I 

108TH CONGRESS 

2D SESSION H. R. 3722

To amend section 1011 of the Medicare Prescription Drug, Improvement, 

and Modernization Act of 2003 to impose conditions on Federal reimbursement of emergency health services furnished to undocumented 

aliens. 

IN THE HOUSE OF REPRESENTATIVES 

JANUARY 21, 2004

Mr. ROHRABACHER introduced the following bill; which was referred to the 

Committee on Energy and Commerce 

A BILL

To amend section 1011 of the Medicare Prescription Drug, 

Improvement, and Modernization Act of 2003 to impose 

conditions on Federal reimbursement of emergency 

health services furnished to undocumented aliens.

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

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Undocumented Alien 

5 Emergency Medical Assistance Amendments of 2004’’. 

6 SEC. 2. FINDINGS. 

7 Congress finds the following: 
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1 (1) The provision of medical care by public or 

2 private health care providers to undocumented aliens 

3 is appropriate only—

4 (A) to protect the health and safety of 

5 United States citizens; 

6 (B) to save the life of an undocumented 

7 alien in a life-threatening medical emergency; 

8 and 

9 (C) to stabilize an emergency medical con10 dition so that an undocumented alien can be re11 patriated for medical treatment in the alien’s 

12 own country. 

13 (2) Federal reimbursement of emergency hos14 pital services furnished to undocumented aliens 

15 should be conditioned upon obtaining sufficient in16 formation to promptly remove the aliens. 

17 (3) Employers who employ undocumented aliens 

18 without completing employment authorization 

19 verification procedures should be held liable for un20 compensated emergency services furnished to such 

21 aliens. 
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1 SEC. 3. CONDITIONS FOR RECEIPT OF FEDERAL ASSIST2 ANCE FOR EMERGENCY SERVICES FOR UN3 DOCUMENTED ALIENS. 

4 (a) IN GENERAL.—Section 1011 of the Medicare Pre5 scription Drug, Improvement, and Modernization Act of 

6 2003 (Public Law 108–173) is amended—

7 (1) in subsection (d)(1), by adding at the end 

8 the following new subparagraph: 

9 ‘‘(C) APPLICATION OF REQUIREMENT.—

10 Under such process, the Secretary shall not 

11 provide payment under subsection (c) to an eli12 gible provider that is a hospital for eligible serv13 ices for an alien described in subsection 

14 (c)(5)(A) unless the requirements of subsection 

15 (f) are met by that provider with respect to 

16 such alien.’’; 

17 (2) in subsection (e)(2), by adding at the end 

18 the following new sentence: ‘‘Such term also in19 cludes, with respect to an undocumented alien de20 scribed in subsection (c)(5)(A), costs for emergency 

21 medical transportation and evacuation incurred by a 

22 hospital in transferring and removing the alien to a 

23 foreign country for receipt of appropriate health care 

24 services.’’; and 

25 (3) by adding at the end the following new sub26 section: 
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1 ‘‘(f) REQUIREMENT FOR COLLECTION OF IMMIGRA2 TION-RELATED INFORMATION FOR UNDOCUMENTED

3 ALIENS.—

4 ‘‘(1) IN GENERAL.—No payment may be made 

5 under subsection (c) to a hospital with respect to the 

6 provision of eligible services to an undocumented 

7 alien described in subsection (c)(5)(A) unless the fol8 lowing requirements are met: 

9 ‘‘(A) The hospital has obtained in good 

10 faith from the alien (or a legal guardian or 

11 other representative on behalf of the alien) the 

12 following information in a document that is 

13 signed by the alien (or such guardian or rep14 resentative) under oath or affirmation and that 

15 is in a form that includes a notice that fraudu16 lent or false statements constitute a criminal 

17 act punishable under Federal law: 

18 ‘‘(i) The citizenship of the alien. 

19 ‘‘(ii) The immigration status of the 

20 alien. 

21 ‘‘(iii) The address of the alien in the 

22 United States. 

23 ‘‘(iv) Such personal or financial data 

24 regarding the alien as the hospital rou25 tinely requires of non-indigent patients, in-
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1 cluding information regarding health insur2 ance. 

3 ‘‘(v) Information on the identity of 

4 any current employer of the alien for 

5 whom the alien has executed an Internal 

6 Revenue Service Form W–4. 

7 A hospital is not liable for the accuracy of the 

8 information provided under this subparagraph 

9 so long as it exercises reasonable care and good 

10 faith in obtaining the information. 

11 ‘‘(B) The hospital obtains one or more 

12 identifiers for the alien and records such identi13 fiers in a digital, electronic format specified by 

14 the Secretary in consultation with the Secretary 

15 of Homeland Security. Such format shall be 

16 compatible with at least one interoperable data17 base maintained by the Secretary of Homeland 

18 Security for the purpose of verifying the iden19 tity and immigration status of aliens. 

20 ‘‘(C) The hospital transmits to the Sec21 retary of Homeland Security, in a digital, elec22 tronic format and manner specified by such 

23 Secretary, the information provided under sub24 paragraph (A) and the identifier (or identifiers) 

25 obtained under subparagraph (B).
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1 ‘‘(2) MAINTENANCE OF HOSPITAL RECORDS.—

2 For a period of at least 5 years, a hospital referred 

3 to in paragraph (1) shall maintain the original docu4 ments described in paragraph (1)(A) on file and 

5 makes such documents available for examination by 

6 the Secretary and the Secretary of Homeland Secu7 rity or their designees. 

8 ‘‘(3) PROVISION OF TECHNICAL SUPPORT.—The 

9 Secretary of Homeland Security shall provide hos10 pitals under this section with software, training, and 

11 technical support services, at no cost to the hospital, 

12 to assist and enable hospitals to comply with the re13 quirements of paragraph (1). 

14 ‘‘(4) PROMPT ACTION BY DHS.—The Secretary 

15 of Homeland Security shall take steps as may be 

16 necessary—

17 ‘‘(A) to obtain, process, and promptly re18 view information transmitted under paragraph 

19 (1)(C); 

20 ‘‘(B) to determine whether an alien for 

21 whom such information is transmitted is remov22 able under any provision of Federal immigra23 tion law; and 

24 ‘‘(C) to initiate removal proceedings under 

25 the relevant provisions of the Immigration and 
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1 Nationality Act in the case of any such alien 

2 who is identified as being removable. 

3 ‘‘(5) REMOVABILITY.—An undocumented alien 

4 who obtains eligible services through a hospital and 

5 does not provide for payment for such services and 

6 who fails to provide accurate information described 

7 in paragraph (1)(A) or an identifier (as defined in 

8 paragraph (6)) shall be treated as removable on the 

9 ground described in section 237(a)(5) of the Immi10 gration and Nationality Act (8 U.S.C. 1227(a)(5)). 

11 ‘‘(6) DEFINITION OF IDENTIFIER.—In this sec12 tion, the term ‘identifier’ means a fingerprint or 

13 other biometric identifier as the Secretary of Home14 land Security may require. 

15 ‘‘(g) RESPONSIBILITY OF CERTAIN EMPLOYERS.—

16 ‘‘(1) IN GENERAL.—In the case of an employer 

17 of an undocumented alien worker described in para18 graph (2) for whom payments are made to a hospital 

19 for eligible services under this section, subject to 

20 paragraph (3), the employer shall be liable to the 

21 Secretary for the amount of the payments so made. 

22 ‘‘(2) UNDOCUMENTED ALIEN WORKER DE23 FINED.—

24 ‘‘(A) IN GENERAL.—For purposes of this 

25 subsection, the term ‘undocumented alien work-
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1 er’ means, with respect to an employer, an un2 documented alien described in subsection 

3 (c)(5)(A)—

4 ‘‘(i) who is an unauthorized alien (as 

5 defined in section 274A(h)(3) of the Immi6 gration and Nationality Act (8 U.S.C. 

7 1324a(h)(3)); 

8 ‘‘(ii) who has provided the employer 

9 with an Internal Revenue Service Form 

10 W–4; and 

11 ‘‘(iii) with respect to whom neither the 

12 conditions described in subparagraph 

13 (B)(i) or the condition described in sub14 paragraph (B)(ii) have been met. 

15 ‘‘(B) CONDITIONS FOR EXEMPTION.—For 

16 purposes of subparagraph (A)(iii)—

17 ‘‘(i) FIRST SET OF CONDITIONS.—The 

18 conditions described in this clause for an 

19 employer and alien are the following: 

20 ‘‘(I) The employer and alien have 

21 fully complied with all requirements of 

22 the employment verification system 

23 prescribed in section 274A(b) of the 

24 Immigration and Nationality Act (8 

25 U.S.C. 1324a(b)). 
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1 ‘‘(II) The employer has enrolled 

2 the alien in a State workmen’s com3 pensation plan. 

4 ‘‘(III) The alien is enrolled under 

5 a health benefits plan or health insur6 ance coverage that provides such level 

7 of coverage with respect to emergency 

8 medical and hospitalization benefits as 

9 the Secretary shall specify, in con10 sultation with the Secretary of Home11 land Security. 

12 ‘‘(IV) The employer has assumed 

13 responsibility for any cost-sharing (in14 cluding applicable deductibles and co15 insurance) that applies to the alien. 

16 ‘‘(ii) ALTERNATIVE CONDITION.—The 

17 condition described in this clause for an 

18 employer and alien are that the employer 

19 has verified the employment authorization 

20 of the alien through the voluntary basic 

21 employment verification pilot program 

22 under section 403(a) of the Immigration 

23 Reform and Immigrant Responsibility Act 

24 of 1996 (division C of Public Law 104–

25 208), where available, or by any other 
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1 means made available for such verification 

2 purposes by the Secretary of Homeland 

3 Security. 

4 ‘‘(3) LIMITATION ON LIABILITY.—The liability 

5 of an employer under this subsection shall be limited 

6 to an employer that employs an undocumented alien 

7 worker at the time (as specified under rules of the 

8 Secretary of Homeland Security) the eligible services 

9 are provided for which payment may be made by the 

10 Secretary under this section. 

11 ‘‘(h) LIMITATION ON CARE REQUIRED.—Notwith12 standing any other provision of law (including section 

13 1867 of the Social Security Act, 42 U.S.C. 1395dd), a 

14 hospital is not required to make available to an undocu15 mented alien described in subsection (c)(5)(A) care or 

16 services if—

17 ‘‘(1) the alien may be transported to the alien’s 

18 country of origin (as determined in accordance with 

19 rules of the Secretary of Homeland Security) with20 out a significant likelihood of material deterioration 

21 of medical condition of the alien (or, in the case of 

22 an alien in active labor, of the child), within reason23 able medical probability, resulting from the transfer 

24 of the alien from the hospital; or 

25 ‘‘(2) the care—
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1 ‘‘(A) involves organ transplantation or 

2 other extraordinary medical treatment (or other 

3 treatment the estimated cost of which exceeds 

4 $50,000); and 

5 ‘‘(B) is for treatment of a condition that 

6 existed before the alien entered the United 

7 States or is not required as a direct and imme8 diate result of an accident in the United 

9 States.’’. 

10 (b) EFFECTIVE DATE.—The amendments made by 

11 subsection (a) shall be effective as if included in the enact12 ment of the Medicare Prescription Drug, Improvement, 

13 and Modernization Act of 2003. 

14 (c) REGULATIONS.—

15 (1) IN GENERAL.—The Secretary of Homeland 

16 Security, in consultation with the Secretary of 

17 Health and Human Services, shall issue interim reg18 ulations implementing the amendments made by 

19 subsection (a) no later than 60 days after the date 

20 of the enactment of this Act and shall permit a pe21 riod of public notice and comment of at least 90 

22 days. 

23 (2) FINAL REGULATIONS.—The Secretary of 

24 Homeland Security, in consultation with the Sec25 retary of Health and Human Services, shall issue 
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1 final regulations implementing such amendments not 

2 later than one year after the date of publication of 

3 such interim regulations. 

4 (d) ANNUAL REPORT ON IMPLEMENTATION.—

5 (1) IN GENERAL.—The Secretary of Homeland 

6 Security, in consultation with the Secretary of 

7 Health and Human Services, shall submit to the 

8 chairman and ranking minority member of the Judi9 ciary and Appropriations Committees of the House 

10 of Representatives and the Senate, the Select Com11 mittee on Homeland Security of the House of Rep12 resentatives, and the Senate Committee on Govern13 mental Affairs an annual report on the implementa14 tion of section 1011 of the Medicare Prescription 

15 Drug, Improvement, and Modernization Act of 2003, 

16 as amended by this section. 

17 (2) ITEMS TO BE INCLUDED.—Each annual re18 port under paragraph (1) shall include—

19 (A) a cost analysis of Federal expenditures 

20 under such section 1011; 

21 (B) a description of the assistance pro22 vided to hospitals under subsection (f)(2) of 

23 such section; 
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1 (C) the number of undocumented aliens re2 moved under subsection (f)(3) of such section; 

3 and 

4 (D) amounts recovered from employers 

5 under subsection (g) of such section. 

6 (e) FEASIBILITY OF EFFECTING TREATIES FOR

7 INTERNATIONAL MEDICAL EVACUATION.—

8 (1) STUDY.—The Secretary of State shall con9 duct an analysis of the feasibility and appropriate10 ness of the following: 

11 (A) Negotiating with foreign states treaties 

12 under which such states provide payment for 

13 the cost of international medical evacuation for 

14 their nationals who require emergency health 

15 care in the United States and who do not other16 wise have insurance or other coverage for the 

17 costs of such care. 

18 (B) In the case of nationals of a foreign 

19 state for whom significant costs are incurred 

20 under section 1011 of the Medicare Prescrip21 tion Drug, Improvement, and Modernization 

22 Act of 2003 and for which state a treaty de23 scribed in subparagraph (A) is not in effect, im24 posing a visa, port of entry, or similar sur25 charge the proceeds of which may be used to-
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1 wards such costs and towards the cost of inter2 national medical evacuation described in such 

3 clause. 

4 (2) REPORT.—The Secretary of State shall sub5 mit to the committees described in subsection (d)(1) 

6 a report on the analysis under paragraph (1).

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