<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".08" citation="COMAR 10.67.05.08" title_num="10" subtitle_num="67" chapter_num="05" heading="Emergency Services Access.">
  <paragraph num="A.">
    <text>An MCO shall develop and maintain policies and procedures for the adequate provision of emergency services for all its enrollees, including:</text>
    <paragraph num="(1)">
      <text>Instituting and monitoring a system for responding to enrollees' emergency medical conditions, with provisions for immediate attention to and appropriate disposition of emergency calls; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Informing and educating its enrollees in the procedures to be followed in the event of an emergency, whether within or outside of the MCO's service area.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>An MCO shall provide medically necessary emergency services 24 hours per day, 7 days per week.</text>
  </paragraph>
  <paragraph num="C.">
    <text>An MCO shall maintain an emergency telephone service, with a physician on call, for the purpose of rendering medical advice and authorizing care at other facilities when use of the MCO's own facilities is impractical.</text>
  </paragraph>
  <paragraph num="D.">
    <text>An MCO may provide emergency services access through adequate and appropriate triage assessments performed by qualified medical professionals.</text>
  </paragraph>
  <paragraph num="E.">
    <text>An MCO shall utilize the trauma triage and transfer protocols established through the Maryland Institute for Emergency Medical Services Systems (MIEMSS) as the basis for directing the severely injured enrollee to the most appropriate level designated trauma center.</text>
  </paragraph>
  <paragraph num="F.">
    <text>An MCO shall reimburse, within 30 days of invoice, the undisputed claims of hospital emergency facilities and providers for the following services provided to the MCO's enrollees:</text>
    <paragraph num="(1)">
      <text>Emergency services, as defined in COMAR 10.67.01.01B;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Medical screening services based on the federal Emergency Medical Treatment and Active Labor Act (EMTALA);</text>
    </paragraph>
    <paragraph num="(3)">
      <text>If the MCO authorized, referred, or otherwise instructed the enrollee to use the emergency facility, medically necessary services that are related to the emergency condition, including poststabilization services; and</text>
    </paragraph>
    <paragraph num="(4)">
      <text>If the MCO fails to provide 24 hour access to a physician, medically necessary services that relate to the condition presented and that are provided by the provider in an emergency facility to the enrollee.</text>
    </paragraph>
  </paragraph>
  <paragraph num="G.">
    <text>Poststabilization Services. The MCO may not require preapproval of, and is financially responsible for, poststabilization services obtained in or outside of the MCO's network and administered to maintain, improve, or resolve the enrollee's stabilized condition if:</text>
    <paragraph num="(1)">
      <text>The MCO does not respond to a request for a preapproval within 1 hour;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The MCO cannot be contacted; or</text>
    </paragraph>
    <paragraph num="(3)">
      <text>The MCO representative and the treating physician cannot reach an agreement concerning the enrollee's care, and an MCO physician is not available for consultation, in which case:</text>
      <paragraph num="(a)">
        <text>The MCO shall give the treating physician the opportunity to consult with an MCO physician; and</text>
      </paragraph>
      <paragraph num="(b)">
        <text>The treating physician may continue care of the patient until a plan is reached or one of the following criteria is met:</text>
        <paragraph num="(i)">
          <text>An MCO physician with privileges at the treating hospital assumes responsibility for the enrollee's care;</text>
        </paragraph>
        <paragraph num="(ii)">
          <text>An MCO physician assumes responsibility for the enrollee's care through transfer;</text>
        </paragraph>
        <paragraph num="(iii)">
          <text>An MCO representative and the treating physician reach an agreement concerning the enrollee's care; or</text>
        </paragraph>
        <paragraph num="(iv)">
          <text>The enrollee is discharged.</text>
        </paragraph>
      </paragraph>
    </paragraph>
  </paragraph>
  <paragraph num="H.">
    <text>An MCO may require that any continuing care be obtained from the MCO's providers or from providers approved by the MCO when the following conditions are satisfied:</text>
    <paragraph num="(1)">
      <text>The enrollee's medical condition is appropriately stabilized and permits transferring responsibility for the enrollee's care, without medically harmful consequences, to these providers; and</text>
    </paragraph>
    <paragraph num="(2)">
      <text>The transfer is consistent with the requirements of the federal Emergency Medical Treatment and Active Labor Act (EMTALA).</text>
    </paragraph>
  </paragraph>
</regulation>