Common use of Emergency Room Services Co-Payment Clause in Contracts

Emergency Room Services Co-Payment. HIP A co-payment will apply to non-emergency use of an emergency room by HIP members. Other than HIP members exempt from cost-sharing as described in Section 13.1.4, all HIP members will be subject to a co-payment for all non-urgent use of hospital emergency department services. The member will incur an $8 co-payment for any inappropriate emergency department visit. Providers will collect the co-payment from members, and POWER Account funds cannot be used by the member to pay the co-payment. The Contractor shall include co-payment information on the member’s ID card which directs the provider to call the Contractor for specific co-payment amount due, as the member may have received a copay waiver by calling the Contractor’s nurse hotline, as described below. All members shall receive an appropriate medical screening examination under section 1867 of the Emergency Medical Treatment and Active Labor Act. The co-payment shall be waived or returned if the member is found to have an emergency condition, as defined in section 1867(e)(1)(A) of the Emergency Medical Treatment and Active Labor Act, or if the member is admitted to the hospital within twenty-four (24) hours of the original visit. In addition, the member co-payment shall be waived for any member who contacts the Contractor’s 24-hour Nurse Call Line prior to utilizing a hospital emergency department. If a member contacts the Nurse Call Line prior to seeking emergency care, the member will not be subject to the prudent layperson review to determine whether an emergency medical condition exists for purposes of applying the co-payment. The Contractor shall have processes in place to communicate emergency department co-payment exemptions on a prospective basis. In addition, the Contractor shall track and monitor whether members who contacted the 24-Hour Nurse Call Line were advised to seek emergency services. Assuming a member has an available and accessible alternate non-emergency services provider and a determination has been made that the member does not have an emergency medical condition and did call the Contractor’s 24-hour Nurse Call Line, in accordance with 42 C.F.R. § 447.54(d), the hospital shall inform the member before providing non-emergency services that: ▪ The hospital may require payment of the co-payment before the service can be provided; ▪ The hospital provides the name and location of an alternate non- emergency services provider that is actually available and accessible; ▪ An alternate provider can provide the services without the imposition of the co- payment; and ▪ The hospital provides a referral to coordinate scheduling of this treatment. The Contractor shall instruct its provider network of the emergency room services co- payment policy and procedure, such as the hospital’s notification responsibilities (outlined above) and the circumstances under which the hospital shall waive or return the co- payment.