Common use of Care Coverage Clause in Contracts

Care Coverage. The Contractor shall cover and pay for Emergency Services regardless of whether the provider that furnishes the services has a contract with the Contractor, as provided for in Section 2.9.2.3.4. The Contractor shall not deny payment for treatment for an Emergency Condition, pursuant to 42 C.F.R. § 438.114, and as provided for in Section 2.9.2.3.4, above. The Contractor shall not deny payment for Emergency Services if a representative of the Contractor instructed the Enrollee to seek Emergency Services. The Contractor shall not limit what constitutes an Emergency Condition on the basis of lists of diagnoses or symptoms. The Contractor shall require providers to notify the Enrollee’s PCP of an Enrollee’s screening and treatment, but may not refuse to cover Emergency Services based on their failure to do so. The attending emergency physician, or the provider actually treating the Enrollee, is responsible for determining when the Enrollee is sufficiently stabilized for transfer or discharge. The Contractor shall cover and pay for Post‑stabilization Care Services in accordance with 42 C.F.R. § 438.114(e), 42 C.F.R. § 422.113(c), and M.G.L. c. 118E, § 17A.