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Developed and maintained by the Division of Legislative Automated Systems.
1997 SESSION
978046432Be it enacted by the General Assembly of Virginia:
1. That the Code of Virginia is amended by adding a section numbered 38.2-4312.3 as follows:
§ 38.2-4312.3. Patient access to emergency services.
A. A health maintenance organization shall have a system to provide to its
members, on a twenty-four-hour basis: (i) access to medical care or (ii) access
by telephone to a physician or [ qualified
licensed ] health care professional with appropriate medical
training who can refer or direct a member for prompt medical care in cases
where there is an immediate, urgent need or medical emergency. Access to a
nonmedical professional who provides appropriate responses to calls from
members and providers concerning after-hours care and covered benefits is not
sufficient to meet the requirements of this section.
B. A health maintenance organization shall reimburse a hospital emergency facility and provider, less any applicable copayments, deductibles, or coinsurance, for medical screening and stabilization services rendered to meet the requirements of the Federal Emergency Medical Treatment and Active Labor Act (42 U.S.C. § 1395 dd) and related to the condition for which the member presented in the hospital emergency facility if (i) the health maintenance organization or its designee or the member's primary care physician or its designee authorized, directed, or referred a member to use the hospital emergency facility; or (ii) the health maintenance organization fails to have a system for provision of twenty-four-hour access in accordance with subsection A above. For purposes of (i) above, a primary care physician may include a physician with whom the primary care physician has made arrangements for on-call backup coverage.
C. [ A health maintenance organization shall provide to
its members a description of procedures to be followed for emergency services,
including: (i) the appropriate use of hospital emergency facilities; (ii) the
appropriate use of any urgent care facilities with which a health maintenance
organization may contract; (iii) the potential responsibility of the member for
payment for nonemergency services rendered in a hospital emergency facility;
and (iv) a member's covered benefits pursuant to the prudent layperson
definition of emergency services in § 38.2-4300. Each
evidence of coverage provided by a health maintenance organization shall
include a description of procedures to be followed by the member for emergency
services, including: (i) the appropriate use of hospital
emergency facilities; (ii) the appropriate use of any urgent care facilities
with which the health maintenance organization may contract; (iii) the
potential responsibility of the member for payment for nonemergency services
rendered in a hospital emergency facility; and (iv) the
member's covered benefits for emergency services, including an
explanation of the prudent layperson standard included in the definition of
emergency services in § 38.2-4300.
]