An Act To Protect Patients and the Prudent Layperson Standard
Sec. 1. 24-A MRSA §4301-A, sub-§§4-A and 4-B are enacted to read:
(1) Placing the physical or mental health of the individual or, with respect to a pregnant woman, the health of the pregnant woman or her unborn child in serious jeopardy;
(2) Serious impairment of a bodily function;
(3) Serious dysfunction of any organ or body part; or
(4) Inadequately controlled pain; or
(1) Inadequate time to effect a safe transfer of the woman to another hospital before delivery; or
(2) A threat to the health or safety of the woman or unborn child if the woman were to be transferred to another hospital.
Sec. 2. 24-A MRSA §4304, sub-§5, as enacted by PL 1999, c. 742, §13, is amended to read:
Sec. 3. 24-A MRSA §4320-C, as enacted by PL 2011, c. 364, §34, is amended to read:
§ 4320-C. Emergency services
If a carrier offering a health plan subject to the requirements of the federal Affordable Care Act provides or covers any benefits with respect to services in an emergency department of a hospital, the plan must cover emergency services in accordance with the requirements of the federal Affordable Care Act, including requirements that emergency services be covered without prior authorization and that cost-sharing requirements, expressed as a copayment amount or coinsurance rate, for out-of-network services are the same as requirements that would apply if such services were provided in network. A carrier offering a health plan in this State shall also comply with the requirements of section 4304, subsection 5.
SUMMARY
This bill establishes a definition of "emergency medical condition" in the law governing utilization review in the Maine Insurance Code and makes clear that the determination of an emergency medical condition relies on the prudent layperson standard regardless of the final diagnosis that is given. The bill also prohibits a carrier from requiring prior authorization for emergency services and requires that utilization review of benefit determinations for emergency services be conducted by a clinical peer, who is a licensed provider in the same or similar specialty as typically manages the medical condition, procedure or treatment under review.