38.2-4312.3 - Patient access to emergency services. - Virginia Statutes

§ 38.2-4312.3. Patient access to emergency services.

A. A health maintenance organization shall have a system to provide to itsmembers, on a twenty-four-hour basis: (i) access to medical care or (ii)access by telephone to a physician or licensed health care professional withappropriate medical training who can refer or direct a member for promptmedical care in cases where there is an immediate, urgent need or medicalemergency. Access to a nonmedical professional who provides appropriateresponses to calls from members and providers concerning after-hours care andcovered benefits is not sufficient to meet the requirements of this section.

B. A health maintenance organization shall reimburse a hospital emergencyfacility and provider, less any applicable copayments, deductibles, orcoinsurance, for medical screening and stabilization services rendered tomeet the requirements of the Federal Emergency Medical Treatment and ActiveLabor Act (42 U.S.C. § 1395dd) and related to the condition for which themember presented in the hospital emergency facility if (i) the healthmaintenance organization or its designee or the member's primary carephysician or its designee authorized, directed, or referred a member to usethe hospital emergency facility; or (ii) the health maintenance organizationfails to have a system for provision of twenty-four-hour access in accordancewith subsection A above. For purposes of (i) above, a primary care physicianmay include a physician with whom the primary care physician has madearrangements for on-call backup coverage.

C. Each evidence of coverage provided by a health maintenance organizationshall include a description of procedures to be followed by the member foremergency services, including: (i) the appropriate use of hospital emergencyfacilities; (ii) the appropriate use of any urgent care facilities with whichthe health maintenance organization may contract; (iii) the potentialresponsibility of the member for payment for nonemergency services renderedin a hospital emergency facility; and (iv) the member's covered benefits foremergency services, including an explanation of the prudent laypersonstandard included in the definition of emergency services in § 38.2-4300.

(1997, c. 139.)