Coverage of Emergency Services for Managed Care
In our April 18, 2000 State Medicaid Director letter, we stated that the Balanced Budget Act
requires that a Medicaid managed care enrollee be permitted to obtain emergency services
immediately at the nearest provider when the need arises. We further stated that when the
prudent layperson standard is met, no restriction may be placed on access to emergency care.
Therefore, managed care organizations (MCOs) and primary care case managers (PCCMs) could
not place visit limitations on Medicaid enrollee presentations to the emergency room.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: December 20, 2002
DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.