II

104TH CONGRESS

2D SESSION S. 2121

To ensure medicare beneficiaries participating in managed care have access

to emergency and urgent care.

IN THE SENATE OF THE UNITED STATES

SEPTEMBER 25, 1996

Mr. GRAHAM (for himself, Mr. GRASSLEY, Ms. MOSELEY-BRAUN, Mr.

CHAFEE, Mr. JEFFORDS, Mr. BAUCUS, Mr. SIMON, Mr. HOLLINGS, and

Mr. WELLSTONE) introduced the following bill; which was read twice and

referred to the Committee on Finance

A BILL

To ensure medicare beneficiaries participating in managed

care have access to emergency and urgent care.

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 ‘‘Medicare Access to

5 Emergency Medical Care Act of 1996’’.

6 SEC. 2. REQUIREMENTS FOR MEDICARE MANAGED CARE.

7 (a) ACCESS TO EMERGENCY SERVICES.—Section

8 1876(c) of the Social Security Act (42 U.S.C. 1395mm(c))

9 is amended by adding at the end the following:
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•S 2121 IS

1 ‘‘(9)(A) A risk-sharing contract under this section

2 shall require an eligible organization that provides any

3 coverage with respect to emergency services to cover emer4 gency services furnished to a member enrolled with the

5 organization—

6 ‘‘(i) without regard to whether or not the pro7 vider furnishing the emergency services has a con8 tractual or other arrangement with the organization

9 for the provision of such services to such members,

10 and

11 ‘‘(ii) without regard to prior authorization.

12 ‘‘(B)(i) A risk-sharing contract under this section

13 shall require an eligible organization that provides any

14 coverage with respect to emergency services—

15 ‘‘(I) to determine and make prompt payment

16 (within the meaning of subsection (g)(6)(A)) in a

17 reasonable and appropriate amount for such services

18 (including services required to be provided under

19 section 1867), and

20 ‘‘(II) subject to clause (ii), to not impose cost21 sharing for services furnished in a hospital emer22 gency department that is calculated in a manner

23 (such as the use of a different percentage) that im24 poses greater cost sharing with respect to such serv-
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1 ices compared to comparable services furnished in

2 other settings.

3 ‘‘(ii) An eligible organization may impose a reason4 able copayment (as determined in accordance with stand5 ards established by the Secretary) in lieu of coinsurance

6 to deter inappropriate use of services of hospital emer7 gency departments.

8 ‘‘(C) In this paragraph, the term ‘emergency services’

9 has the same meaning as in paragraph (10)(D).’’.

10 (b) TIMELY AUTHORIZATION FOR PROMPTLY NEED11 ED CARE IDENTIFIED AS A RESULT OF REQUIRED

12 SCREENING EVALUATION.—Section 1876(c) of such Act

13 (42 U.S.C. 1395mm(c)), as amended by subsection (a),

14 is amended by adding at the end the following:

15 ‘‘(10)(A) The organization must provide access 24

16 hours a day, 7 days a week to individuals who are author17 ized to make any prior authorizations required by the or18 ganization for coverage of items and services (other than

19 emergency services) that a treating physician or other

20 emergency department personnel identify, pursuant to a

21 screening evaluation required under section 1867(a), as

22 being needed promptly by an individual enrolled with the

23 organization under this part.

24 ‘‘(B) The organization is deemed to have approved

25 a request for such promptly needed items and services if
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1 the physician or other emergency department personnel in2 volved—

3 ‘‘(i) has made a reasonable effort to contact an

4 individual described in subparagraph (A) for author5 ization to provide an appropriate referral for such

6 items and services or to provide the items and serv7 ices to the individual and access to the person has

8 not been provided (as required in subparagraph

9 (A)), or

10 ‘‘(ii) has requested such authorization from the

11 person and the person has not denied the authoriza12 tion within 30 minutes after the time the request is

13 made.

14 ‘‘(C) Approval of a request for a prior authorization

15 determination (including a deemed approval under sub16 paragraph (B)) shall be treated as approval of a request

17 for any items and services that are required to treat the

18 medical condition identified pursuant to the required

19 screening evaluation.

20 ‘‘(D) In this paragraph, the term ‘emergency services’

21 means—

22 ‘‘(i) health care items and services furnished in

23 the emergency department of a hospital (including a

24 trauma center), and
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1 ‘‘(ii) ancillary services routinely available to

2 such department,

3 to the extent they are required to evaluate and treat an

4 emergency medical condition (as defined in subparagraph

5 (E)) until the condition is stabilized (as defined in sub6 paragraph (F)).

7 ‘‘(E) In subparagraph (D), the term ‘emergency med8 ical condition’ means a medical condition, the onset of

9 which is sudden, that manifests itself by symptoms of suf10 ficient severity, including severe pain, that a prudent

11 layperson, who possesses an average knowledge of health

12 and medicine, could reasonably expect the absence of im13 mediate medical attention to result in—

14 ‘‘(i) placing the person’s health in serious jeop15 ardy,

16 ‘‘(ii) serious impairment to bodily functions, or

17 ‘‘(iii) serious dysfunction of any bodily organ or

18 part.

19 ‘‘(F) In subparagraph (D), the term ‘stabilized’

20 means, with respect to an emergency medical condition,

21 that no material deterioration of the condition is likely,

22 within reasonable medical probability, to result or occur

23 before an individual can be transferred in compliance with

24 the requirements of section 1867.’’.
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1 (c) CONFORMING AMENDMENT.—Section

2 1876(c)(4)(B) of such Act (42 U.S.C. 1395mm(c)(4)(B))

3 is amended by inserting ‘‘subject to paragraphs (9) and

4 (10),’’ before ‘‘provide’’.

5 (d) EFFECTIVE DATE.—The amendments made by

6 subsections (a) and (b) shall be effective for contract years

7 beginning on or after the date of the enactment of this

8 Act.

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