100.030 Protecting the Prudent Layperson Standard


Protecting the Prudent Layperson Standard: The Texas Medical Association: (1) adopts the following principles related to out-of-network emergency care: Patients who seek emergency care should be protected under the “prudent layperson” standard as established in state and federal law, without regard to prior authorization or retrospective denial for services after emergency care is rendered. Patients must not be financially penalized for receiving emergency care from an out-of-network physician or provider. Insurers must meet appropriate network adequacy standards that include adequate patient access to care, including access to physician specialties. Texas Department of Insurance should enforce such standards through active regulation of health insurance company plans. Insurers must be transparent and proactive in informing enrollees about all deductibles, copayments, and other out-of-pocket costs that enrollees may incur. Medical necessity review of emergency services must be performed by a board-certified emergency medicine physician licensed in Texas and not affiliated with an insurer, a municipal cooperative health benefit plan, health management organization, or the physician or provider or facility in question; and (2) actively opposes any health plan or other payer policy that dissuades patients from seeking needed emergency care in situations where they believe their health is at risk. (Res. 408-A-18).

Last Updated On

June 20, 2019