§ 58-3-190. Coverage required for emergency care. - North Carolina Statutes

§58‑3‑190.  Coverage required for emergency care.

(a)        Every insurer shallprovide coverage for emergency services to the extent necessary to screen andto stabilize the person covered under the plan and shall not require priorauthorization of the services if a prudent layperson acting reasonably wouldhave believed that an emergency medical condition existed. Payment of claimsfor emergency services shall be based on the retrospective review of thepresenting history and symptoms of the covered person.

(b)        With respect toemergency services provided by a health care provider who is not under contractwith the insurer, the services shall be covered if:

(1)        A prudent laypersonacting reasonably would have believed that a delay would worsen the emergency,or

(2)        The covered persondid not seek services from a provider under contract with the insurer becauseof circumstances beyond the control of the covered person.

(c)        An insurer that hasgiven prior authorization for emergency services shall cover the services andshall not retract the authorization after the services have been providedunless the authorization was based on a material misrepresentation about thecovered person's health condition made by the provider of the emergencyservices or the covered person.

(d)        Coverage ofemergency services shall be subject to coinsurance, co‑payments, anddeductibles applicable under the health benefit plan. An insurer shall notimpose cost‑sharing for emergency services provided under this sectionthat differs from the cost‑sharing that would have been imposed if thephysician or provider furnishing the services were a provider contracting withthe insurer.

(e)        Both the emergencydepartment and the insurer shall make a good faith effort to communicate witheach other in a timely fashion to expedite postevaluation or poststabilizationservices in order to avoid material deterioration of the covered person'scondition within a reasonable clinical confidence, or with respect to apregnant woman, to avoid material deterioration of the condition of the unbornchild within a reasonable clinical confidence.

(f)         Insurers shallprovide information to their covered persons on all of the following:

(1)        Coverage ofemergency medical services.

(2)        The appropriate useof emergency services, including the use of the "911" system andother telephone access systems utilized to access prehospital emergencyservices.

(3)        Any cost‑sharingprovisions for emergency medical services.

(4)        The process andprocedures for obtaining emergency services, so that covered persons arefamiliar with the location of in‑plan emergency departments and with thelocation and availability of other in‑plan settings at which coveredpersons may receive medical care.

(g)        As used in thissection, the term:

(1)        "Emergencymedical condition" means a medical condition manifesting itself by acutesymptoms of sufficient severity, including, but not limited to, severe pain, orby acute symptoms developing from a chronic medical condition that would lead aprudent layperson, possessing an average knowledge of health and medicine, toreasonably expect the absence of immediate medical attention to result in anyof the following:

a.         Placing the healthof an individual, or with respect to a pregnant woman, the health of the womanor her unborn child, in serious jeopardy.

b.         Serious impairmentto bodily functions.

c.         Serious dysfunctionof any bodily organ or part.

(2)        "Emergencyservices" means health care items and services furnished or required toscreen for or treat an emergency medical condition until the condition isstabilized, including prehospital care and ancillary services routinelyavailable to the emergency department.

(3)        "Health benefitplan" means any of the following if written by an insurer: an accident andhealth insurance policy or certificate; a nonprofit hospital or medical servicecorporation contract; a health maintenance organization subscriber contract; ora plan provided by a multiple employer welfare arrangement. "Healthbenefit plan" does not mean any plan implemented or administered throughthe Department of Health and Human Services or its representatives."Health benefit plan" also does not mean any of the following kindsof insurance:

a.         Accident.

b.         Credit.

c.         Disability income.

d.         Long‑term ornursing home care.

e.         Medicare supplement.

f.          Specified disease.

g.         Dental or vision.

h.         Coverage issued as asupplement to liability insurance.

i.          Workers'compensation.

j.          Medical paymentsunder automobile or homeowners insurance.

k.         Hospital income orindemnity.

l.          Insurance underwhich benefits are payable with or without regard to fault and that isstatutorily required to be contained in any liability policy or equivalent self‑insurance.

(4)        "Insurer"means an entity that writes a health benefit plan and that is an insurancecompany subject to this Chapter, a service corporation under Article 65 of thisChapter, a health maintenance organization under Article 67 of this Chapter, ora multiple employer welfare arrangement under Article 49 of this Chapter.

(5)        "Tostabilize" means to provide medical care that is appropriate to prevent amaterial deterioration of the person's condition, within reasonable medicalprobability, in accordance with the HCFA (Health Care Financing Administration)interpretative guidelines, policies and regulations pertaining toresponsibilities of hospitals in emergency cases (as provided under theEmergency Medical Treatment and Labor Act, section 1867 of the Social SecurityAct, 42 U.S.C.S. 1395dd), including medically necessary services and suppliesto maintain stabilization until the person is transferred. (1997‑443,s. 11A.122; 1997‑474, s. 2.)