§ 4303. Benefits. (a) Every contract issued by a hospital service\ncorporation or health service corporation which provides coverage for\nin-patient hospital care shall also provide coverage:\n (1) For preadmission testing performed in hospital facilities prior to\nscheduled surgery. A patient who uses the out-patient facilities of a\nhospital shall be entitled to benefits for tests ordered by a physician\nwhich are performed as a planned preliminary to admission of the patient\nas an in-patient for surgery in the same hospital, provided that:\n (A) tests are necessary for and consistent with the diagnosis and\ntreatment of the condition for which surgery is to be performed,\n (B) reservations for a hospital bed and for an operating room shall\nhave been made prior to the performance of the tests,\n (C) surgery actually takes place within seven days of such presurgical\ntests, and\n (D) the patient is physically present at the hospital for the tests.\n (2) (A) For services to treat an emergency condition in hospital\nfacilities:\n (i) without the need for any prior authorization determination;\n (ii) regardless of whether the health care provider furnishing such\nservices is a participating provider with respect to such services;\n (iii) if the emergency services are provided by a non-participating\nprovider, without imposing any administrative requirement or limitation\non coverage that is more restrictive than the requirements or\nlimitations that apply to emergency services received from participating\nproviders; and\n (iv) if the emergency services are provided by a non-participating\nprovider, the cost-sharing requirement (expressed as a copayment or\ncoinsurance) shall be the same requirement that would apply if such\nservices were provided by a participating provider.\n (B) Any requirements of section 2719A(b) of the Public Health Service\nAct, 42 U.S.C. § 300gg19a(b) and regulations thereunder that exceed the\nrequirements of this paragraph with respect to coverage of emergency\nservices shall be applicable to every contract subject to this\nparagraph.\n (C) For the purpose of this provision, "emergency condition" means a\nmedical or behavioral condition that manifests itself by acute symptoms\nof sufficient severity, including severe pain, such that a prudent\nlayperson, possessing an average knowledge of medicine and health, could\nreasonably expect the absence of immediate medical attention to result\nin (i) placing the health of the person afflicted with such condition in\nserious jeopardy, or in the case of a behavioral condition placing the\nhealth of such person or others in serious jeopardy; (ii) serious\nimpairment to such person's bodily functions; (iii) serious dysfunction\nof any bodily organ or part of such person; (iv) serious disfigurement\nof such person; or (v) a condition described in clause (i), (ii) or\n(iii) of section 1867(e)(1)(A) of the Social Security Act.\n (D) For the purpose of this provision, "emergency services" means,\nwith respect to an emergency condition: (i) a medical screening\nexamination as required under section 1867 of the Social Security Act,\n42 U.S.C. § 1395dd, which is within the capability of the emergency\ndepartment of a hospital, including ancillary services routinely\navailable to the emergency department to evaluate such emergency medical\ncondition; and (ii) within the capabilities of the staff and facilities\navailable at the hospital, such further medical examination and\ntreatment as are required under section 1867 of the Social Security Act,\n42 U.S.C. § 1395dd, to stabilize the patient.\n (E) For the purpose of this provision, "to stabilize" means, with\nrespect to an emergency condition, to provide such medical treatment of\nthe condition as may be necessary to assure, within reasonable medical\nprobability, that no material deterioration of the condition is likely\nto result from or occur during the transfer of the subscriber from a\nfacility or to
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