PA Prudent Layperson Act
                           Act 112 of 1997

SENATE AMENDED PRIOR PRINTER'S NOS. 1636, 2807 PRINTER'S NO. 3853
HOUSE BILL 1415 Session of 1995 INTRODUCED BY LAWLESS, BUXTON,
DEMPSEY, BEBKOJONES, DURHAM, MANDERINO, FICHTER, CORNELL, KING, TRICH,
VAN HORNE, MAYERNIK, L. I. COHEN AND PETTIT, APRIL 20, 1995 SENATOR
HOLL, BANKING AND INSURANCE, IN SENATE, AS AMENDED, JUNE 25, 1996 

AN ACT Requiring reimbursement by insurers for certain services performed
by a hospital emergency facility. 

The General Assembly of the Commonwealth of Pennsylvania hereby enacts
as follows: 

Section 1. Definitions. 

The following words and phrases when used in this act shall have the
meanings given to them in this section unless the context clearly
indicates otherwise: 

"Insurer." The term means: (1) Any insurance company, association or
reciprocal, nonprofit hospital plan corporation. 

(2) A nonprofit professional health service plan. 

(3) A health maintenance organization organized and regulated under
the act of December 29, 1972 (P.L.1701, No.364), known as the Health
Maintenance Organization Act. 

(4) A riskassuming preferred provider organization organized and
regulated under the act of May 17, 1921 (P.L.682, No.284), known as
The Insurance Company Law of 1921. 

(5) A preferred provider with a "health management gatekeeper" role
for primary care physicians organized and regulated as a health
services corporation or a preferred provider organization subject to
the provisions of section 630 of The Insurance Company Law of 1921. 

(6) A fraternal benefit society subject to the provisions of the act
of December 14, 1992 (P.L.835, No.134), known as the Fraternal Benefit
Societies Code. 

Medical emergency -- medical condition with acute symptoms of severity or
severe pain, for which:

1. care is sought as soon as possible after the medical condition becomes
evident to the patient or the patient's parent or guardian; and

2. the absence of immediate medical attention could-result in:
 - placing health in serious jeopardy;
 - serious impairment to bodily functions;
 - serious dysfunction of any body part; or
 - other serious medical consequences.

Requirement -- An insurer shall reimburse an insured or provider for medically
necessary services that are provided in a hospital emergency facility due to a
medical emergency.

Information -- A hospital emergency facility shall provide to an insurer, with
any claim for reimbursement of services, information on the presenting
symptoms of the insured, as well as services provided.

Factors considered - An insurer shall consider both the presenting symptoms
and the services provided in processing a claim for reimbursement of emergency
services.

Section 3. Effective date. 

This act shall take effect in 180 days.