ENGROSSED
Senate Bill No. 355
(By Senators Walker, Prezioso, McCabe, Hunter, Dawson, Mitchell,
Sharpe, Ross, Ball, Minear, Redd, Fanning, Helmick, Unger and
Plymale)
____________
[Introduced February 1, 2000; referred to the Committee on
Banking and Insurance; and then to the Committee on Finance.]
____________
A BILL to amend and reenact section eight, article sixteen, chapter
five of the code of West Virginia, one thousand nine hundred
thirty-one, as amended; to amend and reenact section twenty-
one, article one, chapter thirty-three of said code; to amend
and reenact section twenty-one, article fifteen of said
chapter; to amend and reenact section three-i, article sixteen
of said chapter; to amend and reenact section seven-e, article
twenty-four of said chapter; to amend and reenact section
eight-d, article twenty-five of said chapter; and to amend and
reenact section eight-d, article twenty-five-a of said
chapter, all relating to eliminating the date restrictions on
insurance coverage for emergency medical services.
Be it enacted by the Legislature of West Virginia:
That section eight, article sixteen, chapter five of the code
of West Virginia, one thousand nine hundred thirty-one, as amended,
be amended and reenacted; that section twenty-one, article one,
chapter thirty-three of said code be amended and reenacted; that
section twenty-one, article fifteen of said chapter be amended and
reenacted; that section three-i, article sixteen of said chapter be
amended and reenacted; that section seven-e, article twenty-four of
said chapter be amended and reenacted; that section eight-d,
article twenty-five of said chapter be amended and reenacted; and
that section eight-d, article twenty-five-a of said chapter be
amended and reenacted, all to read as follows:
CHAPTER 5. GENERAL POWERS AND AUTHORITY OF THE GOVERNOR,
SECRETARY OF STATE AND ATTORNEY GENERAL; BOARD
OF PUBLIC WORKS; MISCELLANEOUS AGENCIES, COMMISSIONS,
OFFICES, PROGRAMS, ETC.
ARTICLE 16. WEST VIRGINIA PUBLIC EMPLOYEES INSURANCE ACT.
§5-16-8. Conditions of insurance program.
The insurance plans provided for in this article shall be
designed by the public employees insurance agency:
(1) To provide a reasonable relationship between the hospital,
surgical, medical and prescription drug benefits to be included and
the expected reasonable and customary hospital, surgical, medical and prescription drug expenses as established by the director to be
incurred by the affected employee, his or her spouse and his or her
dependents. The establishment of reasonable and customary expenses
by the public employees insurance agency pursuant to the preceding
sentence is not subject to the state administrative procedures act
in chapter twenty-nine-a of this code;
(2) To include reasonable controls which may include
deductible and coinsurance provisions applicable to some or all of
the benefits, and shall include other provisions, including, but
not limited to, copayments, preadmission certification, case
management programs and preferred provider arrangements;
(3) To prevent unnecessary utilization of the various
hospital, surgical, medical and prescription drug services
available;
(4) To provide reasonable assurance of stability in future
years for the plans;
(5) To provide major medical insurance for the employees
covered under this article;
(6) To provide certain group life and accidental death
insurance for the employees covered under this article;
(7) To include provisions for the coordination of benefits
payable by the terms of the plans with the benefits to which the employee, or his or her spouse or his or her dependents may be
entitled by the provisions of any other group hospital, surgical,
medical, major medical, or prescription drug insurance or any
combination thereof;
(8) To provide a cash incentive plan for employees, spouses
and dependents to increase utilization of, and to encourage the use
of, lower cost alternative health care facilities, health care
providers and generic drugs. The plan shall be reviewed annually
by the director and the advisory board;
(9) To provide "wellness" programs and activities which will
include, but not be limited to, benefit plan incentives to
discourage tobacco, alcohol and chemical abuse and an educational
program to encourage proper diet and exercise. In establishing
"wellness" programs, the division of vocational rehabilitation
shall cooperate with the public employees insurance agency in
establishing statewide wellness programs. The director of the
public employees insurance agency shall contract with county boards
of education for the use of facilities, equipment or any service
related to that purpose. Boards of education may charge only the
cost of janitorial service and increased utilities for the use of
the gymnasium and related equipment. The cost of the exercise
program shall be paid by county boards of education, the public employees insurance agency, or participating employees, their
spouses or dependents. All exercise programs shall be made
available to all employees, their spouses or dependents and shall
not be limited to employees of county boards of education;
(10) To provide a program, to be administered by the director,
for a patient audit plan with reimbursement up to a maximum of one
thousand dollars annually, to employees for discovery of health
care provider or hospital overcharges when the affected employee
brings the overcharge to the attention of the plan. The hospital
or health care provider shall certify to the director that it has
provided, prior to or simultaneously with the submission of the
statement of charges for payments, an itemized statement of the
charges to the employee participant for which payment is requested
of the plan;
(11) To require that all employers give written notice to each
covered employee prior to institution of any changes in benefits to
employees, and to include appropriate penalty for any employer not
providing the required information to any employee; and
(12) To provide coverage for emergency services under offered
plans. For the purposes of this subsection, "emergency services"
means services provided in or by a hospital emergency facility, an
ambulance providing related services under the provisions of article four-c, chapter sixteen of this code or the private office
of a dentist to evaluate and treat a medical condition manifesting
itself by the sudden, and at the time, unexpected onset of symptoms
that require immediate medical attention and for which failure to
provide medical attention would result in serious impairment to
bodily function, serious dysfunction to any bodily organ or part,
or would place the person's health in jeopardy. From the first day
of July, one thousand nine hundred ninety-eight,
through the
thirteenth day of June, two thousand, the following provisions
apply: Plans shall provide coverage for emergency services,
including any prehospital services, to the extent necessary to
screen and stabilize the covered person. The plans shall
reimburse, less any applicable copayments, deductibles or
coinsurance, for emergency services rendered and related to the
condition for which the covered person presented. Prior
authorization of coverage shall not be required for the screening
services if a prudent layperson acting reasonably would have
believed that an emergency medical condition existed. Prior
authorization of coverage shall not be required for stabilization
if an emergency medical condition exists. In the event that prior
authorization was obtained, the authorization may not be retracted
after the services have been provided except when the authorization was based on a material misrepresentation about the medical
condition by the provider of the services or the insured person.
The provider of the emergency services and the plan representative
shall make a good faith effort to communicate with each other in a
timely fashion to expedite postevaluation or poststabilization
services. Payment of claims for emergency services shall be based
on the retrospective review of the presenting history and symptoms
of the covered person. For purposes of this subdivision: (A)
"Emergency services" means those services required to screen for or
treat an emergency medical condition until the condition is
stabilized, including prehospital care; (B) "prudent layperson"
means a person who is without medical training and who draws on his
or her practical experience when making a decision regarding
whether an emergency medical condition exists for which emergency
treatment should be sought; (C) "emergency medical condition for
the prudent layperson" means one that manifests itself by acute
symptoms of sufficient severity, including severe pain, such that
the person could reasonably expect the absence of immediate medical
attention to result in serious jeopardy to the individual's health,
or, with respect to a pregnant woman, the health of the unborn
child; serious impairment to bodily functions; or serious
dysfunction of any bodily organ or part; (D) "stabilize" means with respect to an emergency medical condition, to provide medical
treatment of the condition necessary to assure, with reasonable
medical probability that no medical deterioration of the condition
is likely to result from or occur during the transfer of the
individual from a facility:
Provided, That this provision may not
be construed to prohibit, limit or otherwise delay the
transportation required for a higher level of care than that
possible at the treating facility; (E) "medical screening
examination" means an appropriate examination within the capability
of the hospital's emergency department, including ancillary
services routinely available to the emergency department, to
determine whether or not an emergency medical condition exists.
The director is to report annually to the legislative oversight
commission on health and human resources accountability on the
utilization of emergency services, the cost of those services, a
comparison of utilization and costs between enrollees of the
various plans, and possible plan amendments designed to decrease
any inappropriate utilization of emergency services; and (F)
"emergency medical condition" means a condition that manifests
itself by acute symptoms of sufficient severity including severe
pain such that the absence of immediate medical attention could
reasonably be expected to result in serious jeopardy to the individual's health or with respect to a pregnant woman the health
of the unborn child, serious impairment to bodily functions or
serious dysfunction of any bodily part or organ.
CHAPTER 33. INSURANCE.
ARTICLE 1. DEFINITIONS.
§33-1-21. Emergency services.
(a) Emergency services are: Those services provided in or by
a hospital emergency facility, an ambulance providing related
services under the provisions of article four-c, chapter sixteen of
this code or the private office of a dentist to evaluate and treat
a medical condition manifesting itself by the sudden, and at the
time, unexpected onset of symptoms that require immediate medical
attention and that failure to provide medical attention would
result in serious impairment to bodily function, serious
dysfunction to any bodily organ or part or would place the person's
health in jeopardy.
(b) From the first day of July, one thousand nine hundred
ninety-eight,
through the thirtieth day of June, two thousand, the
following provisions apply:
(1) "Emergency medical services" means those services required
to screen for or treat an emergency medical condition until the
condition is stabilized, including prehospital care;
(2) "Prudent layperson" means a person who is without medical
training and who draws on his or her practical experience when
making a decision regarding whether an emergency medical condition
exists for which emergency treatment should be sought;
(3) "Emergency medical condition for the prudent layperson"
means one that manifests itself by acute symptoms of sufficient
severity, including severe pain, such that the person could
reasonably expect the absence of immediate medical attention to
result in serious jeopardy to the individual's health, or, with
respect to a pregnant woman, the health of the unborn child;
serious impairment to bodily functions; or serious dysfunction of
any bodily organ or part;
(4) "Stabilize" means with respect to an emergency medical
condition, to provide medical treatment of the condition necessary
to assure, with reasonable medical probability that no medical
deterioration of the condition is likely to result from or occur
during the transfer of the individual from a facility:
Provided,
That this provision may not be construed to prohibit, limit or
otherwise delay the transportation required for a higher level of
care than that possible at the treating facility;
(5) "Medical screening examination" means an appropriate
examination within the capability of the hospital's emergency department, including ancillary services routinely available to the
emergency department, to determine whether or not an emergency
medical condition exists; and
(6) "Emergency medical condition" means a condition that
manifests itself by acute symptoms of sufficient severity including
severe pain such that the absence of immediate medical attention
could reasonably be expected to result in serious jeopardy to the
individual's health or with respect to a pregnant woman the health
of the unborn child, serious impairment to bodily functions or
serious dysfunction of any bodily part or organ.
ARTICLE 15. ACCIDENT AND SICKNESS INSURANCE.
§33-15-21. Coverage of emergency services.
From the first day of July, one thousand nine hundred ninety-
eight,
through the thirtieth day of June, two thousand, the
following provisions apply:
(a) Every insurer shall provide coverage for emergency medical
services, including prehospital services, to the extent necessary
to screen and to stabilize an emergency medical condition. The
insurer shall not require prior authorization of the screening
services if a prudent layperson acting reasonably would have
believed that an emergency medical condition existed. Prior
authorization of coverage shall not be required for stabilization if an emergency medical condition exists. Payment of claims for
emergency services shall be based on the retrospective review of
the presenting history and symptoms of the covered person.
(b) An insurer that has given prior authorization for
emergency services shall cover the services and shall not retract
the authorization after the services have been provided unless the
authorization was based on a material misrepresentation about the
covered person's health condition made by the referring provider,
the provider of the emergency services or the covered person.
(c) Coverage of emergency services shall be subject to
coinsurance, copayments and deductibles applicable under the health
benefit plan.
(d) The emergency department and the insurer shall make a good
faith effort to communicate with each other in a timely fashion to
expedite postevaluation or poststabilization services in order to
avoid material deterioration of the covered person's condition.
(e) As used in this section:
(1) "Emergency medical services" means those services required
to screen for or treat an emergency medical condition until the
condition is stabilized, including prehospital care;
(2) "Prudent layperson" means a person who is without medical
training and who draws on his or her practical experience when making a decision regarding whether an emergency medical condition
exists for which emergency treatment should be sought;
(3) "Emergency medical condition for the prudent layperson"
means one that manifests itself by acute symptoms of sufficient
severity, including severe pain, such that the person could
reasonably expect the absence of immediate medical attention to
result in serious jeopardy to the individual's health, or, with
respect to a pregnant woman, the health of the unborn child;
serious impairment to bodily functions; or serious dysfunction of
any bodily organ or part;
(4) "Stabilize" means with respect to an emergency medical
condition, to provide medical treatment of the condition necessary
to assure, with reasonable medical probability that no medical
deterioration of the condition is likely to result from or occur
during the transfer of the individual from a facility:
Provided,
That this provision may not be construed to prohibit, limit or
otherwise delay the transportation required for a higher level of
care than that possible at the treating facility;
(5) "Medical screening examination" means an appropriate
examination within the capability of the hospital's emergency
department, including ancillary services routinely available to the
emergency department, to determine whether or not an emergency medical condition exists; and
(6) "Emergency medical condition" means a condition that
manifests itself by acute symptoms of sufficient severity including
severe pain such that the absence of immediate medical attention
could reasonably be expected to result in serious jeopardy to the
individual's health or with respect to a pregnant woman the health
of the unborn child, serious impairment to bodily functions or
serious dysfunction of any bodily part or organ.
ARTICLE 16. GROUP ACCIDENT AND SICKNESS INSURANCE.
§33-16-3i. Coverage of emergency services.
(a) Notwithstanding any provision of any policy, provision,
contract, plan or agreement to which this article applies, any
entity regulated by this article shall provide as benefits to all
subscribers and members coverage for emergency services. A policy,
provision, contract, plan or agreement may apply to emergency
services the same deductibles, coinsurance and other limitations as
apply to other covered services:
Provided, That preauthorization
or precertification shall not be required.
(b) From the first day of July, one thousand nine hundred
ninety-eight,
through the thirtieth day of June, two thousand, the
following provisions apply:
(1) Every insurer shall provide coverage for emergency medical services, including prehospital services, to the extent necessary
to screen and to stabilize an emergency medical condition. The
insurer shall not require prior authorization of the screening
services if a prudent layperson acting reasonably would have
believed that an emergency medical condition existed. Prior
authorization of coverage shall not be required for stablization if
an emergency medical condition exists. Payment of claims for
emergency services shall be based on the retrospective review of
the presenting history and symptoms of the covered person.
(2) An insurer that has given prior authorization for
emergency services shall cover the services and shall not retract
the authorization after the services have been provided unless the
authorization was based on a material misrepresentation about the
covered person's health condition made by the referring provider,
the provider of the emergency services or the covered person.
(3) Coverage of emergency services shall be subject to
coinsurance, copayments and deductibles applicable under the health
benefit plan.
(4) The emergency department and the insurer shall make a good
faith effort to communicate with each other in a timely fashion to
expedite postevaluation or poststabilization services in order to
avoid material deterioration of the covered person's condition.
(5) As used in this section:
(A) "Emergency medical services" means those services required
to screen for or treat an emergency medical condition until the
condition is stabilized, including prehospital care;
(B) "Prudent layperson" means a person who is without medical
training and who draws on his or her practical experience when
making a decision regarding whether an emergency medical condition
exists for which emergency treatment should be sought;
(C) "Emergency medical condition for the prudent layperson"
means one that manifests itself by acute symptoms of sufficient
severity, including severe pain, such that the person could
reasonably expect the absence of immediate medical attention to
result in serious jeopardy to the individual's health, or, with
respect to a pregnant woman, the health of the unborn child;
serious impairment to bodily functions; or serious dysfunction of
any bodily organ or part;
(D) "Stabilize" means with respect to an emergency medical
condition, to provide medical treatment of the condition necessary
to assure, with reasonable medical probability that no medical
deterioration of the condition is likely to result from or occur
during the transfer of the individual from a facility:
Provided,
That this provision may not be construed to prohibit, limit or otherwise delay the transportation required for a higher level of
care than that possible at the treating facility;
(E) "Medical screening examination" means an appropriate
examination within the capability of the hospital's emergency
department, including ancillary services routinely available to the
emergency department, to determine whether or not an emergency
medical condition exists; and
(F) "Emergency medical condition" means a condition that
manifests itself by acute symptoms of sufficient severity including
severe pain such that the absence of immediate medical attention
could reasonably be expected to result in serious jeopardy to the
individual's health or with respect to a pregnant woman the health
of the unborn child, serious impairment to bodily functions or
serious dysfunction of any bodily part or organ.
(c) The commissioner shall require periodic reports regarding
emergency services utilization and costs provided pursuant to the
provisions of this article. Those reports will be provided
annually to the legislative oversight commission on health and
human resources accountability.
ARTICLE 24. HOSPITAL SERVICE CORPORATIONS, MEDICAL SERVICE
CORPORATIONS, DENTAL SERVICE CORPORATIONS AND
HEALTH SERVICE CORPORATIONS.
§33-24-7e. Coverage of emergency services.
(a) Notwithstanding any provision of any policy, provision,
contract, plan or agreement to which this article applies, any
entity regulated by this article shall provide as benefits to all
subscribers and members coverage for emergency services. A policy,
provision, contract, plan or agreement may apply to emergency
services the same deductibles, coinsurance and other limitations as
apply to other covered services:
Provided, That preauthorization
or precertification shall not be required.
(b) From the first day of July, one thousand nine hundred
ninety-eight,
through the thirtieth day of June, two thousand, the
following provisions apply:
(1) Every insurer shall provide coverage for emergency medical
services, including prehospital services, to the extent necessary
to screen and to stabilize an emergency medical condition. The
insurer shall not require prior authorization of the screening
services if a prudent layperson acting reasonably would have
believed that an emergency medical condition existed. Prior
authorization of coverage shall not be required for stabilization
if an emergency medical condition exists. Payment of claims for
emergency services shall be based on the retrospective review of
the presenting history and symptoms of the covered person.
(2) An insurer that has given prior authorization for
emergency services shall cover the services and shall not retract
the authorization after the services have been provided unless the
authorization was based on a material misrepresentation about the
covered person's health condition made by the referring provider,
the provider of the emergency services or the covered person.
(3) Coverage of emergency services shall be subject to
coinsurance, copayments and deductibles applicable under the health
benefit plan.
(4) The emergency department and the insurer shall make a good
faith effort to communicate with each other in a timely fashion to
expedite postevaluation or poststabilization services in order to
avoid material deterioration of the covered person's condition.
(5) As used in this section:
(A) "Emergency medical services" means those services required
to screen for or treat an emergency medical condition until the
condition is stabilized, including prehospital care;
(B) "Prudent layperson" means a person who is without medical
training and who draws on his or her practical experience when
making a decision regarding whether an emergency medical condition
exists for which emergency treatment should be sought;
(C) "Emergency medical condition for the prudent layperson" means one that manifests itself by acute symptoms of sufficient
severity, including severe pain, such that the person could
reasonably expect the absence of immediate medical attention to
result in serious jeopardy to the individual's health, or, with
respect to a pregnant woman, the health of the unborn child;
serious impairment to bodily functions; or serious dysfunction of
any bodily organ or part;
(D) "Stabilize" means with respect to an emergency medical
condition, to provide medical treatment of the condition necessary
to assure, with reasonable medical probability that no medical
deterioration of the condition is likely to result from or occur
during the transfer of the individual from a facility:
Provided,
That this provision may not be construed to prohibit, limit or
otherwise delay the transportation required for a higher level of
care than that possible at the treating facility;
(E) "Medical screening examination" means an appropriate
examination within the capability of the hospital's emergency
department, including ancillary services routinely available to the
emergency department, to determine whether or not an emergency
medical condition exists; and
(F) "Emergency medical condition" means a condition that
manifests itself by acute symptoms of sufficient severity including severe pain such that the absence of immediate medical attention
could reasonably be expected to result in serious jeopardy to the
individual's health or with respect to a pregnant woman the health
of the unborn child, serious impairment to bodily functions or
serious dysfunction of any bodily part or organ.
ARTICLE 25. HEALTH CARE CORPORATIONS.
§33-25-8d. Coverage of emergency services.
(a) Notwithstanding any provision of any policy, provision,
contract, plan or agreement to which this article applies, any
entity regulated by this article shall provide as benefits to all
subscribers and members coverage for emergency services. A policy,
provision, contract, plan or agreement may apply to emergency
services the same deductibles, coinsurance and other limitations as
apply to other covered services:
Provided, That preauthorization
or precertification shall not be required.
(b) From the first day of July, one thousand nine hundred
ninety-eight,
through the thirtieth day of June, two thousand, the
following provisions apply:
(1) Every insurer shall provide coverage for emergency medical
services, including prehospital services, to the extent necessary
to screen and to stabilize an emergency medical condition. The
insurer shall not require prior authorization of the screening services if a prudent layperson acting reasonably would have
believed that an emergency medical condition existed. Prior
authorization of coverage shall not be required for stablization if
an emergency medical condition exists. Payment of claims for
emergency services shall be based on the retrospective review of
the presenting history and symptoms of the covered person.
(2) An insurer that has given prior authorization for
emergency services shall cover the services and shall not retract
the authorization after the services have been provided unless the
authorization was based on a material misrepresentation about the
covered person's health condition made by the referring provider,
the provider of the emergency services or the covered person.
(3) Coverage of emergency services shall be subject to
coinsurance, copayments and deductibles applicable under the health
benefit plan.
(4) The emergency department and the insurer shall make a good
faith effort to communicate with each other in a timely fashion to
expedite postevaluation or poststabilization services in order to
avoid material deterioration of the covered person's condition.
(5) As used in this section:
(A) "Emergency medical services" means those services required
to screen for or treat an emergency medical condition until the
condition is stabilized, including prehospital care;
(B) "Prudent layperson" means a person who is without medical
training and who draws on his or her practical experience when
making a decision regarding whether an emergency medical condition
exists for which emergency treatment should be sought;
(C) "Emergency medical condition for the prudent layperson"
means one that manifests itself by acute symptoms of sufficient
severity, including severe pain, such that the person could
reasonably expect the absence of immediate medical attention to
result in serious jeopardy to the individual's health, or, with
respect to a pregnant woman, the health of the unborn child;
serious impairment to bodily functions; or serious dysfunction of
any bodily organ or part;
(D) "Stabilize" means with respect to an emergency medical
condition, to provide medical treatment of the condition necessary
to assure, with reasonable medical probability that no medical
deterioration of the condition is likely to result from or occur
during the transfer of the individual from a facility:
Provided,
That this provision may not be construed to prohibit, limit or
otherwise delay the transportation required for a higher level of care than that possible at the treating facility;
(E) "Medical screening examination" means an appropriate
examination within the capability of the hospital's emergency
department, including ancillary services routinely available to the
emergency department, to determine whether or not an emergency
medical condition exists; and
(F) "Emergency medical condition" means a condition that
manifests itself by acute symptoms of sufficient severity including
severe pain such that the absence of immediate medical attention
could reasonably be expected to result in serious jeopardy to the
individual's health or with respect to a pregnant woman the health
of the unborn child, serious impairment to bodily functions or
serious dysfunction of any bodily part or organ.
ARTICLE 25A. HEALTH MAINTENANCE ORGANIZATION ACT.
§33-25A-8d. Coverage of emergency services.
(a) Notwithstanding any provision of any policy, provision,
contract, plan or agreement to which this article applies, any
entity regulated by this article shall provide as benefits to all
subscribers and members coverage for emergency services. A policy,
provision, contract, plan or agreement may apply to emergency
services the same deductibles, coinsurance and other limitations as apply to other covered services:
Provided, That preauthorization
or precertification shall not be required.
(b) From the first day of July, one thousand nine hundred
ninety-eight,
through the thirtieth day of June, two thousand, the
following provisions apply:
(1) Every insurer shall provide coverage for emergency medical
services, including prehospital services, to the extent necessary
to screen and to stabilize an emergency medical condition. The
insurer shall not require prior authorization of the screening
services if a prudent layperson acting reasonably would have
believed that an emergency medical condition existed. Prior
authorization of coverage shall not be required for stabilization
if an emergency medical condition exists. Payment of claims for
emergency services shall be based on the retrospective review of
the presenting history and symptoms of the covered person.
(2) An insurer that has given prior authorization for
emergency services shall cover the services and shall not retract
the authorization after the services have been provided unless the
authorization was based on a material misrepresentation about the
covered person's health condition made by the referring provider,
the provider of the emergency services or the covered person.
(3) Coverage of emergency services shall be subject to coinsurance, copayments and deductibles applicable under the health
benefit plan.
(4) The emergency department and the insurer shall make a good
faith effort to communicate with each other in a timely fashion to
expedite postevaluation or poststabilization services in order to
avoid material deterioration of the covered person's condition.
(5) As used in this section:
(A) "Emergency medical services" means those services required
to screen for or treat an emergency medical condition until the
condition is stabilized, including prehospital care;
(B) "Prudent layperson" means a person who is without medical
training and who draws on his or her practical experience when
making a decision regarding whether an emergency medical condition
exists for which emergency treatment should be sought;
(C) "Emergency medical condition for the prudent layperson"
means one that manifests itself by acute symptoms of sufficient
severity, including severe pain, such that the person could
reasonably expect the absence of immediate medical attention to
result in serious jeopardy to the individual's health, or, with
respect to a pregnant woman, the health of the unborn child;
serious impairment to bodily functions; or serious dysfunction of
any bodily organ or part;
(D) "Stabilize" means with respect to an emergency medical
condition, to provide medical treatment of the condition necessary
to assure, with reasonable medical probability that no medical
deterioration of the condition is likely to result from or occur
during the transfer of the individual from a facility:
Provided,
That this provision may not be construed to prohibit, limit or
otherwise delay the transportation required for a higher level of
care than that possible at the treating facility;
(E) "Medical screening examination" means an appropriate
examination within the capability of the hospital's emergency
department, including ancillary services routinely available to the
emergency department, to determine whether or not an emergency
medical condition exists; and
(F) "Emergency medical condition" means a condition that
manifests itself by acute symptoms of sufficient severity including
severe pain such that the absence of immediate medical attention
could reasonably be expected to result in serious jeopardy to the
individual's health or with respect to a pregnant woman the health
of the unborn child, serious impairment to bodily functions or
serious dysfunction of any bodily part or organ.
(6) Each insurer shall provide the enrolled member with a
description of procedures to be followed by the member for emergency services, including the following:
(A) The appropriate use of emergency facilities;
(B) The appropriate use of any prehospital services provided
by the health maintenance organization;
(C) Any potential responsibility of the member for payment for
nonemergency services rendered in an emergency facility;
(D) Any cost-sharing provisions for emergency services; and
(E) An explanation of the prudent layperson standard for
emergency medical condition.
(c) The commissioner shall require periodic reports regarding
emergency services utilization and costs provided pursuant to the
provisions of this article. Those reports will be provided
annually to the legislative oversight commission on health and
human resources accountability.
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