Section 4U: Emergency services provided to insureds for emergency medical conditions
Section 4U. (a) As used in this section, the following words shall have the following meanings:-
''Attending physician'', the emergency physician or consultant physician who actively treats the emergency medical condition of an insured at an emergency facility.
''Emergency medical condition'', a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health of an insured or another person in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined in section 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. section 1395dd(e)(1)(B).
''Insured'', a member or subscriber of a medical service corporation who is treated in an emergency facility for an emergency medical condition, regardless of whether the member's or subscriber's contract with the corporation is delivered, issued or renewed on a group or individual basis.
''Stabilization for discharge'', an emergency medical condition shall be deemed to be stabilized for purposes of discharging an insured, other than for the purpose of transfer from one facility to another facility, when the attending physician has determined that, within reasonable clinical confidence, the insured has reached the point where further care, including diagnostic work-up or treatment, or both, could be reasonably performed on an outpatient basis or a later scheduled inpatient basis if the insured is given a reasonable plan for appropriate follow-up care and discharge instructions, or as further defined in section 1867(e)(3)(A) of the Social Security Act, 42 U.S.C. section 1395dd(e)(3)(A). Stabilization for discharge does not require final resolution of the emergency medical condition.
''Stabilization for transfer'', an emergency medical condition shall be deemed to be stabilized for transfer if an insured can be transferred from one facility to a second facility and the attending physician has determined, within reasonable clinical confidence, that the insured is expected to leave the hospital and be received at a second facility with no material deterioration in his condition, or as further defined in section 1867(c) and (e)(4) of the Social Security Act, 42 U.S.C. section 1395dd(c) and (e)(4). Stabilization for transfer does not require final resolution of the emergency medical condition.
(b) Any contract or subscription certificate between an insured and the corporation shall provide as benefits coverage for emergency services provided to an insured for emergency medical conditions. After an insured has been stabilized for discharge or transfer, the corporation or its designee may require a hospital emergency department to contact the physician on call designated by the corporation or its designee for authorization of post-stabilization services to be provided. The hospital emergency department shall take all reasonable steps to initiate contact with said corporation or its designee within 30 minutes of stabilization. Such authorization shall be deemed granted if said corporation or its designee has not responded to said call within 30 minutes. Notwithstanding the foregoing provision, in the event the attending physician and said on-call physician do not agree on what constitutes appropriate medical treatment, the opinion of the attending physician shall prevail and such treatment shall be considered appropriate treatment for an emergency medical condition provided that such treatment is consistent with generally accepted principles of professional medical practice and is a covered benefit under the contract or subscription certificate of an insured with the corporation. Consistent with the foregoing, said corporation or its designee may enter into contracts with hospitals or emergency physician groups, or both, for the provision of emergency services.
(c) Any contract or subscription certificate between an insured and the medical service corporation may require an insured to contact either the corporation or its designee or the primary care provider of the insured within 48 hours of receiving such emergency services, but notification already given to said corporation, designee or said primary care provider by the attending physician shall satisfy the requirements of this paragraph.
(d) Nothing in this section shall be construed to limit retrospective utilization review activities by said corporation or its designee with respect to screening, stabilization and post-stabilization services for the purposes of assessing quality, utilization patterns and coding and billing practices, but such activities shall not result in retroactive changes to treatment or reimbursement decisions previously made in accordance with this section. In conducting said utilization review activities, said corporation or its designee shall be in compliance with section 12 of chapter 176O and all applicable state and federal confidentiality provisions.
(e) The corporation or its designee shall clearly state in its brochures, contracts, policy manuals and all printed materials that insureds shall have the option of calling the local pre-hospital emergency medical service system by dialing the emergency telephone access number 911, or its local equivalent, whenever an insured is confronted with an emergency medical condition which in the judgment of a prudent layperson would require pre-hospital emergency services. No insured shall in any way be discouraged from using the local pre-hospital emergency medical service system, the 911 telephone number, or the local equivalent, or be denied coverage for medical and transportation expenses incurred as a result of such emergency medical condition.