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Emergency services are outside of the managed care program. The State must cover and pay for emergency services regardless of whether the provider that furnishes the services has a PCCM contract with the State. The State may not deny payment for treatment obtained when an enrollee had an emergency medical condition, including cases in which the absence of immediate medical attention would not have had the outcomes specified under “emergency medical condition” listed below. The State may not deny payment for treatment obtained when a representative of the PCP instructs the enrollee to seek emergency services. When a Medical Assistance managed care beneficiary requires emergency care a referral/authorization is not required.
An “emergency medical condition”: is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
All services needed to evaluate or stabilize an emergency medical condition are considered emergency services and therefore exempt from PCP referral requirements.
Medical Assistance eligible recipients diagnosed as SED (Severely Emotionally Disturbed) or SPMI (Severely and Persistently Mentally Ill) by their mental health professional are excluded from Managed Care requirements for Mental Health Services Only. Authorization from the PCP for all other managed care services is required.
Services listed below are exempt from PCP referral requirements: