A proposed new guideline for health insurers would require them to cover emergency room screening and stabilization services if patients reasonably believe their symptoms merit such care.
If adopted by the full membership of the National Association of Insurance Commissioners and then by the states, the model legislation would require coverage of emergency room screening and stabilization if a "prudent layperson acting reasonably" would have believed an emergency condition existed.
Earlier this month, the NAIC's accident and health insurance committee blessed the prudent layperson standard in its model utilization review act. The model bill would require coverage of emergency room screening services without prior authorization if that standard is met.
In cases in which a hospital doesn't have a contract with the health plan that covers the patient, prior authorization is not necessary if a prudent layperson would have believed that the use of a contracting provider would result in a delay that would worsen the emergency.
Four states-Arkansas, Georgia, Maryland and Virginia-already have passed emergency medicine laws that include prudent layperson language.
Health insurers said the model passed by the NAIC committee represented a compromise from an earlier draft that would have required health plans to cover more services than just screening and stabilization.
Chris Petersen, vice president of state affairs and the legal department at the Health Insurance Association of America, said insurers still believe the model bill would force them to cover inappropriate screening and stabilization services.
"We don't think it's the best solution, but it's better than the broad language that was being considered," Petersen said.
The model bill is part of the NAIC's work on health plan accountability, which seeks uniform state laws and regulations on numerous managed-care and insurance issues. The NAIC is working on seven model bills related to health plan accountability, including contracting practices, quality and credentialing.
Two models have passed the full NAIC membership, and the utilization review model bill faces a vote of the full membership in autumn.