To assure access under group health plans and health insurance coverage to covered emergency medical services.

May 2, 2001

Mr. CARDIN (for himself, Mrs. Roukema, Mr. Abercrombie, Mr. Langevin, Mr. Stark, Mr. Hoeffel, Mr. Blumenauer, Mrs. Thurman, Mr. Farr of California, Mr. McDermott, Mr. Serrano, Mr. Levin, Mr. Wynn, Mrs. Mink of Hawaii, Mr. DeFazio, Mrs. Emerson, Mrs. Napolitano, Ms. Slaughter, Mr. Thompson of Mississippi, Mr. McHugh, Ms. Baldwin, Ms. Hooley of Oregon, Mr. Delahunt, Mr. Coyne, Ms. Eddie Bernice Johnson of Texas, Mr. Bentsen, Mr. Lewis of Georgia, Mr. George Miller of California, Ms. Rivers, Mr. Spence, Mr. Baker, and Mr. Rush) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on Education and the Workforce, and Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned

To assure access under group health plans and health insurance coverage to covered emergency medical services.

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

This Act may be cited as the `Access to Emergency Medical Services Act of 2001'.

SEC. 2. EMERGENCY SERVICES.

(a) COVERAGE OF EMERGENCY SERVICES-

(1) IN GENERAL- If a group health plan, or health insurance coverage offered by a health insurance issuer, provides any benefits with respect to emergency services (as defined in paragraph (2)(B)), the plan or issuer shall cover emergency services furnished under the plan or coverage--

(A) without the need for any prior authorization determination;

(B) whether or not the health care provider furnishing such services is a participating provider with respect to such services;

(C) in a manner so that, if such services are provided to a participant, beneficiary, or enrollee by a nonparticipating health care provider, the participant, beneficiary, or enrollee is not liable for amounts that exceed the amounts of liability that would be incurred if the services were provided by a participating provider; and

(D) without regard to any other term or condition of such plan or coverage (other than exclusion or coordination of benefits, or an affiliation or waiting period, permitted under section 2701 of the Public Health Service Act, section 701 of the Employee Retirement Income Security Act of 1974, or section 9801 of the Internal Revenue Code of 1986, and other than applicable cost sharing).

(2) DEFINITIONS- In this section:

(A) EMERGENCY MEDICAL CONDITION BASED ON PRUDENT LAYPERSON STANDARD- The term `emergency medical condition' means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in a condition described in clause (i), (ii), or (iii) of section 1867(e)(1)(A) of the Social Security Act (42 U.S.C. 1395dd(e)(1)(A)).

(B) EMERGENCY SERVICES- The term `emergency services' means--

(i) a medical screening examination (as required under section 1867 of the Social Security Act, 42 U.S.C. 1395dd)) that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate an emergency medical condition (as defined in subparagraph (A)); and

(ii) within the capabilities of the staff and facilities at the hospital, such further medical examination and treatment as are required under section 1867 of such Act to stabilize the patient.

(C) STABILIZE- The term `to stabilize', with respect to an emergency medical condition (as defined in subparagraph (A)), has the meaning given in section 1867(e)(3) of the Social Security Act (42 U.S.C. 1395dd(e)(3)).

(b) REIMBURSEMENT FOR MAINTENANCE CARE AND POST-STABILIZATION CARE- A group health plan, and health insurance coverage offered by a health insurance issuer, must provide reimbursement for maintenance care and post-stabilization care in accordance with the requirements of section 1852(d)(2) of the Social Security Act (42 U.S.C. 1395w-22(d)(2)). Such reimbursement shall be provided in a manner consistent with subsection (a)(1)(C).

(c) COVERAGE OF EMERGENCY AMBULANCE SERVICES-

(1) IN GENERAL- If a group health plan, or health insurance coverage provided by a health insurance issuer, provides any benefits with respect to ambulance services and emergency services, the plan or issuer shall cover emergency ambulance services (as defined in paragraph (2)) furnished under the plan or coverage under the same terms and conditions under subparagraphs (A) through (D) of subsection (a)(1) under which coverage is provided for emergency services.

(2) EMERGENCY AMBULANCE SERVICES- For purposes of this subsection, the term `emergency ambulance services' means ambulance services (as defined for purposes of section 1861(s)(7) of the Social Security Act) furnished to transport an individual who has an emergency medical condition (as defined in subsection (a)(2)(A)) to a hospital for the receipt of emergency services (as defined in subsection (a)(2)(B)) in a case in which the emergency services are covered under the plan or coverage pursuant to subsection (a)(1) and a prudent layperson, with an average knowledge of health and medicine, could reasonably expect that the absence of such transport would result in placing the health of the individual in serious jeopardy, serious impairment of bodily function, or serious dysfunction of any bodily organ or part.

(d) INFORMATION FOR PARTICIPANTS, BENEFICIARIES, AND ENROLLEES-

(1) GROUP HEALTH PLANS- A group health plan shall--

(A) provide to participants and beneficiaries at the time of initial coverage under the plan (or the effective date of this Act, in the case of individuals who are participants and beneficiaries as of such date), at least annually thereafter, and at the beginning of any open enrollment provided under the plan, the information described in paragraph (3) in printed form;

(B) upon request, make available to participants and beneficiaries, to the applicable authority, and to prospective participants and beneficiaries the information described in paragraph (3) in printed form; and

(C) provide notice to participants and beneficiaries of information relating to any material reduction to the benefits or information described in paragraph (3) not later than 30 days before the date on which the reduction takes effect.

(2) HEALTH INSURANCE ISSUERS- A health insurance issuer, in connection with the provision of health insurance coverage, shall--

(A) provide to individuals enrolled under such coverage at the time of enrollment, and at least annually thereafter, (and to plan administrators of group health plans in connection with which such coverage is offered) the information described in paragraph (3) in printed form;

(B) upon request, make available to the applicable authority, to individuals who are prospective enrollees, to plan administrators of group health plans that may obtain such coverage, and to the public the information described in paragraph (3) in printed form; and

(C) provide notice to enrollees of information relating to any material reduction to the benefits or information described in paragraph (3) not later than 30 days before the date on which the reduction takes effect.

(3) REQUIRED INFORMATION- The information described in this paragraph with respect to a group health plan or health insurance coverage offered by a health insurance issuer is information about the coverage of emergency services, including--

(A) the appropriate use of emergency services, including use of the 911 telephone system or its local equivalent in emergency situations and an explanation of what constitutes an emergency situation;

(B) the process and procedures of the plan or issuer for obtaining emergency services;

(C) any cost-sharing applicable to emergency services; and

(D) the locations of--

(i) emergency departments; and

(ii) other settings in which plan physicians and hospitals provide emergency services and post-stabilization care.

(e) DEFINITIONS- For purposes of this section--

(1) The term `applicable authority' means--

(A) in the case of a group health plan, the Secretary of Health and Human Services and the Secretary of Labor; and

(B) in the case of a health insurance issuer with respect to a specific provision of this section, the applicable State authority or the Secretary of Health and Human Services if such Secretary is enforcing such provisions under section 2722(a)(2) or 2761(a)(2) of the Public Health Service Act (42 U.S.C. 300gg-22(a)(2), 300gg-61(a)(2)).

(2) The terms `applicable State authority', `beneficiary', `group health plan', `health insurance coverage', `health insurance issuer', and `participant' shall have the meanings given to such terms in section 2791 of the Public Health Service Act (42 U.S.C. 300gg-91).

(3) The term `nonparticipating' means, with respect to a health care provider that provides health care items and services to a participant, beneficiary, or enrollee under a group health plan or health insurance coverage, a health care provider that is not a participating health care provider with respect to such items and services.

(4) The term `participating' means, with respect to a health care provider that provides health care items and services to a participant, beneficiary, or enrollee under a group health plan or health insurance coverage offered by a health insurance issuer, a health care provider that furnishes such items and services under a contract or other arrangement with the plan or issuer.

SEC. 3. STANDARDS UNDER THE PUBLIC HEALTH SERVICE ACT.

(a) GROUP MARKET- Subpart 2 of part A of title XXVII of the Public Health Service Act is amended by adding at the end the following new section:

`SEC. 2707. EMERGENCY SERVICES.

`(a) IN GENERAL- Each group health plan (and each health insurance issuer offering group health insurance coverage in connection with such a plan) shall comply with the requirements of section 2 of the Access to Emergency Medical Services Act of 2001, and such requirements shall be deemed to be incorporated into this subsection.

`(b) NOTICE- A group health plan shall comply with the notice requirement under section 711(d) of the Employee Retirement Income Security Act with respect to the requirements referred to in subsection (a), and a health insurance issuer shall comply with such notice requirement as if such section applied to such issuer and such issuer were a group health plan.'.

(b) INDIVIDUAL MARKET- Part B of title XXVII of the Public Health Service Act is amended by inserting after section 2752 the following new section:

`SEC. 2753. EMERGENCY SERVICES.

`(a) IN GENERAL- Each health insurance issuer shall comply with the requirements of section 2 of the Access to Emergency Medical Services Act of 2001 with respect to individual health insurance coverage it offers, and such requirements shall be deemed to be incorporated into this subsection.

`(b) NOTICE- A health insurance issuer under this part shall comply with the notice requirement under section 711(d) of the Employee Retirement Income Security Act with respect to the requirements referred to in subsection (a) as if such section applied to such issuer and such issuer were a group health plan.'.

SEC. 4. STANDARDS UNDER THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974.

(a) IN GENERAL- Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 is amended by adding at the end the following new section:

`SEC. 714. EMERGENCY SERVICES.

`(a) IN GENERAL- Subject to subsection (b), a group health plan (and a health insurance issuer offering group health insurance coverage in connection with such a plan) shall comply with the requirements of section 2 of the Access to Emergency Medical Services Act of 2001, and such requirements shall be deemed to be incorporated into this subsection.

`(b) SATISFACTION OF REQUIREMENTS- For purposes of subsection (a), insofar as a group health plan provides benefits in the form of health insurance coverage through a health insurance issuer, the plan shall be treated as meeting the requirements of the Access to Emergency Medical Services Act of 2001 with respect to such benefits and not be considered as failing to meet such requirements because of a failure of the issuer to meet such requirements so long as the plan sponsor or its representatives did not cause such failure by the issuer.'.

(b) CONFORMING AMENDMENT- Section 732(a) of such Act (29 U.S.C. 1191a(a)) is amended by striking `section 711' and inserting `sections 711 and 714'.

(c) CLERICAL AMENDMENT- The table of contents in section 1 of such Act is amended by inserting after the item relating to section 713 the following new item:

`Sec. 714. Emergency services.'.

SEC. 5. STANDARDS UNDER THE INTERNAL REVENUE CODE OF 1986.

Subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended--

(1) in the table of sections, by inserting after the item relating to section 9812 the following new item:

`Sec. 9813. Standard relating to emergency services.'; and

(2) by inserting after section 9812 the following:

`SEC. 9813. STANDARD RELATING TO EMERGENCY SERVICES.

`A group health plan shall comply with the requirements of section 2 of the Access to Emergency Medical Services Act of 2001, and such requirements shall be deemed to be incorporated into this section.'.

SEC. 6. EFFECTIVE DATE.

(a) GROUP HEALTH COVERAGE-

(1) IN GENERAL- Subject to paragraph (2), the amendments made by sections 3(a), 4, and 5 (and section 2 insofar as it relates to such sections) apply to group health plans for plan years beginning on or after January 1, 2002.

(2) TREATMENT OF COLLECTIVE BARGAINING AGREEMENTS- In the case of a group health plan maintained pursuant to 1 or more collective bargaining agreements between employee representatives and 1 or more employers ratified before the date of the enactment of this Act, the amendments made by sections 3(a), 4, and 5 (and section 2 insofar as it relates to such sections) shall not apply to plan years beginning before the later of--

(A) the date on which the last collective bargaining agreement relating to the plan terminates (determined without regard to any extension thereof agreed to after the date of the enactment of this Act); or

(B) January 1, 2002.

For purposes of subparagraph (A), any plan amendment made pursuant to a collective bargaining agreement relating to the plan that amends the plan solely to conform to any requirement of this Act shall not be treated as a termination of such collective bargaining agreement.

(b) INDIVIDUAL MARKET- The amendment made by section 3(b) (and section 2 insofar as it relates to such section) applies with respect to health insurance coverage offered, sold, issued, renewed, in effect, or operated in the individual market on or after January 1, 2002.

END