Emergency services requirements; restrictive formulary requirements
See bold text below:
Every managed care plan shall include provisions that:
(1)(A) In the event that a patient seeks emergency services and if necessary in the opinion of the emergency health care provider responsible for the patient’s emergency care and treatment and warranted by his or her evaluation, such emergency provider may initiate necessary intervention to stabilize the condition of the patient without seeking or receiving prospective authorization by the managed care entity or managed care plan. No managed care entity or private health benefit plan may subsequently deny payment for an evaluation, diagnostic testing, or treatment provided as part of such intervention for an emergency condition. For purposes of this Code section, the term “emergency health care provider” includes without limitation an emergency services provider and a licensed ambulance service providing 911 emergency medical transportation.
(B) No managed care entity or private health benefit plan which has given prospective authorization after the stabilization of a person’s condition for an evaluation, diagnostic testing, or treatment may subsequently deny payment for the provision of such evaluation, diagnostic testing, or treatment. An acknowledgment of an enrollee’s eligibility for benefits by the managed care entity or private health benefit plan shall not, by itself, be construed as a prospective authorization for the purposes of this Code section.
(C) If in the opinion of the emergency health care provider, a patient’s condition has stabilized and the emergency health care provider certifies that the patient can be transported to another facility without suffering detrimental consequences or aggravating the patient’s condition, the patient may be relocated to another facility which will provide continued care and treatment as necessary; and
(2) When a managed care plan uses a restrictive formulary for prescription drugs, such use shall include a written procedure whereby patients can obtain, without penalty and in a timely fashion, specific drugs and medications not included in the formulary when:
(A) The formulary’s equivalent has been ineffective in the treatment of the patient’s disease or condition; or
(B) The formulary’s drug causes or is reasonably expected to cause adverse or harmful reactions in the patient.