State Law

Nebraska Rev. Statutes-Chapter 44-Insurance (Out-of-Network Emergency Medical Care Act)

08/10/2023 Nebraska Sections 44-6834 through 44-6846

Act, how cited; Definitions, where found;Covered person, defined;Emergency medical condition, defined;Emergency services, defined;Health benefits plan, defined; Health care facility, defined; Health care professional, defined; Health care provider, defined; Insurer, defined; Medical assistance program, defined; Medically necessary, defined;  TRICARE, defined

Medical Necessity-Definition, OON-Payment Issues

The following are definitions under Nebraska’s Out-of-Network Emergency Medical Care Act.  Accordingly, all of these definitions fall under the category “OON-Payment Issues.”  See the bold language below to see the definition falling under “Medical Necessity-Definition.”

Section 44-6834. Act, how cited.

Sections 44-6834 to 44-6850 shall be known and may be cited as the Out-of-Network Emergency Medical Care Act.

Section 44-6835. Definitions, where found.

For purposes of the Out-of-Network Emergency Medical Care Act, the definitions found in sections 44-6836 to 44-6846 apply.

Section 44-6836.  Covered person, defined.

Covered person means a person on whose behalf an insurer is obligated to pay health care expense benefits or provide health care services.

Section 44-6837.  Emergency medical condition, defined.

Emergency medical condition means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including, but not limited to, severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (1) placing the health of the person afflicted with such condition in serious jeopardy or, in the case of a behavioral condition, placing the health of such persons or others in serious jeopardy, (2) serious impairment to such person’s bodily functions, (3) serious impairment of any bodily organ or part of such person, or (4) serious disfigurement of such person.

Section 44-6838. Emergency services, defined.

Emergency services means health care services medically necessary to screen and stabilize a covered person in connection with an emergency medical condition.

Section 44-6839. Health benefits plan, defined.

(1) Health benefits plan means a benefits plan which pays or provides hospital and medical expense benefits for covered services and is delivered or issued for delivery in this state by or through an insurer.

(2) Health benefits plan does not include the medical assistance program, medicare, medicare advantage, accident-only, credit, disability, or long-term care coverage, TRICARE supplement coverage, coverage arising out of a workers’ compensation or similar law, automobile medical payment insurance, personal injury protection insurance, and hospital confinement indemnity coverage.

Section 44-6840. Health care facility, defined.

Health care facility means a general acute hospital, satellite emergency department, or ambulatory surgical center licensed pursuant to the Health Care Facility Licensure Act.

Section 44-6841. Health care professional, defined.

Health care professional means an individual who is credentialed pursuant to the Uniform Credentialing Act, who is acting within the scope of his or her credential, and who provides a covered service defined by the health benefits plan.

Section 44-6842. Health care provider, defined.

Health care provider means a health care professional or health care facility.

Section 44-6843. Insurer, defined.

Insurer means an entity that contracts to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services under a health benefits plan, including (1) any individual or group sickness and accident insurance policy or subscriber contract delivered, issued for delivery, or renewed in this state and any hospital, medical, or surgical expense-incurred policy, except for a policy that provides coverage for a specified disease or other limited-benefit coverage, and (2) any self-funded employee benefit plan to the extent not preempted by federal law.

Section 44-6844. Medical assistance program, defined.

Medical assistance program means the medical assistance program established pursuant to the Medical Assistance Act.

Medical Necessity-Definition

Section 44-6845. Medically necessary, defined.

Medically necessary means a health care service that a health care provider, exercising his or her prudent clinical judgment, would provide to a covered person for the purpose of evaluating, diagnosing, or treating an illness, an injury, or a disease, or its symptoms, and that is in accordance with the generally accepted standards of medical practice; that is clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the covered person’s illness, injury, or disease; that is not primarily for the convenience of the covered person or the health care provider; and that is not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that covered person’s illness, injury, or disease.

Section 44-6846. TRICARE, defined.

TRICARE means a health care program of the United States Department of Defense Military Health System.