Low Income Health Programs: Out-of-Network Emergency Services
Payment for out-of-network emergency and specified post-stabilization services are available through the Low Income Health Programs (LIHPs) for services rendered to certain program enrollees. Payment conditions and rates for out-of-network emergency and post-stabilization services are outlined as follows.
As the Department of Health Care Services (DHCS) announced on January 5, 2011, local governmental entities have an opportunity to implement a LIHP to expand health care coverage to certain low-income adults who are between the ages of 19 and 64 with family incomes at or below 200 percent of the Federal Poverty Level (FPL). This program is authorized pursuant to Assembly Bill 342 (Chapter 723, Statutes of 2010) and AB 1066 (Chapter 86, Statutes of 2011) as delineated in the California Welfare and Institutions Code, Sections 15909-15916, and approved by the Centers for Medicare & Medicaid Services (CMS) under California’s section 1115(a) “Bridge to Reform” Medicaid Demonstration. The Special Terms and Conditions (STCs) provide details regarding DHCS operation of this Demonstration. The following ten counties implemented local LIHPs as of July 1, 2011: Alameda, Contra Costa, Kern, Los Angeles, Orange, San Diego, San Francisco, San Mateo, Santa Clara and Ventura. Local LIHPs for the remaining approved applicants will roll out on a flow basis as contracts are executed and programs are implemented. The programs will be effective through December 31, 2013, when the majority of enrollees become Medi-Cal eligible under national health care reform.
Each local LIHP will set its own income eligibility standard and may operate a Medicaid Coverage Expansion (MCE) Program for individuals with incomes at or below 133 percent of the FPL and an optional Health Care Coverage Initiative (HCCI) Program for individuals with incomes above 133 and up to 200 percent of the FPL. These local LIHPs will provide a limited scope of services, generally through closed provider networks.
LIHPs are not required to pay for emergency and specified post-stabilization services that are provided outside their network delivery system. Under limited circumstances, however, LIHPs will be required to pay for medically necessary emergency care services (including emergency transportation) and required post-stabilization care for MCE enrollees. The LIHP may deny payment for any out-of-network emergency and specified post-stabilization services that are not described in this bulletin. LIHPs are not required to pay for the out-of-network emergency and post-stabilization services described in this bulletin that are furnished to HCCI enrollees (STCs 63.e and f)
Scope of Covered Out-of-Network Emergency and Post-Stabilization Services
Local LIHPs must provide coverage for emergency services (including psychiatric emergency services that meet the definition of an emergency medical condition) provided in the United States in a hospital emergency room for emergency medical conditions and required post-stabilization care for MCE enrollees, whether the provider that renders the care is inside or outside of the LIHP network. If the emergency provider is not a LIHP network provider, the LIHP is required to pay for services rendered to an enrollee only if the enrollee falls within the MCE population and only if the requirements of this bulletin have been met.
- The LIHP will pay for medically necessary emergency services provided in the United States, District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands and American Samoa that would be covered under the Medi-Cal State Plan that are furnished by out-of-network providers to MCE enrollees, if they are provided in a hospital emergency room for an emergency medical condition.
- “Emergency services” are covered inpatient and outpatient services that are furnished by a provider that is qualified to furnish these services under the Medicaid program and are needed to evaluate or stabilize an emergency medical condition. LIHPs must pay for both the institutional and professional components of the services. LIHPs are not required to pay for emergency services furnished by providers that are not qualified to participate in Medicaid.
- Emergency outpatient services must be provided in a state-licensed, hospital-based emergency room. LIHPs are not required to pay providers for out-of-network emergency services provided in settings other than a hospital emergency room, such as a physician’s office or urgent care clinic, even if those services are for an emergency medical condition.
- Payments will extend to emergency services rendered in the inpatient hospital setting, if the patient is initially admitted to the emergency room and inpatient services are necessary to stabilize the patient.
- Prescription drugs and pharmaceutical services provided by out-of-network pharmacies will be covered if the drugs are prescribed in a hospital emergency room for an emergency medical condition, but only in amounts sufficient to last until the LIHP enrollee can reasonably be expected to have the prescription filled by a pharmacy in the LIHP network.
- An “emergency medical condition” is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in any of the following: placing the health of the individual in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.
- LIHPs are not required to pay for non-emergency services that are provided in hospital emergency rooms.
- LIHPs are not required to pay for screening examinations unless the MCE enrollee’s symptoms were of sufficient severity to have warranted emergency attention under the prudent layperson standard.
- LIHPs will pay for required post-stabilization care provided in the United States, District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands and American Samoa to MCE enrollees by out-of-network providers. Post-stabilization care services are limited to covered services approved by the LIHP in accordance with its established approval protocol. Post-stabilization care services are services related to an emergency medical condition that are provided after an enrollee is stabilized in order to maintain the stabilized condition or to improve or resolve the enrollee’s condition.
- LIHPs must pay for out-of-network emergency medical transportation (for example ,ambulance services) for MCE enrollees, only to the extent covered by the Medi-Cal State Plan. The requirements are discussed in paragraph four of the following section. LIHPs must cover emergency medical transportation to the nearest facility capable of meeting the medical needs of the patient for the covered emergency condition.
Payment for Out-of-Network Emergency and Required Post-stabilization Services for MCE Enrollees
The local LIHP’s financial liability in instances of emergency and post-stabilization services provided by out-of-network providers is limited to MCE enrollees. Payment to providers is contingent on the satisfaction of two conditions: notifying the local LIHP of the patient’s emergency room visit and adhering to local LIHP protocols for approval of post-stabilization services.
- Out-of-network providers must notify the local LIHP within 24 hours of registering/admitting the patient into the emergency room. Information about how to notify the local LIHP is located on the Identification (ID) card of the LIHP enrollee. If the local LIHP is not notified within 24 hours, then it is not required to pay the hospital or any other provider for the services. The local LIHP designates network and out-of-network providers based on contractual and reimbursement arrangements that the local LIHP negotiates with providers. Local LIHPs operated by counties that also operate Designated Public Hospitals will determine whether the 24-hour notice requirement applies to services furnished before the patient is enrolled in the LIHP, during a period in which coverage was effective.
- Each claim for admission to an inpatient hospital setting from an emergency room must be accompanied by a physician’s, dentist’s or podiatrist’s written statement supporting the medically necessary admission. Local LIHPs are required to pay for services provided after admission only if these requirements are met.
- Out-of-network providers must obtain approval for post-stabilization care according to the protocol established by the local LIHP in the enrollee’s county of residence. Failure to obtain authorization in accordance with the local LIHP’s protocols will result in denial of payment.
- Each claim for emergency medical transportation services must be accompanied by a written statement by the transportation provider or by a physician, podiatrist or dentist that supports a finding that the services were medically necessary and justified and that an emergency existed. The provider should describe the circumstances necessitating the emergency service, including the name of the person or agency requesting the service, the nature and time of the emergency, the facility to which the patient was transported, relevant clinical information about the patient's condition, why the emergency services rendered were considered to be immediately necessary and the name of the physician accepting responsibility for the patient. Local LIHPs are required to pay for out-of-network emergency medical transportation services only if these requirements are met.
- Local LIHPs may impose procedural requirements related to a provider’s submission of claims and/or invoices (such as time limits) for out-of-network emergency and post-stabilization services. Upon presentation of a LIHP ID card by the MCE enrollee or other verification of MCE eligibility by the provider, the out-of-network provider may submit a claim and/or invoice to the local LIHP for reimbursement for the period of retroactive eligibility, if any, subject to the local LIHP’s procedural requirements.
- Local LIHPs shall ensure that enrollees are provided with ID cards that include information that emergency service providers can use to contact the local LIHP to notify it of emergency services, including inpatient admissions, and to obtain authorization for post-stabilization services. Local LIHPs may also publish the information about notification and authorization protocols on their websites.
Payment Rates and Balance Billing
Out-of-network providers must accept LIHP rates as payment in full for services rendered to MCE enrollees and may not balance bill MCE enrollees or otherwise hold MCE enrollees liable for payment. If the local LIHP denies payment for emergency services or post-stabilization care based on the provider’s failure to notify the local LIHP or comply with the local LIHP’s protocol, the provider may not bill the MCE enrollee for the services.
Local LIHPs may pay the following amounts for medically necessary out-of-network emergency and post stabilization services, including services provided out of state, but only as required by the Code of Federal Regulations, Title 42, Section 431.52(b)(1):
- Except for covered inpatient hospital services, local LIHPs will pay 30 percent of the applicable regulatory fee-for-service rate under the California State Plan (excluding any supplemental payments) for emergency and post-stabilization services, including emergency medical transportation services, emergency department services and professional services provided in the emergency room or inpatient hospital setting (California Code of Regulations, Title 22, Sections 51501- 51535.7).
- For medically necessary emergency mental health services provided by out-of-network providers, the local LIHP may pay 30 percent of the average rate that is paid by the mental health plan in the county of the LIHP enrollees’ residence.
- For medically necessary emergency inpatient hospital services and approved inpatient post-stabilization services following an emergency admission, local LIHPs may pay 30 percent of the applicable regional unweighted average of per diem rates paid to Selective Provider Contracting Program (SPCP)-contracted hospitals. The relevant SPCP rates are accessible on the MMCD All Plan & Policy Letters – Subject Listing page under the subject listing of “Rates.”