I

106TH CONGRESS

1ST SESSION H. R. 904

To assure access under group health plans and health insurance coverage

to covered emergency medical services.

IN THE HOUSE OF REPRESENTATIVES

MARCH 2, 1999

Mr. CARDIN (for himself, Mrs. ROUKEMA, Mr. SHAYS, Mr. TIERNEY, Mr.

CAMPBELL, Mr. BERRY, Mr. SERRANO, Mr. DELAHUNT, Mr. BENTSEN,

Mr. COOKSEY, Mr. ABERCROMBIE, Mr. UNDERWOOD, Mr. STARK, Mr.

DEFAZIO, Mr. KLECZKA, Mrs. JOHNSON of Connecticut, Mr. WEYGAND,

Mr. GREEN of Texas, Mr. MCNULTY, Mr. BOEHLERT, Mr. GALLEGLY,

Mr. LAFALCE, Mr. ACKERMAN, Ms. SLAUGHTER, Mr. DOYLE, Mrs.

MALONEY of New York, Mrs. THURMAN, Mr. HINCHEY, Mr. INSLEE, Mr.

LEWIS of Georgia, Mr. COYNE, Mr. ROTHMAN, Mr. ENGLISH, Mrs. MINK

of Hawaii, Mr. WALSH, Mr. KLINK, Ms. HOOLEY of Oregon, Mrs. EMERSON, Mr. LEVIN, Mr. DAVIS of Florida, Mr. UPTON, Ms. EDDIE BERNICE

JOHNSON of Texas, Mr. GONZALEZ, and Mrs. MYRICK) introduced the

following bill; which was referred to the Committee on Commerce, and

in addition to the Committees on Education and the Workforce, and

Ways and Means, for a period to be subsequently determined by the

Speaker, in each case for consideration of such provisions as fall within

the jurisdiction of the committee concerned

A BILL

To assure access under group health plans and health

insurance coverage to covered emergency medical services.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,
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1 SECTION 1. SHORT TITLE.

2 This Act may be cited as the ‘‘Access to Emergency

3 Medical Services Act of 1999’’.

4 SEC. 2. EMERGENCY SERVICES.

5 (a) COVERAGE OF EMERGENCY SERVICES.—

6 (1) IN GENERAL.—If a group health plan, or

7 health insurance coverage offered by a health insur8 ance issuer, provides any benefits with respect to

9 emergency services (as defined in paragraph (2)(B)),

10 the plan or issuer shall cover emergency services fur11 nished under the plan or coverage—

12 (A) without the need for any prior author13 ization determination;

14 (B) whether or not the health care pro15 vider furnishing such services is a participating

16 provider with respect to such services;

17 (C) in a manner so that, if such services

18 are provided to a participant, beneficiary, or en19 rollee by a nonparticipating health care pro20 vider, the participant, beneficiary, or enrollee is

21 not liable for amounts that exceed the amounts

22 of liability that would be incurred if the services

23 were provided by a participating provider; and

24 (D) without regard to any other term or

25 condition of such plan or coverage (other than

26 exclusion or coordination of benefits, or an af-
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1 filiation or waiting period, permitted under sec2 tion 2701 of the Public Health Service Act, sec3 tion 701 of the Employee Retirement Income

4 Security Act of 1974, or section 9801 of the In5 ternal Revenue Code of 1986, and other than

6 applicable cost sharing).

7 (2) DEFINITIONS.—In this section:

8 (A) EMERGENCY MEDICAL CONDITION

9 BASED ON PRUDENT LAYPERSON STANDARD.—

10 The term ‘‘emergency medical condition’’ means

11 a medical condition manifesting itself by acute

12 symptoms of sufficient severity (including se13 vere pain) such that a prudent layperson, who

14 possesses an average knowledge of health and

15 medicine, could reasonably expect the absence

16 of immediate medical attention to result in a

17 condition described in clause (i), (ii), or (iii) of

18 section 1867(e)(1)(A) of the Social Security Act

19 (42 U.S.C. 1395dd(e)(1)(A)).

20 (B) EMERGENCY SERVICES.—The term

21 ‘‘emergency services’’ means—

22 (i) a medical screening examination

23 (as required under section 1867 of the So24 cial Security Act, 42 U.S.C. 1395dd)) that

25 is within the capability of the emergency
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1 department of a hospital, including ancil2 lary services routinely available to the

3 emergency department to evaluate an

4 emergency medical condition (as defined in

5 subparagraph (A)); and

6 (ii) within the capabilities of the staff

7 and facilities at the hospital, such further

8 medical examination and treatment as are

9 required under section 1867 of such Act to

10 stabilize the patient.

11 (C) STABILIZE.—The term ‘‘to stabilize’’

12 means, with respect to an emergency medical

13 condition, to provide such medical treatment of

14 the condition as may be necessary to assure,

15 within reasonable medical probability, that no

16 material deterioration of the condition is likely

17 to result from or occur during the transfer of

18 the individual from a facility.

19 (b) REIMBURSEMENT FOR MAINTENANCE CARE AND

20 POST-STABILIZATION CARE.—In the case of services

21 (other than emergency services) for which benefits are

22 available under a group health plan, or under health insur23 ance coverage offered by a health insurance issuer, the

24 plan or issuer shall provide for reimbursement with re25 spect to such services provided to a participant, bene-
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1 ficiary, or enrollee other than through a participating

2 health care provider in a manner consistent with sub3 section (a)(1)(C) (and shall otherwise comply with the

4 guidelines established under section 1852(d)(2) of the So5 cial Security Act (relating to promoting efficient and time6 ly coordination of appropriate maintenance and post-sta7 bilization care of an enrollee after an enrollee has been

8 determined to be stable), or, in the absence of guidelines

9 under such section, such guidelines as the Secretary shall

10 establish to carry out this subsection), if the services are

11 maintenance care or post-stabilization care covered under

12 such guidelines.

13 (c) INFORMATION FOR PARTICIPANTS, BENE14 FICIARIES, AND ENROLLEES.—

15 (1) GROUP HEALTH PLANS.—A group health

16 plan shall—

17 (A) provide to participants and bene18 ficiaries at the time of initial coverage under

19 the plan (or the effective date of this Act, in the

20 case of individuals who are participants and

21 beneficiaries as of such date), at least annually

22 thereafter, and at the beginning of any open en23 rollment provided under the plan, the informa24 tion described in paragraph (3) in printed form;

25 and
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1 (B) upon request, make available to par2 ticipants and beneficiaries, to the applicable au3 thority, and to prospective participants and

4 beneficiaries the information described in para5 graph (3) in printed form.

6 (2) HEALTH INSURANCE ISSUERS.—A health

7 insurance issuer, in connection with the provision of

8 health insurance coverage, shall—

9 (A) provide to individuals enrolled under

10 such coverage at the time of enrollment, and at

11 least annually thereafter, (and to plan adminis12 trators of group health plans in connection with

13 which such coverage is offered) the information

14 described in paragraph (3) in printed form; and

15 (B) upon request, make available to the

16 applicable authority, to individuals who are pro17 spective enrollees, to plan administrators of

18 group health plans that may obtain such cov19 erage, and to the public the information de20 scribed in paragraph (3) in printed form.

21 (3) REQUIRED INFORMATION.—The informa22 tion described in this paragraph with respect to a

23 group health plan or health insurance coverage of24 fered by a health insurance issuer is information
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1 about the coverage of emergency services,

2 including—

3 (A) the appropriate use of emergency serv4 ices, including use of the 911 telephone system

5 or its local equivalent in emergency situations

6 and an explanation of what constitutes an

7 emergency situation;

8 (B) the process and procedures of the plan

9 or issuer for obtaining emergency services;

10 (C) any cost-sharing applicable to emer11 gency services; and

12 (D) the locations of—

13 (i) emergency departments; and

14 (ii) other settings in which plan physi15 cians and hospitals provide emergency

16 services and post-stabilization care.

17 (d) DEFINITIONS.—For purposes of this section—

18 (1) The term ‘‘applicable authority’’ means—

19 (A) in the case of a group health plan, the

20 Secretary of Health and Human Services and

21 the Secretary of Labor; and

22 (B) in the case of a health insurance issuer

23 with respect to a specific provision of this sec24 tion, the applicable State authority or the Sec25 retary of Health and Human Services if such
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1 Secretary is enforcing such provisions under

2 section 2722(a)(2) or 2761(a)(2) of the Public

3 Health Service Act (42 U.S.C. 300gg–22(a)(2),

4 300gg–61(a)(2)).

5 (2) The terms ‘‘applicable State authority’’,

6 ‘‘beneficiary’’, ‘‘group health plan’’, ‘‘health insur7 ance coverage’’, ‘‘health insurance issuer’’, and ‘‘par8 ticipant’’ shall have the meanings given to such

9 terms in section 2791 of the Public Health Service

10 Act (42 U.S.C. 300gg–91).

11 (3) The term ‘‘nonparticipating’’ means, with

12 respect to a health care provider that provides health

13 care items and services to a participant, beneficiary,

14 or enrollee under a group health plan or health in15 surance coverage, a health care provider that is not

16 a participating health care provider with respect to

17 such items and services.

18 (4) The term ‘‘participating’’ means, with re19 spect to a health care provider that provides health

20 care items and services to a participant, beneficiary,

21 or enrollee under a group health plan or health in22 surance coverage offered by a health insurance

23 issuer, a health care provider that furnishes such

24 items and services under a contract or other ar25 rangement with the plan or issuer.
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1 SEC. 3. STANDARDS UNDER THE PUBLIC HEALTH SERVICE

2 ACT.

3 (a) GROUP MARKET.—Subpart 2 of part A of title

4 XXVII of the Public Health Service Act is amended by

5 adding at the end the following new section:

6 ‘‘SEC. 2707. EMERGENCY SERVICES.

7 ‘‘(a) IN GENERAL.—Each group health plan (and

8 each health insurance issuer offering group health insur9 ance coverage in connection with such a plan) shall comply

10 with the requirements of the Access to Emergency Medical

11 Services Act of 1999, and such requirements shall be

12 deemed to be incorporated into this subsection.

13 ‘‘(b) NOTICE.—A group health plan shall comply with

14 the notice requirement under section 711(d) of the Em15 ployee Retirement Income Security Act with respect to the

16 requirements referred to in subsection (a), and a health

17 insurance issuer shall comply with such notice requirement

18 as if such section applied to such issuer and such issuer

19 were a group health plan.’’.

20 (b) INDIVIDUAL MARKET.—Part B of title XXVII of

21 the Public Health Service Act is amended by inserting

22 after section 2752 the following new section:

23 ‘‘SEC. 2753. EMERGENCY SERVICES.

24 ‘‘(a) IN GENERAL.—Each health insurance issuer

25 shall comply with the requirements of the Access to Emer26 gency Medical Services Act of 1999 with respect to indi-
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1 vidual health insurance coverage it offers, and such re2 quirements shall be deemed to be incorporated into this

3 subsection.

4 ‘‘(b) NOTICE.—A health insurance issuer under this

5 part shall comply with the notice requirement under sec6 tion 711(d) of the Employee Retirement Income Security

7 Act with respect to the requirements referred to in sub8 section (a) as if such section applied to such issuer and

9 such issuer were a group health plan.’’.

10 SEC. 4. STANDARDS UNDER THE EMPLOYEE RETIREMENT

11 INCOME SECURITY ACT OF 1974.

12 (a) IN GENERAL.—Subpart B of part 7 of subtitle

13 B of title I of the Employee Retirement Income Security

14 Act of 1974 is amended by adding at the end the following

15 new section:

16 ‘‘SEC. 714. EMERGENCY SERVICES.

17 ‘‘(a) IN GENERAL.—Subject to subsection (b), a

18 group health plan (and a health insurance issuer offering

19 group health insurance coverage in connection with such

20 a plan) shall comply with the requirements of the Access

21 to Emergency Medical Services Act of 1999, and such re22 quirements shall be deemed to be incorporated into this

23 subsection.

24 ‘‘(b) SATISFACTION OF REQUIREMENTS.—For pur25 poses of subsection (a), insofar as a group health plan pro-
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1 vides benefits in the form of health insurance coverage

2 through a health insurance issuer, the plan shall be treat3 ed as meeting the requirements of the Access to Emer4 gency Medical Services Act of 1999 with respect to such

5 benefits and not be considered as failing to meet such re6 quirements because of a failure of the issuer to meet such

7 requirements so long as the plan sponsor or its representa8 tives did not cause such failure by the issuer.’’.

9 (b) CONFORMING AMENDMENT.—Section 732(a) of

10 such Act (29 U.S.C. 1191a(a)) is amended by striking

11 ‘‘section 711’’ and inserting ‘‘sections 711 and 714’’.

12 (c) CLERICAL AMENDMENT.—The table of contents

13 in section 1 of such Act is amended by inserting after the

14 item relating to section 713 the following new item:

‘‘Sec. 714. Emergency services.’’.

15 SEC. 5. STANDARDS UNDER THE INTERNAL REVENUE CODE

16 OF 1986.

17 Subchapter B of chapter 100 of the Internal Revenue

18 Code of 1986 is amended—

19 (1) in the table of sections, by inserting after

20 the item relating to section 9812 the following new

21 item:

‘‘Sec. 9813. Standard relating to emergency services.’’; and

22 (2) by inserting after section 9812 the follow23 ing:
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1 ‘‘SEC. 9813. STANDARD RELATING TO EMERGENCY SERV2 ICES.

3 ‘‘A group health plan shall comply with the require4 ments of the Access to Emergency Medical Services Act

5 of 1999, and such requirements shall be deemed to be in6 corporated into this section.’’.

7 SEC. 6. EFFECTIVE DATE.

8 (a) GROUP HEALTH COVERAGE.—

9 (1) IN GENERAL.—Subject to paragraph (2),

10 the amendments made by sections 3(a), 4, and 5

11 (and section 2 insofar as it relates to such sections)

12 apply to group health plans for plan years beginning

13 on or after January 1, 2000.

14 (2) TREATMENT OF COLLECTIVE BARGAINING

15 AGREEMENTS.—In the case of a group health plan

16 maintained pursuant to 1 or more collective bargain17 ing agreements between employee representatives

18 and 1 or more employers ratified before the date of

19 the enactment of this Act, the amendments made by

20 sections 3(a), 4, and 5 (and section 2 insofar as it

21 relates to such sections) shall not apply to plan

22 years beginning before the later of—

23 (A) the date on which the last collective

24 bargaining agreement relating to the plan ter25 minates (determined without regard to any ex-
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1 tension thereof agreed to after the date of the

2 enactment of this Act); or

3 (B) January 1, 2000.

4 For purposes of subparagraph (A), any plan amend5 ment made pursuant to a collective bargaining

6 agreement relating to the plan that amends the plan

7 solely to conform to any requirement of this Act

8 shall not be treated as a termination of such collec9 tive bargaining agreement.

10 (b) INDIVIDUAL MARKET.—The amendment made by

11 section 3(b) (and section 2 insofar as it relates to such

12 section) applies with respect to health insurance coverage

13 offered, sold, issued, renewed, in effect, or operated in the

14 individual market on or after January 1, 2000.

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