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.

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.