7 LONG TITLE
8 General Description:
9 This bill amends the Insurance Code related to health insurance coverage for emergency
11 Highlighted Provisions:
12 This bill:
13 ▸ requires a health insurer to, at a minimum, provide coverage for emergency care that
14 is medically necessary to stabilize an emergency medical condition; and
15 ▸ authorizes the insurance commissioner to impose fines if an insurer violates the
16 emergency care coverage standards.
17 Money Appropriated in this Bill:
19 Other Special Clauses:
21 Utah Code Sections Affected:
23 31A-22-627, as last amended by Laws of Utah 2006, Chapter 188
25 Be it enacted by the Legislature of the state of Utah:
26 Section 1. Section 31A-22-627 is amended to read:
27 31A-22-627. Coverage of emergency medical services.
28 (1) A health insurance policy or health maintenance organization contract:
29 (a) shall provide, at a minimum, coverage of emergency services as required in 29
30 C.F.R. Sec. 2590.715-2719A; and
31 (b) may not:
33 condition until after the insured's condition has been stabilized; or
35 covered treatment considered medically necessary to stabilize the emergency medical condition
36 of an insured.
37 (2) A health insurance policy or health maintenance organization contract may require
38 authorization for the continued treatment of an emergency medical condition after the insured's
39 condition has been stabilized. If such authorization is required, an insurer who does not accept
40 or reject a request for authorization may not deny a claim for any evaluation, diagnostic testing,
41 or other treatment considered medically necessary that occurred between the time the request
42 was received and the time the insurer rejected the request for authorization.
43 (3) For purposes of this section:
44 (a) "emergency medical condition" means a medical condition manifesting itself by
45 acute symptoms of sufficient severity, including severe pain, such that a prudent layperson,
46 who possesses an average knowledge of medicine and health, would reasonably expect the
47 absence of immediate medical attention at a hospital emergency department to result in:
48 (i) placing the insured's health, or with respect to a pregnant woman, the health of the
49 woman or her unborn child, in serious jeopardy;
50 (ii) serious impairment to bodily functions; or
51 (iii) serious dysfunction of any bodily organ or part; and
52 (b) "hospital emergency department" means that area of a hospital in which emergency
53 services are provided on a 24-hour-a-day basis.
54 (4) Nothing in this section may be construed as:
55 (a) altering the level or type of benefits that are provided under the terms of a contract
56 or policy; or
57 (b) restricting a policy or contract from providing enhanced benefits for certain
58 emergency medical conditions that are identified in the policy or contract.
59 (5) Notwithstanding Section 31A-2-308, if the commissioner finds an insurer has
60 violated this section, the commissioner may:
61 (a) work with the insurer to improve the insurer's compliance with this section; or
62 (b) impose the following fines:
63 (i) not more than $5,000; or
64 (ii) twice the amount of any profit gained Ŝ→ from violations of this section ←Ŝ .