An Act To Protect Patients and the Prudent Layperson Standard
Maine Legislature, Session 129, LD 1155
Committee: Health Coverage, Insurance and Financial Services
Sponsors: GIDEON, FOLEY, MASTRACCIO, PERRY, SWALLOW, TEPLER, TUELL, CARPENTER, MOORE
Amends: 24-A MRSA §4301-A, 24-A MRSA §4304, 24-A MRSA §4320-C

Legislative Document
No. 1155
H.P. 844
House of Representatives, March 7, 2019
An Act To Protect Patients and the Prudent Layperson Standard
Reference to the Committee on Health Coverage, Insurance and Financial Services 
suggested and ordered printed.
ROBERT B. HUNT
Clerk
Presented by Speaker GIDEON of Freeport.
Cosponsored by Senator FOLEY of York and
Representatives: MASTRACCIO of Sanford, PERRY of Calais, SWALLOW of Houlton, 
TEPLER of Topsham, TUELL of East Machias, Senators: CARPENTER of Aroostook, 
MOORE of Washington, SANBORN, H. of Cumberland.
Be it enacted by the People of the State of Maine as follows:
Sec. 1.  24-A MRSA §4301-A, sub-§§4-A and 4-B are enacted to read:
4-A.  Emergency medical condition.  "Emergency medical condition" means the 
sudden and, at the time, unexpected onset of a physical or mental health condition 
manifesting itself by symptoms of sufficient severity, regardless of the final diagnosis 
that is given, that would lead a prudent layperson, possessing an average knowledge of 
medicine and health, to believe:
A.  That the absence of immediate medical attention for an individual could 
reasonably be expected to result in:
(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
B.  With respect to a pregnant woman who is having contractions, that there is:
(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.
4-B.  Emergency service.  "Emergency service" means a health care item or service 
furnished or required to evaluate and treat an emergency medical condition that is 
provided in an emergency facility or setting by a health care provider.
Sec. 2.  24-A MRSA §4304, sub-§5, as enacted by PL 1999, c. 742, §13, is 
amended to read:
5.  Emergency services.  When conducting utilization review or making a benefit 
determination for emergency services, a carrier shall provide benefits for emergency 
services consistent with the requirements of this subsection and any applicable bureau 
rule.
A.  A carrier may not require prior authorization for emergency services.
B.  Before a carrier denies benefits or reduces payment for an emergency service 
based on a determination of the absence of an emergency medical condition or a 
determination that a lower level of care was needed than is required for an emergency 
medical condition, the carrier shall review the enrollee's medical record related to the 
emergency medical condition subject to dispute.  If a carrier requests records related 
to a potential denial of or payment reduction for an enrollee's benefits when 
emergency services were furnished to an enrollee, a provider has an affirmative duty 
to respond to the carrier in a timely manner.  A carrier's utilization review of 
emergency services must be conducted by a clinical peer that is board certified in the 
same specialty and licensed to practice in this State.
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.