layperson acting reasonably would have believed that an emergency medical condition existed. RCW The plan must cover out-of-network emergency services necessary to Emergency 48.43.093 screen and stabilize a covered person if a prudent layperson would have Medical (1)(a); reasonably believed that use of an in-network emergency department Services (EHB) 42 U.S.C. would result in a delay that would worsen the emergency, or if a (Cont’d) provision of federal, state, or local law requires the use of a specific provider or facility. 45 C.F.R. The issuer must not require prior authorization of emergency services 147.138(b)(2) provided prior to the point of stabilization if a prudent layperson (ii) acting reasonably would have believed that an emergency medical condition existed and that use of an in-network emergency department would result in a delay that would worsen the emergency. 42 Emergency out-of-network coverage must be consistent with scope of regular contract benefits. RCW Coverage of emergency services may be subject to applicable 48.43.093 (1)(c) copayments, coinsurance, and deductibles, and an issuer may impose reasonable differential cost-sharing arrangements for out-of-network emergency services, if such differential between in-network and cost-sharing does not exceed dollars. RCW Differential cost sharing for out-of-network emergency services beyond 48.43.093 (1)(c) evaluation and stabilization may not be applied if: Due to circumstances beyond the enrollee’s control, the enrollee was unable to go to an in-network emergency department in a timely fashion without serious impairment to their health; or A prudent layperson possessing an average knowledge of health and medicine have reasonably believed that they would be unable to go to an in-network emergency department in a timely fashion
Emergency Medical Services (EHB) (Cont’d) layperson acting reasonably would have believed that an emergency medical condition existed. RCW 48.43.093 (1)(a); 42 U.S.C. The plan must cover out-of-network emergency services necessary to screen and stabilize a covered person if a prudent layperson would have reasonably believed that use of an in-network emergency department would result in a delay that would worsen the emergency, or if a provision of federal, state, or local law requires the use of a specific provider or facility. 45 C.F.R. 147.138(b)(2) (ii) The issuer must not require prior authorization of emergency services provided prior to the point of stabilization if a prudent layperson acting reasonably would have believed that an emergency medical condition existed and that use of an in-network emergency department would result in a delay that would worsen the emergency. 42 Emergency out-of-network coverage must be consistent with scope of regular contract benefits. RCW 48.43.093 (1)(c) Coverage of emergency services may be subject to applicable copayments, coinsurance, and deductibles, and an issuer may impose reasonable differential cost-sharing arrangements for out-of-network emergency services, if such differential between in-network and cost-sharing does not exceed dollars. RCW 48.43.093 (1)(c) Differential cost sharing for out-of-network emergency services beyond evaluation and stabilization may not be applied if: Due to circumstances beyond the enrollee’s control, the enrollee was unable to go to an in-network emergency department in a timely fashion without serious impairment to their health; or A prudent layperson possessing an average knowledge of health and medicine have reasonably believed that they would be unable to go to an in-network emergency department in a timely fashion
checklist-forms-2018-hmo-individual-analyst-checklist.docx