The Prudent Layperson Standard was specifically drafted to allow patients to get the services they need, when they need them.
McCaskills letter outlines Anthems potential violation of federal law by disapproving emergency room claims that may be required to be allowed under the Prudent Layperson Standard, a law that requires emergency room coverage where absence of immediate medical attention would place the health of the individual in serious jeopardy.
Reforms include: SB 50, that sets up a three-step process for denied care; HB 185, that sets up a prudent layperson standard
for judging emergency medical treatment; and HB 186, that requires companies to have a process for referral to specialized physicians.
Prudent layperson standard
for emergencies: Thirty-one state laws specify automatic coverage for emergency medical conditions "of sufficient severity, including severe pain, that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of medical attention to result in placing the person's health in jeopardy.
The Act calls for a prudent layperson standard for defining medical emergencies, the prohibition of prior authorization requirements, a process to assure medically necessary care even after the patient has been stabilized, and methods for resolving disputes between EDs and health plans (American College of Emergency Physicians, "Questions and Answers: Access to Emergency Medical Services Act" undated).
Third, while the prudent layperson standard is gaining in popularity, we do not know whether it might discriminate against immigrants or persons with low educational achievement, who perhaps have different ideas of emergency situations than those belonging to the average American.
Many of the legislative initiatives address similar issues such as: (a) emergency services including the application of a prudent layperson standard
in determining payment coverage for emergency services rendered and bans on pre-authorization; (b) provisions that affect coverage of experimental therapies; (c) anti-gag rules; and (d) information disclosure on the part of health plans to current and potential enrollees including information on financial incentives for providers, prior authorization requirements, and quality indicators.
This is often referred to as the prudent layperson standard