Definitions of Emergency and Urgently Needed Services

20.2 – Definitions of Emergency and Urgently Needed Services (Rev. 120, Issued: 01-16-15, Effective: 01-01-15, Implementation: 01-01-15) An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: • Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child; • Serious impairment to bodily functions; or • Serious dysfunction of any bodily organ or part. Emergency medical condition status is not affected if a later medical review found no actual emergency present. Emergency services are covered inpatient and outpatient services that are: • Furnished by a provider qualified to furnish emergency services; and • Needed to evaluate or treat an emergency medical condition. Urgently needed services are covered services that: • Are not emergency services as defined in this section but are medically necessary and immediately required as a result of an unforeseen illness, injury, or condition; • Are provided when (A) the enrollee is temporarily absent from the plan’s service (or, if applicable, continuation) area and therefore, he/she cannot obtain the needed service from a network provider; or (B) when the enrollee is in the service or continuation area but the network is temporarily unavailable or inaccessible; and • Given the circumstances, it was not reasonable, for the enrollee to wait to obtain the needed services from his/her regular plan provider after the enrollee returns to the service area or the network becomes available. An MA organization may choose to cover non-emergency services outside the network at higher cost-sharing.