CMS Pub. 100-16, ch. mc86c17f, § 10.2

(Rev. 77, Issued: 10-28-05, Effective Date: 10-28-05)

(42 CFR 417.401) Each Medicare enrollee is entitled to receive timely and reasonable

payment directly (or have payment made on his or her behalf) for services he or she

obtained from a provider or supplier outside the Medicare cost plan if those services are:

• Emergency services or urgently needed services as defined below. The Medicare

cost plan must pay for emergent and urgently needed services even from

providers and suppliers outside the Medicare cost plan and even in the absence of

the Medicare cost plan’s prior approval (42 CFR 417.414(c)); or

• Services denied by the Medicare cost plan and found upon appeal to be services

the enrollee was entitled to have furnished by the Medicare cost plan.

Emergency Services means covered inpatient or outpatient services that are furnished by

an appropriate source other than the Medicare cost plan that:

• Are needed immediately because of an injury or sudden illness; or

• Are such that the time required to reach the Medicare cost plan’s providers or

suppliers (or alternatives authorized by the Medicare cost plan) would mean risk

of permanent damage to the enrollee’s health.

Once initiated, the services continue to be considered emergency services as long as (a)

transfer of the enrollee to the Medicare cost plan’s source of health care or authorized

alternative is precluded because of risk to the enrollee’s health or because transfer would

be unreasonable, given the distance and the nature of the medical condition; and (b) such

services must be, or appear to be, needed immediately.

All procedures performed during evaluation and treatment of an emergency condition

related to the care of that condition must be covered. For example, if the attending

physician orders diagnostic pulmonary angiography as part of the evaluation for a

member who is treated in an emergency room for chest pain, then a retrospective review,

cannot decide that the angiography was unnecessary and refuse coverage.

The Medicare cost plan is not responsible for the care provided for an unrelated non-emergency problem during treatment for an emergency situation. For example, the

Medicare cost plan is not responsible for any costs, such as a biopsy, associated with

treatment of skin lesions performed by the attending physician who is treating a fracture.

If there is a disagreement over the stability of the patient for transfer to another inpatient

facility, the judgment of the attending physician at the transferring facility prevails and is

binding on the Medicare cost plan.

Urgently Needed Services means covered services that are needed by an enrollee who is

temporarily absent from the Medicare cost plan’s geographic area and that:

• Are required in order to prevent serious deterioration of the enrollee’s health as a

result of unforeseen injury or illness; and

• Cannot be delayed until the enrollee returns to the Medicare cost plan’s

geographic area.

The Medicare cost plan need not pay for post-stabilization services offered outside of its

network or not approved by the Medicare cost plan if:

• These services are not emergency;

• These services are not urgently needed; and

• These services are not offered by the Medicare cost plan as a basic or optional

supplemental benefit.

However, medically necessary follow-up care to emergency and urgent care is covered, if

the care cannot be delayed without adverse medical effects.

Routine out-of-area renal dialysis is covered only under original Medicare.