II

106TH CONGRESS

1ST SESSION S. 517

To assure access under group health plans and health insurance coverage

to covered emergency medical services.

IN THE SENATE OF THE UNITED STATES

MARCH 3, 1999

Mr. GRAHAM (for himself, Mr. CHAFEE, Ms. MIKULSKI, Mr. DEWINE, and

Mr. ROBB) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions

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,

3 SECTION 1. SHORT TITLE.

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

5 Medical Services Act of 1999’’.

6 SEC. 2. EMERGENCY SERVICES.

7 (a) COVERAGE OF EMERGENCY SERVICES.—

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

9 health insurance coverage offered by a health insur10 ance issuer, provides any benefits with respect to
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1 emergency services (as defined in paragraph (2)(B)),

2 the plan or issuer shall cover emergency services fur3 nished under the plan or coverage—

4 (A) without the need for any prior author5 ization determination;

6 (B) whether or not the health care pro7 vider furnishing such services is a participating

8 provider with respect to such services;

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

10 are provided to a participant, beneficiary, or en11 rollee by a nonparticipating health care pro12 vider, the participant, beneficiary, or enrollee is

13 not liable for amounts that exceed the amounts

14 of liability that would be incurred if the services

15 were provided by a participating provider; and

16 (D) without regard to any other term or

17 condition of such plan or coverage (other than

18 exclusion or coordination of benefits, or an af19 filiation or waiting period, permitted under sec20 tion 2701 of the Public Health Service Act (42

21 U.S.C. 300gg et seq.), section 701 of the Em22 ployee Retirement Income Security Act of 1974

23 (29 U.S.C. 1181 et seq.), or section 9801 of the

24 Internal Revenue Code of 1986, and other than

25 applicable cost sharing).
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1 (2) DEFINITIONS.—In this section:

2 (A) EMERGENCY MEDICAL CONDITION

3 BASED ON PRUDENT LAYPERSON STANDARD.—

4 The term ‘‘emergency medical condition’’ means

5 a medical condition manifesting itself by acute

6 symptoms of sufficient severity (including se7 vere pain) such that a prudent layperson, who

8 possesses an average knowledge of health and

9 medicine, could reasonably expect the absence

10 of immediate medical attention to result in a

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

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

13 (42 U.S.C. 1395dd(e)(1)(A)).

14 (B) EMERGENCY SERVICES.—The term

15 ‘‘emergency services’’ means—

16 (i) a medical screening examination

17 (as required under section 1867 of the So18 cial Security Act (42 U.S.C. 1395dd)) that

19 is within the capability of the emergency

20 department of a hospital, including ancil21 lary services routinely available to the

22 emergency department to evaluate an

23 emergency medical condition (as defined in

24 subparagraph (A)); and
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1 (ii) within the capabilities of the staff

2 and facilities at the hospital, such further

3 medical examination and treatment as are

4 required under section 1867 of such Act to

5 stabilize the patient.

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

7 means, with respect to an emergency medical

8 condition, to provide such medical treatment of

9 the condition as may be necessary to assure,

10 within reasonable medical probability, that no

11 material deterioration of the condition is likely

12 to result from or occur during the transfer of

13 the individual from a facility.

14 (b) REIMBURSEMENT FOR MAINTENANCE CARE AND

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

16 (other than emergency services) for which benefits are

17 available under a group health plan, or under health insur18 ance coverage offered by a health insurance issuer, the

19 plan or issuer shall provide for reimbursement with re20 spect to such services provided to a participant, bene21 ficiary, or enrollee other than through a participating

22 health care provider in a manner consistent with sub23 section (a)(1)(C) (and shall otherwise comply with the

24 guidelines established under section 1852(d)(2) of the So25 cial Security Act (42 U.S.C. 1395w–22(d)(2)) (relating to
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1 promoting efficient and timely coordination of appropriate

2 maintenance and post-stabilization care of an enrollee

3 after an enrollee has been determined to be stable), or,

4 in the absence of guidelines under such section, such

5 guidelines as the Secretary shall establish to carry out this

6 subsection), if the services are maintenance care or post7 stabilization care covered under such guidelines.

8 (c) INFORMATION FOR PARTICIPANTS, BENE9 FICIARIES, AND ENROLLEES.—

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

11 plan shall—

12 (A) provide to participants and bene13 ficiaries at the time of initial coverage under

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

15 case of individuals who are participants and

16 beneficiaries as of such date), at least annually

17 thereafter, and at the beginning of any open en18 rollment provided under the plan, the informa19 tion described in paragraph (3) in printed form;

20 and

21 (B) upon request, make available to par22 ticipants and beneficiaries, to the applicable au23 thority, and to prospective participants and

24 beneficiaries the information described in para25 graph (3) in printed form.
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1 (2) HEALTH INSURANCE ISSUERS.—A health

2 insurance issuer, in connection with the provision of

3 health insurance coverage, shall—

4 (A) provide to individuals enrolled under

5 such coverage at the time of enrollment, and at

6 least annually thereafter, (and to plan adminis7 trators of group health plans in connection with

8 which such coverage is offered) the information

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

10 (B) upon request, make available to the

11 applicable authority, to individuals who are pro12 spective enrollees, to plan administrators of

13 group health plans that may obtain such cov14 erage, and to the public the information de15 scribed in paragraph (3) in printed form.

16 (3) REQUIRED INFORMATION.—The informa17 tion described in this paragraph with respect to a

18 group health plan or health insurance coverage of19 fered by a health insurance issuer is information

20 about the coverage of emergency services,

21 including—

22 (A) the appropriate use of emergency serv23 ices, including use of the 911 telephone system

24 or its local equivalent in emergency situations
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1 and an explanation of what constitutes an

2 emergency situation;

3 (B) the process and procedures of the plan

4 or issuer for obtaining emergency services;

5 (C) any cost-sharing applicable to emer6 gency services; and

7 (D) the locations of—

8 (i) emergency departments; and

9 (ii) other settings in which plan physi10 cians and hospitals provide emergency

11 services and post-stabilization care.

12 (d) DEFINITIONS.—In this section:

13 (1) APPLICABLE AUTHORITY.—The term ‘‘ap14 plicable authority’’ means—

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

16 Secretary of Health and Human Services and

17 the Secretary of Labor; and

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

19 with respect to a specific provision of this sec20 tion, the applicable State authority or the Sec21 retary of Health and Human Services if such

22 Secretary is enforcing such provisions under

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

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

25 300gg–61(a)(2)).
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1 (2) NONPARTICIPATING.—The term ‘‘non2 participating’’ means, with respect to a health care

3 provider that provides health care items and services

4 to a participant, beneficiary, or enrollee under a

5 group health plan or health insurance coverage, a

6 health care provider that is not a participating

7 health care provider with respect to such items and

8 services.

9 (3) PARTICIPATING.—The term ‘‘participating’’

10 means, with respect to a health care provider that

11 provides health care items and services to a partici12 pant, beneficiary, or enrollee under a group health

13 plan or health insurance coverage offered by a

14 health insurance issuer, a health care provider that

15 furnishes such items and services under a contract

16 or other arrangement with the plan or issuer.

17 (4) OTHER TERMS.—The terms ‘‘applicable

18 State authority’’, ‘‘beneficiary’’, ‘‘group health

19 plan’’, ‘‘health insurance coverage’’, ‘‘health insur20 ance issuer’’, and ‘‘participant’’ shall have the mean21 ings given to such terms in section 2791 of the Pub22 lic Health Service Act (42 U.S.C. 300gg–91).
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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, as amended by

5 the Omnibus Consolidated and Emergency Supplemental

6 Appropriations Act, 1999 (Public Law 105–277), is

7 amended by adding at the end the following new section:

8 ‘‘SEC. 2707. EMERGENCY SERVICES.

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

10 each health insurance issuer offering group health insur11 ance coverage in connection with such a plan) shall comply

12 with the requirements of the Access to Emergency Medical

13 Services Act of 1999, and such requirements shall be

14 deemed to be incorporated into this subsection.

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

16 the notice requirement under section 711(d) of the Em17 ployee Retirement Income Security Act with respect to the

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

19 insurance issuer shall comply with such notice requirement

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

21 were a group health plan.’’.

22 (b) INDIVIDUAL MARKET.—Subpart 3 of part B of

23 title XXVII of the Public Health Service Act, as amended

24 by the Omnibus Consolidated and Emergency Supple25 mental Appropriations Act, 1999 (Public Law 105–277),

26 is amended by adding at the end the following new section:
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1 ‘‘SEC. 2753. EMERGENCY SERVICES.

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

3 shall comply with the requirements of the Access to Emer4 gency Medical Services Act of 1999 with respect to indi5 vidual health insurance coverage it offers, and such re6 quirements shall be deemed to be incorporated into this

7 subsection.

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

9 part shall comply with the notice requirement under sec10 tion 711(d) of the Employee Retirement Income Security

11 Act with respect to the requirements referred to in sub12 section (a) as if such section applied to such issuer and

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

14 SEC. 4. STANDARDS UNDER THE EMPLOYEE RETIREMENT

15 INCOME SECURITY ACT OF 1974.

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

17 B of title I of the Employee Retirement Income Security

18 Act of 1974, as amended by the Omnibus Consolidated

19 and Emergency Supplemental Appropriations Act, 1999

20 (Public Law 105–277), is amended by adding at the end

21 the following:

22 ‘‘SEC. 714. EMERGENCY SERVICES.

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

24 group health plan (and a health insurance issuer offering

25 group health insurance coverage in connection with such

26 a plan) shall comply with the requirements of the Access
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1 to Emergency Medical Services Act of 1999, and such re2 quirements shall be deemed to be incorporated into this

3 subsection.

4 ‘‘(b) SATISFACTION OF REQUIREMENTS.—For pur5 poses of subsection (a), insofar as a group health plan pro6 vides benefits in the form of health insurance coverage

7 through a health insurance issuer, the plan shall be treat8 ed as meeting the requirements of the Access to Emer9 gency Medical Services Act of 1999 with respect to such

10 benefits and not be considered as failing to meet such re11 quirements because of a failure of the issuer to meet such

12 requirements so long as the plan sponsor or its representa13 tives did not cause such failure by the issuer.’’.

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

15 the Employee Retirement Income Security Act of 1974

16 (29 U.S.C. 1191a(a)) is amended by striking ‘‘section

17 711’’ and inserting ‘‘sections 711 and 714’’.

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

19 in section 1 of the Employee Retirement Income Security

20 Act of 1974 is amended by inserting after the item relat21 ing to section 713 the following new item:

‘‘Sec. 714. Emergency services.’’.

22 SEC. 5. STANDARDS UNDER THE INTERNAL REVENUE CODE

23 OF 1986.

24 Subchapter B of chapter 100 of the Internal Revenue

25 Code of 1986 is amended—
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1 (1) in the table of sections, by inserting after

2 the item relating to section 9812 the following new

3 item:

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

4 (2) by inserting after section 9812 the follow5 ing:

6 ‘‘SEC. 9813. STANDARD RELATING TO EMERGENCY SERV7 ICES.

8 ‘‘A group health plan shall comply with the require9 ments of the Access to Emergency Medical Services Act

10 of 1999, and such requirements shall be deemed to be in11 corporated into this section.’’.

12 SEC. 6. EFFECTIVE DATE.

13 (a) GROUP HEALTH COVERAGE.—

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

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

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

17 shall apply to group health plans and health insur18 ance coverage offered in connection with group

19 health plans for plan years beginning on or after

20 January 1, 2000.

21 (2) TREATMENT OF COLLECTIVE BARGAINING

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

23 maintained pursuant to 1 or more collective bargain24 ing agreements between employee representatives

25 and 1 or more employers ratified before the date of
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1 the enactment of this Act, the amendments made by

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

3 relates to such sections) shall not apply to plan

4 years beginning before the later of—

5 (A) the date on which the last collective

6 bargaining agreement relating to the plan ter7 minates (determined without regard to any ex8 tension thereof agreed to after the date of the

9 enactment of this Act); or

10 (B) January 1, 2000.

11 For purposes of subparagraph (A), any plan amend12 ment made pursuant to a collective bargaining

13 agreement relating to the plan that amends the plan

14 solely to conform to any requirement of this Act

15 shall not be treated as a termination of such collec16 tive bargaining agreement.

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

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

19 section) shall apply with respect to health insurance cov20 erage offered, sold, issued, renewed, in effect, or operated

21 in the individual market on or after January 1, 2000.

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