CA
"ARTICLE II - DEFINITIONS...
DD. Emergency Medical Condition
means a medical condition which is manifested by acute symptoms of sufficient
severity (including severe pain), such that a prudent lay person, who possesses
an average knowledge of health and medicine, could reasonably expect the
absence of immediate medical attention to result in:
1. placing the health of
the individual (or, in the case of a pregnant woman, the health of the
woman or her unborn child) in serious jeopardy,
2. serious impairment to
bodily function, or
3. serious dysfunction of
any bodily organ or part." California Contract, pages 2, 7.
CT
"Part II: General Contract
Terms for MCOs
1. Definitions...
L. Emergency:
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 placing the health
of the individual (or with respect to a pregnant woman, the health of the
woman or her unborn child) in serious jeopardy, serious impairment to body
functions or serious dysfunction of any body organ or part…" Connecticut
Contract, pages 11-12.
DE
"5.10.2 Member Handbook Minimum
Contents...
The Federal Definition of
Medical Emergency:
a) `Emergency Services'
means, with respect to an individual enrolled with an MCO, covered inpatient
and outpatient services that they:
(i) are furnished
by a provider that is qualified to furnish such services under this title,
and
(ii) are needed to
evaluate or stabilize an emergency medical condition (as defined in subpart.
(b)
b) `Emergency medical
condition' means 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;
(i) placing the health
of the individual (or with respect to a pregnant women, the health of the
woman or her unborn child) in serious jeopardy,
(ii) serious impairment
to bodily functions, or
(iii) serious dysfunction
of any bodily organ or part…" Delaware RFP, pages II.20-II.22.
DC
"ARTICLE XXII - DEFINITIONS...
I. The term
'emergency medical condition' means a medical condition manifesting itself
by acute symptoms of sufficient severity (including sever 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 -
1. Placing
the health of the individual (or, with respect to a pregnant woman the
health of the woman or her unborn child) in serious jeopardy,
2. Serious
health impairment of bodily functions, or
3. Serious
dysfunction of any bodily organ or part." District of Columbia Contract,
pages 48-49.
FL
"24. Emergency Medical Condition… (an emergency medical condition is: (a) A medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain or other acute symptoms, such that a prudent lay person, pursuant to Section 4704 of the 197 Balanced Budget Act, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention could reasonably be expected to result in any of the following: 1) serious jeopardy to the health of a patient, including a pregnant woman or a fetus. 2) serious impairment to bodily functions. 3) serious dysfunction of any bodily organ or part. (b) With respect to a pregnant woman: 1) that there is inadequate time to effect safe transfer to another hospital prior to delivery. 2) that a transfer may pose a threat to the health and safety of the patient or fetus. 3) that there is evidence of the onset and persistence of uterine contractions or rupture of the membrane." Florida Contract, page 154.
HI
"41.020 Emergency Room...
HCFA defines the circumstance
under which payment is required as 1) the services were needed immediately
because of an injury or sudden illness; and 2) the time required to reach
the contractor's facilities, or the facilities of a provider with which
the contractor has arrangements, would have meant risk of permanent damage
to the recipient's health…" Hawaii RFP, page 55.
"Medical emergency - 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 placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to body functions or serious dysfunction of any bodily organ or part" Hawaii RFP, Appendix A, page 4.
IA
"1.3 Definitions...
-Emergent Medical Condition
- 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 it
to result in:
1. Placing the health
of the person or, with respect to a pregnant woman, the health of the woman
or her unborn child in serious jeopardy,
2. Serious impairment
to bodily functions, or
3. Serious dysfunction
of any bodily organ or part.
The determination of whether
an Emergent Medical Condition exists shall be decided by a medical professional
and shall be based on the Enrollee's medical condition, including presenting
symptoms and medical history (as related to severe pain) prior to treatment."
Iowa Contract, pages 6-7.
KS
"B. 1. COVER
EMERGENCY SERVICES UNDER 'PRUDENT LAYPERSON' DEFINITION Contract
Section IIC, page 6, and Exhibit E, Definitions are amended by adding the
following language under Emergency room services based on medical necessity:
A.
MCO agrees to cover (pay for) emergency services for Medicaid HMO members
who seek emergency treatment for any medical condition…that manifests 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 placing the health of the individual (or with respect to a pregnant
woman, the health of the woman or her unborn child) in serious jeopardy,
serious impairment to body functions or serious dysfunction of any bodily
organ or part...
D… 2.
APPENDIX E DEFINITIONS
Appendix E shall be modified
to replace the Emergency Services definition with the Prudent Layperson
definition as follows: 'Emergency services means covered inpatient and
outpatient services that are needed to evaluate or stabilize an emergency
medical condition that is found to exist using a prudent layperson standard.'"
Kansas Contract, Amendment One.
KY
"Emergency Medical Condition
: Emergency services are to cover inpatient and outpatient services furnished
by a qualified provider and are needed to evaluate or stabilize an emergency
medical condition. An emergency medical condition is one 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:
(a) Placing
the health of the individual (or, with respect to a pregnant woman, the
health of the woman or her unborn child);
(b) Serious
impairment to bodily functions;
(c) Serious
dysfunction of any bodily organ or part." Kentucky Contract,
pages
11-12.
ME
"II. DEFINITIONS.
A. The following terms
used in this Contract shall be interpreted as defined herein, except to
the extent that the context may clearly require otherwise: ...
22. Emergency Services
means…or (ii) with respect to a pregnant woman who is having contractions,
a situation where there is not adequate time to effect a safe transfer
to another hospital before delivery, or transfer may pose a threat to the
health or safety of the woman or the fetus." Maine Contract, pages
2, 4.
MD
"Dear State Medicaid Director:
...
The purpose of this letter
is to advise you of the changes made by the BBA regarding coverage of emergency
services by managed care organizations (MCOs)...
The BBA defines emergency medical condition as 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 placing the health of the individual (or with respect to a pregnant woman or her unborn child) in serious jeopardy, serious impairment to body functions or serious dysfunction of any bodily organ or part…" Maryland Contract, HCFA State Medicaid Letter, 2/20/98.
MA
"SECTION 1. DEFINITION OF
TERMS...
Emergency Medical Condition
- a medical condition that manifests itself by acute symptoms of sufficient
severity (including severe pain) such that a prudent lay person, who possesses
an average knowledge of health and medicine, could reasonably expect the
absence of immediate medical attention to result in: (1) placing
the health of the individual (or, with respect to a pregnant woman, the
health of the woman or her unborn child) in serious jeopardy; (2) serious
impairment to bodily functions; or (3) serious dysfunction of any bodily
organ or part…" Massachusetts Contract, pages 6-10.
MI
"DEFINITIONS/EXPLANATION
OF TERMS...
Emergency Medical Care
Emergency medical condition
means a medical condition manifesting itself by acute symptoms of sufficient
severity (including severe pain) such that a prudent lay person, with an
average knowledge of health and medicine, could reasonably expect the absence
of immediate medical attention to result in: (i) serious jeopardy to the
health of the individual or; in the case of a pregnant woman, the health
of the woman or her unborn child; (ii) serious impairment to bodily functions;
or (iii) serious dysfunction of any bodily organ or part…" Michigan
Contract, pages vi-vii.
MN
"Section 2.29. Medical Emergency means 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: placing the physical or mental health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; , continuation of severe pain; serious impairment to bodily functions; serious dysfunction of any bodily organ or part; or death. Labor and delivery is a Medical Emergency if it meets this definition." Minnesota Contract, page 13.
MO
"b. Covered Services...
23) Emergency medical
services. Emergency medical services are defined as those health
care items and services furnished or required to evaluate or stabilize
a sudden and unforeseen situation or occurrence or a sudden onset of a
medical or behavioral condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) that the failure to provide
immediate medical attention could reasonably be expected by a prudent lay
person, possessing average knowledge of health and medicine, to result
in:
* placing the patient's
health (or with respect to a pregnant woman, the health of the woman or
her unborn child) in serious jeopardy; or
* serious impairment if
bodily functions; or
* serious dysfunction of
any bodily organ or part; or
* serious harm to a member
or others due to an alcohol or drug abuse emergency; or
* injury to self or
bodily harm to others; or
* with respect to a pregnant
woman who is having contractions: (1) that there is inadequate time to
effect a safe transfer of another hospital before delivery or in (2) that
transfer may pose a threat to the health or safety of the woman or the
unborn." Missouri RFP, page 10.
MT
"EMERGENCY MEDUCAL CONDITION-
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:
1. Placing the health
of the individual (or, with respect to a pregnant woman, the health of
the woman or her unborn child) in serious jeopardy…" Montana Contract
, page 27.
NV
"DEFINITIONS
Emergency Medical Condition:
A medical condition manifesting itself by acute symptoms of sufficient
severity (including severe pain) as perceived by a prudent layperson, possessing
an average knowledge of health and medicine, who could reasonably expect
the absence of immediate medical attention to result in placing the health
of the individual (or, with respect to a pregnant woman, the health of
the woman or her unborn child) in serious jeopardy; serious impairment
to bodily functions; or serious dysfunction of any bodily organ or part."
Nevada Contract, page 16.
NJ
"ARTICLE 10
COVERED HEALTH CARE SERVICES...
10.10 Emergency Services...
With respect to a
pregnant woman who is having contractions, an emergency exists where there
is inadequate time to effect a safe transfer to another hospital before
delivery; or the transfer may pose a threat to the health or safety of
the woman or the unborn child...
K. Women who
arrive at any emergency room in active labor shall be considered as an
emergency situation…" New Jersey Contract, pages 51-56.
NM
"4. Article 2, Section
2.A.1.e.i., is amended as follows:
2.A.l.e.i.(D)...
(3) that an
emergency 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 placing the health of the individual (or with respect to a pregnant
woman, the health of the woman or her unborn child) in serious jeopardy,
serious impairment to body function or serious dysfunction of any bodily
organ or part..." New Mexico Contract, Amendment #1, pages 1-2.
NC
"APPENDIX I
DEFINITION OF TERMS…
1.19 Emergency Medical
Condition...
(B) With respect to
a pregnant woman who is having contractions:
(1) that there is
inadequate time to effect a safe transfer to another hospital before delivery,
or
(2) that transfer
may pose a threat to the health or safety of the woman or the unborn child."
North Carolina Contract, Appendix I.
OH
"5101:3-26-01 Managed
care plan: Definitions.
As used in Chapter 5101:3-26
of the Administrative Code: …
(U) 'EMERGENCY MEDICAL
CONDITION' MEANS 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 ANY OF THE
FOLLOWING: PLACING THE HEALTH OF THE INDIVIDUAL (OR, WITH RESPECT
TO A PREGNANT WOMAN, THE HEALTH OF THE WOMAN OR HER UNBORN CHILD) IN SERIOUS
JEOPARDY; SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; OR SERIOUS DYSFUNCTION
OF ANY BODILY ORGAN OR PART." Ohio RFP, Appendix E, OAC 5101:3-26-01,
page 2.
OK
"1.4 Definitions
Each of the following terms
shall have the indicated meanings unless the context clearly requires otherwise:
...
29. EMERGENCY MEDICAL
CONDITION...
With respect to a pregnant
woman who is having contractions, an emergency medical condition exists
if there is inadequate time to effect a safe transfer to another hospital
before delivery, or if the transfer may pose a threat to the health or
safety of the woman or the unborn child…" Oklahoam RFP, pages 5,
7-8.
OR
"E. Capitated Services...
F. Emergency Services
(1) Contractor's obligation
to pay for Emergency Services under Section 3A(1) of this Agreement that
are received from providers other than Contractor or its subcontractors
is limited to Covered Services provided for diagnosis and treatment of
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 (a) placing the health
of the individual (or with respect to a pregnant woman, the health of both
the woman or her unborn child) in serious jeopardy, (b) serious impairment
to bodily functions, or (c) serious dysfunction of any bodily organ or
part. (See OAR 410-141-0000, Definition of Terms, for additional information
as it applies to dental services provided in a hospital emergency room.)…"
Oregon Contract, pages 7-8.
PA
"Emergency Services-Services provided after the sudden onset of medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the prudent layperson would believe that the absence of immediate medical attention could reasonably be expected to result in (a) placing the patient's health in serious jeopardy; (b) serious impairment to bodily functions; or ( c ) serious dysfunction of any bodily organ or part. This includes active labor..." Pennsylvania RFP, page ix.
SC
"Emergency Services - 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: placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy..." South Carolina Contract, page A3.
TX
"Emergency Medical Condition
means 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 care could result in:
(a) placing the patient's
health in serious jeopardy;
(b) serious impairment to
bodily functions;
(c) serious dysfunction
of any bodily organ or part;
(d) serious disfigurement;
or
(e) in the case of a pregnant
woman, serious jeopardy to the health of the fetus." Texas Contract,
page 6.
UT
"ATTACHMENT B - Special Provisions
Article I - Definitions...
F. 'Emergency Services'
means those services provided in a hospital, clinic, office, or other facility
that is equipped to furnish the required care, after the sudden onset of
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 that
the absence of immediate medical attention to result in:
1. Placing
the health of the individual (or, with respect to a pregnant woman, the
health of a woman or her unborn child) in serious jeopardy;
2. Serious
impairment to bodily functions; or
3. Serious
dysfunction of any bodily organ or part." Utah Contract, Attachment
B, page 1.
UTMH
"Article I
DEFINITIONS…
'Emergency' means a psychiatric
condition manifesting itself by acute symptoms of sufficient severity 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 -
a. Placing
the health or safety of the Enrollee (or with respect to a pregnant woman,
the health of the woman or her unborn child) in serious jeopardy;
b. Placing
the health or safety of other individuals in serious jeopardy; or
c. Serious
impairment to bodily functions or serious dysfunction of any bodily organ
or part." Utah Mental Health Contract, page 1.
"Article III
SCOPE OF SERVICES...
A. Covered Services...
5. Emergency
Services...
c. The CONTRACTOR
must pay for Emergency Services where the presenting symptoms are of sufficient
severity that a person with average knowledge of health and medicine would
reasonably expect the absence of immediate medical attention to result
in placing the health of the individual (or with respect to a pregnant
woman, the health of the woman or her unborn child) in serious jeopardy,
serious impairment to bodily functions, or serious dysfunction of any bodily
organ or part.
d. The CONTRACTOR
may not retroactively deny a claim of Emergency Services because the condition,
which appeared to be an Emergency under the prudent layperson standard,
turned out to be non-emergency in nature. In these cases, the CONTRACTOR
must review the presenting symptoms of the Enrollee and must pay for Emergency
Services where the presenting symptoms were of sufficient severity to have
warranted emergency attention under the prudent layperson standard."
Utah Mental Health Contract, page 5.
VA
"ARTICLE I - DEFINITIONS...
Emergency Medical Condition
- Coverage of emergency services by the Contractor will be determined by
the 'prudent layperson' standard.
Emergency Services - Covered inpatient and outpatient services furnished by a qualified Medicaid provider that are necessary to evaluate or stabilize an emergency medical condition. Contractor must cover cases where the presenting symptoms are of sufficient severity that a person with average knowledge of health and medicine would reasonably expect the absence of immediate medical attention to result in (i) placing their health or the health of an unborn child in immediate jeopardy, (ii) serious impairment of bodily functions, or (iii) serious dysfunction of any bodily organ or part." Virginia Contract, pages 7-8.
WV
"3.7 Emergency Services...
Emergency care services
include those services needed immediately and are provided for conditions
where the presenting symptoms are of sufficient severity that a person
with average knowledge of health and medicine would reasonably expect the
absence of immediate medical attention to result in placing their health
or the health of an unborn child in immediate jeopardy; serious impairment
of bodily functions; or serious dysfunction of any bodily organ or part.
These include accidental injury and poison-related problems and complaints
which may be indicative of serious, life-threatening medical problems,
e.g. chest or abdominal pain, difficulty breathing or swallowing, or loss
of consciousness...
The Managed Care Plan is required to inform enrollees of the following regarding their rights of access to, and coverage of, emergency services, both inside and outside of the plan's network: ...
* Definition of Emergency
Medical Condition: Coverage of emergency services by the Managed Care Plan
will be determined under the prudent layperson standard. That standard
considers the symptoms (including severe pain) of the presenting enrollee.
The Managed Care Plan must cover cases where the presenting symptoms are
of sufficient severity that a person with average knowledge of health and
medicine would reasonably expect the absence of immediate medical attention
to result in:
- placing their health
or the health of an unborn child in immediate jeopardy,
- serious impairment
of bodily functions, or
- serious dysfunction
of any bodily organ or part." West Virginia Contract, pages 10-11.
WI
"The term 'emergency medical
condition' means -
A. 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:
1. placing the health
of the individual (or, with respect to a pregnant woman, the health of
the woman or her unborn child) in serious jeopardy...
B. with respect to
a pregnant woman who is in active labor -
1. that there is inadequate
time to effect a safe transfer to another hospital before delivery; or
2. that transfer may
pose a threat to the health or safety of the woman or the unborn child."
Wisconsin Contract, page 2.