I
104TH CONGRESS
1ST SESSION
H. R. 2011
To assure equitable coverage and treatment of emergency services under
health plans.
IN THE HOUSE OF REPRESENTATIVES
JULY 11, 1995
Mr. CARDIN (for himself, Mrs. ROUKEMA, Mr. MCDERMOTT, Mr. TOWNS, Mr.
PALLONE, Ms. RIVERS, Mr. NADLER, Mr. WISE, Mr. LEWIS of Georgia,
Mr. FAZIO of California, Mr. MORAN, Mr. BEILENSON, and Mr. JOHN-
SON of South Dakota) introduced the following bill; which was referred
to the Committee on Commerce, and in addition to the Committee on
Ways and Means, for a period to be subsequently determined by the
Speaker, in each case for consideration of such provisions as fall within
the jurisdiction of the committee concerned
A BILL
To assure equitable coverage and treatment of emergency
services under health plans.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) SHORT TITLE.—This Act may be cited as the
‘‘Access to Emergency Medical Services Act of 1995’’.
(b) TABLE OF CONTENTS.—The table of contents of
this Act is as follows:
Sec. 1. Short title.
Sec. 2. Findings; purposes.
Sec. 3. Assuring equitable health plan coverage with respect to emergency serv-
ices.
Sec. 4. Requirements for medicare and medicaid managed care.
Sec. 5. Effect on State law.
Sec. 6. Enforcement.
Sec. 7. Regulations.
Sec. 8. Definitions.
Sec. 9. Effective dates.
Sec. 10. Report on application to plans including medical savings accounts.
SEC. 2. FINDINGS; PURPOSES.
(a) FINDINGS.—The Congress finds the following:
(1) Federal medicare law requires emergency
physicians and other providers to evaluate, treat,
and stabilize any individual seeking treatment in a
hospital emergency department.
(2) This law specifically prohibits emergency
physicians from delaying any treatment needed to
evaluate or stabilize an individual in order to deter-
mine the health insurance status of the individual.
(3) Many health plans routinely deny payment
for these Federally-required emergency services fur-
nished to their enrollees, basing such denials on—
(A) failure to obtain prior approval of such
services from the plan, or
(B) an after-the-fact determination that
the medical condition identified through the
Federally-required evaluation was not an emer-
gency medical condition.
(4) These denials by health plans impose sig-
nificant financial burdens on—
(A) their enrollees who, based on symp-
toms that reasonably suggest a medical emer-
gency, prudently seek care in a hospital emer-
gency department, and
(B) emergency physicians, the hospital
emergency departments, and others involved in
furnishing emergency services to the enrollees.
(5) These burdens discourage enrollees from
seeking emergency care in cases where it is appro-
priate and, ultimately, threaten the financial liveli-
hood of hospital emergency departments in providing
emergency services to the entire population, includ-
ing beneficiaries of the medicare and medicaid pro-
grams and of other Federal health care programs.
(6) Health plans have engaged in practices that
discourage the appropriate use of the 911 emergency
telephone number and may adversely impact on the
health of enrollees.
(b) PURPOSES.—The purposes of this Act are—
(1) to require health plans to cover and pay for
their fair share for emergency services that hospital
emergency departments are required to provide;
(2) to protect health plan enrollees by establish-
ing a uniform definition of emergency medical condi-
tion that is based on the average knowledge of a
prudent layperson;
(3) to prohibit health plans from requiring prior
approval for Federally-required emergency services;
and
(4) to assure that health plans promote the ap-
propriate use of the 911 emergency telephone num-
ber.
SEC. 3. ASSURING EQUITABLE HEALTH PLAN COVERAGE
WITH RESPECT TO EMERGENCY SERVICES.
(a) PROHIBITION OF CONTRACTUAL LIMITATIONS ON
COVERAGE OF EMERGENCY SERVICES.—A health plan
that provides any coverage with respect to emergency serv-
ices shall cover emergency services furnished to an enrollee
of the plan—
(1) without regard to whether or not the pro-
vider furnishing the emergency services has a con-
tractual or other arrangement with the plan for the
provision of such services to such enrollees, and
(2) without regard to prior authorization.
(b) PROHIBITION OF DISCRIMINATORY PAYMENT OR
COST-SHARING.—
(1) IN GENERAL.—A health plan that provides
any coverage with respect to emergency services—
(A) shall determine and make prompt pay-
ment in a reasonable and appropriate amount
for such services (including services required to
be provided under section 1867 of the Social
Security Act), and
(B) subject to paragraph (2), may not im-
pose cost-sharing for services furnished in a
hospital emergency department that is cal-
culated in a manner (such as the use of a dif-
ferent percentage) that imposes greater cost
sharing with respect to such services compared
to comparable services furnished in other set-
tings.
(2) IMPOSITION OF REASONABLE COPAYMENT
PERMITTED.—A health plan may impose a reason-
able copayment (as determined in accordance with
standards established by the Secretary) in lieu of co-
insurance to deter inappropriate use of services of
hospital emergency departments.
(c) ASSURING TIMELINESS OF PRIOR AUTHORIZA-
TION DETERMINATION FOR NEEDED CARE IDENTIFIED
IN INITIAL EVALUATION.—
(1) IN GENERAL.—