Common use of Post-Stabilization Services Clause in Contracts

Post-Stabilization Services. As described in 42 CFR 438.114(e), which relates to coverage and payment of post- stabilization care services, and IC 12-15-12, the Contractor shall cover post- stabilization services related to an emergency medical condition that are provided after a member is stabilized in order to maintain the stabilized condition, or to improve or resolve the member's condition. The Contractor shall demonstrate to FSSA that it has a mechanism in place to be available to all emergency room providers twenty-four (24) hours-a-day, seven (7) days-a-week to respond within one hour to an emergency room provider’s request for authorization of continued treatment after the Contractor’s member has been stabilized and the emergency room provider believes continued treatment is necessary to maintain stabilization. The requirements at 42 CFR 422.113(c)(2)(iii)(A) (C), 42 CFR 438.114(e), and 42 CFR 422.113(c)(2)(i)-(ii) are applied to the Contractor. The Contractor is financially responsible for post-stabilization services obtained within or outside the network that are pre-approved by a plan provider or Contractor representative. The Contractor is also financially responsible for post-stabilization services that are not pre-approved but administered to a member to maintain the stabilized condition within one (1) hour of the request to the Contractor for pre-approval of further post-stabilization services. The Contractor must also reimburse for post-stabilization services when (i) the Contractor does not respond within one (1) hour to a request for pre-approval, (ii) the Contractor cannot be contacted or (iii) the Contractor and treating physician cannot reach an agreement concerning the members’ care and a Contractor physician is not available for consultation. In this situation, per 42 CFR 438.114(e) and 42 CFR 422.113(c)(3)(i)-(iv), the Contractor must give the treating physician the opportunity to consult with a plan physician and the treating physician may continue with the care of the patient until a plan physician is reached or one of the following conditions is met: ▪ A plan physician with privileges at the treating hospital assumes responsibility for the member's care; ▪ A plan physician assumes responsibility for the member's care through transfer;

Post-Stabilization Services. As described in 42 CFR 438.114(e), which relates to coverage and payment of post- stabilization care services, and IC 12-15-12, the Contractor shall cover post- stabilization services related to an emergency medical condition that are provided after a member is stabilized in order to maintain the stabilized condition, or to improve or resolve the member's condition. The Contractor shall demonstrate to FSSA that it has a mechanism in place to be available to all emergency room providers twenty-four (24) hours24)-hours-a-day, seven (7) days7)-days-a-week to respond within one hour to an emergency room provider’s request for authorization of continued treatment after the Contractor’s member has been stabilized and the emergency room provider believes continued treatment is necessary to maintain stabilization. The requirements at 42 CFR 422.113(c)(2)(iii)(A) (C422.113(c)(2)(iii)(A)-(C), 42 CFR 438.114(e), and 42 CFR 422.113(c)(2)(i)-(ii) ), are applied to the Contractor. The Contractor is financially responsible for post-stabilization services obtained within or outside the network that are pre-approved by a plan provider or Contractor representative. The Contractor is also financially responsible for post-stabilization services that are not pre-approved but administered to a member to maintain the stabilized condition within one (1) hour of the request to the Contractor for pre-approval of further post-stabilization services. The Contractor must also reimburse for post-stabilization services when (i) the Contractor does not respond within one (1) hour to a request for pre-approval, (ii) the Contractor cannot be contacted or (iii) the Contractor and treating physician cannot reach an agreement concerning the members’ care and a Contractor physician is not available for consultation. In this situation, per 42 CFR 438.114(e) and 42 CFR 422.113(c)(3)(i)-(iv), the Contractor must give the treating physician the opportunity to consult with a plan physician and the treating physician may continue with the care of the patient until a plan physician is reached or one of the following conditions is met: ▪ A plan physician with privileges at the treating hospital assumes responsibility for the member's care; ▪ A plan physician assumes responsibility for the member's care through transfer;

Post-Stabilization Services. As described in In accordance with 42 CFR 438.114(e), which relates to coverage and payment of post- stabilization care services, ) and IC 1200-1500-1200-00, the Contractor shall must cover post- post-stabilization services. Post-stabilization services are covered services related to an emergency Emergency medical condition that are provided after a member is stabilized in order to maintain the stabilized condition, or or, to improve or resolve the member's condition. The Contractor shall demonstrate to FSSA that it has a mechanism in place to be available to all emergency room providers twenty-four (24) hours-a-day, seven (7) days-a-week to respond within one hour to an emergency room provider’s request for authorization of continued treatment after the Contractor’s member has been stabilized and the emergency room provider believes continued treatment is necessary to maintain stabilization. The requirements at 42 CFR 422.113(c)(2)(iii)(A) (C422.113(c)(2)(iii), 42 CFR 438.114(e), and 42 CFR 422.113(c)(2)(i)-(ii) are applied to the Contractor. The Contractor is financially responsible for post-stabilization services obtained within or outside the network that are pre-approved by a plan provider or Contractor representative. The Contractor is also financially responsible for post-stabilization services that are not pre-approved but administered to a member to maintain the stabilized condition within one (1) hour of the request to the Contractor for pre-approval of further post-stabilization services. The Contractor must also reimburse for post-stabilization services when (i) the Contractor does not respond within one (1) hour to a request for pre-approval, (ii) the Contractor cannot be contacted or (iii) the Contractor and treating physician cannot reach an agreement concerning the members’ care and a Contractor physician is not available for consultation. In this situation, per 42 CFR 438.114(e) and 42 CFR 422.113(c)(3)(i)-(iv422.113(c)(3), the Contractor must give the treating physician the opportunity to consult with a plan physician and the treating physician may continue with the care of the patient until a plan physician is reached or one of the following conditions is met: ▪ A plan physician with privileges at the treating hospital assumes responsibility for the member's care; ▪ A plan physician assumes responsibility for the member's care through transfer;; ▪ A Contractor representative and the treating physician reach an agreement concerning the member's care; or ▪ The member is discharged. The Contractor shall limit charges to members for post-stabilization care services to an amount no greater than what the Contractor would charge the enrollee if they obtained the services through the Contractor per 42 CFR 438.114(e) and 42 CFR 422.113(c)(2)(iv).

Post-Stabilization Services. As described in 42 CFR 438.114(e), which relates to coverage and payment of post- stabilization care services, and IC 12-15-12, the Contractor shall cover post- post-stabilization services related to an emergency medical condition that are provided after a member is stabilized in order to maintain the stabilized condition, or to improve or resolve the member's condition. The Contractor shall demonstrate to FSSA that it has a mechanism in place to be available to all emergency room providers twenty-four (24) hours-a-day, seven (7) days-a-a- week to respond within one hour to an emergency room provider’s request for authorization of continued treatment after the Contractor’s member has been stabilized and the emergency room provider believes continued treatment is necessary to maintain stabilization. The requirements at 42 CFR 422.113(c)(2)(iii)(A) (C422.113(c)(2)(iii)(A)-(C), 42 CFR 438.114(e), and 42 CFR 422.113(c)(2)(i)-(ii) are applied to the Contractor. The Contractor is financially responsible for post-stabilization services obtained within or outside the network that are pre-approved by a plan provider or Contractor representative. The Contractor is also financially responsible for post-stabilization services that are not pre-approved but administered to a member to maintain the stabilized condition within one (1) hour of the request to the Contractor for pre-pre- approval of further post-stabilization services. The Contractor must also reimburse for post-post- stabilization services when (i) the Contractor does not respond within one (1) hour to a request for pre-approval, (ii) the Contractor cannot be contacted or (iii) the Contractor and treating physician cannot reach an agreement concerning the members’ care and a Contractor physician is not available for consultation. In this situation, per 42 CFR 438.114(e) and 42 CFR 422.113(c)(3)(i)-(iv), the Contractor must give the treating physician the opportunity to consult with a plan physician and the treating physician may continue with the care of the patient until a plan physician is reached or one of the following conditions is met: ▪ A plan physician with privileges at the treating hospital assumes responsibility for the member's care; ▪ A plan physician assumes responsibility for the member's care through transfer;

Post-Stabilization Services. As described in 42 CFR 438.114(e), which relates to coverage and payment of post- stabilization care services, and IC 12-15-12, the Contractor shall cover post- stabilization services related to an emergency medical condition that are provided after a member is stabilized in order to maintain the stabilized condition, or to improve or resolve the member's condition. The Contractor shall demonstrate to FSSA that it has a mechanism in place to be available to all emergency room providers twenty-four (24) hours-a-day, seven (7) days-a-week to respond within one hour to an emergency room provider’s request for authorization of continued treatment after the Contractor’s member has been stabilized and the emergency room provider believes continued treatment is necessary to maintain stabilization. The requirements at 42 CFR 422.113(c)(2)(iii)(A) (C422.113(c)(2)(iii)(A)-(C), 42 CFR 438.114(e), and 42 CFR 422.113(c)(2)(i)-(ii) are applied to the Contractor. The Contractor is financially responsible for post-stabilization services obtained within or outside the network that are pre-approved by a plan provider or Contractor representative. The Contractor is also financially responsible for post-stabilization services that are not pre-approved but administered to a member to maintain the stabilized condition within one (1) hour of the request to the Contractor for pre-approval of further post-stabilization services. The Contractor must also reimburse for post-stabilization services when (i) the Contractor does not respond within one (1) hour to a request for pre-approval, (ii) the Contractor cannot be contacted or (iii) the Contractor and treating physician cannot reach an agreement concerning the members’ care and a Contractor physician is not available for consultation. In this situation, per 42 CFR 438.114(e) and 42 CFR 422.113(c)(3)(i)-(iv), the Contractor must give the treating physician the opportunity to consult with a plan physician and the treating physician may continue with the care of the patient until a plan physician is reached or one of the following conditions is met: EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE ▪ A plan physician with privileges at the treating hospital assumes responsibility for the member's care; ▪ A plan physician assumes responsibility for the member's care through transfer;

Post-Stabilization Services. As described in 42 CFR 438.114(e), which relates to coverage and payment of post- stabilization care services, and IC 12-15-12, the Contractor shall cover post- post-stabilization services related to an emergency medical condition that are provided after a member is stabilized in order to maintain the stabilized condition, or to improve or resolve the member's condition. The Contractor shall demonstrate to FSSA that it has a mechanism in place to be available to all emergency room providers twenty-four (24) hours-a-day, seven (7) days-a-a- week to respond within one hour to an emergency room provider’s request for authorization of continued treatment after the Contractor’s member has been stabilized and the emergency room provider believes continued treatment is necessary to maintain stabilization. The requirements at 42 CFR 422.113(c)(2)(iii)(A) (C422.113(c)(2)(iii)(A)-(C), 42 CFR 438.114(e), and 42 CFR 422.113(c)(2)(i)-(ii) are applied to the Contractor. The Contractor is financially responsible for post-stabilization services obtained within or outside the network that are pre-approved by a plan provider or Contractor representative. The Contractor is also financially responsible for post-stabilization services that are not pre-approved but administered to a member to maintain the stabilized condition within one (1) hour of the request to the Contractor for pre-pre- approval of further post-stabilization services. The Contractor must also reimburse for post-post- stabilization services when (i) the Contractor does not respond within one (1) hour to a request for pre-approval, (ii) the Contractor cannot be contacted or (iii) the Contractor and treating physician cannot reach an agreement concerning the members’ care and a Contractor physician is not available for consultation. In this situation, per 42 CFR EXHIBIT 1 SCOPE OF WORK – HOOSIER HEALTHWISE 438.114(e) and 42 CFR 422.113(c)(3)(i)-(iv), the Contractor must give the treating physician the opportunity to consult with a plan physician and the treating physician may continue with the care of the patient until a plan physician is reached or one of the following conditions is met: ▪ A plan physician with privileges at the treating hospital assumes responsibility for the member's care; ▪ A plan physician assumes responsibility for the member's care through transfer;