Determining payment amounts to out-of-network providers furnishing emergency services
(a) (1) In this section the following words have the meanings indicated.
(2) “Emergency medical condition” means a medical condition that manifests itself by acute symptoms of such severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson, who possesses an average knowledge of health and medicine, to result in a condition described in § 1867(e)(1) of the Social Security Act.
(3) “Emergency services” means, with respect to an emergency medical condition:
(i) a medical screening examination that is within the capability of the emergency department of a hospital or freestanding medical facility, including ancillary services routinely available to the emergency department to evaluate an emergency medical condition; or
(ii) any other examination or treatment within the capabilities of the staff and facilities available at the hospital or freestanding medical facility that is necessary to stabilize the patient.
(b) If a carrier provides or covers any benefits for emergency services in an emergency department of a hospital or freestanding medical facility, the carrier:
(1) may not require an insured individual to obtain prior authorization for the emergency services; and
(2) shall provide coverage for the emergency services regardless of whether the health care provider providing the emergency services has a contractual relationship with the carrier to furnish emergency services.
(c) If a health care provider of emergency services does not have a contractual relationship with the carrier to provide emergency services, the carrier:
(1) may not impose any administrative requirement or limitation on coverage that would be more restrictive than administrative requirements or limitations imposed on coverage for emergency services furnished by a health care provider with a contractual relationship with the carrier;
(2) subject to § 14–205.2 of this article and § 19–710.1 of the Health – General Article, may not impose any cost–sharing amount greater than the amount imposed for emergency services furnished by a health care provider with a contractual relationship with the carrier; and
(3) shall reimburse the health care provider at the reimbursement rate specified in subsection (d) of this section.
(d) Except as provided in § 14–205.2 of this article and § 19–710.1 of the Health – General Article, a carrier shall reimburse a health care provider of emergency services that does not have a contractual relationship with the carrier the greater of:
(1) the median amount negotiated with in–network providers for the emergency service, excluding any in–network copayment or coinsurance;
(2) the amount for the emergency service calculated using the same method the health benefit plan generally uses to determine payments for out–of–network services, excluding any in–network copayment or coinsurance, without reduction for out–of–network cost–sharing that generally applies under the health benefit plan; or
(3) the amount that would be paid under Medicare Part A or Part B for the emergency service, excluding any in–network copayment or coinsurance.