I

107TH CONGRESS

1ST SESSION H. R. 1674

To assure access under group health plans and health insurance coverage

to covered emergency medical services.

IN THE HOUSE OF REPRESENTATIVES

MAY 2, 2001

Mr. CARDIN (for himself, Mrs. ROUKEMA, Mr. ABERCROMBIE, Mr. LANGEVIN,

Mr. STARK, Mr. HOEFFEL, Mr. BLUMENAUER, Mrs. THURMAN, Mr.

FARR of California, Mr. MCDERMOTT, Mr. SERRANO, Mr. LEVIN, Mr.

WYNN, Mrs. MINK of Hawaii, Mr. DEFAZIO, Mrs. EMERSON, Mrs.

NAPOLITANO, Ms. SLAUGHTER, Mr. THOMPSON of Mississippi, Mr.

MCHUGH, Ms. BALDWIN, Ms. HOOLEY of Oregon, Mr. DELAHUNT, Mr.

COYNE, Ms. EDDIE BERNICE JOHNSON of Texas, Mr. BENTSEN, Mr.

LEWIS of Georgia, Mr. GEORGE MILLER of California, Ms. RIVERS, Mr.

SPENCE, Mr. BAKER, and Mr. RUSH) introduced the following bill; which

was referred to the Committee on Energy and 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 2001’’.

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 with respect to an emergency medical condition

13 (as defined in subparagraph (A)), has the

14 meaning given in section 1867(e)(3) of the So15 cial Security Act (42 U.S.C. 1395dd(e)(3)).

16 (b) REIMBURSEMENT FOR MAINTENANCE CARE AND

17 POST-STABILIZATION CARE.—A group health plan, and

18 health insurance coverage offered by a health insurance

19 issuer, must provide reimbursement for maintenance care

20 and post-stabilization care in accordance with the require21 ments of section 1852(d)(2) of the Social Security Act (42

22 U.S.C. 1395w–22(d)(2)). Such reimbursement shall be

23 provided in a manner consistent with subsection (a)(1)(C).

24 (c) COVERAGE OF EMERGENCY AMBULANCE SERV25 ICES.—
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1 (1) IN GENERAL.—If a group health plan, or

2 health insurance coverage provided by a health in3 surance issuer, provides any benefits with respect to

4 ambulance services and emergency services, the plan

5 or issuer shall cover emergency ambulance services

6 (as defined in paragraph (2)) furnished under the

7 plan or coverage under the same terms and condi8 tions under subparagraphs (A) through (D) of sub9 section (a)(1) under which coverage is provided for

10 emergency services.

11 (2) EMERGENCY AMBULANCE SERVICES.—For

12 purposes of this subsection, the term ‘‘emergency

13 ambulance services’’ means ambulance services (as

14 defined for purposes of section 1861(s)(7) of the So15 cial Security Act) furnished to transport an indi16 vidual who has an emergency medical condition (as

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

18 receipt of emergency services (as defined in sub19 section (a)(2)(B)) in a case in which the emergency

20 services are covered under the plan or coverage pur21 suant to subsection (a)(1) and a prudent layperson,

22 with an average knowledge of health and medicine,

23 could reasonably expect that the absence of such

24 transport would result in placing the health of the

25 individual in serious jeopardy, serious impairment of
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1 bodily function, or serious dysfunction of any bodily

2 organ or part.

3 (d) INFORMATION FOR PARTICIPANTS, BENE4 FICIARIES, AND ENROLLEES.—

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

6 plan shall—

7 (A) provide to participants and bene8 ficiaries at the time of initial coverage under

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

10 case of individuals who are participants and

11 beneficiaries as of such date), at least annually

12 thereafter, and at the beginning of any open en13 rollment provided under the plan, the informa14 tion described in paragraph (3) in printed form;

15 (B) upon request, make available to par16 ticipants and beneficiaries, to the applicable au17 thority, and to prospective participants and

18 beneficiaries the information described in para19 graph (3) in printed form; and

20 (C) provide notice to participants and

21 beneficiaries of information relating to any ma22 terial reduction to the benefits or information

23 described in paragraph (3) not later than 30

24 days before the date on which the reduction

25 takes effect.
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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;

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; and

16 (C) provide notice to enrollees of informa17 tion relating to any material reduction to the

18 benefits or information described in paragraph

19 (3) not later than 30 days before the date on

20 which the reduction takes effect.

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 (e) 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 section 2 of the Access to Emer11 gency Medical Services Act of 2001, and such require12 ments shall be deemed to be incorporated into this sub13 section.

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

15 the notice requirement under section 711(d) of the Em16 ployee Retirement Income Security Act with respect to the

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

18 insurance issuer shall comply with such notice requirement

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

20 were a group health plan.’’.

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

22 the Public Health Service Act is amended by inserting

23 after section 2752 the following new section:

24 ‘‘SEC. 2753. EMERGENCY SERVICES.

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

26 shall comply with the requirements of section 2 of the Ac-
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1 cess to Emergency Medical Services Act of 2001 with re2 spect to individual health insurance coverage it offers, and

3 such requirements shall be deemed to be incorporated into

4 this subsection.

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

6 part shall comply with the notice requirement under sec7 tion 711(d) of the Employee Retirement Income Security

8 Act with respect to the requirements referred to in sub9 section (a) as if such section applied to such issuer and

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

11 SEC. 4. STANDARDS UNDER THE EMPLOYEE RETIREMENT

12 INCOME SECURITY ACT OF 1974.

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

14 B of title I of the Employee Retirement Income Security

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

16 new section:

17 ‘‘SEC. 714. EMERGENCY SERVICES.

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

19 group health plan (and a health insurance issuer offering

20 group health insurance coverage in connection with such

21 a plan) shall comply with the requirements of section 2

22 of the Access to Emergency Medical Services Act of 2001,

23 and such requirements shall be deemed to be incorporated

24 into this subsection.
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1 ‘‘(b) SATISFACTION OF REQUIREMENTS.—For pur2 poses of subsection (a), insofar as a group health plan pro3 vides benefits in the form of health insurance coverage

4 through a health insurance issuer, the plan shall be treat5 ed as meeting the requirements of the Access to Emer6 gency Medical Services Act of 2001 with respect to such

7 benefits and not be considered as failing to meet such re8 quirements because of a failure of the issuer to meet such

9 requirements so long as the plan sponsor or its representa10 tives did not cause such failure by the issuer.’’.

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

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

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

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

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

16 item relating to section 713 the following new item:

‘‘Sec. 714. Emergency services.’’.

17 SEC. 5. STANDARDS UNDER THE INTERNAL REVENUE CODE

18 OF 1986.

19 Subchapter B of chapter 100 of the Internal Revenue

20 Code of 1986 is amended—

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

22 the item relating to section 9812 the following new

23 item:

‘‘Sec. 9813. Standard relating to emergency services.’’; and
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1 (2) by inserting after section 9812 the fol2 lowing:

3 ‘‘SEC. 9813. STANDARD RELATING TO EMERGENCY SERV4 ICES.

5 ‘‘A group health plan shall comply with the require6 ments of section 2 of the Access to Emergency Medical

7 Services Act of 2001, and such requirements shall be

8 deemed to be incorporated into this section.’’.

9 SEC. 6. EFFECTIVE DATE.

10 (a) GROUP HEALTH COVERAGE.—

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

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

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

14 apply to group health plans for plan years beginning

15 on or after January 1, 2002.

16 (2) TREATMENT OF COLLECTIVE BARGAINING

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

18 maintained pursuant to 1 or more collective bar19 gaining agreements between employee representa20 tives and 1 or more employers ratified before the

21 date of the enactment of this Act, the amendments

22 made by sections 3(a), 4, and 5 (and section 2 inso23 far as it relates to such sections) shall not apply to

24 plan years beginning before the later of—
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1 (A) the date on which the last collective

2 bargaining agreement relating to the plan ter3 minates (determined without regard to any ex4 tension thereof agreed to after the date of the

5 enactment of this Act); or

6 (B) January 1, 2002.

7 For purposes of subparagraph (A), any plan amend8 ment made pursuant to a collective bargaining

9 agreement relating to the plan that amends the plan

10 solely to conform to any requirement of this Act

11 shall not be treated as a termination of such collec12 tive bargaining agreement.

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

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

15 section) applies with respect to health insurance coverage

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

17 individual market on or after January 1, 2002.

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