                                 CODE OF VIRGINIA

PATIENT ACCESS TO EMERGENCY SERVICES (§ 38.2-4312.3)

A. A health maintenance organization shall have a system to provide to its
members, on a 24-hour basis: (i) access to medical care or (ii) access by
telephone to a physician or licensed health care professional with appropriate
medical training who can refer or direct a member for prompt medical care in
cases where there is an immediate, urgent need or medical emergency. Access to a
nonmedical professional who provides appropriate responses to calls from members
and providers concerning after-hours care and covered benefits is not sufficient
to meet the requirements of this section.

B. A health maintenance organization shall reimburse a hospital emergency
facility and provider, less any applicable copayments, deductibles, or
coinsurance, for medical screening and stabilization services rendered to meet
the requirements of the Federal Emergency Medical Treatment and Active Labor Act
(42 U.S.C. &#xA7; 1395dd) and related to the condition for which the member
presented in the hospital emergency facility if (i) the health maintenance
organization or its designee or the member&#8217;s primary care physician or its
designee authorized, directed, or referred a member to use the hospital
emergency facility; or (ii) the health maintenance organization fails to have a
system for provision of 24-hour access in accordance with subsection A above.
For purposes of (i) above, a primary care physician may include a physician with
whom the primary care physician has made arrangements for on-call backup
coverage.

C. Each evidence of coverage provided by a health maintenance organization shall
include a description of procedures to be followed by the member for emergency
services, including: (i) the appropriate use of hospital emergency facilities;
(ii) the appropriate use of any urgent care facilities with which the health
maintenance organization may contract; (iii) the potential responsibility of the
member for payment for nonemergency services rendered in a hospital emergency
facility; and (iv) the member&#8217;s covered benefits for emergency services,
including an explanation of the prudent layperson standard included in the
definition of emergency services in &#xA7; 38.2-4300.

D. The provisions of this section shall not apply in any instance in which the
provisions of this section are inconsistent or in conflict with a provision of
Article 6 (&#xA7; 38.2-3438 et seq.) of Chapter 34.

HISTORY: 1997, c. 139; 2011, c. 882.