Charges for Emergency Services

The State of New Hampshire Insurance Department 21 South Fruit Street, Suite 14 Concord, NH 03301 Roger A. Sevigny Commissioner Alexander K. Feldvebel Deputy Commissioner BULLETIN Docket No.: INS No. 08-029-AB TO: All New Hampshire Licensed Health Insurance Companies, Health Maintenance Organizations, Fraternal Benefit Societies and Third Party Administrators FROM: Roger A. Sevigny Insurance Commissioner DATE: May 1, 2008 RE: Charges for Emergency Services This bulletin is intended to clarify when a member or policyholder may be charged a co-payment, a deductible, or co-insurance for services billed as emergency services. It has come to the attention of the department that members and policyholders are being charged deductibles, co-payments, and co-insurance at emergency facility and provider fee levels for services provided at facilities that are not licensed hospital emergency facilities. This practice violates New Hampshire’s managed care law by subjecting members and policyholders to costs that are not allowed under RSA 420:J. RSA 420-J:3 defines emergency services as those services provided to “an enrollee, insured, or subscriber in a licensed hospital emergency facility by a provider after the sudden onset of a medical condition that could be expected to result in 1)serious jeopardy to the patient‘s health; 2) serious impairment to bodily functions; or 3) serious dysfunction to any bodily organ or part.” In order for services to qualify as emergency services and be billed and charged to the member or subscriber at an emergency service level rate, the services must be provided at a licensed hospital emergency facility. Services that are provided at a facility that is not licensed as a hospital emergency facility do not qualify as emergency services under the managed care law. Any increased cost for that service either in emergency facility fees or in provider fees cannot be passed through to the member by the imposition of a higher deductible, co-pay, or co-insurance. A service that is not provided at a licensed hospital emergency facility cannot be charged to the member or policyholder at an emergency service rate. To ensure that a member does not incur an increased liability for medical services provided at a facility that is not a licensed hospital emergency facility, a carrier shall not by contract agree to Page 1 of 2 accept provider billings at emergency service rates for services that do not meet the definition of emergency services under RSA 420-J:3. In the event that a carrier agrees by contract to reimburse services as emergency services that do not meet the definition of emergency services in RSA 420- J:3, the carrier shall ensure that it has a process in place to hold its members and policyholders harmless for emergency service charges, and to re-price the services at non-emergency service rates for the purpose of determining the member’s liability for co-payments, co-insurance and deductibles. Page 2 of 2