Differences between Emergency and Urgently Needed Services

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 the enrollee is temporarily absent from the plan’s service (or, if applicable, continuation) area, or under unusual and extraordinary circumstances, when the enrollee is in the service or continuation area, and the network is temporarily unavailable or inaccessible; and 

•  It was not reasonable given the circumstances to wait to obtain the services through the plan network. 

Please note that an MA organization may choose to cover services outside the network at higher cost-sharing for non-emergency services obtained outside network providers’ normal business hours (e.g., covering services at an urgent care center on weekends or holidays).

Reference: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R107MCM.pdf