I

105TH CONGRESS

1ST SESSION H. R. 815

To amend the Internal Revenue Code of 1986, the Public Health Service

Act, the Employee Retirement Income Security Act of 1974, and titles

XVIII and XIX of the Social Security Act to assure access to emergency

medical services under group health plans, health insurance coverage,

and the Medicare and Medicaid Programs.

IN THE HOUSE OF REPRESENTATIVES

FEBRUARY 25, 1997

Mr. CARDIN (for himself, Mrs. ROUKEMA, Mr. DINGELL, Mr. SHAYS, Mr.

STARK, Mr. DAVIS of Virginia, Mr. WAXMAN, Mr. CONDIT, Mr. BROWN

of Ohio, Mr. KENNEDY of Rhode Island, Mr. POMEROY, Mrs. THURMAN,

Mr. GEJDENSON, Mrs. MEEK of Florida, Mr. CLEMENT, Mr. DOYLE, Mr.

NORWOOD, Mr. LEVIN, Mr. EVANS, Mr. MCDERMOTT, Mr. FROST, Mr.

CAMPBELL, Mr. CONYERS, Mr. RAHALL, Mr. MCGOVERN, and Mr.

GANSKE) introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committees on Commerce, 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 Internal Revenue Code of 1986, the Public

Health Service Act, the Employee Retirement Income

Security Act of 1974, and titles XVIII and XIX of

the Social Security Act to assure access to emergency

medical services under group health plans, health insurance coverage, and the Medicare and Medicaid Programs.
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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; TABLE OF CONTENTS.

4 (a) SHORT TITLE.—This Act may be cited as the

5 ‘‘Access to Emergency Medical Services Act of 1997’’.

6 (b) TABLE OF CONTENTS.—The table of contents of

7 this Act is as follows:

Sec. 1. Short title; table of contents.

Sec. 2. Amendments to the Internal Revenue Code of 1986.

Sec. 3. Amendments to the Employee Retirement Income Security Act of 1974.

Sec. 4. Amendments to the Public Health Service Act relating to the group

market.

Sec. 5. Amendments to the Public Health Service Act relating to the individual

market.

Sec. 6. Application to private coverage for medicare and medicaid beneficiaries.

Sec. 7. Establishment of guidelines.

8 SEC. 2. AMENDMENTS TO THE INTERNAL REVENUE CODE

9 OF 1986.

10 (a) IN GENERAL.—Subtitle K of the Internal Reve11 nue Code of 1986 (as added by section 401(a) of the

12 Health Insurance Portability and Accountability Act of

13 1996) is amended—

14 (1) by striking all that precedes section 9801

15 and inserting the following:

16 ‘‘Subtitle K—Group Health Plan

17 Requirements

‘‘CHAPTER 100. Group health plan requirements.
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1 ‘‘CHAPTER 100—GROUP HEALTH PLAN

2 REQUIREMENTS

‘‘Subchapter A. Requirements relating to portability, access, and

renewability.

‘‘Subchapter B. Other requirements.

‘‘Subchapter C. General provisions.

3 ‘‘Subchapter A—Requirements Relating to

4 Portability, Access, and Renewability

‘‘Sec. 9801. Increased portability through limitation on preexisting condition exclusions.

‘‘Sec. 9802. Prohibiting discrimination against individual participants and beneficiaries based on health status.

‘‘Sec. 9803. Guaranteed renewability in multiemployer plans and

certain multiple employer welfare arrangements.’’,

5 (2) by redesignating sections 9804, 9805, and

6 9806 as sections 9831, 9832, and 9833, respectively,

7 (3) by inserting before section 9831 (as so re8 designated) the following:

9 ‘‘Subchapter C—General Provisions

‘‘Sec. 9831. General exceptions.

‘‘Sec. 9832. Definitions.

‘‘Sec. 9833. Regulations.’’, and

10 (4) by inserting after section 9803 the follow11 ing:

12 ‘‘Subchapter B—Other Requirements

‘‘Sec. 9811. Assuring equitable coverage of emergency services,

maintenance care, and post-stabilization care.
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1 ‘‘SEC. 9811. ASSURING EQUITABLE COVERAGE OF EMER2 GENCY SERVICES, MAINTENANCE CARE, AND

3 POST-STABILIZATION CARE.

4 ‘‘(a) PROHIBITION OF CERTAIN RESTRICTIONS ON

5 COVERAGE OF EMERGENCY SERVICES.—

6 ‘‘(1) IN GENERAL.—If a group health plan pro7 vides any benefits with respect to emergency services

8 (as defined in paragraph (2)(B)), the plan (and any

9 health insurance issuer offering health insurance

10 coverage in connection with such a plan) shall cover

11 emergency services furnished to a participant or ben12 eficiary of the plan—

13 ‘‘(A) without the need for any prior au14 thorization determination,

15 ‘‘(B) subject to paragraph (3), whether or

16 not the physician or provider furnishing such

17 services is a participating physician or provider

18 with respect to such services, and

19 ‘‘(C) subject to paragraph (3), without re20 gard to any other term or condition of such

21 plan or coverage (other than an exclusion of

22 benefits, or an affiliation or waiting period, per23 mitted under section 9801).

24 ‘‘(2) EMERGENCY SERVICES; EMERGENCY MEDI25 CAL CONDITION.—For purposes of this section—
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1 ‘‘(A) EMERGENCY MEDICAL CONDITION

2 BASED ON PRUDENT LAYPERSON.—The term

3 ‘emergency medical condition’ means a medical

4 condition manifesting itself by acute symptoms

5 of sufficient severity (including severe pain)

6 such that a prudent layperson, who possesses

7 an average knowledge of health and medicine,

8 could reasonably expect the absence of imme9 diate medical attention to result in—

10 ‘‘(i) placing the health of the individ11 ual (or, with respect to a pregnant woman,

12 the health of the woman or her unborn

13 child) in serious jeopardy,

14 ‘‘(ii) serious impairment to bodily

15 functions, or

16 ‘‘(iii) serious dysfunction of any bodily

17 organ or part.

18 ‘‘(B) EMERGENCY SERVICES.—The term

19 ‘emergency services’ means—

20 ‘‘(i) a medical screening examination

21 (as required under section 1867 of the So22 cial Security Act) that is within the capa23 bility of the emergency department of a
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1 hospital, including ancillary services rou2 tinely available to the emergency depart3 ment, to evaluate an emergency medical

4 condition (as defined in subparagraph

5 (A)), and

6 ‘‘(ii) within the capabilities of the

7 staff and facilities available at the hospital,

8 such further medical examination and

9 treatment as are required under section

10 1867 of the Social Security Act to stabilize

11 the patient.

12 ‘‘(C) TRAUMA AND BURN CENTERS.—The

13 provisions of clause (ii) of subparagraph (B)

14 apply to a trauma or burn center, in a hospital,

15 that—

16 ‘‘(i) is designated by the State, a re17 gional authority of the State, or by the

18 designee of the State, or

19 ‘‘(ii) is in a State that has not made

20 such designations and meets medically rec21 ognized national standards.

22 ‘‘(3) APPLICATION OF NETWORK RESTRICTION

23 PERMITTED IN CERTAIN CASES.—

24 ‘‘(A) IN GENERAL.—Except as provided in

25 subparagraph (B), if a group health plan (and
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1 an issuer of health insurance coverage in con2 nection with such a plan) denies, limits, or oth3 erwise differentiates in coverage or payment for

4 benefits other than emergency services on the

5 basis that the physician or provider of such

6 services is a nonparticipating physician or pro7 vider, the plan and issuer may deny, limit, or

8 differentiate in coverage or payment for emer9 gency services on such basis.

10 ‘‘(B) NETWORK RESTRICTIONS NOT PER11 MITTED IN CERTAIN EXCEPTIONAL CASES.—

12 The denial or limitation of, or differentiation in,

13 coverage or payment of benefits for emergency

14 services under subparagraph (A) shall not apply

15 in the following cases:

16 ‘‘(i) CIRCUMSTANCES BEYOND CON17 TROL OF PARTICIPANT OR BENEFICIARY.—

18 The participant or beneficiary is unable to

19 go to a participating hospital for such serv20 ices due to circumstances beyond the con21 trol of the participant or beneficiary (as

22 determined consistent with guidelines and

23 subparagraph (C)).

24 ‘‘(ii) LIKELIHOOD OF AN ADVERSE

25 HEALTH CONSEQUENCE BASED ON
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1 LAYPERSON’S JUDGMENT.—A prudent

2 layperson possessing an average knowledge

3 of health and medicine could reasonably

4 believe that, under the circumstances and

5 consistent with guidelines, the time re6 quired to go to a participating hospital for

7 such services could result in any of the ad8 verse health consequences described in a

9 clause of subsection (a)(2)(A).

10 ‘‘(iii) PHYSICIAN REFERRAL.—A par11 ticipating physician or other person au12 thorized by the plan refers the participant

13 or beneficiary to an emergency department

14 of a hospital and does not specify an emer15 gency department of a hospital that is a

16 participating hospital with respect to such

17 services.

18 ‘‘(C) APPLICATION OF ‘BEYOND CONTROL’

19 STANDARDS.—For purposes of applying sub20 paragraph (B)(i), receipt of emergency services

21 from a nonparticipating hospital shall be treat22 ed under the guidelines as being ‘due to cir23 cumstances beyond the control of the partici24 pant or beneficiary’ if any of the following con25 ditions are met:
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1 ‘‘(i) UNCONSCIOUS.—The participant

2 or beneficiary was unconscious or in an

3 otherwise altered mental state at the time

4 of initiation of the services.

5 ‘‘(ii) AMBULANCE DELIVERY.—The

6 participant or beneficiary was transported

7 by an ambulance or other emergency vehi8 cle directed by a person other than the

9 participant or beneficiary to the non10 participating hospital in which the services

11 were provided.

12 ‘‘(iii) NATURAL DISASTER.—A natural

13 disaster or civil disturbance prevented the

14 participant or beneficiary from presenting

15 to a participating hospital for the provision

16 of such services.

17 ‘‘(iv) NO GOOD FAITH EFFORT TO IN18 FORM OF CHANGE IN PARTICIPATION DUR19 ING A CONTRACT YEAR.—The status of the

20 hospital changed from a participating hos21 pital to a nonparticipating hospital with re22 spect to emergency services during a con23 tract year and the plan or issuer failed to
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1 make a good faith effort to notify the par2 ticipant or beneficiary involved of such

3 change.

4 ‘‘(v) OTHER CONDITIONS.—There

5 were other factors (such as those identified

6 in guidelines) that prevented the partici7 pant or beneficiary from controlling selec8 tion of the hospital in which the services

9 were provided.

10 ‘‘(b) ASSURING COORDINATED COVERAGE OF MAIN11 TENANCE CARE AND POST-STABILIZATION CARE.—

12 ‘‘(1) IN GENERAL.—In the case of a participant

13 or beneficiary who is covered under a group health

14 plan (or under health insurance coverage issued by

15 a health insurance issuer offered in connection with

16 such a plan) and who has received emergency serv17 ices pursuant to a screening evaluation conducted

18 (or supervised) by a treating physician at a hospital

19 that is a nonparticipating provider with respect to

20 emergency services, if—

21 ‘‘(A) pursuant to such evaluation, the phy22 sician identifies post-stabilization care (as de23 fined in paragraph (3)(B)) that is required by

24 the participant or beneficiary,
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1 ‘‘(B) the plan or coverage provides benefits

2 with respect to the care so identified and the

3 plan requires (but for this subsection) an af4 firmative prior authorization determination as a

5 condition of coverage of such care, and

6 ‘‘(C) the treating physician (or another in7 dividual acting on behalf of such physician) ini8 tiates, not later than 30 minutes after the time

9 the treating physician determines that the con10 dition of the participant or beneficiary is sta11 bilized, a good faith effort to contact a physi12 cian or other person authorized by the plan or

13 issuer (by telephone or other means) to obtain

14 an affirmative prior authorization determination

15 with respect to the care,

16 then, without regard to terms and conditions speci17 fied in paragraph (2) the plan or issuer shall cover

18 maintenance care (as defined in paragraph (3)(A))

19 furnished to the participant or beneficiary during

20 the period specified in paragraph (4) and shall cover

21 post-stabilization care furnished to the participant or

22 beneficiary during the period beginning under para23 graph (5) and ending under paragraph (6).
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1 ‘‘(2) TERMS AND CONDITIONS WAIVED.—The

2 terms and conditions (of a plan or coverage) de3 scribed in this paragraph that are waived under

4 paragraph (1) are as follows:

5 ‘‘(A) The need for any prior authorization

6 determination.

7 ‘‘(B) Any limitation on coverage based on

8 whether or not the physician or provider fur9 nishing the care is a participating physician or

10 provider with respect to such care.

11 ‘‘(C) Any other term or condition of the

12 plan or coverage (other than an exclusion of

13 benefits, or an affiliation or waiting period, per14 mitted under section 9801 and other than a re15 quirement relating to medical necessity for cov16 erage of benefits).

17 ‘‘(3) MAINTENANCE CARE AND POST-STA18 BILIZATION CARE DEFINED.—In this subsection:

19 ‘‘(A) MAINTENANCE CARE.—The term

20 ‘maintenance care’ means, with respect to an

21 individual who is stabilized after provision of

22 emergency services, medically necessary items

23 and services (other than emergency services)

24 that are required by the individual to ensure
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1 that the individual remains stabilized during

2 the period described in paragraph (4).

3 ‘‘(B) POST-STABILIZATION CARE.—The

4 term ‘post-stabilization care’ means, with re5 spect to an individual who is determined to be

6 stable pursuant to a medical screening examina7 tion or who is stabilized after provision of emer8 gency services, medically necessary items and

9 services (other than emergency services and

10 other than maintenance care) that are required

11 by the individual.

12 ‘‘(4) PERIOD OF REQUIRED COVERAGE OF

13 MAINTENANCE CARE.—The period of required cov14 erage of maintenance care of an individual under

15 this subsection begins at the time of the request (or

16 the initiation of the good faith effort to make the

17 request) under paragraph (1)(C) and ends when—

18 ‘‘(A) the individual is discharged from the

19 hospital;

20 ‘‘(B) a physician (designated by the plan

21 or issuer involved) and with privileges at the

22 hospital involved arrives at the emergency de23 partment of the hospital and assumes respon24 sibility with respect to the treatment of the in25 dividual; or
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1 ‘‘(C) the treating physician and the plan or

2 issuer agree to another arrangement with re3 spect to the care of the individual.

4 ‘‘(5) WHEN POST-STABILIZATION CARE RE5 QUIRED TO BE COVERED.—

6 ‘‘(A) WHEN TREATING PHYSICIAN UNABLE

7 TO COMMUNICATE REQUEST.—If the treating

8 physician or other individual makes the good

9 faith effort to request authorization under para10 graph (1)(C) but is unable to communicate the

11 request directly with an authorized person re12 ferred to in such paragraph within 30 minutes

13 after the time of initiating such effort, then

14 post-stabilization care is required to be covered

15 under this subsection beginning at the end of

16 such 30-minute period.

17 ‘‘(B) WHEN ABLE TO COMMUNICATE RE18 QUEST, AND NO TIMELY RESPONSE.—

19 ‘‘(i) IN GENERAL.—If the treating

20 physician or other individual under para21 graph (1)(C) is able to communicate the

22 request within the 30-minute period de23 scribed in subparagraph (A), the post-sta24 bilization care requested is required to be

25 covered under this subsection beginning 30
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1 minutes after the time when the plan or is2 suer receives the request unless a person

3 authorized by the plan or issuer involved

4 communicates (or makes a good faith ef5 fort to communicate) a denial of the re6 quest for the prior authorization deter7 mination within 30 minutes of the time

8 when the plan or issuer receives the re9 quest and the treating physician does not

10 request under clause (ii) to communicate

11 directly with an authorized physician con12 cerning the denial.

13 ‘‘(ii) REQUEST FOR DIRECT PHYSI14 CIAN-TO-PHYSICIAN COMMUNICATION CON15 CERNING DENIAL.—If a denial of a request

16 is communicated under clause (i), the

17 treating physician may request to commu18 nicate respecting the denial directly with a

19 physician who is authorized by the plan or

20 issuer to deny or affirm such a denial.
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1 ‘‘(C) WHEN NO TIMELY RESPONSE TO RE2 QUEST FOR PHYSICIAN-TO-PHYSICIAN COMMU3 NICATION.—If a request for physician-to-physi4 cian communication is made under subpara5 graph (B)(ii), the post-stabilization care re6 quested is required to be covered under this

7 subsection beginning 30 minutes after the time

8 when the plan or issuer receives the request

9 from a treating physician unless a physician,

10 who is authorized by the plan or issuer to re11 verse or affirm the initial denial of the care,

12 communicates (or makes a good faith effort to

13 communicate) directly with the treating physi14 cian within such 30-minute period.

15 ‘‘(D) DISAGREEMENTS OVER POST-STA16 BILIZATION CARE.—If, after a direct physician17 to-physician communication under subpara18 graph (C), the denial of the request for the

19 post-stabilization care is not reversed and the

20 treating physician communicates to the plan or

21 issuer involved a disagreement with such deci22 sion, the post-stabilization care requested is re23 quired to be covered under this subsection be24 ginning as follows:
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1 ‘‘(i) DELAY TO ALLOW FOR PROMPT

2 ARRIVAL OF PHYSICIAN ASSUMING RE3 SPONSIBILITY.—If the plan or issuer com4 municates that a physician (designated by

5 the plan or issuer) with privileges at the

6 hospital involved will arrive promptly (as

7 determined under guidelines) at the emer8 gency department of the hospital in order

9 to assume responsibility with respect to the

10 treatment of the participant or beneficiary

11 involved, the required coverage of the post12 stabilization care begins after the passage

13 of such time period as would allow the

14 prompt arrival of such a physician.

15 ‘‘(ii) OTHER CASES.—If the plan or

16 issuer does not so communicate, the re17 quired coverage of the post-stabilization

18 care begins immediately.

19 ‘‘(6) NO REQUIREMENT OF COVERAGE OF POST20 STABILIZATION CARE IF ALTERNATE PLAN OF

21 TREATMENT.—

22 ‘‘(A) IN GENERAL.—Coverage of post-sta23 bilization care is not required under this sub24 section with respect to an individual when—
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1 ‘‘(i) subject to subparagraph (B), a

2 physician (designated by the plan or issuer

3 involved) and with privileges at the hos4 pital involved arrives at the emergency de5 partment of the hospital and assumes re6 sponsibility with respect to the treatment

7 of the individual; or

8 ‘‘(ii) the treating physician and the

9 plan or issuer agree to another arrange10 ment with respect to the post-stabilization

11 care (such as an appropriate transfer of

12 the individual involved to another facility

13 or an appointment for timely followup

14 treatment for the individual).

15 ‘‘(B) SPECIAL RULE WHERE ONCE CARE

16 INITIATED.—Required coverage of requested

17 post-stabilization care shall not end by reason

18 of subparagraph (A)(i) during an episode of

19 care (as determined by guidelines) if the treat20 ing physician initiated such care (consistent

21 with a previous paragraph) before the arrival of

22 a physician described in such subparagraph.

23 ‘‘(7) CONSTRUCTION.—Nothing in this sub24 section shall be construed as—
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1 ‘‘(A) preventing a plan or issuer from au2 thorizing coverage of maintenance care or post3 stabilization care in advance or at any time; or

4 ‘‘(B) preventing a treating physician or

5 other individual described in paragraph (1)(C)

6 and a plan or issuer from agreeing to modify

7 any of the time periods specified in paragraph

8 (5) as it relates to cases involving such persons.

9 ‘‘(c) LIMITS ON COST-SHARING FOR SERVICES FUR10 NISHED IN EMERGENCY DEPARTMENTS.—If a group

11 health plan provides any benefits with respect to emer12 gency services, the plan (or a health insurance issuer offer13 ing health insurance coverage in connection with such a

14 plan) may impose cost sharing with respect to such serv15 ices only if the following conditions are met:

16 ‘‘(1) LIMITATIONS ON COST-SHARING DIF17 FERENTIAL FOR NONPARTICIPATING PROVIDERS.—

18 ‘‘(A) NO DIFFERENTIAL FOR CERTAIN

19 SERVICES.—In the case of services furnished

20 under the circumstances described in clause (i),

21 (ii), or (iii) of subsection (a)(3)(B) (relating to

22 circumstances beyond the control of the bene23 ficiary, the likelihood of an adverse health con24 sequence based on layperson’s judgment, and

25 physician referral), the cost-sharing for such
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1 services provided by a nonparticipating provider

2 or physician does not exceed the cost-sharing

3 for such services provided by a participating

4 provider or physician.

5 ‘‘(B) ONLY REASONABLE DIFFERENTIAL

6 FOR OTHER SERVICES.—In the case of other

7 emergency services, any differential by which

8 the cost-sharing for such services provided by a

9 nonparticipating provider or physician exceeds

10 the cost-sharing for such services provided by a

11 participating provider or physician is reasonable

12 (as determined under guidelines).

13 ‘‘(2) ONLY REASONABLE DIFFERENTIAL BE14 TWEEN EMERGENCY SERVICES AND OTHER SERV15 ICES.—Any differential by which the cost-sharing for

16 services furnished in an emergency department ex17 ceeds the cost-sharing for such services furnished in

18 another setting is reasonable (as determined under

19 guidelines).

20 ‘‘(3) CONSTRUCTION.—Nothing in paragraph

21 (1)(B) or (2) shall be construed as authorizing

22 guidelines other than guidelines that establish maxi23 mum cost-sharing differentials.

24 ‘‘(d) INFORMATION ON ACCESS TO EMERGENCY

25 SERVICES.—A group health plan (or a health insurance
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1 issuer, to the extent a health insurance issuer offers group

2 health insurance coverage in connection with such a plan)

3 shall provide education to participants and beneficiaries

4 of the plan on—

5 ‘‘(1) coverage of emergency services (as defined

6 in subsection (a)(2)(B)) by the plan in accordance

7 with the provisions of this section,

8 ‘‘(2) the appropriate use of emergency services,

9 including use of the 911 telephone system or its

10 local equivalent,

11 ‘‘(3) any cost sharing applicable to emergency

12 services,

13 ‘‘(4) the process and procedures of the plan for

14 obtaining emergency services, and

15 ‘‘(5) the locations of—

16 ‘‘(A) emergency departments, and

17 ‘‘(B) other settings,

18 in which participating physicians and hospitals pro19 vide emergency services and post-stabilization care.

20 ‘‘(e) GENERAL DEFINITIONS.—For purposes of this

21 section:

22 ‘‘(1) COST SHARING.—The term ‘cost sharing’

23 means any deductible, coinsurance amount, copay24 ment or other out-of-pocket payment (other than

25 premiums or enrollment fees) that a group health
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1 plan (or a health insurance issuer offering group

2 health insurance issuer in connection with such a

3 plan) imposes on participants and beneficiaries of

4 the plan with respect to the coverage of benefits.

5 ‘‘(2) GOOD FAITH EFFORT.—The term ‘good

6 faith effort’ has the meaning given such term in

7 guidelines and requires such appropriate documenta8 tion as is specified under such guidelines.

9 ‘‘(3) GUIDELINES.—The term ‘guidelines’

10 means guidelines established in accordance with sec11 tion 7 of the Access to Emergency Medical Services

12 Act of 1997.

13 ‘‘(4) NONPARTICIPATING PHYSICIAN OR PRO14 VIDER.—The term ‘nonparticipating physician or

15 provider’ means, with respect to health care items

16 and services furnished to a participant or beneficiary

17 of a group health plan, a physician or provider that

18 is not a participating physician or provider for such

19 services.

20 ‘‘(5) PARTICIPATING PHYSICIAN OR PRO21 VIDER.—The term ‘participating physician or pro22 vider’ means, with respect to health care items and

23 services furnished to a participant or beneficiary of

24 a group health plan, a physician or provider that

25 furnishes such items and services under a contract
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1 or other arrangement with such plan (or with a

2 health insurance issuer offering group health insur3 ance coverage in connection with such a plan).

4 ‘‘(6) PRIOR AUTHORIZATION DETERMINA5 TION.—The term ‘prior authorization determination’

6 means, with respect to items and services for which

7 coverage may be provided under a group health plan,

8 a determination (before the provision of the items

9 and services and as a condition of coverage of the

10 items and services under the plan) of whether or not

11 such items and services will be covered under the

12 plan.

13 ‘‘(7) STABILIZE.—The term ‘to stabilize’

14 means, with respect to an emergency medical condi15 tion, to provide (in complying with section 1867 of

16 the Social Security Act) such medical treatment of

17 the condition as may be necessary to assure, within

18 reasonable medical probability, that no material de19 terioration of the condition is likely to result from

20 or occur during the transfer of the individual from

21 the facility.

22 ‘‘(8) STABILIZED.—The term ‘stabilized’

23 means, with respect to an emergency medical condi24 tion, that no material deterioration of the condition
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1 is likely, within reasonable medical probability, to re2 sult from or occur before an individual can be trans3 ferred from the facility, in compliance with the re4 quirements of section 1867 of the Social Security

5 Act.

6 ‘‘(9) TREATING PHYSICIAN.—The term ‘treat7 ing physician’ includes a treating health care profes8 sional who is licensed under State law to provide

9 emergency services other than under the supervision

10 of a physician.’’

11 (b) CONFORMING AMENDMENTS.—

12 (1) Chapter 100 of such Code (as added by sec13 tion 401 of the Health Insurance Portability and Ac14 countability Act of 1996 and as previously amended

15 by this section) is further amended—

16 (A) in the last sentence of section

17 9801(c)(1), by striking ‘‘section 9805(c)’’ and

18 inserting ‘‘section 9832(c)’’;

19 (B) in section 9831(b), by striking

20 ‘‘9805(c)(1)’’ and inserting ‘‘9832(c)(1)’’;

21 (C) in section 9831(c)(1), by striking

22 ‘‘9805(c)(2)’’ and inserting ‘‘9832(c)(2)’’;

23 (D) in section 9831(c)(2), by striking

24 ‘‘9805(c)(3)’’ and inserting ‘‘9832(c)(3)’’; and
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1 (E) in section 9831(c)(3), by striking

2 ‘‘9805(c)(4)’’ and inserting ‘‘9832(c)(4)’’.

3 (2) Section 4980D of such Code (as added by

4 section 402 of the Health Insurance Portability and

5 Accountability Act of 1996) is amended—

6 (A) in subsection (c)(3)(B)(i)(I), by strik7 ing ‘‘9805(d)(3)’’ and inserting ‘‘9832(d)(3)’’;

8 (B) in subsection (d)(1), by inserting

9 ‘‘(other than a failure attributable to section

10 9811)’’ after ‘‘on any failure’’;

11 (C) in subsection (d)(3), by striking

12 ‘‘9805’’ and inserting ‘‘9832’’;

13 (D) in subsection (f)(1), by striking

14 ‘‘9805(a)’’ and inserting ‘‘9832(a)’’.

15 (3) The table of subtitles for such Code is

16 amended by striking the item relating to subtitle K

17 (as added by section 401(b) of the Health Insurance

18 Portability and Accountability Act of 1996) and in19 serting the following new item:

‘‘SUBTITLE K. Group health plan requirements.’’

20 (c) EFFECTIVE DATE.—(1) Subject to paragraph (2),

21 the amendments made by this section shall apply to group

22 health plans for plan years beginning on or after 18

23 months after the date of the enactment of this Act.

24 (2) In the case of a group health plan maintained

25 pursuant to 1 or more collective bargaining agreements
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1 between employee representatives and 1 or more employ2 ers ratified before the date of enactment of this Act, the

3 amendments made by this section shall not apply to plan

4 years beginning before the later of—

5 (A) the date on which the last collective bar6 gaining agreements relating to the plan terminates

7 (determined without regard to any extension thereof

8 agreed to after the date of enactment of this Act),

9 or

10 (B) 18 months after the date of the enactment

11 of this Act.

12 For purposes of subparagraph (A), any plan amendment

13 made pursuant to a collective bargaining agreement relat14 ing to the plan which amends the plan solely to conform

15 to any requirement added by this section shall not be

16 treated as a termination of such collective bargaining

17 agreement.

18 SEC. 3. AMENDMENTS TO THE EMPLOYEE RETIREMENT IN19 COME SECURITY ACT OF 1974.

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

21 B of title I of the Employee Retirement Income Security

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

23 new section:
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1 ‘‘SEC. 713. ASSURING EQUITABLE COVERAGE OF EMER2 GENCY SERVICES, MAINTENANCE CARE, AND

3 POST-STABILIZATION CARE.

4 ‘‘(a) PROHIBITION OF CERTAIN RESTRICTIONS ON

5 COVERAGE OF EMERGENCY SERVICES.—

6 ‘‘(1) IN GENERAL.—If a group health plan pro7 vides any benefits with respect to emergency services

8 (as defined in paragraph (2)(B)), the plan (and any

9 health insurance issuer offering health insurance

10 coverage in connection with such a plan) shall cover

11 emergency services furnished to a participant or ben12 eficiary of the plan—

13 ‘‘(A) without the need for any prior au14 thorization determination,

15 ‘‘(B) subject to paragraph (3), whether or

16 not the physician or provider furnishing such

17 services is a participating physician or provider

18 with respect to such services, and

19 ‘‘(C) subject to paragraph (3), without re20 gard to any other term or condition of such

21 plan or coverage (other than an exclusion of

22 benefits, or an affiliation or waiting period, per23 mitted under section 701).

24 ‘‘(2) EMERGENCY SERVICES; EMERGENCY MEDI25 CAL CONDITION.—For purposes of this section—
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1 ‘‘(A) EMERGENCY MEDICAL CONDITION

2 BASED ON PRUDENT LAYPERSON.—The term

3 ‘emergency medical condition’ means a medical

4 condition manifesting itself by acute symptoms

5 of sufficient severity (including severe pain)

6 such that a prudent layperson, who possesses

7 an average knowledge of health and medicine,

8 could reasonably expect the absence of imme9 diate medical attention to result in—

10 ‘‘(i) placing the health of the individ11 ual (or, with respect to a pregnant woman,

12 the health of the woman or her unborn

13 child) in serious jeopardy,

14 ‘‘(ii) serious impairment to bodily

15 functions, or

16 ‘‘(iii) serious dysfunction of any bodily

17 organ or part.

18 ‘‘(B) EMERGENCY SERVICES.—The term

19 ‘emergency services’ means—

20 ‘‘(i) a medical screening examination

21 (as required under section 1867 of the So22 cial Security Act) that is within the capa23 bility of the emergency department of a
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1 hospital, including ancillary services rou2 tinely available to the emergency depart3 ment, to evaluate an emergency medical

4 condition (as defined in subparagraph

5 (A)), and

6 ‘‘(ii) within the capabilities of the

7 staff and facilities available at the hospital,

8 such further medical examination and

9 treatment as are required under section

10 1867 of the Social Security Act to stabilize

11 the patient.

12 ‘‘(C) TRAUMA AND BURN CENTERS.—The

13 provisions of clause (ii) of subparagraph (B)

14 apply to a trauma or burn center, in a hospital,

15 that—

16 ‘‘(i) is designated by the State, a re17 gional authority of the State, or by the

18 designee of the State, or

19 ‘‘(ii) is in a State that has not made

20 such designations and meets medically rec21 ognized national standards.

22 ‘‘(3) APPLICATION OF NETWORK RESTRICTION

23 PERMITTED IN CERTAIN CASES.—

24 ‘‘(A) IN GENERAL.—Except as provided in

25 subparagraph (B), if a group health plan (and
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1 an issuer of health insurance coverage in con2 nection with such a plan) denies, limits, or oth3 erwise differentiates in coverage or payment for

4 benefits other than emergency services on the

5 basis that the physician or provider of such

6 services is a nonparticipating physician or pro7 vider, the plan and issuer may deny, limit, or

8 differentiate in coverage or payment for emer9 gency services on such basis.

10 ‘‘(B) NETWORK RESTRICTIONS NOT PER11 MITTED IN CERTAIN EXCEPTIONAL CASES.—

12 The denial or limitation of, or differentiation in,

13 coverage or payment of benefits for emergency

14 services under subparagraph (A) shall not apply

15 in the following cases:

16 ‘‘(i) CIRCUMSTANCES BEYOND CON17 TROL OF PARTICIPANT OR BENEFICIARY.—

18 The participant or beneficiary is unable to

19 go to a participating hospital for such serv20 ices due to circumstances beyond the con21 trol of the participant or beneficiary (as

22 determined consistent with guidelines and

23 subparagraph (C)).

24 ‘‘(ii) LIKELIHOOD OF AN ADVERSE

25 HEALTH CONSEQUENCE BASED ON
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1 LAYPERSON’S JUDGMENT.—A prudent

2 layperson possessing an average knowledge

3 of health and medicine could reasonably

4 believe that, under the circumstances and

5 consistent with guidelines, the time re6 quired to go to a participating hospital for

7 such services could result in any of the ad8 verse health consequences described in a

9 clause of subsection (a)(2)(A).

10 ‘‘(iii) PHYSICIAN REFERRAL.—A par11 ticipating physician or other person au12 thorized by the plan refers the participant

13 or beneficiary to an emergency department

14 of a hospital and does not specify an emer15 gency department of a hospital that is a

16 participating hospital with respect to such

17 services.

18 ‘‘(C) APPLICATION OF ‘BEYOND CONTROL’

19 STANDARDS.—For purposes of applying sub20 paragraph (B)(i), receipt of emergency services

21 from a nonparticipating hospital shall be treat22 ed under the guidelines as being ‘due to cir23 cumstances beyond the control of the partici24 pant or beneficiary’ if any of the following con25 ditions are met:
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1 ‘‘(i) UNCONSCIOUS.—The participant

2 or beneficiary was unconscious or in an

3 otherwise altered mental state at the time

4 of initiation of the services.

5 ‘‘(ii) AMBULANCE DELIVERY.—The

6 participant or beneficiary was transported

7 by an ambulance or other emergency vehi8 cle directed by a person other than the

9 participant or beneficiary to the non10 participating hospital in which the services

11 were provided.

12 ‘‘(iii) NATURAL DISASTER.—A natural

13 disaster or civil disturbance prevented the

14 participant or beneficiary from presenting

15 to a participating hospital for the provision

16 of such services.

17 ‘‘(iv) NO GOOD FAITH EFFORT TO IN18 FORM OF CHANGE IN PARTICIPATION DUR19 ING A CONTRACT YEAR.—The status of the

20 hospital changed from a participating hos21 pital to a nonparticipating hospital with re22 spect to emergency services during a con23 tract year and the plan or issuer failed to
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1 make a good faith effort to notify the par2 ticipant or beneficiary involved of such

3 change.

4 ‘‘(v) OTHER CONDITIONS.—There

5 were other factors (such as those identified

6 in guidelines) that prevented the partici7 pant or beneficiary from controlling selec8 tion of the hospital in which the services

9 were provided.

10 ‘‘(b) ASSURING COORDINATED COVERAGE OF MAIN11 TENANCE CARE AND POST-STABILIZATION CARE.—

12 ‘‘(1) IN GENERAL.—In the case of a participant

13 or beneficiary who is covered under a group health

14 plan (or under health insurance coverage issued by

15 a health insurance issuer offered in connection with

16 such a plan) and who has received emergency serv17 ices pursuant to a screening evaluation conducted

18 (or supervised) by a treating physician at a hospital

19 that is a nonparticipating provider with respect to

20 emergency services, if—

21 ‘‘(A) pursuant to such evaluation, the phy22 sician identifies post-stabilization care (as de23 fined in paragraph (3)(B)) that is required by

24 the participant or beneficiary,
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1 ‘‘(B) the plan or coverage provides benefits

2 with respect to the care so identified and the

3 plan requires (but for this subsection) an af4 firmative prior authorization determination as a

5 condition of coverage of such care, and

6 ‘‘(C) the treating physician (or another in7 dividual acting on behalf of such physician) ini8 tiates, not later than 30 minutes after the time

9 the treating physician determines that the con10 dition of the participant or beneficiary is sta11 bilized, a good faith effort to contact a physi12 cian or other person authorized by the plan or

13 issuer (by telephone or other means) to obtain

14 an affirmative prior authorization determination

15 with respect to the care,

16 then, without regard to terms and conditions speci17 fied in paragraph (2) the plan or issuer shall cover

18 maintenance care (as defined in paragraph (3)(A))

19 furnished to the participant or beneficiary during

20 the period specified in paragraph (4) and shall cover

21 post-stabilization care furnished to the participant or

22 beneficiary during the period beginning under para23 graph (5) and ending under paragraph (6).
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1 ‘‘(2) TERMS AND CONDITIONS WAIVED.—The

2 terms and conditions (of a plan or coverage) de3 scribed in this paragraph that are waived under

4 paragraph (1) are as follows:

5 ‘‘(A) The need for any prior authorization

6 determination.

7 ‘‘(B) Any limitation on coverage based on

8 whether or not the physician or provider fur9 nishing the care is a participating physician or

10 provider with respect to such care.

11 ‘‘(C) Any other term or condition of the

12 plan or coverage (other than an exclusion of

13 benefits, or an affiliation or waiting period, per14 mitted under section 701 and other than a re15 quirement relating to medical necessity for cov16 erage of benefits).

17 ‘‘(3) MAINTENANCE CARE AND POST-STA18 BILIZATION CARE DEFINED.—In this subsection:

19 ‘‘(A) MAINTENANCE CARE.—The term

20 ‘maintenance care’ means, with respect to an

21 individual who is stabilized after provision of

22 emergency services, medically necessary items

23 and services (other than emergency services)

24 that are required by the individual to ensure
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1 that the individual remains stabilized during

2 the period described in paragraph (4).

3 ‘‘(B) POST-STABILIZATION CARE.—The

4 term ‘post-stabilization care’ means, with re5 spect to an individual who is determined to be

6 stable pursuant to a medical screening examina7 tion or who is stabilized after provision of emer8 gency services, medically necessary items and

9 services (other than emergency services and

10 other than maintenance care) that are required

11 by the individual.

12 ‘‘(4) PERIOD OF REQUIRED COVERAGE OF

13 MAINTENANCE CARE.—The period of required cov14 erage of maintenance care of an individual under

15 this subsection begins at the time of the request (or

16 the initiation of the good faith effort to make the re17 quest) under paragraph (1)(C) and ends when—

18 ‘‘(A) the individual is discharged from the

19 hospital;

20 ‘‘(B) a physician (designated by the plan

21 or issuer involved) and with privileges at the

22 hospital involved arrives at the emergency de23 partment of the hospital and assumes respon24 sibility with respect to the treatment of the in25 dividual; or
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1 ‘‘(C) the treating physician and the plan or

2 issuer agree to another arrangement with re3 spect to the care of the individual.

4 ‘‘(5) WHEN POST-STABILIZATION CARE RE5 QUIRED TO BE COVERED.—

6 ‘‘(A) WHEN TREATING PHYSICIAN UNABLE

7 TO COMMUNICATE REQUEST.—If the treating

8 physician or other individual makes the good

9 faith effort to request authorization under para10 graph (1)(C) but is unable to communicate the

11 request directly with an authorized person re12 ferred to in such paragraph within 30 minutes

13 after the time of initiating such effort, then

14 post-stabilization care is required to be covered

15 under this subsection beginning at the end of

16 such 30-minute period.

17 ‘‘(B) WHEN ABLE TO COMMUNICATE RE18 QUEST, AND NO TIMELY RESPONSE.—

19 ‘‘(i) IN GENERAL.—If the treating

20 physician or other individual under para21 graph (1)(C) is able to communicate the

22 request within the 30-minute period de23 scribed in subparagraph (A), the post-sta24 bilization care requested is required to be

25 covered under this subsection beginning 30
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1 minutes after the time when the plan or is2 suer receives the request unless a person

3 authorized by the plan or issuer involved

4 communicates (or makes a good faith ef5 fort to communicate) a denial of the re6 quest for the prior authorization deter7 mination within 30 minutes of the time

8 when the plan or issuer receives the re9 quest and the treating physician does not

10 request under clause (ii) to communicate

11 directly with an authorized physician con12 cerning the denial.

13 ‘‘(ii) REQUEST FOR DIRECT PHYSI14 CIAN-TO-PHYSICIAN COMMUNICATION CON15 CERNING DENIAL.—If a denial of a request

16 is communicated under clause (i), the

17 treating physician may request to commu18 nicate respecting the denial directly with a

19 physician who is authorized by the plan or

20 issuer to deny or affirm such a denial.
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1 ‘‘(C) WHEN NO TIMELY RESPONSE TO RE2 QUEST FOR PHYSICIAN-TO-PHYSICIAN COMMU3 NICATION.—If a request for physician-to-physi4 cian communication is made under subpara5 graph (B)(ii), the post-stabilization care re6 quested is required to be covered under this

7 subsection beginning 30 minutes after the time

8 when the plan or issuer receives the request

9 from a treating physician unless a physician,

10 who is authorized by the plan or issuer to re11 verse or affirm the initial denial of the care,

12 communicates (or makes a good faith effort to

13 communicate) directly with the treating physi14 cian within such 30-minute period.

15 ‘‘(D) DISAGREEMENTS OVER POST-STA16 BILIZATION CARE.—If, after a direct physician17 to-physician communication under subpara18 graph (C), the denial of the request for the

19 post-stabilization care is not reversed and the

20 treating physician communicates to the plan or

21 issuer involved a disagreement with such deci22 sion, the post-stabilization care requested is re23 quired to be covered under this subsection be24 ginning as follows:
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1 ‘‘(i) DELAY TO ALLOW FOR PROMPT

2 ARRIVAL OF PHYSICIAN ASSUMING RE3 SPONSIBILITY.—If the plan or issuer com4 municates that a physician (designated by

5 the plan or issuer) with privileges at the

6 hospital involved will arrive promptly (as

7 determined under guidelines) at the emer8 gency department of the hospital in order

9 to assume responsibility with respect to the

10 treatment of the participant or beneficiary

11 involved, the required coverage of the post12 stabilization care begins after the passage

13 of such time period as would allow the

14 prompt arrival of such a physician.

15 ‘‘(ii) OTHER CASES.—If the plan or

16 issuer does not so communicate, the re17 quired coverage of the post-stabilization

18 care begins immediately.

19 ‘‘(6) NO REQUIREMENT OF COVERAGE OF POST20 STABILIZATION CARE IF ALTERNATE PLAN OF

21 TREATMENT.—

22 ‘‘(A) IN GENERAL.—Coverage of post-sta23 bilization care is not required under this sub24 section with respect to an individual when—
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1 ‘‘(i) subject to subparagraph (B), a

2 physician (designated by the plan or issuer

3 involved) and with privileges at the hos4 pital involved arrives at the emergency de5 partment of the hospital and assumes re6 sponsibility with respect to the treatment

7 of the individual; or

8 ‘‘(ii) the treating physician and the

9 plan or issuer agree to another arrange10 ment with respect to the post-stabilization

11 care (such as an appropriate transfer of

12 the individual involved to another facility

13 or an appointment for timely followup

14 treatment for the individual).

15 ‘‘(B) SPECIAL RULE WHERE ONCE CARE

16 INITIATED.—Required coverage of requested

17 post-stabilization care shall not end by reason

18 of subparagraph (A)(i) during an episode of

19 care (as determined by guidelines) if the treat20 ing physician initiated such care (consistent

21 with a previous paragraph) before the arrival of

22 a physician described in such subparagraph.

23 ‘‘(7) CONSTRUCTION.—Nothing in this sub24 section shall be construed as—
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1 ‘‘(A) preventing a plan or issuer from au2 thorizing coverage of maintenance care or post3 stabilization care in advance or at any time; or

4 ‘‘(B) preventing a treating physician or

5 other individual described in paragraph (1)(C)

6 and a plan or issuer from agreeing to modify

7 any of the time periods specified in paragraph

8 (5) as it relates to cases involving such persons.

9 ‘‘(c) LIMITS ON COST-SHARING FOR SERVICES FUR10 NISHED IN EMERGENCY DEPARTMENTS.—If a group

11 health plan provides any benefits with respect to emer12 gency services, the plan (or a health insurance issuer offer13 ing health insurance coverage in connection with such a

14 plan) may impose cost sharing with respect to such serv15 ices only if the following conditions are met:

16 ‘‘(1) LIMITATIONS ON COST-SHARING DIF17 FERENTIAL FOR NONPARTICIPATING PROVIDERS.—

18 ‘‘(A) NO DIFFERENTIAL FOR CERTAIN

19 SERVICES.—In the case of services furnished

20 under the circumstances described in clause (i),

21 (ii), or (iii) of subsection (a)(3)(B) (relating to

22 circumstances beyond the control of the bene23 ficiary, the likelihood of an adverse health con24 sequence based on layperson’s judgment, and

25 physician referral), the cost-sharing for such
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1 services provided by a nonparticipating provider

2 or physician does not exceed the cost-sharing

3 for such services provided by a participating

4 provider or physician.

5 ‘‘(B) ONLY REASONABLE DIFFERENTIAL

6 FOR OTHER SERVICES.—In the case of other

7 emergency services, any differential by which

8 the cost-sharing for such services provided by a

9 nonparticipating provider or physician exceeds

10 the cost-sharing for such services provided by a

11 participating provider or physician is reasonable

12 (as determined under guidelines).

13 ‘‘(2) ONLY REASONABLE DIFFERENTIAL BE14 TWEEN EMERGENCY SERVICES AND OTHER SERV15 ICES.—Any differential by which the cost-sharing for

16 services furnished in an emergency department ex17 ceeds the cost-sharing for such services furnished in

18 another setting is reasonable (as determined under

19 guidelines).

20 ‘‘(3) CONSTRUCTION.—Nothing in paragraph

21 (1)(B) or (2) shall be construed as authorizing

22 guidelines other than guidelines that establish maxi23 mum cost-sharing differentials.

24 ‘‘(d) INFORMATION ON ACCESS TO EMERGENCY

25 SERVICES.—A group health plan (or a health insurance
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1 issuer, to the extent a health insurance issuer offers group

2 health insurance coverage in connection with such a plan)

3 shall provide education to participants and beneficiaries

4 of the plan on—

5 ‘‘(1) coverage of emergency services (as defined

6 in subsection (a)(2)(B)) by the plan in accordance

7 with the provisions of this section,

8 ‘‘(2) the appropriate use of emergency services,

9 including use of the 911 telephone system or its

10 local equivalent,

11 ‘‘(3) any cost sharing applicable to emergency

12 services,

13 ‘‘(4) the process and procedures of the plan for

14 obtaining emergency services, and

15 ‘‘(5) the locations of—

16 ‘‘(A) emergency departments, and

17 ‘‘(B) other settings,

18 in which participating physicians and hospitals pro19 vide emergency services and post-stabilization care.

20 ‘‘(e) GENERAL DEFINITIONS.—For purposes of this

21 section:

22 ‘‘(1) COST SHARING.—The term ‘cost sharing’

23 means any deductible, coinsurance amount, copay24 ment or other out-of-pocket payment (other than

25 premiums or enrollment fees) that a group health
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1 plan (or a health insurance issuer offering group

2 health insurance issuer in connection with such a

3 plan) imposes on participants and beneficiaries of

4 the plan with respect to the coverage of benefits.

5 ‘‘(2) GOOD FAITH EFFORT.—The term ‘good

6 faith effort’ has the meaning given such term in

7 guidelines and requires such appropriate documenta8 tion as is specified under such guidelines.

9 ‘‘(3) GUIDELINES.—The term ‘guidelines’

10 means guidelines established in accordance with sec11 tion 7 of the Access to Emergency Medical Services

12 Act of 1997.

13 ‘‘(4) NONPARTICIPATING PHYSICIAN OR PRO14 VIDER.—The term ‘nonparticipating physician or

15 provider’ means, with respect to health care items

16 and services furnished to a participant or beneficiary

17 of a group health plan, a physician or provider that

18 is not a participating physician or provider for such

19 services.

20 ‘‘(5) PARTICIPATING PHYSICIAN OR PRO21 VIDER.—The term ‘participating physician or pro22 vider’ means, with respect to health care items and

23 services furnished to a participant or beneficiary of

24 a group health plan, a physician or provider that

25 furnishes such items and services under a contract
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1 or other arrangement with such plan (or with a

2 health insurance issuer offering group health insur3 ance coverage in connection with such a plan).

4 ‘‘(6) PRIOR AUTHORIZATION DETERMINA5 TION.—The term ‘prior authorization determination’

6 means, with respect to items and services for which

7 coverage may be provided under a group health plan,

8 a determination (before the provision of the items

9 and services and as a condition of coverage of the

10 items and services under the plan) of whether or not

11 such items and services will be covered under the

12 plan.

13 ‘‘(7) STABILIZE.—The term ‘to stabilize’

14 means, with respect to an emergency medical condi15 tion, to provide (in complying with section 1867 of

16 the Social Security Act) such medical treatment of

17 the condition as may be necessary to assure, within

18 reasonable medical probability, that no material de19 terioration of the condition is likely to result from or

20 occur during the transfer of the individual from the

21 facility.

22 ‘‘(8) STABILIZED.—The term ‘stabilized’

23 means, with respect to an emergency medical condi24 tion, that no material deterioration of the condition
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1 is likely, within reasonable medical probability, to re2 sult from or occur before an individual can be trans3 ferred from the facility, in compliance with the re4 quirements of section 1867 of the Social Security

5 Act.

6 ‘‘(9) TREATING PHYSICIAN.—The term ‘treat7 ing physician’ includes a treating health care profes8 sional who is licensed under State law to provide

9 emergency services other than under the supervision

10 of a physician.

11 ‘‘(f) CONTINUED APPLICABILITY OF STATE LAW

12 WITH RESPECT TO HEALTH INSURANCE ISSUERS.—The

13 provisions of section 731(a) (relating to State authority

14 to provide for standards and requirements for health in15 surance issuers to the extent the standards and require16 ments do not prevent the application of a requirement of

17 this part) apply with respect to the requirements of this

18 section.’’.

19 (b) CONFORMING AMENDMENTS.—

20 (1) Section 731(c) of such Act (29 U.S.C.

21 1191(c)), as amended by section 603(b)(1) of Public

22 Law 104–204, is amended by striking ‘‘section 711’’

23 and inserting ‘‘sections 711 and 713’’.
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1 (2) Section 732(a) of such Act (29 U.S.C.

2 1191a(a)), as amended by section 603(b)(2) of Pub3 lic Law 104–204, is amended by striking ‘‘section

4 711’’ and inserting ‘‘sections 711 and 713’’.

5 (3) The table of contents in section 1 of such

6 Act is amended by inserting after the item relating

7 to section 712 the following new item:

‘‘Sec. 713. Assuring equitable coverage of emergency services, maintenance care,

and post-stabilization care.’’.

8 (c) EFFECTIVE DATE.—(1) Subject to paragraph (2),

9 the amendments made by this section shall apply to group

10 health plans for plan years beginning on or after the date

11 that is 18 months after the date of the enactment of this

12 Act.

13 (2) In the case of a group health plan maintained

14 pursuant to 1 or more collective bargaining agreements

15 between employee representatives and 1 or more employ16 ers ratified before the date of enactment of this Act, the

17 amendments made by this section shall not apply to plan

18 years beginning before the later of—

19 (A) the date on which the last collective bar20 gaining agreements relating to the plan terminates

21 (determined without regard to any extension thereof

22 agreed to after the date of enactment of this Act),

23 or
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1 (B) 18 months after the date of the enactment

2 of this Act.

3 For purposes of subparagraph (A), any plan amendment

4 made pursuant to a collective bargaining agreement relat5 ing to the plan which amends the plan solely to conform

6 to any requirement added by this section shall not be

7 treated as a termination of such collective bargaining

8 agreement.

9 SEC. 4. AMENDMENTS TO THE PUBLIC HEALTH SERVICE

10 ACT RELATING TO THE GROUP MARKET.

11 (a) IN GENERAL.—Subpart 2 of part A of title

12 XXVII of the Public Health Service Act is amended by

13 adding at the end the following new section:

14 ‘‘SEC. 2706. ASSURING EQUITABLE COVERAGE OF EMER15 GENCY SERVICES, MAINTENANCE CARE, AND

16 POST-STABILIZATION CARE.

17 ‘‘(a) PROHIBITION OF CERTAIN RESTRICTIONS ON

18 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 (and any

22 health insurance issuer offering health insurance

23 coverage in connection with such a plan) shall cover

24 emergency services furnished to a participant or ben25 eficiary of the plan—
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1 ‘‘(A) without the need for any prior au2 thorization determination,

3 ‘‘(B) subject to paragraph (3), whether or

4 not the physician or provider furnishing such

5 services is a participating physician or provider

6 with respect to such services, and

7 ‘‘(C) subject to paragraph (3), without re8 gard to any other term or condition of such

9 plan or coverage (other than an exclusion of

10 benefits, or an affiliation or waiting period, per11 mitted under section 2701).

12 ‘‘(2) EMERGENCY SERVICES; EMERGENCY MEDI13 CAL CONDITION.—For purposes of this section—

14 ‘‘(A) EMERGENCY MEDICAL CONDITION

15 BASED ON PRUDENT LAYPERSON.—The term

16 ‘emergency medical condition’ means a medical

17 condition manifesting itself by acute symptoms

18 of sufficient severity (including severe pain)

19 such that a prudent layperson, who possesses

20 an average knowledge of health and medicine,

21 could reasonably expect the absence of imme22 diate medical attention to result in—

23 ‘‘(i) placing the health of the individ24 ual (or, with respect to a pregnant woman,
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1 the health of the woman or her unborn

2 child) in serious jeopardy,

3 ‘‘(ii) serious impairment to bodily

4 functions, or

5 ‘‘(iii) serious dysfunction of any bodily

6 organ or part.

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 the Social Security Act to stabilize

23 the patient.

24 ‘‘(C) TRAUMA AND BURN CENTERS.—The

25 provisions of clause (ii) of subparagraph (B)
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1 apply to a trauma or burn center, in a hospital,

2 that—

3 ‘‘(i) is designated by the State, a re4 gional authority of the State, or by the

5 designee of the State, or

6 ‘‘(ii) is in a State that has not made

7 such designations and meets medically rec8 ognized national standards.

9 ‘‘(3) APPLICATION OF NETWORK RESTRICTION

10 PERMITTED IN CERTAIN CASES.—

11 ‘‘(A) IN GENERAL.—Except as provided in

12 subparagraph (B), if a group health plan (and

13 an issuer of health insurance coverage in con14 nection with such a plan) denies, limits, or oth15 erwise differentiates in coverage or payment for

16 benefits other than emergency services on the

17 basis that the physician or provider of such

18 services is a nonparticipating physician or pro19 vider, the plan and issuer may deny, limit, or

20 differentiate in coverage or payment for emer21 gency services on such basis.

22 ‘‘(B) NETWORK RESTRICTIONS NOT PER23 MITTED IN CERTAIN EXCEPTIONAL CASES.—

24 The denial or limitation of, or differentiation in,

25 coverage or payment of benefits for emergency
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1 services under subparagraph (A) shall not apply

2 in the following cases:

3 ‘‘(i) CIRCUMSTANCES BEYOND CON4 TROL OF PARTICIPANT OR BENEFICIARY.—

5 The participant or beneficiary is unable to

6 go to a participating hospital for such serv7 ices due to circumstances beyond the con8 trol of the participant or beneficiary (as

9 determined consistent with guidelines and

10 subparagraph (C)).

11 ‘‘(ii) LIKELIHOOD OF AN ADVERSE

12 HEALTH CONSEQUENCE BASED ON

13 LAYPERSON’S JUDGMENT.—A prudent

14 layperson possessing an average knowledge

15 of health and medicine could reasonably

16 believe that, under the circumstances and

17 consistent with guidelines, the time re18 quired to go to a participating hospital for

19 such services could result in any of the ad20 verse health consequences described in a

21 clause of subsection (a)(2)(A).

22 ‘‘(iii) PHYSICIAN REFERRAL.—A par23 ticipating physician or other person au24 thorized by the plan refers the participant

25 or beneficiary to an emergency department
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1 of a hospital and does not specify an emer2 gency department of a hospital that is a

3 participating hospital with respect to such

4 services.

5 ‘‘(C) APPLICATION OF ‘BEYOND CONTROL’

6 STANDARDS.—For purposes of applying sub7 paragraph (B)(i), receipt of emergency services

8 from a nonparticipating hospital shall be treat9 ed under the guidelines as being ‘due to cir10 cumstances beyond the control of the partici11 pant or beneficiary’ if any of the following con12 ditions are met:

13 ‘‘(i) UNCONSCIOUS.—The participant

14 or beneficiary was unconscious or in an

15 otherwise altered mental state at the time

16 of initiation of the services.

17 ‘‘(ii) AMBULANCE DELIVERY.—The

18 participant or beneficiary was transported

19 by an ambulance or other emergency vehi20 cle directed by a person other than the

21 participant or beneficiary to the non22 participating hospital in which the services

23 were provided.

24 ‘‘(iii) NATURAL DISASTER.—A natural

25 disaster or civil disturbance prevented the
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1 participant or beneficiary from presenting

2 to a participating hospital for the provision

3 of such services.

4 ‘‘(iv) NO GOOD FAITH EFFORT TO IN5 FORM OF CHANGE IN PARTICIPATION DUR6 ING A CONTRACT YEAR.—The status of the

7 hospital changed from a participating hos8 pital to a nonparticipating hospital with re9 spect to emergency services during a con10 tract year and the plan or issuer failed to

11 make a good faith effort to notify the par12 ticipant or beneficiary involved of such

13 change.

14 ‘‘(v) OTHER CONDITIONS.—There

15 were other factors (such as those identified

16 in guidelines) that prevented the partici17 pant or beneficiary from controlling selec18 tion of the hospital in which the services

19 were provided.

20 ‘‘(b) ASSURING COORDINATED COVERAGE OF MAIN21 TENANCE CARE AND POST-STABILIZATION CARE.—

22 ‘‘(1) IN GENERAL.—In the case of a participant

23 or beneficiary who is covered under a group health

24 plan (or under health insurance coverage issued by

25 a health insurance issuer offered in connection with
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1 such a plan) and who has received emergency serv2 ices pursuant to a screening evaluation conducted

3 (or supervised) by a treating physician at a hospital

4 that is a nonparticipating provider with respect to

5 emergency services, if—

6 ‘‘(A) pursuant to such evaluation, the phy7 sician identifies post-stabilization care (as de8 fined in paragraph (3)(B)) that is required by

9 the participant or beneficiary,

10 ‘‘(B) the plan or coverage provides benefits

11 with respect to the care so identified and the

12 plan requires (but for this subsection) an af13 firmative prior authorization determination as a

14 condition of coverage of such care, and

15 ‘‘(C) the treating physician (or another in16 dividual acting on behalf of such physician) ini17 tiates, not later than 30 minutes after the time

18 the treating physician determines that the con19 dition of the participant or beneficiary is sta20 bilized, a good faith effort to contact a physi21 cian or other person authorized by the plan or

22 issuer (by telephone or other means) to obtain

23 an affirmative prior authorization determination

24 with respect to the care,
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1 then, without regard to terms and conditions speci2 fied in paragraph (2) the plan or issuer shall cover

3 maintenance care (as defined in paragraph (3)(A))

4 furnished to the participant or beneficiary during

5 the period specified in paragraph (4) and shall cover

6 post-stabilization care furnished to the participant or

7 beneficiary during the period beginning under para8 graph (5) and ending under paragraph (6).

9 ‘‘(2) TERMS AND CONDITIONS WAIVED.—The

10 terms and conditions (of a plan or coverage) de11 scribed in this paragraph that are waived under

12 paragraph (1) are as follows:

13 ‘‘(A) The need for any prior authorization

14 determination.

15 ‘‘(B) Any limitation on coverage based on

16 whether or not the physician or provider fur17 nishing the care is a participating physician or

18 provider with respect to such care.

19 ‘‘(C) Any other term or condition of the

20 plan or coverage (other than an exclusion of

21 benefits, or an affiliation or waiting period, per22 mitted under section 2701 and other than a re23 quirement relating to medical necessity for cov24 erage of benefits).
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1 ‘‘(3) MAINTENANCE CARE AND POST-STA2 BILIZATION CARE DEFINED.—In this subsection:

3 ‘‘(A) MAINTENANCE CARE.—The term

4 ‘maintenance care’ means, with respect to an

5 individual who is stabilized after provision of

6 emergency services, medically necessary items

7 and services (other than emergency services)

8 that are required by the individual to ensure

9 that the individual remains stabilized during

10 the period described in paragraph (4).

11 ‘‘(B) POST-STABILIZATION CARE.—The

12 term ‘post-stabilization care’ means, with re13 spect to an individual who is determined to be

14 stable pursuant to a medical screening examina15 tion or who is stabilized after provision of emer16 gency services, medically necessary items and

17 services (other than emergency services and

18 other than maintenance care) that are required

19 by the individual.

20 ‘‘(4) PERIOD OF REQUIRED COVERAGE OF

21 MAINTENANCE CARE.—The period of required cov22 erage of maintenance care of an individual under

23 this subsection begins at the time of the request (or

24 the initiation of the good faith effort to make the re25 quest) under paragraph (1)(C) and ends when—
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1 ‘‘(A) the individual is discharged from the

2 hospital;

3 ‘‘(B) a physician (designated by the plan

4 or issuer involved) and with privileges at the

5 hospital involved arrives at the emergency de6 partment of the hospital and assumes respon7 sibility with respect to the treatment of the in8 dividual; or

9 ‘‘(C) the treating physician and the plan or

10 issuer agree to another arrangement with re11 spect to the care of the individual.

12 ‘‘(5) WHEN POST-STABILIZATION CARE RE13 QUIRED TO BE COVERED.—

14 ‘‘(A) WHEN TREATING PHYSICIAN UNABLE

15 TO COMMUNICATE REQUEST.—If the treating

16 physician or other individual makes the good

17 faith effort to request authorization under para18 graph (1)(C) but is unable to communicate the

19 request directly with an authorized person re20 ferred to in such paragraph within 30 minutes

21 after the time of initiating such effort, then

22 post-stabilization care is required to be covered

23 under this subsection beginning at the end of

24 such 30-minute period.
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1 ‘‘(B) WHEN ABLE TO COMMUNICATE RE2 QUEST, AND NO TIMELY RESPONSE.—

3 ‘‘(i) IN GENERAL.—If the treating

4 physician or other individual under para5 graph (1)(C) is able to communicate the

6 request within the 30-minute period de7 scribed in subparagraph (A), the post-sta8 bilization care requested is required to be

9 covered under this subsection beginning 30

10 minutes after the time when the plan or is11 suer receives the request unless a person

12 authorized by the plan or issuer involved

13 communicates (or makes a good faith ef14 fort to communicate) a denial of the re15 quest for the prior authorization deter16 mination within 30 minutes of the time

17 when the plan or issuer receives the re18 quest and the treating physician does not

19 request under clause (ii) to communicate

20 directly with an authorized physician con21 cerning the denial.

22 ‘‘(ii) REQUEST FOR DIRECT PHYSI23 CIAN-TO-PHYSICIAN COMMUNICATION CON24 CERNING DENIAL.—If a denial of a request

25 is communicated under clause (i), the
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1 treating physician may request to commu2 nicate respecting the denial directly with a

3 physician who is authorized by the plan or

4 issuer to deny or affirm such a denial.

5 ‘‘(C) WHEN NO TIMELY RESPONSE TO RE6 QUEST FOR PHYSICIAN-TO-PHYSICIAN COMMU7 NICATION.—If a request for physician-to-physi8 cian communication is made under subpara9 graph (B)(ii), the post-stabilization care re10 quested is required to be covered under this

11 subsection beginning 30 minutes after the time

12 when the plan or issuer receives the request

13 from a treating physician unless a physician,

14 who is authorized by the plan or issuer to re15 verse or affirm the initial denial of the care,

16 communicates (or makes a good faith effort to

17 communicate) directly with the treating physi18 cian within such 30-minute period.

19 ‘‘(D) DISAGREEMENTS OVER POST-STA20 BILIZATION CARE.—If, after a direct physician21 to-physician communication under subpara22 graph (C), the denial of the request for the

23 post-stabilization care is not reversed and the

24 treating physician communicates to the plan or
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1 issuer involved a disagreement with such deci2 sion, the post-stabilization care requested is re3 quired to be covered under this subsection be4 ginning as follows:

5 ‘‘(i) DELAY TO ALLOW FOR PROMPT

6 ARRIVAL OF PHYSICIAN ASSUMING RE7 SPONSIBILITY.—If the plan or issuer com8 municates that a physician (designated by

9 the plan or issuer) with privileges at the

10 hospital involved will arrive promptly (as

11 determined under guidelines) at the emer12 gency department of the hospital in order

13 to assume responsibility with respect to the

14 treatment of the participant or beneficiary

15 involved, the required coverage of the post16 stabilization care begins after the passage

17 of such time period as would allow the

18 prompt arrival of such a physician.

19 ‘‘(ii) OTHER CASES.—If the plan or

20 issuer does not so communicate, the re21 quired coverage of the post-stabilization

22 care begins immediately.

23 ‘‘(6) NO REQUIREMENT OF COVERAGE OF POST24 STABILIZATION CARE IF ALTERNATE PLAN OF

25 TREATMENT.—
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1 ‘‘(A) IN GENERAL.—Coverage of post-sta2 bilization care is not required under this sub3 section with respect to an individual when—

4 ‘‘(i) subject to subparagraph (B), a

5 physician (designated by the plan or issuer

6 involved) and with privileges at the hos7 pital involved arrives at the emergency de8 partment of the hospital and assumes re9 sponsibility with respect to the treatment

10 of the individual; or

11 ‘‘(ii) the treating physician and the

12 plan or issuer agree to another arrange13 ment with respect to the post-stabilization

14 care (such as an appropriate transfer of

15 the individual involved to another facility

16 or an appointment for timely followup

17 treatment for the individual).

18 ‘‘(B) SPECIAL RULE WHERE ONCE CARE

19 INITIATED.—Required coverage of requested

20 post-stabilization care shall not end by reason

21 of subparagraph (A)(i) during an episode of

22 care (as determined by guidelines) if the treat23 ing physician initiated such care (consistent

24 with a previous paragraph) before the arrival of

25 a physician described in such subparagraph.
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1 ‘‘(7) CONSTRUCTION.—Nothing in this sub2 section shall be construed as—

3 ‘‘(A) preventing a plan or issuer from au4 thorizing coverage of maintenance care or post5 stabilization care in advance or at any time; or

6 ‘‘(B) preventing a treating physician or

7 other individual described in paragraph (1)(C)

8 and a plan or issuer from agreeing to modify

9 any of the time periods specified in paragraph

10 (5) as it relates to cases involving such persons.

11 ‘‘(c) LIMITS ON COST-SHARING FOR SERVICES FUR12 NISHED IN EMERGENCY DEPARTMENTS.—If a group

13 health plan provides any benefits with respect to emer14 gency services, the plan (or a health insurance issuer offer15 ing health insurance coverage in connection with such a

16 plan) may impose cost sharing with respect to such serv17 ices only if the following conditions are met:

18 ‘‘(1) LIMITATIONS ON COST-SHARING DIF19 FERENTIAL FOR NONPARTICIPATING PROVIDERS.—

20 ‘‘(A) NO DIFFERENTIAL FOR CERTAIN

21 SERVICES.—In the case of services furnished

22 under the circumstances described in clause (i),

23 (ii), or (iii) of subsection (a)(3)(B) (relating to
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1 circumstances beyond the control of the bene2 ficiary, the likelihood of an adverse health con3 sequence based on layperson’s judgment, and

4 physician referral), the cost-sharing for such

5 services provided by a nonparticipating provider

6 or physician does not exceed the cost-sharing

7 for such services provided by a participating

8 provider or physician.

9 ‘‘(B) ONLY REASONABLE DIFFERENTIAL

10 FOR OTHER SERVICES.—In the case of other

11 emergency services, any differential by which

12 the cost-sharing for such services provided by a

13 nonparticipating provider or physician exceeds

14 the cost-sharing for such services provided by a

15 participating provider or physician is reasonable

16 (as determined under guidelines).

17 ‘‘(2) ONLY REASONABLE DIFFERENTIAL BE18 TWEEN EMERGENCY SERVICES AND OTHER SERV19 ICES.—Any differential by which the cost-sharing for

20 services furnished in an emergency department ex21 ceeds the cost-sharing for such services furnished in

22 another setting is reasonable (as determined under

23 guidelines).

24 ‘‘(3) CONSTRUCTION.—Nothing in paragraph

25 (1)(B) or (2) shall be construed as authorizing
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1 guidelines other than guidelines that establish maxi2 mum cost-sharing differentials.

3 ‘‘(d) INFORMATION ON ACCESS TO EMERGENCY

4 SERVICES.—A group health plan (or a health insurance

5 issuer, to the extent a health insurance issuer offers group

6 health insurance coverage in connection with such a plan)

7 shall provide education to participants and beneficiaries

8 of the plan on—

9 ‘‘(1) coverage of emergency services (as defined

10 in subsection (a)(2)(B)) by the plan in accordance

11 with the provisions of this section,

12 ‘‘(2) the appropriate use of emergency services,

13 including use of the 911 telephone system or its

14 local equivalent,

15 ‘‘(3) any cost sharing applicable to emergency

16 services,

17 ‘‘(4) the process and procedures of the plan for

18 obtaining emergency services, and

19 ‘‘(5) the locations of—

20 ‘‘(A) emergency departments, and

21 ‘‘(B) other settings,

22 in which participating physicians and hospitals pro23 vide emergency services and post-stabilization care.

24 ‘‘(e) GENERAL DEFINITIONS.—For purposes of this

25 section:
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1 ‘‘(1) COST SHARING.—The term ‘cost sharing’

2 means any deductible, coinsurance amount, copay3 ment or other out-of-pocket payment (other than

4 premiums or enrollment fees) that a group health

5 plan (or a health insurance issuer offering group

6 health insurance issuer in connection with such a

7 plan) imposes on participants and beneficiaries of

8 the plan with respect to the coverage of benefits.

9 ‘‘(2) GOOD FAITH EFFORT.—The term ‘good

10 faith effort’ has the meaning given such term in

11 guidelines and requires such appropriate documenta12 tion as is specified under such guidelines.

13 ‘‘(3) GUIDELINES.—The term ‘guidelines’

14 means guidelines established in accordance with sec15 tion 7 of the Access to Emergency Medical Services

16 Act of 1997.

17 ‘‘(4) NONPARTICIPATING PHYSICIAN OR PRO18 VIDER.—The term ‘nonparticipating physician or

19 provider’ means, with respect to health care items

20 and services furnished to a participant or beneficiary

21 of a group health plan, a physician or provider that

22 is not a participating physician or provider for such

23 services.
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1 ‘‘(5) PARTICIPATING PHYSICIAN OR PRO2 VIDER.—The term ‘participating physician or pro3 vider’ means, with respect to health care items and

4 services furnished to a participant or beneficiary of

5 a group health plan, a physician or provider that

6 furnishes such items and services under a contract

7 or other arrangement with such plan (or with a

8 health insurance issuer offering group health insur9 ance coverage in connection with such a plan).

10 ‘‘(6) PRIOR AUTHORIZATION DETERMINA11 TION.—The term ‘prior authorization determination’

12 means, with respect to items and services for which

13 coverage may be provided under a group health plan,

14 a determination (before the provision of the items

15 and services and as a condition of coverage of the

16 items and services under the plan) of whether or not

17 such items and services will be covered under the

18 plan.

19 ‘‘(7) STABILIZE.—The term ‘to stabilize’

20 means, with respect to an emergency medical condi21 tion, to provide (in complying with section 1867 of

22 the Social Security Act) such medical treatment of

23 the condition as may be necessary to assure, within

24 reasonable medical probability, that no material de25 terioration of the condition is likely to result from or
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1 occur during the transfer of the individual from the

2 facility.

3 ‘‘(8) STABILIZED.—The term ‘stabilized’

4 means, with respect to an emergency medical condi5 tion, that no material deterioration of the condition

6 is likely, within reasonable medical probability, to re7 sult from or occur before an individual can be trans8 ferred from the facility, in compliance with the re9 quirements of section 1867 of the Social Security

10 Act.

11 ‘‘(9) TREATING PHYSICIAN.—The term ‘treat12 ing physician’ includes a treating health care profes13 sional who is licensed under State law to provide

14 emergency services other than under the supervision

15 of a physician.

16 ‘‘(f) CONTINUED APPLICABILITY OF STATE LAW

17 WITH RESPECT TO HEALTH INSURANCE ISSUERS.—The

18 provisions of section 2723(a) (relating to State authority

19 to provide for standards and requirements for health in20 surance issuers to the extent the standards and require21 ments do not prevent the application of a requirement of

22 this part) apply with respect to the requirements of this

23 section.’’.

24 (b) CONFORMING AMENDMENT.—Section 2723(c) of

25 such Act (42 U.S.C. 300gg–23(c)), as amended by section
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1 604(b)(2) of Public Law 104–204, is amended by striking

2 ‘‘section 2704’’ and inserting ‘‘sections 2704 and 2706’’.

3 (c) EFFECTIVE DATE.—(1) Subject to paragraph (2),

4 the amendments made by this section shall apply to group

5 health plans for plan years beginning on or after the date

6 that is 18 months after the date of the enactment of this

7 Act.

8 (2) In the case of a group health plan maintained

9 pursuant to 1 or more collective bargaining agreements

10 between employee representatives and 1 or more employ11 ers ratified before the date of enactment of this Act, the

12 amendments made by this section shall not apply to plan

13 years beginning before the later of—

14 (A) the date on which the last collective bar15 gaining agreements relating to the plan terminates

16 (determined without regard to any extension thereof

17 agreed to after the date of enactment of this Act),

18 or

19 (B) 18 months after the date of the enactment

20 of this Act.

21 For purposes of subparagraph (A), any plan amendment

22 made pursuant to a collective bargaining agreement relat23 ing to the plan which amends the plan solely to conform

24 to any requirement added by this section shall not be
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1 treated as a termination of such collective bargaining

2 agreement.

3 SEC. 5. AMENDMENTS TO THE PUBLIC HEALTH SERVICE

4 ACT RELATING TO THE INDIVIDUAL MARKET.

5 (a) IN GENERAL.—Part B of title XXVII of the Pub6 lic Health Service Act is amended—

7 (1) by redesignating the subpart 3 relating to

8 other requirements as subpart 2, and

9 (2) by adding at the end of such subpart the

10 following new section:

11 ‘‘SEC. 2752. ASSURING EQUITABLE COVERAGE OF EMER12 GENCY SERVICES, MAINTENANCE CARE, AND

13 POST-STABILIZATION CARE.

14 ‘‘(a) IN GENERAL.—The provisions of section 2706

15 shall apply to health insurance coverage offered by a

16 health insurance issuer in the individual market in the

17 same manner as it applies to health insurance coverage

18 offered by a health insurance issuer in connection with a

19 group plan. In applying the previous sentence, the ref20 erence in section 2706(b)(2)(C) to section 2701 is deemed

21 a reference to subpart 1 of this part.

22 ‘‘(b) CONTINUED APPLICABILITY OF STATE LAW

23 WITH RESPECT TO HEALTH INSURANCE ISSUERS.—The

24 provisions of section 2762 (relating to State authority to
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1 provide for standards and requirements for health insur2 ance issuers to the extent the standards and requirements

3 do not prevent the application of a requirement of this

4 part) apply with respect to the requirements of this sec5 tion.’’.

6 (b) CONFORMING AMENDMENT.—Section 2763(b)(2)

7 of such Act (42 U.S.C. 300gg–63(b)(2)), as added by sec8 tion 605(b)(3)(B) of Public Law 104–204, is amended by

9 striking ‘‘section 2751’’ and inserting ‘‘sections 2751 and

10 2752’’.

11 (c) EFFECTIVE DATE.—The amendments made by

12 this section shall apply with respect to health insurance

13 coverage offered, sold, issued, renewed, in effect, or oper14 ated in the individual market on or after the date that

15 is 18 months after the date of the enactment of this Act.

16 SEC. 6. APPLICATION TO PRIVATE COVERAGE FOR MEDI17 CARE AND MEDICAID BENEFICIARIES.

18 (a) MEDICARE.—Subparagraph (B) of section

19 1876(c)(4) of the Social Security Act (42 U.S.C.

20 1395mm(c)(4)) is amended to read as follows:

21 ‘‘(B) meets the requirements of section 2706 of

22 the Public Health Service Act with respect to indi23 viduals enrolled with the organization under this sec24 tion.’’.
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1 (b) MEDICAID.—Title XIX of such Act (42 U.S.C.

2 1396 et seq.) is amended by inserting after section 1908

3 the following new section:

4 ‘‘ACCESS TO EMERGENCY SERVICES FOR BENEFICIARIES

5 ENROLLED IN PRIVATE HEALTH PLANS

6 ‘‘SEC. 1909. (a) IN GENERAL.—A state plan may not

7 be approved under this title unless the plan requires each

8 health insurance issuer or other entity with a contract

9 with such plan to provide coverage or benefits to individ10 uals eligible for medical assistance under the plan to com11 ply with the provisions of section 2706 of the Public

12 Health Service Act with respect to such coverage or bene13 fits.

14 ‘‘(b) COST SHARING.—Nothing in this section or sec15 tion 2706(c) of the Public Health Service Act shall be con16 strued as authorizing a health insurance issuer or entity

17 to impose cost sharing with respect to the coverage or ben18 efits described in subsection (a) that is inconsistent with

19 the cost sharing that is otherwise permitted under this

20 title.

21 ‘‘(c) WAIVERS PROHIBITED.—The requirement of

22 subsection (a) may not be waived under section 1115 or

23 section 1915(b) of the Social Security Act.’’.

24 (c) MEDICARE SELECT POLICIES.—Section

25 1882(t)(1) of such Act (42 U.S.C. 1395ss(t)(1)) is amend26 ed—
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1 (1) in subparagraph (B), by inserting ‘‘subject

2 to subparagraph (G),’’ after ‘‘(B)’’,

3 (2) by striking ‘‘and’’ at the end of subpara4 graph (E),

5 (3) by striking the period at the end of sub6 paragraph (F) and inserting ‘‘; and’’, and

7 (4) by adding at the end the following new sub8 paragraph:

9 ‘‘(G) the issuer of the policy complies with the

10 requirements of section 2752 of the Public Health

11 Service Act with respect to enrollees under this sub12 section.’’.

13 (d) EFFECTIVE DATES.—

14 (1) MEDICARE.—The amendment made by sub15 section (a) shall apply to eligible organizations under

16 section 1876 of the Social Security Act for contract

17 years beginning on or after the date that is 18

18 months after the date of the enactment of this Act.

19 (2) MEDICAID.—The amendment made by sub20 section (b) shall apply to State plans under title

21 XIX of the Social Security Act for contract years be22 ginning on or after the date that is 18 months after

23 the date of the enactment of this Act.

24 (3) MEDICARE SELECT.—The amendments

25 made by subsection (c) shall apply to policies for
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1 contract years beginning on or after the date that is

2 18 months after the date of the enactment of this

3 Act.

4 SEC. 7. ESTABLISHMENT OF GUIDELINES.

5 (a) IN GENERAL.—The Secretary of Labor, the Sec6 retary of Health and Human Services, and the Secretary

7 of the Treasury (in this section referred to as ‘‘the Sec8 retaries’’) shall, in accordance with the process described

9 in subsection (b), jointly establish guidelines to carry out

10 section 9811 of the Internal Revenue Code of 1986, sec11 tion 713 of the Employee Retirement Income Security Act

12 of 1974, and sections 2706 and 2752 of the Public Health

13 Service Act, including all such guidelines as may be re14 ferred to in such sections.

15 (b) PROCESS.—

16 (1) ADVISORY PANEL.—Not later than 90 days

17 after the date of the enactment of this Act, the Sec18 retaries shall jointly establish an advisory panel to

19 assist in the development of the guidelines referred

20 to in subsection (a). The members of the panel shall

21 include individuals representing—

22 (A) emergency medical personnel, includ23 ing emergency physicians, emergency nurses,

24 and other appropriate emergency health care

25 professionals;
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1 (B) health insurance issuers, including at

2 least one health maintenance organization;

3 (C) hospitals;

4 (D) employers;

5 (E) the States; and

6 (F) consumers.

7 (2) NOTICE AND COMMENT.—Not later than

8 180 days after the date of the enactment of this Act,

9 the Secretaries shall jointly cause to have published

10 in the Federal Register notice of proposed rule11 making on the guidelines referred to in subsection

12 (a). Not later than 60 days after the close of the pe13 riod for public comment on such guidelines, the Sec14 retaries shall jointly cause to have published in the

15 Federal Register a final rule establishing such guide16 lines.

Æ