Armed with this success, ACEP state chapters began to push similar legislation in their states. ACEP went to the National Council of State Legislatures in 1994 to provide information, background, and model legislation to other states. All together, 47 states eventually passed prudent layperson standard legislation.

In 1997, the federal Balanced Budget Act extended the prudent layperson standard to Medicare and Medicaid managed care plans. In 1998, President Bill Clinton extended the standard to all federal health plans.

In 2010, the Affordable Care Act further extended and codified the prudent layperson standard to group and individual market health insurance plans. It is essentially the law of the land and the protection for our patients from unlawful and unethical practices by insurers who want to save money at the patient’s expense.

The Battle Goes On

Recently, emergency physicians have watched as Anthem BlueCross BlueShield has moved forward with policies that ignore the law. Despite multiple discussions with Anthem by ACEP leadership, legislators, and others, Anthem has made only small tweaks to its policy to deny payments retroactively, despite the fact that the patient has a policy providing coverage.

In July 2018, ACEP and the Medical Association of Georgia sued Anthem for its violation of this federally mandated patient protection.

Once again, ACEP is putting our patients’ health first and ensuring that this patient protection is upheld for those seeking emergency care.  

Dr. Martinez is chief medical officer for Adeptus Health in Irving, Texas; assistant professor of emergency medicine at Emory University in Atlanta; and an  editorial board member.