2023 Montana Code Annotated › Title 33. Insurance and Insurance Companies › Chapter 32. Health Utilization Review › Part 2. Utilization Review -- Conduct › 33-32-215. Emergency services

33-32-215. (Temporary) Emergency services.
(1) When conducting a utilization review or making a benefit determination for emergency services, a health insurance issuer that provides benefits for services in an emergency department of a hospital shall follow the provisions of this section.
(2) A health insurance issuer shall cover emergency services that screen and stabilize a covered person:
(a) without the need for prior authorization of the emergency services if a prudent lay person would have reasonably believed that an emergency medical condition existed even if the emergency services are provided on an out-of-network basis;
(b) without regard to whether the health care provider furnishing the services is a participating provider with respect to the emergency services;
(c) if the emergency services are provided out-of-network, without imposing any administrative requirement or limitation on coverage that is more restrictive than the requirements or limitations that apply to emergency services received from network providers;
(d) if the emergency services are provided out-of-network, by complying with the cost-sharing requirements in subsection (4); and
(e) without regard to any other term or condition of coverage, other than:
(i) the exclusion of or coordination of benefits;
(ii) an affiliation or waiting period as permitted under 42 U.S.C. 300gg-19a; or
(iii) cost-sharing, as provided in subsection (4)(a) or (4)(b), as applicable.
(3) For in-network emergency services, coverage of emergency services is subject to applicable copayments, coinsurance, and deductibles.
(4) (a) Except as provided in subsection (4)(b), for out-of-network emergency services, any cost-sharing requirement imposed with respect to a covered person may not exceed the cost-sharing requirement for a covered person if the services were provided in-network.
(b) A covered person may be required to pay, in addition to the in-network cost-sharing expenses, the excess amount the out-of-network provider charges that exceeds the amount the health insurance issuer is required to pay under this subsection (4).
(c) A health insurance issuer complies with the requirements of this section by paying for emergency services provided by an out-of-network provider in an amount not less than the greatest of the following and taking into account exceptions in subsections (4)(d) and (4)(e):
(i) the amount negotiated with in-network providers for emergency services, excluding any in-network cost-sharing imposed with respect to the covered person;
(ii) the amount of the emergency service calculated using the same method the plan uses to determine payments for out-of-network services but using the in-network cost-sharing provisions instead of the out-of-network cost-sharing provisions; or
(iii) the amount that would be paid under medicare for the emergency services, excluding any in-network cost-sharing requirements.
(d) For capitated or other health plans that do not have a negotiated charge for each service for in-network providers, subsection (4)(c)(i) does not apply.
(e) If a health plan has more than one negotiated amount for in-network providers for a particular emergency service, the amount in subsection (4)(c)(i) is the median of those negotiated amounts.
(5) Only in-network cost-sharing amounts may be imposed on out-of-network emergency services.
(6) A health insurance issuer shall allow a covered person, the person's authorized representative, and the person's health care provider at least 24 hours following an emergency admission or the provision of emergency services to notify the health insurance issuer of the admission or provision of emergency services. If the admission or the emergency services occur on a holiday or weekend, a health insurance issuer shall allow notification no later than by the next business day following the admission or provision of emergency services.
(7) If prior authorization is required for a postevaluation or poststabilization services review, a health insurance issuer shall provide access to a designated representative 24 hours a day, 7 days a week, to facilitate the review.
(8) A health insurance issuer may not impose prior authorization or step therapy requirements for an oral therapy prescription used to treat opioid use disorder.
33-32-215. (Effective January 1, 2025) Emergency services.
(1) When conducting a utilization review or making a benefit determination for emergency services, a health insurance issuer that provides benefits for services in an emergency department of a hospital shall follow the provisions of this section.
(2) A health insurance issuer shall cover emergency services that screen and stabilize a covered person:
(a) without the need for prior authorization of the emergency services if a prudent lay person would have reasonably believed that an emergency medical condition existed even if the emergency services are provided on an out-of-network basis;
(b) without regard to whether the health care provider furnishing the services is a participating provider with respect to the emergency services;
(c) if the emergency services are provided out-of-network, without imposing any administrative requirement or limitation on coverage that is more restrictive than the requirements or limitations that apply to emergency services received from network providers;
(d) if the emergency services are provided out-of-network, by complying with the cost-sharing requirements in subsection (4); and
(e) without regard to any other term or condition of coverage, other than:
(i) the exclusion of or coordination of benefits;
(ii) an affiliation or waiting period as permitted under 42 U.S.C. 300gg-19a; or
(iii) cost-sharing, as provided in subsection (4)(a).
(3) For in-network emergency services, coverage of emergency services is subject to applicable copayments, coinsurance, and deductibles.
(4) (a) Only in-network cost sharing amounts may be imposed on out-of-network emergency services.
(b) A health insurance issuer complies with the requirements of this section by paying for emergency services provided by an out-of-network provider in an amount not less than the greatest of the following and taking into account exceptions in subsections (4)(c) and (4)(d):
(i) the amount negotiated with in-network providers for emergency services, excluding any in-network cost-sharing imposed with respect to the covered person;
(ii) the amount of the emergency service calculated using the same method the plan uses to determine payments for out-of-network services but using the in-network cost-sharing provisions instead of the out-of-network cost-sharing provisions; or
(iii) the amount that would be paid under medicare for the emergency services, excluding any in-network cost-sharing requirements.
(c) For capitated or other health plans that do not have a negotiated charge for each service for in-network providers, subsection (4)(b)(i) does not apply.
(d) If a health plan has more than one negotiated amount for in-network providers for a particular emergency service, the amount in subsection (4)(b)(i) is the median of those negotiated amounts.
(5) A health insurance issuer shall allow a covered person, the person's authorized representative, and the person's health care provider at least 24 hours following an emergency admission or the provision of emergency services to notify the health insurance issuer of the admission or provision of emergency services. If the admission or the emergency services occur on a holiday or weekend, a health insurance issuer shall allow notification no later than by the next business day following the admission or provision of emergency services.
(6) If prior authorization is required for a postevaluation or poststabilization services review, a health insurance issuer shall provide access to a designated representative 24 hours a day, 7 days a week, to facilitate the review.
History: En. Sec. 7, Ch. 428, L. 2015; amd. Sec. 5, Ch. 470, L. 2019; amd. Sec. 33, Ch. 157, L. 2023.