THE VALUED VOICE

Vol. 65, Issue 23
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Thursday, June 10, 2021

   

Proposed Insurer Policy Would Have Denied Coverage for Emergency Care

Policy Now on Hold Due to Negative Feedback from Providers
The American Hospital Association (AHA)  this week asked for an immediate reversal of a planned new policy from UnitedHealthcare (UHC) that would retroactively deny coverage for emergency care. In a letter to UHC, AHA said the policy would have a chilling effect on patients obtaining care and would jeopardize their health and well-being. 
 
On Thursday, June 10, UHC announced in a tweet that the implementation of the policy is on hold until at least the end of the public health emergency period. 

“We have been seeing some worrisome insurer policies being proposed over the past six months including restrictions on networks for certain services, restrictions on coverage, and this one which is particularly egregious, as it could deter patients from seeking emergency care,” said Wisconsin Hospital Association (WHA) Senior Vice President for Public Policy Joanne Alig. “We are pleased that UHC has decided to put the policy on hold, and hope it is not just a temporary delay but a permanent policy reversal.”   

At issue in this instance is whether an insurer should be able to determine after the fact that a patient should have sought care in an emergency room or somewhere else. Federal law and state law in Wisconsin require that insurers cover emergency services, and in doing so they are required to apply what is known as a “prudent layperson standard,” which is an important patient protection. The prudent layperson standard essentially says that if a reasonable person with an average knowledge of health and medicine thinks his or her health is in jeopardy based on his or her symptoms, then it is an emergency medical condition. 

The policy stated by UHC is similar to one implemented by Anthem/Blue Cross Blue Shield which is being challenged in court by the American College of Emergency Physicians and the Medical Association of Georgia. The Anthem policy has not been implemented in Wisconsin.

Details about the UHC policy were unclear.  The UHC network bulletin available publicly on the company’s website did not indicate in which states it would have reviewed emergency department visits, and news reports varied on the precise number of states,  however it appears that the policy would have been implemented in over 30 states, including in Wisconsin. According to a report from USA Today, UHC had indicated the policy could have applied to 10% of emergency room visits.  There has also been conflicting information about whether the policy would have applied to the individual market, but it appears the policy would have applied to employer-sponsored group plans.  According to reports from the Wisconsin Office of the Insurance commissioner, UHC has about 12% of the group health market share in Wisconsin.  
 

This story originally appeared in the June 10, 2021 edition of WHA Newsletter

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Thursday, June 10, 2021

Proposed Insurer Policy Would Have Denied Coverage for Emergency Care

Policy Now on Hold Due to Negative Feedback from Providers
The American Hospital Association (AHA)  this week asked for an immediate reversal of a planned new policy from UnitedHealthcare (UHC) that would retroactively deny coverage for emergency care. In a letter to UHC, AHA said the policy would have a chilling effect on patients obtaining care and would jeopardize their health and well-being. 
 
On Thursday, June 10, UHC announced in a tweet that the implementation of the policy is on hold until at least the end of the public health emergency period. 

“We have been seeing some worrisome insurer policies being proposed over the past six months including restrictions on networks for certain services, restrictions on coverage, and this one which is particularly egregious, as it could deter patients from seeking emergency care,” said Wisconsin Hospital Association (WHA) Senior Vice President for Public Policy Joanne Alig. “We are pleased that UHC has decided to put the policy on hold, and hope it is not just a temporary delay but a permanent policy reversal.”   

At issue in this instance is whether an insurer should be able to determine after the fact that a patient should have sought care in an emergency room or somewhere else. Federal law and state law in Wisconsin require that insurers cover emergency services, and in doing so they are required to apply what is known as a “prudent layperson standard,” which is an important patient protection. The prudent layperson standard essentially says that if a reasonable person with an average knowledge of health and medicine thinks his or her health is in jeopardy based on his or her symptoms, then it is an emergency medical condition. 

The policy stated by UHC is similar to one implemented by Anthem/Blue Cross Blue Shield which is being challenged in court by the American College of Emergency Physicians and the Medical Association of Georgia. The Anthem policy has not been implemented in Wisconsin.

Details about the UHC policy were unclear.  The UHC network bulletin available publicly on the company’s website did not indicate in which states it would have reviewed emergency department visits, and news reports varied on the precise number of states,  however it appears that the policy would have been implemented in over 30 states, including in Wisconsin. According to a report from USA Today, UHC had indicated the policy could have applied to 10% of emergency room visits.  There has also been conflicting information about whether the policy would have applied to the individual market, but it appears the policy would have applied to employer-sponsored group plans.  According to reports from the Wisconsin Office of the Insurance commissioner, UHC has about 12% of the group health market share in Wisconsin.  
 

This story originally appeared in the June 10, 2021 edition of WHA Newsletter