1. (a) Subject to appeal to the office and except as provided in subsection (b), an individual shall be held responsible under the plan for receiving nonemergency services in an emergency room setting, including prohibiting the individual from using funds in the individual's health care account to pay for the nonemergency services and paying a copayment for the services of at least:

   1. (1) eight dollars ($8) for an individual who has an income of one hundred percent (100%) or less of the federal poverty level; or

   2. (2) thirty-five dollars ($35) for an individual who has an income of more than one hundred percent (100%) of the federal poverty level;

      for the nonemergency use of a hospital emergency department.

2. (b) An individual may not be prohibited from using funds in the individual's health care account to pay for nonemergency services provided in an emergency room setting for a medical condition that arises suddenly and unexpectedly and manifests itself by acute symptoms of such severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to:

   1. (1) place an individual's health in serious jeopardy;
   2. (2) result in serious impairment to the individual's bodily functions; or
   3. (3) result in serious dysfunction of a bodily organ or part of the individual.
3. (c) In addition to the copayments described in subsection (a), the office of the secretary shall require a plan participant who has an income above one hundred percent (100%) of the federal poverty level to pay additional cost sharing requirements established by the office of the secretary in the amount of at least one dollar ($1) and not more than thirty-five dollars ($35).
4. (d) Unless otherwise allowed by federal law, the total aggregate amount of cost sharing charges imposed on a quarterly basis for a plan participant under this chapter may not exceed five percent (5%) of the plan participant's family income.

As added by P.L.30-2016, SEC.34. Amended by P.L.114-2018, SEC.7; P.L.63-2026, SEC.26.