36-2909. Emergency hospital services;
retroactive coverage; costs
A. If a member receives emergency hospitalization and medical care on or after the
date of eligibility determination or the eligibility effective date from a hospital that
does not have a contract to care for the person, the administration or the contractor is
liable only for the costs of emergency hospitalization and medical care up to the time
the person is discharged or until the time the person can be transferred. The
administration or the prepaid capitated provider is also liable for further care in the
following circumstances:
1. If the attending physician reasonably determines that the condition of the
person receiving emergency hospitalization and medical care is such that it is medically
inadvisable to transfer the person.
2. If the administration or the contractor does not transport the person from the
hospital providing care after it has been determined that the person can be transferred.
B. Except for charges for services subject to section 36-2908, subsection B, all
charges incurred by an eligible person who has not yet enrolled for hospitalization and
medical care under subsection A of this section are payable by the administration
pursuant to section 36-2903.01, subsection G or H or as specified in contract by the
contractor pursuant to the subcontracted rate or section 36-2904, subsection H or I.
C. As a condition to receiving reimbursement pursuant to subsection B of this
section, a hospital that is not a contractor or subcontractor under the system must
designate a primary care physician or primary care practitioner to act as a coordinator
of the services provided to persons who have been determined eligible but have not yet
enrolled, before the persons' enrollment, discharge or transfer.
D. Emergency hospitalization and medical care provided pursuant to this section
shall be in accordance with rules adopted pursuant to section 36-2903.01, subsection E in
order to qualify for reimbursement.
E. The director shall adopt rules that provide that members who have been
determined eligible shall be enrolled with contractors as soon as practicable.
F. This section does not prevent the director or the contractor from denying
payment for hospitalization or medical care that is not authorized or deemed medically
necessary in accordance with rules adopted by the director.
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