paid for items and services if the plan had not vio-
lated such section; or
(3) in the case of a pattern of repeated and
substantial violations, $1,000,000.
(b) PROCEDURES.—
(1) IN
GENERAL.—The provisions of section
1128A of the Social Security Act (other than sub-
sections (a) and (b)) shall apply to a civil money
penalty under this section in the same manner as
such provisions apply with respect to a penalty or
proceeding under section 1128A(a) of such Act.
(2) CORRECTIVE ACTION.—In determining the
amount or scope of any civil money penalty under
this section, the Secretary shall take into account
whether a health plan has taken corrective action,
such as—
(A) payment for items and services for
which coverage or payment has been denied in
violation of a requirement of section 3, and
(B) establishment of policies and proce-
dures to prevent the same type of violation from
occurring in the future.
(c) INDEMNIFICATION.—The Secretary may, out of
any civil money penalty collected pursuant to this section,
make a payment to an enrollee or provider (as appro-
priate) in an amount equal to the amount a health plan
would have paid for an item or service (if any) if the plan
had not denied coverage or payment for such item or serv-
ice in violation of section 3.
(d) VIOLATIONS.—For purposes of subsection (a),
the Secretary shall treat at least the following acts or
omissions as violations of section 3:
(1) COVERAGE
OF
EMERGENCY
SERVICES.—
Failure to cover emergency services in violation of
section 3(a).
(2) FAILURE
TO
PROVIDE
FOR
PAYMENT.—
Failure to provide for payment for emergency serv-
ices in violation of section 3(b)(1)(A).
(3) IMPROPER COST SHARING.—Imposition of
cost sharing in violation of section 3(b)(1)(B).
(4) ACCESS TO PRIOR AUTHORIZATION.—Fail-
ure to provide access to prior authorization deter-
minations in violation of section 3(c)(1)(A).
(4) DEEMED
APPROVAL.—Failure to pay for
services that are deemed to be approved under sec-
tion 3(c).
(5) EDUCATIONAL MATERIALS.—Failure to in-
clude educational materials as required by section
3(d)(1).
(6) USE OF 911.—Discouraging the appropriate
use of the 911 emergency telephone number or de-
nial of payment in violation of paragraph (2) or (3)
of section 3(d).
SEC. 7. REGULATIONS.
The Secretary shall issue such rules and regulations
as may be necessary to carry out the provisions of this
Act.
SEC. 8. DEFINITIONS.
For purposes of this Act:
(1) COST-SHARING.—The term ‘‘cost-sharing’’
means 
any 
deductible, 
coinsurance 
amount,
copayment, or other out-of-pocket payment that an
enrollee is responsible for paying with respect to a
health care item or service covered under a health
plan.
(2) EMERGENCY
DEPARTMENT.—The term
‘‘emergency department’’ includes, with respect to a
hospital, a trauma center in the hospital if the cen-
ter—
(A) is designated under section 1213 of
the Public Health Service Act, or
(B) is in a State that has not made such
designations and is determined by the Secretary
to meet the standards under such section for
such designation.
(3) EMERGENCY
MEDICAL
CONDITION.—The
term ‘‘emergency medical condition’’ means a medi-
cal condition, the onset of which is sudden, that
manifests itself by symptoms of sufficient severity,
including severe pain, that a prudent layperson, who
possesses an average knowledge of health and medi-
cine, could reasonably expect the absence of imme-
diate medical attention to result in—
(A) placing the person’s health in serious
jeopardy,
(B) serious impairment to bodily functions,
or
(C) serious dysfunction of any bodily organ
or part.
(4) EMERGENCY SERVICES.—The term ‘‘emer-
gency services’’ means—
(A) health care items and services fur-
nished in the emergency department of a hos-
pital, and
(B) ancillary services routinely available to
such department,
to the extent they are required to evaluate and treat
an emergency medical condition (as defined in para-
graph (3)) until the condition is stabilized.
(5) ENROLLEE.—The term ‘‘enrollee’’ means,
with respect to a health plan, an individual enrolled
with the health plan.
(6) HEALTH PLAN.—
(A) IN GENERAL.—The term ‘‘health plan’’
refers to any plan or arrangement (other than
a plan or arrangement described in subpara-
graph (B)) that provides, or pays the cost of,
health benefits, whether through insurance, re-
imbursement, or otherwise.
(B) EXCEPTION.— A plan or arrangement
is described in this subparagraph if it is:
(i) Coverage only for accidental death
or dismemberment.
(ii) Coverage providing wages or pay-
ments in lieu of wages for any period dur-
ing which the employee is absent from
work on account of sickness or injury.
(iii) A Medicare supplemental policy
(as defined in section 1882(g)(1) of the
Social Security Act).
(iv) Coverage issued as a supplement
to liability insurance.
(v) Worker’s compensation or similar
insurance.
(vi) Automobile medical-payment in-
surance.
(vii) Coverage for a specified disease
or illness.
(viii) A long-term care policy.
(ix) A Federally-funded health care
program (except when such program con-
tracts with a health plan to provide items
and services to individuals eligible for ben-
efits under the program).
(7) MANAGED CARE PLAN.—The term ‘‘man-
aged care plan’’ means a health plan that provides
or arranges for the provision of health care items
and services to enrollees primarily through partici-
pating physicians and providers.
(8) PARTICIPATING.—The term ‘‘participating’’
means, with respect to a physician or provider, a
physician or provider that furnishes health care
items and services to enrollees of managed care plan
under an agreement with the plan.
(9) PRIOR AUTHORIZATION DETERMINATION.—
The 
term 
‘‘prior 
authorization 
determination’’
means, with respect to health care items and serv-
ices for which coverage may be provided under a
health plan, a determination, before the provision of
the items and services and as a condition of coverage
of the items and services under the plan, that cov-
erage will be provided for the items and services
under the plan.
(10) 
SECRETARY.—The 
term 
‘‘Secretary’’
means the Secretary of Health and Human Services.
(11) 
STABILIZED.—The 
term 
‘‘stabilized’’
means, with respect to an emergency medical condi-
tion, that no material deterioration of the condition
is likely, within reasonable medical probability, to re-
sult or occur before an individual can be transferred
in compliance with the requirements of section 1867
of the Social Security Act.
(12) 911 EMERGENCY TELEPHONE NUMBER.—
The term ‘‘911 emergency telephone number’’ in-
cludes, in the case of a geographic area where 911
is not in use for emergencies, such other telephone
number as is in use for emergencies.
SEC. 9. EFFECTIVE DATES.
(a) IN GENERAL.—This Act and the amendments
made by this Act shall become effective on the earlier of—
(1) 30 days after the date the Secretary issues
regulations pursuant to subsection (c), or
(2) 210 days after the date of the enactment of
this Act (without regard to whether such regulations
have been issued by such date).
(b) APPLICATION.—The provisions of section 3 (other
than paragraphs (1) and (2) of subsection (d)) shall apply
to items and services furnished on or after the effective
date described in subsection (a).
(c) DEADLINE FOR REGULATIONS.—The Secretary
shall issue regulations to implement this Act and the
amendments made by this Act not later than 6 months
after the date of the enactment of this Act. Such regula-
tions may take effect on a final basis at the time of publi-
cation, subject to revision based on subsequent public com-
ment.
SEC. 10. REPORT ON APPLICATION TO PLANS INCLUDING
MEDICAL SAVINGS ACCOUNTS.
(a) STUDY.—The Secretary shall provide for a study
of the application of this Act in the case of health plans
composed of a high-deductible, catastrophic health insur-
ance policy with a medical savings account. In particular,
the study shall evaluate the feasibility and desirability of
requiring the application of amounts in such an account
toward costs in providing emergency services and in pro-
viding promptly needed items and services identified in
connection with the provision of emergency services.
(b) REPORT.—The Secretary shall submit to Con-
gress a report on such study not later than 18 months
after the date of the enactment of this Act.
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