CurrentAspirus ArisePolicy CP-AMCR24-001A

Post Stabilization Care

Defines coverage, exclusions, and operational rules for post-stabilization care services related to emergency medical conditions for Aspirus Medicare Advantage products, including worldwide emergency care provisions and limitations.

Policy Summary

PayerAspirus Arise

PolicyPost Stabilization Care

Policy CodePolicy CP-AMCR24-001A

Change TypeAnnual review (editorial)

Effective DateAug 1, 2024

Next Review Date

Key ActionNo prior authorization is required for post-stabilization care services under this policy.

SourceLink

POLICY UPDATE CHANGES

New policy created August 1, 2024 (V1).

Annual review updated effective date and clarified emergency services bullets (V2, 10/8/2024).

Annual review on 10/8/2025 with editorial updates (V3).

Has_material_change flag indicates no material change.

2Aspirus Medicare Advantage products applicable

1Benefit category: Emergency Care

3End of post-stabilization triggers listed

Coverage Summary

Scope: This policy applies to Aspirus Medicare Advantage Elite (PPO) and Aspirus Medicare Advantage Essential Rx (PPO) and governs coverage for post-stabilization care services under those products. (Policy Number: CP-AMCR24-001A; Original Effective Date: August 1, 2024; Last Review Date: October 8, 2025.)

Background: Post-stabilization care services are services that are related to an emergency medical condition, are provided after a member is stabilized, and are provided to maintain the stabilized condition or, in certain circumstances, to improve or resolve the member's condition. The policy clarifies coverage, exclusions, and operational rules for these services and references applicable CMS regulations governing emergency and post-stabilization services.

Coverage stance summary: Coverage is mixed — post-stabilization care services are covered when the specified criteria are met, subject to the policy's conditions, limitations, and exclusions (including specific rules for worldwide emergency care and requirements for returning to network facilities for continued inpatient care).

Key Policy Facts

Applicable productsAspirus Medicare Advantage Elite, Essential Rx

Benefit categoryEmergency Care

Effective date2024-08-01

Last review2025-10-08

Policy numberCP-AMCR24-001A

StatusCURRENT

Medical-Necessity Criteria

Definition of Post-Stabilization Care Services

Covered when ALL of the following are met:

ALL of the following

Service is related to an emergency medical condition.
Service is provided after a member is stabilized.
Service is provided to maintain the stabilized condition, or under certain circumstances to improve or resolve the member's condition.

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Emergency Medical Condition (Prudent Layperson Standard)

An emergency exists when a prudent layperson could reasonably expect that absence of immediate medical attention could result in:

Jeopardy to the health of the individual or, for a pregnant woman, the woman or her unborn child.
Serious impairment to bodily functions.
Serious dysfunction of any bodily organ or part; loss of limb or loss of function of limb.
Injury, illness, severe pain, or medical condition that is worsening.
To prevent loss of life.

Emergency Services (definition)

ALL of the following

Furnished by a provider qualified to furnish emergency services.
Needed to evaluate, treat, or stabilize an emergency medical condition.

Stabilization Decision

ALL of the following

The treating physician must decide when the member is considered stabilized for transfer or discharge; that decision is binding on the health plan.
Decision may be based on distance or member's post discharge need for care.
If disagreement about transfer from one inpatient setting to another:
- Member or authorized person may request the health plan pay for continued out-of-network services.
- If the health plan declines payment, appeal rights are available to the member.

End of Post Stabilization (Financial Responsibility Ends When)

ANY of the following

A plan (in-network) physician with privileges at the treating hospital assumes responsibility for the member's care.
A plan (in-network) physician assumes responsibility for the member's care through transfer.
A health plan representative and the treating physician reach an agreement concerning the member's care.
The member is discharged.

Coverage Conditions and Limitations

ALL of the following

Cost sharing for necessary emergency services furnished out-of-network is the same as services furnished in-network.
If a member needs inpatient care at an out-of-network hospital after stabilization, they must return to a network hospital for continued covered care.

Not Covered & Worldwide Emergency Care Exclusions

Not Covered

ALL of the following

Post discharge care unless authorized by Aspirus Health Plan.

Worldwide Emergency Care Coverage

Applies to emergency care outside the United States and its territories when ALL of the following are met:

ALL of the following

Services furnished by a provider qualified to furnish emergency services and needed to evaluate or stabilize an emergency medical condition.
Services provided after stabilization that are required to maintain the condition.
Post-stabilization services end at discharge.
Ground ambulance for emergency transportation to the nearest appropriate hospital for emergency care is covered.

Exclusions that apply to Worldwide emergency care

Air ambulance (fixed wing or rotary wing) outside the U.S. & its territories is not covered.
Transportation back to the United States or its territories is not covered.
Prescriptions filled by pharmacies outside the United States are not covered, even if for a medical emergency.

Provider Actions & Operational Rules

Prior Authorization

Prior authorization not required

No prior authorization is required for post-stabilization care services under this policy.

Documentation Required

Stabilization decision documentation

The treating physician's determination that the member is stabilized for transfer or discharge is binding on the health plan. Documentation of the treating physician's stabilization decision and any agreement with the plan may be necessary for appeals or coverage disputes.

Denial Risk

Out-of-network inpatient care after stabilization

If a member remains at an out-of-network hospital for inpatient care after stabilization and does not return to a network hospital, coverage may not continue; continued out-of-network inpatient care requires return to a network hospital for coverage to continue.

Billing Rule

Member cost-share parity

Member cost share for post-stabilization care services may not be greater than the member's responsibility for the same services obtained through an in-network provider.

Documentation Required

Reimbursement for services outside U.S.

To request reimbursement for emergency and post-stabilization charges incurred outside the U.S., submit an itemized bill of services received, medical records, and proof of payment translated into English and converted to U.S. currency to Aspirus Claims Reimbursement.

Definitions & Background

Emergency medical condition: Acute symptoms of sufficient severity (including severe pain) such that a prudent layperson with average knowledge of health and medicine could reasonably expect that absence of immediate medical attention would result in jeopardy to health, serious impairment to bodily functions, serious dysfunction of any bodily organ or part (including loss of limb or function), injury/illness or worsening condition, or be needed to prevent loss of life.

Clinically Stable: The point in a member's condition when no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during discharge or transfer from the hospital.

Background/context: This policy clarifies when post-stabilization care services are covered for Aspirus Medicare Advantage products and references CMS regulations (e.g., 42 CFR 438.114 / 42 CFR 422.113) and Aspirus Medicare Evidence of Coverage documents for applicability to Medicare products; Coverage Policies are intended as general references and providers should consult plan documents for product-specific detail.

Name	Number / Citation	Type
CMS Emergency and post-stabilization services	42 CFR 438.114 / 42 CFR 422.113	NCD

Revision History

2024-08-01policy_adoption (V1)

New policy created and became effective (Original Effective Date: August 1, 2024).

2024-10-08annual_review (V2, non-material)

Annual review (V2): updated effective date, removed row from product, added bullets to Emergency services, and updated disclaimer verbiage.

2025-10-08annual_review (V3, non-material)Latest

Annual review (V3): noted effective date for 2026 in internal history; editorial updates to post-stabilization notes (asterisk info), moved information from Covered to Not Covered/Noted info, removed bolding and redundant definitions.

OpenPayer

Post Stabilization Care

Coverage Summary

Medical-Necessity Criteria

Not Covered & Worldwide Emergency Care Exclusions

Coding

Provider Actions & Operational Rules

Definitions & Background

Medicare Determinations

Revision History