500.3406k Emergency health services; medically necessary coverage; "stabilization" defined.

267 words·~1 min read·/mi/chapter-500/500-3406k

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Sec. 3406k.

(1)An insurer that delivers, issues for delivery, or renews in this state a health insurance policy that provides coverage for emergency health services shall provide coverage for medically necessary services provided to an insured for the sudden onset of a medical condition that manifests itself by signs and symptoms of sufficient severity, including severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the individual's health or to a pregnancy in the case of a pregnant woman, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. An insurer shall not require a physician to transfer a patient before the physician determines that the patient has reached the point of stabilization. An insurer shall not deny payment for emergency health services up to the point of stabilization provided to an insured under this subsection because of either of the following:

(a)The final diagnosis.

(b)Prior authorization not being given by the insurer before emergency health services were provided.

(2)As used in this section, "stabilization" means the point at which no material deterioration of a condition is likely, within reasonable medical probability, to result from or occur during transfer of the patient.

History: Add. 1998, Act 125 , Imd. Eff. June 10, 1998 ;-- Am. 2004, Act 7 , Imd. Eff. Feb. 20, 2004 ;-- Am. 2016, Act 276 , Imd. Eff. July 1, 2016

Popular Name: Act 218