Utah Code 31A-22-627. Coverage of emergency medical services
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(1) A health insurance policy or managed care organization contract:
Terms Used In Utah Code 31A-22-627
- Contract: A legal written agreement that becomes binding when signed.
- Emergency medical condition: means a medical condition that:(56)(a) manifests itself by acute symptoms, including severe pain; and(56)(b) would cause a prudent layperson possessing an average knowledge of medicine and health to reasonably expect the absence of immediate medical attention through a hospital emergency department to result in:(56)(b)(i) placing the layperson's health or the layperson's unborn child's health in serious jeopardy;(56)(b)(ii) serious impairment to bodily functions; or(56)(b)(iii) serious dysfunction of any bodily organ or part. See Utah Code 31A-1-301
- Form: means one of the following prepared for general use:
(74)(a)(i) a policy;(74)(a)(ii) a certificate;(74)(a)(iii) an application;(74)(a)(iv) an outline of coverage; or(74)(a)(v) an endorsement. See Utah Code 31A-1-301- health insurance: means insurance providing:
(84)(a)(i) a health care benefit; or(84)(a)(ii) payment of an incurred health care expense. See Utah Code 31A-1-301- Insurance: includes :
(96)(b)(i) a risk distributing arrangement providing for compensation or replacement for damages or loss through the provision of a service or a benefit in kind;(96)(b)(ii) a contract of guaranty or suretyship entered into by the guarantor or surety as a business and not as merely incidental to a business transaction; and(96)(b)(iii) a plan in which the risk does not rest upon the person who makes an arrangement, but with a class of persons who have agreed to share the risk. See Utah Code 31A-1-301- Insured: means a person to whom or for whose benefit an insurer makes a promise in an insurance policy and includes:
(103)(a)(i) a policyholder;(103)(a)(ii) a subscriber;(103)(a)(iii) a member; and(103)(a)(iv) a beneficiary. See Utah Code 31A-1-301- Managed care organization: means a person:
(122)(a) licensed as a health maintenance organization under Chapter 8, Health Maintenance Organizations and Limited Health Plans; or(122)(b)(122)(b)(i) licensed under:(122)(b)(i)(A) Chapter 5, Domestic Stock and Mutual Insurance Corporations;(122)(b)(i)(B) Chapter 7, Nonprofit Health Service Insurance Corporations; or(122)(b)(i)(C) Chapter 14, Foreign Insurers; and(122)(b)(ii) that requires an enrollee to use, or offers incentives, including financial incentives, for an enrollee to use, network providers. See Utah Code 31A-1-301- Policy: includes a service contract issued by:
(150)(b)(i) a motor club under Chapter 11, Motor Clubs;(150)(b)(ii) a service contract provided under Chapter 6a, Service Contracts; and(150)(b)(iii) a corporation licensed under:(150)(b)(iii)(A) Chapter 7, Nonprofit Health Service Insurance Corporations; or(150)(b)(iii)(B) Chapter 8, Health Maintenance Organizations and Limited Health Plans. See Utah Code 31A-1-301(1)(a) shall provide coverage of emergency services; and(1)(b) may not:(1)(b)(i) require any form of preauthorization for treatment of an emergency medical condition until after the insured‘s condition has been stabilized;(1)(b)(ii) deny a claim for any covered evaluation, covered diagnostic test, or other covered treatment considered medically necessary to stabilize the emergency medical condition of an insured; or(1)(b)(iii) impose any cost-sharing requirement for out-of-network that exceeds the cost-sharing requirement imposed for in-network.(2)(2)(a) A health insurance policy or managed care organization contract may require authorization for the continued treatment of an emergency medical condition after the insured’s condition has been stabilized.(2)(b) If authorization described in Subsection (2)(a) is required, an insurer who does not accept or reject a request for authorization may not deny a claim for any evaluation, diagnostic testing, or other treatment considered medically necessary that occurred between the time the request was received and the time the insurer rejected the request for authorization.(3) For purposes of this section:(3)(a) “Hospital emergency department” means that area of a hospital in which emergency services are provided on a 24-hour-a-day basis.(3)(b) “Stabilize” means the same as that term is defined in 42 U.S.C. § 1395dd(e)(3).(4) Nothing in this section may be construed as:(4)(a) altering the level or type of benefits that are provided under the terms of a contract or policy; or(4)(b) restricting a policy or contract from providing enhanced benefits for certain emergency medical conditions that are identified in the policy or contract.(5) Notwithstanding Section 31A-2-308, if the commissioner finds an insurer has violated this section, the commissioner may:(5)(a) work with the insurer to improve the insurer’s compliance with this section; or(5)(b) impose the following fines:(5)(b)(i) not more than $5,000; or(5)(b)(ii) twice the amount of any profit gained from violations of this section. - Form: means one of the following prepared for general use: