicaid prevailing FFS reimbursement level for emergency services, less any payments for direct costs of medical education and direct costs of graduate medical education included in the FFS reimbursement rate. In emergency situations, no preauthorization pre-authorization is required to provide necessary medical care and enrollees may seek care from non-participating providers. The MCO must reimburse for Medcaid emergency transportation at a rate of at least one one-hundred percent (100%) of the Medicaid fee schedule for emergency ground transportation and emergency air transportation. The MCO is required to inform enrollees or their representatives regarding their rights of access to and coverage of emergency services, both inside and outside of the plan’s network. Coverage of emergency services by the MCO will be determined under the “prudent layperson” standard. That standard considers the symptoms (including severe pain) of the presenting enrollee. The MCO may not limit what constitutes an Emergency Medical or Behavioral Health Condition on the basis of lists of diagnoses or symptoms. The MCO may not deny payment for treatment obtained when an enrollee had an emergency medical or dental condition in which the absence of immediate medical attention would have placed the health of the individual, or in the case of a pregnant women, the woman or her unborn child, in serious jeopardy; resulted in serious impairment to bodily functions; or resulted in 3 Qualified medical personnel must be accessible twenty-four (24) hours each day, seven (7) days a week, to provide direction to patients in need of urgent or emergency care. Such medical personnel include, but are not limited to, physicians, physicians on-call, licensed practical nurses, or registered nurses. serious dysfunction of any bodily organ or part. The MCO may not deny payment for treatment when a representative of the MCO instructs the enrollee to seek emergency care. The MCO may not retroactively deny a claim for an emergency screening examination because the condition, which appeared to be an emergency medical condition under the prudent layperson standard (as defined above), turned out to be non-emergency in nature. Hospitals are required to evaluate each enrollee presenting for services in the emergency room and must be reimbursed for this evaluation. If emergency room care is later deemed non-emergency, the MCO is not permitted to bill the Medicaid patient; the MCO and the hospital must should determine who pays for this care, except for the applicable non-emergency copays paid by the enrollee. The MCO may not require prior authorization for emergency services. This applies to out-of- network as well as to in-network services which an enrollee seeks in an emergency. Placement in an IMD is considered an emergency service services and as such, the MCO cannot require a prior authorization for placement in the IMD the first forty-eight (48) hours. A medical screening examination needed to diagnose an enrollee’s emergency medical condition must be provided in a hospital-based emergency department that meets the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 CFR §489.20, §489.24 and §438.114(b)&(c)). The MCO must pay for the enrollee’s emergency medical screening examination, as required by 42 U.S.C. §1395dd. The MCO must reimburse the providers for both the physician's services and the hospital's emergency services, including the emergency room and its ancillary services, so long as the “prudent layperson” standard (as defined above) has been met.

Emergency Care. MCO policy and procedures, covered Medicaid services, claims adjudication methodology, and reimbursement performance for emergency care services must comply with all applicable state and federal laws, rules, and regulations, including 42 CFR §438.114, whether the provider is in the MCO’s network or out-of-network. The MCO must cover and pay for all medical, behavioral, inpatient pharmacy, and dental services, and emergency transportation services described in Contract Appendix Exhibit A that may be required on an emergency basis twenty-four (24) 24 hours each day, seven (7) days a week, either in the MCO’s facilities or through arrangements approved by BMS.3 BMS.2 The terms “Emergency Careemergency care,” “Urgent Careurgent care,” “Emergency Medical Conditionsemergency medical conditions,” and “Emergency Dental Conditionemergency dental condition” are defined in Article II of this Contractcontract. Reimbursement for emergency services provided in-network and out-of-network must be equal to the Medicaid prevailing FFS fee-for-service (FFS) reimbursement level for emergency services, less any payments for direct costs of medical education and direct costs of graduate medical education included in the FFS reimbursement rate. In emergency situations, no preauthorization pre-authorization is required to provide necessary medical care and enrollees may seek care from non-participating providers. The MCO must reimburse for emergency transportation at a rate of at least one hundred percent (100%) of the Medicaid fee schedule for emergency ground transportation and emergency air transportation. The MCO is required to inform enrollees regarding their rights of access to and coverage of emergency services, both inside and outside of the plan’s network. If the enrollee is participating in a chronic care health home, the health home must be notified of any use of emergency services and be notified of any inpatient admission or discharge of a health home member that the MCO learns of through its inpatient admission initial authorization and concurrent review processes within 24 hours. Coverage of emergency services by the MCO will be determined under the “prudent layperson” standard. That standard considers the symptoms (including severe pain) of the presenting enrollee. The MCO may not limit what constitutes an Emergency Medical or Behavioral Health Condition on the basis of lists of diagnoses or symptoms. The MCO may not deny payment for treatment obtained when an enrollee had an emergency medical or dental condition in which the absence of immediate medical attention would have placed the health of the individual, or in the case of a pregnant women, the woman or her unborn child, in serious jeopardy; resulted in serious impairment to bodily functions; or resulted in 3 Qualified medical personnel must be accessible twenty-four (24) hours each day, seven (7) days a week, to provide direction to patients in need of urgent or emergency care. Such medical personnel include, but are not limited to, physicians, physicians on-call, licensed practical nurses, or registered nurses. serious dysfunction of any bodily organ or part. The MCO may not deny payment for treatment when a representative of the MCO instructs the enrollee to seek emergency care. The MCO may not retroactively deny a claim for an emergency screening examination because the condition, which appeared to be an emergency medical condition under the prudent layperson standard (as defined above), turned out to be non-emergency in nature. Hospitals are required to evaluate each enrollee presenting for services in the emergency room and must be reimbursed for this evaluation. If emergency room care is later deemed non-emergency, the MCO is not permitted to bill the Medicaid patient; the MCO and the hospital must determine who pays for this care, except for the applicable non-emergency copays paid by the enrollee. The MCO may not require prior authorization for emergency services. This applies to out-of- network as well as to in-network services which an enrollee seeks in an emergency. Placement in an IMD is considered an emergency service and as such, the MCO cannot require a prior authorization for placement in the IMD the first forty-eight (48) hours. A medical screening examination needed to diagnose an enrollee’s emergency medical condition must be provided in a hospital-based emergency department that meets the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 CFR §489.20, §489.24 and §438.114(b)&(c)). The MCO must pay for the enrollee’s emergency medical screening examination, as required by 42 U.S.C. §1395dd. The MCO must reimburse providers for both the physician's services and the hospital's emergency services, including the emergency room and its ancillary services, so long as the “prudent layperson” standard (as defined above) has been met.

Emergency Care. MCO policy and procedures, covered Medicaid services, claims adjudication methodology, and reimbursement performance for emergency care services must comply with all applicable state and federal laws, rules, and regulations, including 42 CFR §438.114, whether the provider is in the MCO’s network or out-of-network. The MCO must cover and pay for all medical, behavioral, inpatient pharmacy, dental services, and emergency transportation described in Contract Appendix A that may be required on an emergency basis twenty-four (24) hours each day, seven (7) days a week, either in the MCO’s facilities or through arrangements approved by BMS.3 The terms “Emergency Care,” “Urgent Care,” “Emergency Medical Conditions,” and “Emergency Dental Condition” are defined in Article II of this Contract. Reimbursement for emergency services provided in-network and out-of-network must be equal to the Medicaid prevailing FFS reimbursement level for emergency services, less any payments for direct costs of medical education and direct costs of graduate medical education included in the FFS reimbursement rate. In emergency situations, no preauthorization pre-authorization is required to provide necessary medical care and enrollees may seek care from non-participating providers. The MCO must reimburse for emergency transportation at a rate of at least one one-hundred percent (100%) of the Medicaid fee schedule for emergency ground transportation and emergency air transportation. The MCO is required to inform enrollees regarding their rights of access to and coverage of emergency services, both inside and outside of the plan’s network. 3 Qualified medical personnel must be accessible twenty-four (24) hours each day, seven (7) days a week, to provide direction to patients in need of urgent or emergency care. Such medical personnel include, but are not limited to, physicians, physicians on-call, licensed practical nurses, or registered nurses. Coverage of emergency services by the MCO will be determined under the “prudent layperson” standard. That standard considers the symptoms (including severe pain) of the presenting enrollee. The MCO may not limit what constitutes an Emergency Medical or Behavioral Health Condition on the basis of lists of diagnoses or symptoms. The MCO may not deny payment for treatment obtained when an enrollee had an emergency medical or dental condition in which the absence of immediate medical attention would have placed the health of the individual, or in the case of a pregnant women, the woman or her unborn child, in serious jeopardy; resulted in serious impairment to bodily functions; or resulted in 3 Qualified medical personnel must be accessible twenty-four (24) hours each day, seven (7) days a week, to provide direction to patients in need of urgent or emergency care. Such medical personnel include, but are not limited to, physicians, physicians on-call, licensed practical nurses, or registered nurses. serious dysfunction of any bodily organ or part. The MCO may not deny payment for treatment when a representative of the MCO instructs the enrollee to seek emergency care. The MCO may not retroactively deny a claim for an emergency screening examination because the condition, which appeared to be an emergency medical condition under the prudent layperson standard (as defined above), turned out to be non-emergency in nature. Hospitals are required to evaluate each enrollee presenting for services in the emergency room and must be reimbursed for this evaluation. If emergency room care is later deemed non-emergency, the MCO is not permitted to bill the Medicaid patient; the MCO and the hospital must should determine who pays for this care, except for the applicable non-emergency copays paid by the enrollee. The MCO may not require prior authorization for emergency services. This applies to out-of- network as well as to in-network services which an enrollee seeks in an emergency. Placement in an IMD is considered an emergency service and as such, the MCO cannot require a prior authorization for placement in the IMD the first forty-eight (48) hours. A medical screening examination needed to diagnose an enrollee’s emergency medical condition must be provided in a hospital-based emergency department that meets the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 CFR §489.20, §489.24 and §438.114(b)&(c)). The MCO must pay for the enrollee’s emergency medical screening examination, as required by 42 U.S.C. §1395dd. The MCO must reimburse the providers for both the physician's services and the hospital's emergency services, including the emergency room and its ancillary services, so long as the “prudent layperson” standard (as defined above) has been met.

Emergency Care. MCO policy and procedures, covered Medicaid services, claims adjudication methodology, and reimbursement performance for emergency care services must comply with all applicable state and federal laws, rules, and regulations, including 42 CFR §438.114, whether the provider is in the MCO’s network or out-of-network. The MCO must cover and pay for all medical, behavioral, inpatient pharmacy, dental services, and emergency transportation described in Contract Appendix A that may be required on an emergency basis twenty-four (24) hours each day, seven (7) days a week, either in the MCO’s facilities or through arrangements approved by BMS.3 DHHR.2 The terms “Emergency Care,” “Urgent Care,” “Emergency Medical Conditions,” and “Emergency Dental Condition” are defined in Article II of this Contract. Reimbursement for emergency services provided in-network and out-of-network must be equal to the Medicaid prevailing FFS reimbursement level for emergency services, less any payments for direct costs of medical education and direct costs of graduate medical education included in the FFS reimbursement rate. In emergency situations, no preauthorization pre-authorization is required to provide necessary medical care and enrollees may seek care from non-participating providers. The MCO must reimburse for Medcaid emergency transportation at a rate of at least one one-hundred percent (100%) of the Medicaid fee schedule for emergency ground transportation and emergency air transportation. The MCO is required to inform enrollees or their representatives regarding their rights of access to and coverage of emergency services, both inside and outside of the plan’s network. Coverage of emergency services by the MCO will be determined under the “prudent layperson” standard. That standard considers the symptoms (including severe pain) of the presenting enrollee. The MCO may not limit what constitutes an Emergency Medical or Behavioral Health Condition on the basis of lists of diagnoses or symptoms. The MCO may not deny payment for treatment obtained when an enrollee had an emergency medical or dental condition in which the absence of immediate medical attention would have placed the health of the individual, or in the case of a pregnant women, the woman or her unborn child, in serious jeopardy; resulted in serious impairment to bodily functions; or resulted in 3 Qualified medical personnel must be accessible twenty-four (24) hours each day, seven (7) days a week, to provide direction to patients in need of urgent or emergency care. Such medical personnel include, but are not limited to, physicians, physicians on-call, licensed practical nurses, or registered nurses. serious dysfunction of any bodily organ or part. The MCO may not deny payment for treatment when a representative of the MCO instructs the enrollee to seek emergency care. The MCO may not retroactively deny a claim for an emergency screening examination because the condition, which appeared to be an emergency medical condition under the prudent layperson standard (as defined above), turned out to be non-emergency in nature. Hospitals are required to evaluate each enrollee presenting for services in the emergency room and must be reimbursed for this evaluation. If emergency room care is later deemed non-emergency, the MCO is not permitted to bill the Medicaid patient; the MCO and the hospital must determine who pays for this care, except for the applicable non-emergency copays paid by the enrollee. The MCO may not require prior authorization for emergency services. This applies to out-of- network as well as to in-network services which an enrollee seeks in an emergency. Placement in an IMD is considered an emergency service and as such, the MCO cannot require a prior authorization for placement in the IMD the first forty-eight (48) hours. A medical screening examination needed to diagnose an enrollee’s emergency medical condition must be provided in a hospital-based emergency department that meets the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 CFR §489.20, §489.24 and §438.114(b)&(c)). The MCO must pay for the enrollee’s emergency medical screening examination, as required by 42 U.S.C. §1395dd. The MCO must reimburse providers for both the physician's services and the hospital's emergency services, including the emergency room and its ancillary services, so long as the “prudent layperson” standard (as defined above) has been met.

Emergency Care. MCO policy and procedures, covered Medicaid and WVCHIP services, claims adjudication methodology, and reimbursement performance for emergency care services must comply with all applicable state and federal laws, rules, and regulations, including 42 CFR §438.114, whether the provider is in the MCO’s network or out-of-network. The MCO must cover and pay for all medical, behavioral, inpatient pharmacy, dental services, and emergency transportation described in Contract Appendix A that may be required on an emergency basis twenty-four (24) hours each day, seven (7) days a week, either in the MCO’s facilities or through arrangements approved by BMS.3 The terms “Emergency Care,” “Urgent Care,” “Emergency Medical Conditions,” and “Emergency Dental Condition” are defined in Article II of this Contract. Reimbursement for emergency services provided in-network and out-of-network must be equal to the Medicaid prevailing FFS reimbursement level for emergency services, less any payments for direct costs of medical education and direct costs of graduate medical education included in the FFS reimbursement rate. In emergency situations, no preauthorization is required to provide necessary medical care and enrollees may seek care from non-participating providers. The MCO must reimburse for emergency transportation at a rate of at least one hundred percent (100%) of the Medicaid fee schedule for emergency ground transportation and emergency air transportation. Upon BMS notification to the MCO of any changes to the emergency transportation reimbursement rates, the MCO must update payment rates to emergency transportation providers to the effective date in the notification by BMS. If payment was already made for a claim within the current SFY with a date of service on or after the effective date of the rate change, the MCO must reprocess the claim to reimburse at the new rate. Claims reprocessing at the new rate includes those claims with dates of service in a prior SFY if the payment had been made in the current SFY. The new payment rate must be loaded into the MCO’s claims payment system within thirty (30) calendar days of notification of the payment rate change. The MCO is required to inform enrollees regarding their rights of access to and coverage of emergency services, both inside and outside of the plan’s network. Coverage of emergency services by the MCO will be determined under the “prudent layperson” standard. That standard considers the symptoms (including severe pain) of the presenting enrollee. The MCO may not limit what constitutes an Emergency Medical or Behavioral Health Condition on the basis of lists of diagnoses or symptoms. The MCO may not deny payment for treatment obtained when an enrollee had an emergency medical or dental condition in which the absence of immediate medical attention would have placed the health of the individual, or in the case of a pregnant women, the woman or her unborn child, in serious jeopardy; resulted in serious impairment to bodily functions; or resulted in 3 Qualified medical personnel must be accessible twenty-four (24) hours each day, seven (7) days a week, to provide direction to patients in need of urgent or emergency care. Such medical personnel include, but are not limited to, physicians, physicians on-call, licensed practical nurses, or registered nurses. serious dysfunction of any bodily organ or part. The MCO may not deny payment for treatment when a representative of the MCO instructs the enrollee to seek emergency care. The MCO may not retroactively deny a claim for an emergency screening examination because the condition, which appeared to be an emergency medical condition under the prudent layperson standard (as defined above), turned out to be non-emergency in nature. Hospitals are required to evaluate each enrollee presenting for services in the emergency room and must be reimbursed for this evaluation. If emergency room care is later deemed non-emergency, the MCO is not permitted to bill the Medicaid patient; the MCO and the hospital must determine who pays for this care, except for the applicable non-emergency copays paid by the enrollee. The MCO may not require prior authorization for emergency services. This applies to out-of- network as well as to in-network services which an enrollee seeks in an emergency. Placement in an IMD is considered an emergency service and as such, the MCO cannot require a prior authorization for placement in the IMD the first forty-eight (48) hours. A medical screening examination needed to diagnose an enrollee’s emergency medical condition must be provided in a hospital-based emergency department that meets the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 CFR §489.20, §489.24 and §438.114(b)&(c)). The MCO must pay for the enrollee’s emergency medical screening examination, as required by 42 U.S.C. §1395dd. The MCO must reimburse providers for both the physician's services and the hospital's emergency services, including the emergency room and its ancillary services, so long as the “prudent layperson” standard (as defined above) has been met.

Emergency Care. MCO policy and procedures, covered Medicaid services, claims adjudication methodology, and reimbursement performance for emergency care services must comply with all applicable state and federal laws, rules, and regulations, including 42 CFR §438.114, whether the provider is in the MCO’s network or out-of-network. The MCO must shall cover and pay for all medical, behavioral, inpatient pharmacy, dental services, and emergency transportation medical services described in Contract Appendix Exhibit A that may be required on an emergency basis twenty-four (24) 24 hours each day, seven (7) days a week, either in the MCO’s facilities or through arrangements approved by BMS.3 BMS.4 The terms “Emergency Careemergency care,” “Urgent Care,” “Emergency Medical Conditionsurgent care,” and “Emergency Dental Conditionemergency medical conditions” are defined in Article II of this Contractcontract. Reimbursement for emergency services provided in-network and out-of-network must be equal to the Medicaid prevailing FFS fee-for-service (FFS) reimbursement level for emergency services, less any payments for direct costs of medical education and direct costs of graduate medical education included in the FFS reimbursement rate. In emergency situations, no preauthorization pre-authorization is required to provide necessary medical care and enrollees may seek care from non-participating nonparticipating providers. The MCO must reimburse for emergency transportation at a rate of at least one hundred percent (100%) of the Medicaid fee schedule for emergency ground transportation and emergency air transportation. The MCO is required to inform enrollees regarding their rights of access to and coverage of emergency services, both inside and outside of the plan’s network. Coverage of emergency services by the MCO will be determined under the “prudent layperson” standard. That standard considers the symptoms (including severe pain) of the presenting enrollee. The MCO may not limit what constitutes an Emergency Medical or Behavioral Health Condition on the basis of lists of diagnoses or symptoms. The MCO may not deny payment for treatment obtained when an enrollee had an emergency medical or dental condition in which the absence of immediate medical attention would have placed the health of the individual, or in the case of a pregnant women, the woman or her unborn child, in serious jeopardy; resulted in serious impairment to bodily functions; or resulted in 3 Qualified medical personnel must be accessible twenty-four (24) hours each day, seven (7) days a week, to provide direction to patients in need of urgent or emergency care. Such medical personnel include, but are not limited to, physicians, physicians on-call, licensed practical nurses, or registered nurses. serious dysfunction of any bodily organ or part. The MCO may not deny payment for treatment when a representative of the MCO instructs the enrollee to seek emergency care. The MCO may not retroactively deny a claim for an emergency screening examination because the condition, which appeared to be an emergency medical condition under the prudent layperson standard (as defined above), turned out to be non-emergency in nature. Hospitals are required to evaluate each enrollee presenting for services in the emergency room and must be reimbursed for this evaluation. If emergency room care is later deemed non-emergency, the MCO is not permitted to bill xxxx the Medicaid patient; the MCO and the hospital must should determine who pays for this care, except for the applicable non-emergency copays paid by the enrollee. The MCO may not require prior authorization for emergency services. This applies to out-of- network as well as to in-network services which an enrollee seeks in an emergency. Placement in The MCO shall not limit what constitutes an IMD is considered an emergency service and as such, the MCO cannot require a prior authorization for placement in the IMD the first forty-eight (48) hours. A medical screening examination needed to diagnose an enrollee’s emergency medical condition must be provided in a hospital-based emergency department that meets on the requirements basis of the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 CFR §489.20, §489.24 and §438.114(b)&(c)). The MCO must pay for the enrollee’s emergency medical screening examination, as required by 42 U.S.C. §1395dd. The MCO must reimburse providers for both the physician's services and the hospital's emergency services, including the emergency room and its ancillary services, so long as the “prudent layperson” standard (as defined above) has been metlists of diagnosis or symptoms.

Emergency Care. MCO policy and procedures, covered Medicaid services, claims adjudication methodology, and reimbursement performance for emergency care services must comply with all applicable state and federal laws, rules, and regulations, including 42 CFR §438.114, whether the provider is in the MCO’s network or out-of-network. The MCO must cover and pay for all medical, behavioral, inpatient pharmacy, dental services, and emergency transportation described in Contract Appendix A that may be required on an emergency basis twenty-four (24) hours each day, seven (7) days a week, either in the MCO’s facilities or through arrangements approved by BMS.3 The terms “Emergency Care,” “Urgent Care,” “Emergency Medical Conditions,” and “Emergency Dental Condition” are defined in Article II of this Contract. Reimbursement for emergency services provided in-network and out-of-network must be equal to the Medicaid prevailing FFS reimbursement level for emergency services, less any payments for direct costs of medical education and direct costs of graduate medical education included in the FFS reimbursement rate. In emergency situations, no preauthorization pre-authorization is required to provide necessary medical care and enrollees may seek care from non-participating providers. The MCO must reimburse for emergency transportation at a rate of at least one one-hundred percent (100%) of the Medicaid fee schedule for emergency ground transportation and emergency air transportationtransportation effective January 1, 2019. The MCO is required to inform enrollees regarding their rights of access to and coverage of emergency services, both inside and outside of the plan’s network. 3 Qualified medical personnel must be accessible twenty-four (24) hours each day, seven (7) days a week, to provide direction to patients in need of urgent or emergency care. Such medical personnel include, but are not limited to, physicians, physicians on-call, licensed practical nurses, or registered nurses. Coverage of emergency services by the MCO will be determined under the “prudent layperson” standard. That standard considers the symptoms (including severe pain) of the presenting enrollee. The MCO may not limit what constitutes an Emergency Medical or Behavioral Health Condition on the basis of lists of diagnoses or symptoms. The MCO may not deny payment for treatment obtained when an enrollee had an emergency medical or dental condition in which the absence of immediate medical attention would have placed the health of the individual, or in the case of a pregnant women, the woman or her unborn child, in serious jeopardy; resulted in serious impairment to bodily functions; or resulted in 3 Qualified medical personnel must be accessible twenty-four (24) hours each day, seven (7) days a week, to provide direction to patients in need of urgent or emergency care. Such medical personnel include, but are not limited to, physicians, physicians on-call, licensed practical nurses, or registered nurses. serious dysfunction of any bodily organ or part. The MCO may not deny payment for treatment when a representative of the MCO instructs the enrollee to seek emergency care. The MCO may not retroactively deny a claim for an emergency screening examination because the condition, which appeared to be an emergency medical condition under the prudent layperson standard (as defined above), turned out to be non-emergency in nature. Hospitals are required to evaluate each enrollee presenting for services in the emergency room and must be reimbursed for this evaluation. If emergency room care is later deemed non-emergency, the MCO is not permitted to bill the Medicaid patient; the MCO and the hospital must should determine who pays for this care, except for the applicable non-emergency copays paid by the enrollee. The MCO may not require prior authorization for emergency services. This applies to out-of- network as well as to in-network services which an enrollee seeks in an emergency. Placement in an IMD is considered an emergency service and as such, the MCO cannot require a prior authorization for placement in the IMD the first forty-eight (48) hours. A medical screening examination needed to diagnose an enrollee’s emergency medical condition must be provided in a hospital-based emergency department that meets the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 CFR §489.20, §489.24 and §438.114(b)&(c)). The MCO must pay for the enrollee’s emergency medical screening examination, as required by 42 U.S.C. §1395dd. The MCO must reimburse the providers for both the physician's services and the hospital's emergency services, including the emergency room and its ancillary services, so long as the “prudent layperson” standard (as defined above) has been met.