without serious impairment to their health. Required 45 CFR In addition to the in-network cost-sharing, plan can balance bill Terms of §147.138(b)(3) individual for the excess of out-of-network provider charges, over the Emergency (i) minimum amount the plan is required to pay (see Coverage 45 CFR Plan complies with the above cost-sharing requirements for (Cont’d) §147.138(b) network emergency services if it provides coverage at the level of the (3)(i)(A-C) greatest of these three amounts: (1) the median in-network rate, (2) the usual, customary and reasonable rate (or similar rate determined using the plan or issuer’s general formula for determining payments for out-of-network services, or (3) the Medicare rate. Note: See regulations for more specifics. RCW For inpatient admission, the issuer may require notification within a 48.43.093 (2) specified time frame or as soon thereafter as medically possible, but no less than twenty-four hours. RCW 48.43.093 The issuer must have someone available 24/7 for preauth of (1)(d) or post-stabilization services RCW The issuer may reserve the right to require transfer of a hospitalized 48.43.093 (2) enrollee upon stabilization.
Required Terms of Emergency Coverage (Cont’d) without serious impairment to their health. 45 CFR §147.138(b)(3) (i) In addition to the in-network cost-sharing, plan can balance bill individual for the excess of out-of-network provider charges, over the minimum amount the plan is required to pay (see 45 CFR §147.138(b) (3)(i)(A-C) Plan complies with the above cost-sharing requirements for emergency services if it provides coverage at the level of the greatest of these three amounts: (1) the median in-network rate, (2) the usual, customary and reasonable rate (or similar rate determined using the plan or issuer’s general formula for determining payments for out-of-network services, or (3) the Medicare rate. Note: See regulations for more specifics. RCW 48.43.093 (2) For inpatient admission, the issuer may require notification within a specified time frame or as soon thereafter as medically possible, but no less than twenty-four hours. RCW 48.43.093 (1)(d) The issuer must have someone available 24/7 for preauth of or post-stabilization services RCW 48.43.093 (2) The issuer may reserve the right to require transfer of a hospitalized enrollee upon stabilization. network
checklist-forms-2018-hmo-individual-analyst-checklist.docx