(A) ACCESS TO PROCESS.—If an enrollee
of a health plan receives emergency services
from an emergency department pursuant to a
screening evaluation conducted by a treating
physician or other emergency department per-
sonnel and pursuant to the evaluation such phy-
sician or personnel identifies items and services
(other than emergency services) promptly need-
ed by the enrollee, the health plan shall provide
access 24 hours a day, 7 days a week, to such
persons as may be authorized to make any prior
authorization determinations respecting cov-
erage of such promptly needed items and serv-
ices.
(B) DEEMED APPROVAL.—A health plan is
deemed to have approved a request for a prior
authorization for such promptly needed items
and services if such physician or other person-
nel—
(i) has attempted to contact such a
person for authorization—
(I) to provide an appropriate re-
ferral for the items and services, or
(II) to provide the items and
services to the enrollee,
and access to the person has not been pro-
vided (as required under subparagraph
(A)), or
(ii) has requested such authorization
from such a person and the person has not
denied the authorization within 30 minutes
after the time the request is made.
(2) REFERRAL
BY
PHYSICIAN
TO
HOSPITAL
EMERGENCY DEPARTMENT DEEMED PRIOR AUTHOR-
IZATION.—If a physician (or, in the case of a man-
aged care plan, a participating physician or other
person authorized to make prior authorization deter-
minations for the plan) refers an enrollee to a hos-
pital emergency department for evaluation or treat-
ment, a request for prior authorization of the items
and services reasonably furnished the enrollee pursu-
ant to such referral shall be deemed to have been
made and approved.
(3) EFFECT OF APPROVAL.—
(A) IN GENERAL.—Approval of a request
for a prior authorization determination (includ-
ing a deemed approval under paragraph (1) or
(2)) shall be treated as approval of any health
care items and services required to treat the
medical condition identified pursuant to a
screening evaluation referred to in paragraph
(1)(A).
(B) PAYMENT.—A health plan may not
subsequently deny or reduce payment for an
item or service furnished pursuant to such an
approval unless the approval was based on in-
formation about the medical condition of an en-
rollee that was fraudulent.
(d) ENCOURAGING APPROPRIATE USE OF 911 EMER-
GENCY TELEPHONE NUMBER.—A health plan—
(1) shall include, in any educational materials
the plan makes available to its enrollees on the pro-
cedures for obtaining emergency services—
(A) a statement that it is appropriate for
an enrollee to use the 911 emergency telephone
number for an emergency medical condition (as
defined in section 8(3)), and
(B) an explanation of what is an emer-
gency medical condition;
(2) shall not discourage appropriate use of the
911 emergency telephone number by enrollees with
emergency medical conditions; and
(3) shall not deny coverage or payment for an
item or service solely on the basis that an enrollee
uses the 911 emergency telephone number to sum-
mon treatment for an emergency medical condition.
SEC. 4. REQUIREMENTS FOR MEDICARE AND MEDICAID
MANAGED CARE.
(a) 
MEDICARE.—Subparagraph 
(B) 
of 
section
1876(c)(4) of the Social Security Act (42 U.S.C.
1395mm(c)(4)) is amended to read as follows:
‘‘(B) meets the requirements of section 3 of the
Access to Emergency Medical Care Act of 1995 with
respect to enrollees of the plan who are enrolled
under this section.’’.
(b) MEDICAID.—Title XIX of the Social Security Act
(42 U.S.C. 1396 et seq.) is amended by inserting after
section 1908 the following new section:
‘‘ACCESS TO EMERGENCY SERVICES FOR INDIVIDUALS
ENROLLED IN MANAGED CARE PLAN
‘‘SEC. 1909. (a) IN GENERAL.—A state plan may not
be approved under this title unless the plan requires each
managed care plan providing (or arranging for the provi-
sion of) health care items and services to individuals who
are eligible for medical assistance and enrolled with the
managed care plan to comply with the requirements of sec-
tion 3 of the Access to Emergency Medical Care Act of
1995 with respect to such individuals.
‘‘(b) WAIVERS PROHIBITED.—The requirement of
subsection (a) may not be waived under section 1115 or
section 1915(b).
‘‘(c) MANAGED CARE PLAN.—For purposes of this
section, the term ‘managed care plan’ means a health plan
that provides or arranges for the provision health care
items and services to enrollees primarily through partici-
pating physicians and providers.’’.
SEC. 5. EFFECT ON STATE LAW.
(a) PREEMPTION.—Nothing in this Act shall be con-
strued as preempting or otherwise superseding any provi-
sion of State law unless such provision directly conflicts
with this Act.
(b) CONSUMER PROTECTIONS.—A provision of State
law shall not be considered to conflict directly with this
Act if the provision provides the enrollees of health plans
with protections that exceed the protections of this Act.
SEC. 6. ENFORCEMENT.
(a) CIVIL MONEY PENALTIES.—A health plan that
violates a requirement of section 3 shall be subject to a
civil money penalty of not more than the greatest of—
(1) $10,000 for each such violation;
(2) in the case of a violation of section 3, 3
times the amount that the health plan would have