First Substitute H.B. 185

Representative Mary Carlson proposes to substitute the following bill:

1 HEALTH INSURERS - COVERAGE OF
2 EMERGENCY MEDICAL SERVICES
3 2000 GENERAL SESSION
4 STATE OF UTAH
5 Sponsor: Mary Carlson
6 AN ACT RELATING TO INSURANCE; ESTABLISHING A PRUDENT LAYPERSON
7 STANDARD FOR COVERAGE OF EMERGENCY MEDICAL CONDITIONS; AND
8 PROVIDING AN EFFECTIVE DATE.
9 This act affects sections of Utah Code Annotated 1953 as follows:
10 ENACTS:
11 31A-22-625, Utah Code Annotated 1953
12 Be it enacted by the Legislature of the state of Utah:
13 Section 1. Section 31A-22-625 is enacted to read:
14 31A-22-625. Coverage of emergency medical services.
15 (1) A health insurance policy or health maintenance organization contract may not:
16 (a) require any form of preauthorization for treatment of an emergency medical condition
17 until after the insured's condition has been stabilized; or
18 (b) deny a claim for any evaluation, diagnostic test, or other covered treatment considered
19 medically necessary to stabilize the emergency medical condition of an insured.
20 (2) A health insurance policy or health maintenance organization contract may require
21 authorization for the continued treatment of an emergency medical condition after the insured's
22 condition has been stabilized. If such authorization is required, an insurer who does not accept or
23 reject a request for authorization may not deny a claim for any evaluation, diagnostic testing, or
24 other treatment considered medically necessary that occurred between the time the request was
25 received and the time the insurer rejected the request for authorization.

26 (3) For purposes of this section h :
26a (a) h "emergency medical condition" means a medical condition
27 manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a
28 prudent layperson, who possesses an average knowledge of medicine and health, would reasonably
29 expect the absence of immediate medical attention at h [ an ] A HOSPITAL h emergency h [ treatment
29a facility, as defined
30 in rule, ] DEPARTMENT h to result in:
31 h [ (a) ] (i) h placing the insured's health, or with respect to a pregnant woman, the health of
31a the
32 woman or her unborn child, in serious jeopardy;
33 h [ (b) ] (ii) h serious impairment to bodily functions; or
34 h [ (c) ] (iii) h serious dysfunction of any bodily organ or part h ; AND
34a (b) "HOSPITAL EMERGENCY DEPARTMENT" MEANS THAT AREA OF A HOSPITAL IN WHICH
34b EMERGENCY SERVICES ARE PROVIDED ON A 24-HOUR-A-DAY BASIS. h
34b1 h (4) NOTHING IN THIS SECTION MAY BE CONSTRUED AS:
34b2 (a) ALTERING THE LEVEL OR TYPE OF BENEFITS THAT ARE PROVIDED UNDER THE TERMS
34b3 OF A CONTRACT OR POLICY ; OR
34b4 (b) RESTRICTING A POLICY OR CONTRACT FROM PROVIDING ENHANCED BENEFITS FOR
34b5 CERTAIN EMERGENCY MEDICAL CONDITIONS THAT ARE IDENTIFIED IN THE POLICY OR
34b6 CONTRACT. h
35 Section 2. Effective date.
36 This act takes effect on July 1, 2000.