I

106TH CONGRESS

1ST SESSION H. R. 1777

To amend the Public Health Service Act, the Employee Retirement Income

Security Act of 1974, and the Internal Revenue Code of 1986 to assure

access to covered emergency hospital services and emergency ambulance

services under a prudent layperson test under group health plans and

health insurance coverage.

IN THE HOUSE OF REPRESENTATIVES

MAY 12, 1999

Mr. UPTON (for himself, Mr. TOWNS, and Mrs. EMERSON) introduced the following bill; which was referred to the Committee on Commerce, and in

addition to the Committees on Ways and Means, and Education and the

Workforce, 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 amend the Public Health Service Act, the Employee Retirement Income Security Act of 1974, and the Internal

Revenue Code of 1986 to assure access to covered emergency hospital services and emergency ambulance services

under a prudent layperson test under group health plans

and health insurance coverage.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,
2

•HR 1777 IH

1 SECTION 1. SHORT TITLE.

2 This Act may be cited as the ‘‘Emergency Ambulance

3 Services Access Assurance Act of 1999’’.

4 SEC. 2. ASSURING ACCESS TO EMERGENCY SERVICES.

5 (a) GROUP HEALTH PLANS.—

6 (1) PUBLIC HEALTH SERVICE ACT AMEND7 MENTS.—Subpart 2 of part A of title XXVII of the

8 Public Health Service Act is amended by adding at

9 the end the following new section:

10 ‘‘SEC. 2707. STANDARD RELATING TO ACCESS TO EMER11 GENCY SERVICES AND EMERGENCY AMBU12 LANCE SERVICES.

13 ‘‘(a) COVERAGE OF EMERGENCY SERVICES.—

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

15 health insurance coverage offered in connection with

16 a health insurance issuer, provides any benefits with

17 respect to emergency services (as defined in para18 graph (2)(B)), the plan or issuer shall cover emer19 gency services furnished under the plan or

20 coverage—

21 ‘‘(A) without the need for any prior au22 thorization determination;

23 ‘‘(B) whether or not the health care pro24 vider furnishing such services is a participating

25 provider with respect to such services;
3

•HR 1777 IH

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

2 are provided to a participant, beneficiary, or en3 rollee by a nonparticipating health care provider

4 without prior authorization by the plan or

5 issuer, the participant, beneficiary, or enrollee

6 is not liable for amounts that exceed the

7 amounts of liability that would be incurred if

8 the services were provided by a participating

9 health care provider with prior authorization by

10 the plan or issuer; and

11 ‘‘(D) without regard to any other term or

12 condition of such coverage (other than exclusion

13 or coordination of benefits, or an affiliation or

14 waiting period, permitted under section 2701 of

15 this Act, section 701 of the Employee Retire16 ment Income Security Act of 1974, or section

17 9801 of the Internal Revenue Code of 1986,

18 and other than applicable cost-sharing).

19 ‘‘(2) DEFINITIONS.—In this section:

20 ‘‘(A) EMERGENCY MEDICAL CONDITION

21 BASED ON PRUDENT LAYPERSON STANDARD.—

22 The term ‘emergency medical condition’ means

23 a medical condition manifesting itself by acute

24 symptoms of sufficient severity (including se25 vere pain) such that a prudent layperson, who
4

•HR 1777 IH

1 possesses an average knowledge of health and

2 medicine, could reasonably expect the absence

3 of immediate medical attention to result in a

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

5 section 1867(e)(1)(A) of the Social Security

6 Act.

7 ‘‘(B) EMERGENCY SERVICES.—The term

8 ‘emergency services’ means—

9 ‘‘(i) a medical screening examination

10 (as required under section 1867 of the So11 cial Security Act) that is within the capa12 bility of the emergency department of a

13 hospital, including ancillary services rou14 tinely available to the emergency depart15 ment to evaluate an emergency medical

16 condition (as defined in subparagraph

17 (A)), and

18 ‘‘(ii) within the capabilities of the

19 staff and facilities available at the hospital,

20 such further medical examination and

21 treatment as are required under section

22 1867 of such Act to stabilize the patient.

23 ‘‘(C) NONPARTICIPATING.—The term ‘non24 participating’ means, with respect to a health

25 care provider that provides health care items
5

•HR 1777 IH

1 and services to a participant, beneficiary, or en2 rollee under group health plan or health insur3 ance coverage, a health care provider that is not

4 a participating health care provider with respect

5 to such items and services.

6 ‘‘(D) PARTICIPATING.—The term ‘partici7 pating’ means, with respect to a health care

8 provider that provides health care items and

9 services to a participant, beneficiary, or enrollee

10 under group health plan or health insurance

11 coverage offered by a health insurance issuer, a

12 health care provider that furnishes such items

13 and services under a contract or other arrange14 ment with the plan or issuer.

15 ‘‘(b) COVERAGE OF EMERGENCY AMBULANCE SERV16 ICES.—

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

18 health insurance coverage offered in connection with

19 a group health plan by a health insurance issuer,

20 provides any benefits with respect to ambulance

21 services and emergency services, the plan or issuer

22 shall cover emergency ambulance services (as defined

23 in paragraph (2))) furnished under the plan or cov24 erage under the same terms and conditions under

25 subparagraphs (A) through (D) of subsection (a)(1)
6

•HR 1777 IH

1 under which coverage is provided for emergency

2 services.

3 ‘‘(2) EMERGENCY AMBULANCE SERVICES.—For

4 purposes of this subsection, the term ‘emergency

5 ambulance services’ means ambulance services (as

6 defined for purposes of section 1861(s)(7) of the So7 cial Security Act) furnished to transport an indi8 vidual who has an emergency medical condition (as

9 defined in subsection (a)(2)(A)) to a hospital for the

10 receipt of emergency services (as defined in sub11 section (a)(2)(B)) in a case in which the emergency

12 services are covered under the plan or coverage pur13 suant to subsection (a)(1) and a prudent layperson,

14 with an average knowledge of health and medicine,

15 could reasonably expect that the absence of such

16 transport would result in placing the health of the

17 individual in serious jeopardy, serious impairment of

18 bodily function, or serious dysfunction of any bodily

19 organ or part.

20 ‘‘(c) NOTICE.—A group health plan under this part

21 shall comply with the notice requirement under section

22 714(b) of the Employee Retirement Income Security Act

23 of 1974 with respect to the requirements of this section

24 as if such section applied to such plan.’’.
7

•HR 1777 IH

1 (2) Section 2723(c) of such Act (42 U.S.C.

2 300gg–23(c)) is amended by striking ‘‘section 2704’’

3 and inserting ‘‘sections 2704 and 2707’’.

4 (3) ERISA AMENDMENTS.—(A) Subpart B of

5 part 7 of subtitle B of title I of the Employee Re6 tirement Income Security Act of 1974 is amended by

7 adding at the end the following new section:

8 ‘‘SEC. 714. STANDARD RELATING TO ACCESS TO EMER9 GENCY SERVICES AND EMERGENCY AMBU10 LANCE SERVICES.

11 ‘‘(a) COVERAGE OF EMERGENCY SERVICES.—

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

13 health insurance coverage offered in connection with

14 a health insurance issuer, provides any benefits with

15 respect to emergency services (as defined in para16 graph (2)(B)), the plan or issuer shall cover emer17 gency services furnished under the plan or

18 coverage—

19 ‘‘(A) without the need for any prior au20 thorization determination;

21 ‘‘(B) whether or not the health care pro22 vider furnishing such services is a participating

23 provider with respect to such services;

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

25 are provided to a participant, beneficiary, or en-
8

•HR 1777 IH

1 rollee by a nonparticipating health care provider

2 without prior authorization by the plan or

3 issuer, the participant, beneficiary, or enrollee

4 is not liable for amounts that exceed the

5 amounts of liability that would be incurred if

6 the services were provided by a participating

7 health care provider with prior authorization by

8 the plan or issuer; and

9 ‘‘(D) without regard to any other term or

10 condition of such coverage (other than exclusion

11 or coordination of benefits, or an affiliation or

12 waiting period, permitted under section 2701 of

13 the Public Health Service Act, section 701 of

14 this Act, or section 9801 of the Internal Rev15 enue Code of 1986, and other than applicable

16 cost-sharing).

17 ‘‘(2) DEFINITIONS.—In this section:

18 ‘‘(A) EMERGENCY MEDICAL CONDITION

19 BASED ON PRUDENT LAYPERSON STANDARD.—

20 The term ‘emergency medical condition’ means

21 a medical condition manifesting itself by acute

22 symptoms of sufficient severity (including se23 vere pain) such that a prudent layperson, who

24 possesses an average knowledge of health and

25 medicine, could reasonably expect the absence
9

•HR 1777 IH

1 of immediate medical attention to result in a

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

3 section 1867(e)(1)(A) of the Social Security

4 Act.

5 ‘‘(B) EMERGENCY SERVICES.—The term

6 ‘emergency services’ means—

7 ‘‘(i) a medical screening examination

8 (as required under section 1867 of the So9 cial Security Act) that is within the capa10 bility of the emergency department of a

11 hospital, including ancillary services rou12 tinely available to the emergency depart13 ment to evaluate an emergency medical

14 condition (as defined in subparagraph

15 (A)), and

16 ‘‘(ii) within the capabilities of the

17 staff and facilities available at the hospital,

18 such further medical examination and

19 treatment as are required under section

20 1867 of such Act to stabilize the patient.

21 ‘‘(C) NONPARTICIPATING.—The term ‘non22 participating’ means, with respect to a health

23 care provider that provides health care items

24 and services to a participant, beneficiary, or en25 rollee under group health plan or health insur-
10

•HR 1777 IH

1 ance coverage, a health care provider that is not

2 a participating health care provider with respect

3 to such items and services.

4 ‘‘(D) PARTICIPATING.—The term ‘partici5 pating’ means, with respect to a health care

6 provider that provides health care items and

7 services to a participant, beneficiary, or enrollee

8 under group health plan or health insurance

9 coverage offered by a health insurance issuer, a

10 health care provider that furnishes such items

11 and services under a contract or other arrange12 ment with the plan or issuer.

13 ‘‘(b) COVERAGE OF EMERGENCY AMBULANCE SERV14 ICES.—

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

16 health insurance coverage offered in connection with

17 a group health plan by a health insurance issuer,

18 provides any benefits with respect to ambulance

19 services and emergency services, the plan or issuer

20 shall cover emergency ambulance services (as defined

21 in paragraph (2))) furnished under the plan or cov22 erage under the same terms and conditions under

23 subparagraphs (A) through (D) of subsection (a)(1)

24 under which coverage is provided for emergency

25 services.
11

•HR 1777 IH

1 ‘‘(2) EMERGENCY AMBULANCE SERVICES.—For

2 purposes of this subsection, the term ‘emergency

3 ambulance services’ means ambulance services (as

4 defined for purposes of section 1861(s)(7) of the So5 cial Security Act) furnished to transport an indi6 vidual who has an emergency medical condition (as

7 defined in subsection (a)(2)(A)) to a hospital for the

8 receipt of emergency services (as defined in sub9 section (a)(2)(B)) in a case in which the emergency

10 services are covered under the plan or coverage pur11 suant to subsection (a)(1) and a prudent layperson,

12 with an average knowledge of health and medicine,

13 could reasonably expect that the absence of such

14 transport would result in placing the health of the

15 individual in serious jeopardy, serious impairment of

16 bodily function, or serious dysfunction of any bodily

17 organ or part.

18 ‘‘(c) NOTICE UNDER GROUP HEALTH PLAN.—The

19 imposition of the requirement of this section shall be treat20 ed as a material modification in the terms of the plan de21 scribed in section 102(a)(1), for purposes of assuring no22 tice of such requirements under the plan; except that the

23 summary description required to be provided under the

24 last sentence of section 104(b)(1) with respect to such

25 modification shall be provided by not later than 60 days
12

•HR 1777 IH

1 after the first day of the first plan year in which such

2 requirement apply.’’.

3 (B) Section 731(c) of such Act (29 U.S.C.

4 1191(c)) is amended by striking ‘‘section 711’’ and

5 inserting ‘‘sections 711 and 714’’.

6 (C) The table of contents in section 1 of such

7 Act is amended by inserting after the item relating

8 to section 713 the following new item:

‘‘Sec. 714. Standard relating to access to emergency services and emergency ambulance services.’’.

9 (4) INTERNAL REVENUE CODE AMEND10 MENTS.—

11 (A) IN GENERAL.—Subchapter B of chap12 ter 100 of the Internal Revenue Code of 1986

13 is amended by inserting after section 9812 the

14 following new section:

15 ‘‘SEC. 9813. STANDARD RELATING TO ACCESS TO EMER16 GENCY SERVICES AND EMERGENCY AMBU17 LANCE SERVICES.

18 ‘‘(a) COVERAGE OF EMERGENCY SERVICES.—

19 ‘‘(1) IN GENERAL.—If a group health plan pro20 vides any benefits with respect to emergency services

21 (as defined in paragraph (2)(B)), the plan shall

22 cover emergency services furnished under the plan—

23 ‘‘(A) without the need for any prior au24 thorization determination;
13

•HR 1777 IH

1 ‘‘(B) whether or not the health care pro2 vider furnishing such services is a participating

3 provider with respect to such services;

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

5 are provided to a participant or beneficiary by

6 a nonparticipating health care provider without

7 prior authorization by the plan, the participant

8 or beneficiary is not liable for amounts that ex9 ceed the amounts of liability that would be in10 curred if the services were provided by a par11 ticipating health care provider with prior au12 thorization by the plan; and

13 ‘‘(D) without regard to any other term or

14 condition of such coverage (other than exclusion

15 or coordination of benefits, or an affiliation or

16 waiting period, permitted under section 2701 of

17 the Public Health Service Act, section 701 of

18 the Employee Retirement Income Security Act

19 of 1974, or section 9801 of this Code, and

20 other than applicable cost-sharing).

21 ‘‘(2) DEFINITIONS.—In this section:

22 ‘‘(A) EMERGENCY MEDICAL CONDITION

23 BASED ON PRUDENT LAYPERSON STANDARD.—

24 The term ‘emergency medical condition’ means

25 a medical condition manifesting itself by acute
14

•HR 1777 IH

1 symptoms of sufficient severity (including se2 vere pain) such that a prudent layperson, who

3 possesses an average knowledge of health and

4 medicine, could reasonably expect the absence

5 of immediate medical attention to result in a

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

7 section 1867(e)(1)(A) of the Social Security

8 Act.

9 ‘‘(B) EMERGENCY SERVICES.—The term

10 ‘emergency services’ means—

11 ‘‘(i) a medical screening examination

12 (as required under section 1867 of the So13 cial Security Act) that is within the capa14 bility of the emergency department of a

15 hospital, including ancillary services rou16 tinely available to the emergency depart17 ment to evaluate an emergency medical

18 condition (as defined in subparagraph

19 (A)), and

20 ‘‘(ii) within the capabilities of the

21 staff and facilities available at the hospital,

22 such further medical examination and

23 treatment as are required under section

24 1867 of such Act to stabilize the patient.
15

•HR 1777 IH

1 ‘‘(C) NONPARTICIPATING.—The term ‘non2 participating’ means, with respect to a health

3 care provider that provides health care items

4 and services to a participant or beneficiary

5 under group health plan, a health care provider

6 that is not a participating health care provider

7 with respect to such items and services.

8 ‘‘(D) PARTICIPATING.—The term ‘partici9 pating’ means, with respect to a health care

10 provider that provides health care items and

11 services to a participant or beneficiary under

12 group health plan, a health care provider that

13 furnishes such items and services under a con14 tract or other arrangement with the plan.

15 ‘‘(b) COVERAGE OF EMERGENCY AMBULANCE SERV16 ICES.—

17 ‘‘(1) IN GENERAL.—If a group health plan pro18 vides any benefits with respect to ambulance services

19 and emergency services, the plan shall cover emer20 gency ambulance services (as defined in paragraph

21 (2))) furnished under the coverage under the same

22 terms and conditions under subparagraphs (A)

23 through (D) of subsection (a)(1) under which cov24 erage is provided for emergency services.
16

•HR 1777 IH

1 ‘‘(2) EMERGENCY AMBULANCE SERVICES.—For

2 purposes of this subsection, the term ‘emergency

3 ambulance services’ means ambulance services (as

4 defined for purposes of section 1861(s)(7) of the So5 cial Security Act) furnished to transport an indi6 vidual who has an emergency medical condition (as

7 defined in subsection (a)(2)(A)) to a hospital for the

8 receipt of emergency services (as defined in sub9 section (a)(2)(B)) in a case in which the emergency

10 services are covered under the plan pursuant to sub11 section (a)(1) and a prudent layperson, with an av12 erage knowledge of health and medicine, could rea13 sonably expect that the absence of such transport

14 would result in placing the health of the individual

15 in serious jeopardy, serious impairment of bodily

16 function, or serious dysfunction of any bodily organ

17 or part.’’.

18 (B) CLERICAL AMENDMENT.—The table of

19 sections of such subchapter is amended by in20 serting after the item relating to section 9812

21 the following new item:

‘‘Sec. 9813. Standard relating to access to emergency services

and emergency ambulance services.’’.

22 (b) INDIVIDUAL HEALTH INSURANCE.—(1) Part B

23 of title XXVII of the Public Health Service Act is amend-
17

•HR 1777 IH

1 ed by inserting after section 2752 the following new sec2 tion:

3 ‘‘SEC. 2753. STANDARD RELATING TO ACCESS TO EMER4 GENCY SERVICES AND EMERGENCY AMBU5 LANCE SERVICES.

6 ‘‘(a) IN GENERAL.—The provisions of subsections (a)

7 and (b) of section 2707 shall apply to health insurance

8 coverage offered by a health insurance issuer in the indi9 vidual market in the same manner as they apply to health

10 insurance coverage offered by a health insurance issuer

11 in connection with a group health plan in the small or

12 large group market.

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

14 part shall comply with the notice requirement under sec15 tion 714(b) of the Employee Retirement Income Security

16 Act of 1974 with respect to the requirements referred to

17 in subsection (a) as if such section applied to such issuer

18 and such issuer were a group health plan.’’.

19 (2) Section 2762(b)(2) of such Act (42 U.S.C.

20 300gg–62(b)(2)) is amended by striking ‘‘section 2751’’

21 and inserting ‘‘sections 2751 and 2753’’.

22 (c) EFFECTIVE DATES.—

23 (1) GROUP HEALTH PLANS AND GROUP

24 HEALTH INSURANCE COVERAGE.—Subject to para25 graph (3), the amendments made by subsection (a)
18

•HR 1777 IH

1 apply with respect to group health plans for plan

2 years beginning on or after January 1, 2000.

3 (2) INDIVIDUAL HEALTH INSURANCE COV4 ERAGE.—The amendments made by subsection (b)

5 apply with respect to health insurance coverage of6 fered, sold, issued, renewed, in effect, or operated in

7 the individual market on or after such date.

8 (3) COLLECTIVE BARGAINING EXCEPTION.—In

9 the case of a group health plan maintained pursuant

10 to 1 or more collective bargaining agreements be11 tween employee representatives and 1 or more em12 ployers ratified before the date of enactment of this

13 Act, the amendments made subsection (a) shall not

14 apply to plan years beginning before the later of—

15 (A) the date on which the last collective

16 bargaining agreements relating to the plan ter17 minates (determined without regard to any ex18 tension thereof agreed to after the date of en19 actment of this Act), or

20 (B) January 1, 2000.

21 For purposes of subparagraph (A), any plan amend22 ment made pursuant to a collective bargaining

23 agreement relating to the plan which amends the

24 plan solely to conform to any requirement added by
19

•HR 1777 IH

1 subsection (a) shall not be treated as a termination

2 of such collective bargaining agreement.

3 (4) LIMITATION ON ENFORCEMENT ACTIONS.—

4 No enforcement action shall be taken, pursuant to

5 the amendments made by this subsections (a) and

6 (b), against a group health plan or health insurance

7 issuer with respect to a violation of a requirement

8 imposed by such amendments, to the extent that vio9 lation or failure occurs before the date of issuance

10 of regulations issued in connection with such re11 quirement, if the plan or issuer has sought to com12 ply in good faith with such requirement.

13 (d) COORDINATION OF ADMINISTRATION.—The Sec14 retary of Labor, the Secretary of the Treasury, and the

15 Secretary of Health and Human Services shall ensure,

16 through the execution of an interagency memorandum of

17 understanding among such Secretaries, that—

18 (1) regulations, rulings, and interpretations

19 issued by such Secretaries relating to the same mat20 ter over which two or more such Secretaries have re21 sponsibility under the provisions of this Act (and the

22 amendments made thereby) are administered so as

23 to have the same effect at all times; and

24 (2) coordination of policies relating to enforcing

25 the same requirements through such Secretaries in
20

•HR 1777 IH

1 order to have a coordinated enforcement strategy

2 that avoids duplication of enforcement efforts and

3 assigns priorities in enforcement.

Æ