Chief Sponsor: Karen Mayne

House Sponsor: Mike K. McKell


8     General Description:
9           This bill amends the Insurance Code related to health insurance coverage for emergency
10     care.
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:
18          None
19     Other Special Clauses:
20          None
21     Utah Code Sections Affected:
22     AMENDS:
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:
32          [(a)] (i) require any form of preauthorization for treatment of an emergency medical
33     condition until after the insured's condition has been stabilized; or
34          [(b)] (ii) deny a claim for any covered evaluation, covered diagnostic test, or other
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 from violations of this section.