Section 12-15-12-17 - Coverage for post-stabilization care services(a) This section applies to post-stabilization care services provided to an individual enrolled in a Medicaid risk based managed care program.(b) The managed care organization through which an individual is enrolled in a risk based managed care program, is financially responsible for the following services provided to the enrollee: (1) Post-stabilization care services that are preapproved by the managed care organization.(2) Post-stabilization care services that are not preapproved by the managed care organization, but that are administered to maintain the enrollee's stabilized condition within one (1) hour of a request to the managed care organization for preapproval of further post-stabilization care services.(3) Post-stabilization care services provided after an enrollee is stabilized that are not preapproved by the managed care organization, but that are administered to maintain, improve, or resolve the enrollee's stabilized condition if the managed care organization:(A) does not respond to a request for preapproval within one (1) hour;(B) cannot be contacted; or(C) cannot reach an agreement with the enrollee's treating physician concerning the enrollee's care, and a physician representing the managed care organization is not available for consultation.(c) If the conditions described in subsection (b)(3)(C) exist, the managed care organization shall give the enrollee's treating physician an opportunity to consult with a physician representing the managed care organization. The enrollee's treating physician may continue with care of the enrollee until a physician representing the managed care organization is reached or until one (1) of the following criteria is met: (1) A physician: (A) representing the managed care organization; and(B) who has privileges at the treating hospital; assumes responsibility for the enrollee's care.
(2) A physician representing the managed care organization assumes responsibility for the enrollee's care through transfer.(3) A representative of the managed care organization and the treating physician reach an agreement concerning the enrollee's care.(4) The enrollee is discharged from the treating hospital.(d) This subsection applies to post-stabilization care services provided under subsection (b)(1), (b)(2), and (b)(3) to an individual enrolled in a Medicaid risk based managed care program by a provider who has not contracted with the individual's managed care organization to provide post-stabilization care services under subsection (b)(1), (b)(2), and (b)(3) to the individual. Payment for post-stabilization care services provided under subsection (b)(1), (b)(2), and (b)(3) must be in an amount equal to one hundred percent (100%) of the current Medicaid fee for service reimbursement rates for such services.(e) This section does not prohibit a managed care organization from entering into a subcontract with another managed care organization providing for the latter managed care organization to assume financial responsibility for making the payments required under this section.(f) This section does not limit the ability of the office or the managed care organization to: (2) make a determination of; the medical necessity of the post-stabilization care services provided to an enrollee for purposes of determining coverage for such services.
Amended by P.L. 152-2017,SEC. 16, eff. 7/1/2017.As added by P.L. 223-2001, SEC.8.