H.B. 185 Enrolled

HEALTH INSURERS - COVERAGE OF
EMERGENCY MEDICAL SERVICES
2000 GENERAL SESSION
STATE OF UTAH
Sponsor: Mary Carlson
Patrice M. Arent

AN ACT RELATING TO INSURANCE; ESTABLISHING A PRUDENT LAYPERSON
STANDARD FOR COVERAGE OF EMERGENCY MEDICAL CONDITIONS; AND
PROVIDING AN EFFECTIVE DATE.
This act affects sections of Utah Code Annotated 1953 as follows:
ENACTS:
31A-22-625, Utah Code Annotated 1953
Be it enacted by the Legislature of the state of Utah:
Section 1. Section 31A-22-625 is enacted to read:
31A-22-625. Coverage of emergency medical services.
(1) A health insurance policy or health maintenance organization contract may not:
(a) require any form of preauthorization for treatment of an emergency medical condition
until after the insured's condition has been stabilized; or
(b) deny a claim for any evaluation, diagnostic test, or other covered treatment considered
medically necessary to stabilize the emergency medical condition of an insured.
(2) A health insurance policy or health maintenance organization contract may require
authorization for the continued treatment of an emergency medical condition after the insured's
condition has been stabilized. If such authorization is required, an insurer who does not accept or
reject a request for authorization may not deny a claim for any evaluation, diagnostic testing, or
other treatment considered medically necessary that occurred between the time the request was
received and the time the insurer rejected the request for authorization.
(3) For purposes of this section:
(a) "emergency medical condition" means a medical condition manifesting itself by acute
symptoms of sufficient severity, including severe pain, such that a prudent layperson, who possesses

an average knowledge of medicine and health, would reasonably expect the absence of immediate
medical attention at a hospital emergency department to result in:
(i) placing the insured's health, or with respect to a pregnant woman, the health of the woman
or her unborn child, in serious jeopardy;
(ii) serious impairment to bodily functions; or
(iii) serious dysfunction of any bodily organ or part; and
(b) "hospital emergency department" means that area of a hospital in which emergency
services are provided on a 24-hour-a-day basis.
(4) Nothing in this section may be construed as:
(a) altering the level or type of benefits that are provided under the terms of a contract or
policy; or
(b) restricting a policy or contract from providing enhanced benefits for certain emergency
medical conditions that are identified in the policy or contract.
Section 2. Effective date.
This act takes effect on July 1, 2000.

- 2 -