1. (a) A health care insurer shall follow the provisions of this section when conducting a utilization review or making a benefit determination for emergency services.

2. (b) A health care insurer shall cover emergency services to screen and stabilize a covered person

   1. (1) without the need for prior authorization of emergency services if a prudent person would reasonably believe that an emergency medical condition exists even if the emergency services are provided on an out-of-network basis;
   2. (2) without regard to whether the health care provider furnishing the services is a participating provider with respect to the services;
   3. (3) if the emergency services are provided out-of-network, without imposing an administrative requirement or limitation on coverage that is more restrictive than the requirements or limitations that apply to emergency services received from network providers;
   4. (4) if the emergency services are provided out-of-network, by complying with the cost-sharing requirements of (d) - (h) of this section; and

   5. (5) without regard to another term or condition of coverage, other than

      1. (A) the exclusion of, or coordination of, benefits;
      2. (B) an affiliation or waiting period permitted under 42 U.S.C. 300gg-19a; or
      3. (C) applicable cost-sharing, under (c) - (h) of this section.
3. (c) For in-network emergency services, coverage of emergency services is subject to applicable copayments, coinsurance, and deductibles.
4. (d) Except under (e) of this section, for out-of-network emergency services, a cost-sharing requirement expressed as a copayment amount or coinsurance rate imposed with respect to a covered person may not exceed the cost-sharing requirement imposed with respect to a covered person if the services were provided in-network.
5. (e) A covered person may be required to pay, in addition to the in-network cost-sharing, the excess of the amount the out-of-network provider charges over the amount a health care insurer is required to pay under (d) of this section.

6. (f) A health care insurer complies with the requirements of (d) and (e) 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, taking into account the exceptions under (g) and (h) of this section:

   1. (1) the amount negotiated with in-network providers for emergency services, excluding an in-network copayment or coinsurance imposed with respect to the covered person;
   2. (2) 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
   3. (3) the amount that would be paid under Medicare for the emergency services, excluding an in-network copayment or coinsurance requirements.
7. (g) For capitated or other health care insurance policies that do not have a negotiated charge for each service for in-network providers, (f)(1) of this section does not apply.
8. (h) If a health plan has more than one negotiated amount for in-network providers for a particular emergency service, the amount in (f)(1) of this section is the median of those negotiated amounts.
9. (i) A health care insurer may impose only in-network cost-sharing amounts on out-of-network emergency services.
10. (j) If prior authorization is required for a post-evaluation or post-stabilization services review, a health care insurer shall provide access to a designated representative 24 hours a day, seven days a week, to facilitate the review.

(Eff. 3/15/2018, Register 225)

Authority: AS 21.06.090, AS 21.07.005