42 USC 300gg-19a - Patient protections

U.S Code last checked for updates: Nov 25, 2024

§ 300gg–19a.

Patient protections

(a)

Choice of health care professional

(b)

Coverage of emergency services

(1)

In general

If a group health plan, or a health insurance issuer offering group or individual health insurance issuer,1

 So in original. Probably should be “coverage,”.

provides or covers any benefits with respect to services in an emergency department of a hospital, the plan or issuer shall cover emergency services (as defined in paragraph (2)(B))—

(A)

without the need for any prior authorization determination;

(B)

whether the health care provider furnishing such services is a participating provider with respect to such services;

(C)

in a manner so that, if such services are provided to a participant, beneficiary, or enrollee—

(i)

by a nonparticipating health care provider with or without prior authorization; or

(ii)

(I)

such services will be provided without imposing any requirement under the plan for prior authorization of services or any limitation on coverage where the provider of services does not have a contractual relationship with the plan for the providing of services that is more restrictive than the requirements or limitations that apply to emergency department services received from providers who do have such a contractual relationship with the plan; and

(II)

if such services are provided out-of-network, the cost-sharing requirement (expressed as a copayment amount or coinsurance rate) is the same requirement that would apply if such services were provided in-network; 2

 So in original. The word “and” probably should appear.

(D)

without regard to any other term or condition of such coverage (other than exclusion or coordination of benefits, or an affiliation or waiting period, permitted under section 2701 3

 See References in Text note below.

of this Act, section 1181 of title 29, or section 9801 of title 26, and other than applicable cost-sharing).

(2)

Definitions

In this subsection:

(A)

Emergency medical condition

(B)

Emergency services

The term “emergency services” means, with respect to an emergency medical condition—

(i)

a medical screening examination (as required under section 1395dd of this title) that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition, and

(ii)

within the capabilities of the staff and facilities available at the hospital, such further medical examination and treatment as are required under section 1395dd of this title to stabilize the patient.

(C)

Stabilize

(c)

Access to pediatric care

(1)

Pediatric care

(2)

Construction

(d)

Patient access to obstetrical and gynecological care

(1)

General rights

(A)

Direct access

(B)

Obstetrical and gynecological care

(2)

Application of paragraph

A group health plan, or health insurance issuer offering group or individual health insurance coverage, described in this paragraph is a group health plan or coverage that—

(A)

provides coverage for obstetric or gynecologic care; and

(B)

requires the designation by a participant, beneficiary, or enrollee of a participating primary care provider.

(3)

Construction

Nothing in paragraph (1) shall be construed to—

(A)

waive any exclusions of coverage under the terms and conditions of the plan or health insurance coverage with respect to coverage of obstetrical or gynecological care; or

(B)

preclude the group health plan or health insurance issuer involved from requiring that the obstetrical or gynecological provider notify the primary care health care professional or the plan or issuer of treatment decisions.

(e)

Application

(July 1, 1944, ch. 373, title XXVII, § 2719A, as added Pub. L. 111–148, title X, § 10101(h), Mar. 23, 2010, 124 Stat. 888; amended Pub. L. 116–260, div. BB, title I, § 102(a)(3)(A), Dec. 27, 2020, 134 Stat. 2771.)

cite as: 42 USC 300gg-19a