The American College of Emergency Physicians has worked tirelessly for more than 17 years for a passage of a national “prudent layperson” standard to require health insurance plans to base coverage of emergency care on a patient’s symptoms, not the final diagnosis.
After a long journey and a tough fight, the newly passed health care reform legislation applies this standard to nearly 100% of all the health plans in America.
The standard was included as part of an amendment called the Patients’ Bill of Rights, sponsored by Sen.
Benjamin L. Cardin (D-Md.). Sen. Cardin is the champion and original congressional sponsor of the ACEP-supported bill in 1995 to enact a national prudent layperson standard, which was applied to Medicare and Medicaid in 1997.
ACEP has always been a leader at the national and state levels in advocating for the prudent layperson standard.
A “prudent layperson” has been defined in the law as one who possesses an average knowledge of health and medicine, and the standard establishes the criteria that insurance coverage is based not on ultimate diagnosis, but on whether a prudent person might anticipate serious impairment to his or her health in an emergency situation.
“ACEP has long believed that anyone who seeks emergency care suffering from symptoms that appear to be an emergency, such as chest pain, should not be denied coverage if the final diagnosis does not turn out to be an emergency,” said Dr. Angela Gardner, ACEP President.
The newly passed health care reform legislation applies this standard to nearly 100% of all the health plans in america.
“The new bill also prohibits health plans from requiring patients to seek prior authorization before seeking emergency care, which is also part of that standard,” she added.
In the past, most managed care plans would determine the necessity for emergency care based on the final diagnosis, rather than on the symptoms that prompted patients to seek emergency care.
For example, a person with a severe headache and blurred vision might be denied coverage for an emergency visit because the condition turned out to be minor and easily treated.
ACEP argued against this, saying it was prudent for the person to seek care, because these symptoms can be indications of life-threatening conditions.Cal Chaney, ACEP General Counsel and Executive Associate Director of ACEP’s Policy Division, said he remembers when he and ACEP leaders traveled from state to state, in many cases helping ACEP chapters start or enhance legislative programs to advocate for the standard at the state level.