[Congressional Bills 104th Congress]
[From the U.S. Government Publishing Office]
[S. 2121 Introduced in Senate (IS)]







104th CONGRESS
  2d Session
                                S. 2121

  To ensure medicare beneficiaries participating in managed care have 
                  access to emergency and urgent care.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                           September 25, 1996

 Mr. Graham (for himself, Mr. Grassley, Ms. Moseley-Braun, Mr. Chafee, 
 Mr. Jeffords, Mr. Baucus, Mr. Simon, Mr. Hollings, and Mr. Wellstone) 
introduced the following bill; which was read twice and referred to the 
                          Committee on Finance

_______________________________________________________________________

                                 A BILL


 
  To ensure medicare beneficiaries participating in managed care have 
                  access to emergency and urgent care.

    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 ``Medicare Access to Emergency Medical 
Care Act of 1996''.

SEC. 2. REQUIREMENTS FOR MEDICARE MANAGED CARE.

    (a) Access to Emergency Services.--Section 1876(c) of the Social 
Security Act (42 U.S.C. 1395mm(c)) is amended by adding at the end the 
following:
    ``(9)(A) A risk-sharing contract under this section shall require 
an eligible organization that provides any coverage with respect to 
emergency services to cover emergency services furnished to a member 
enrolled with the organization--
            ``(i) without regard to whether or not the provider 
        furnishing the emergency services has a contractual or other 
        arrangement with the organization for the provision of such 
        services to such members, and
            ``(ii) without regard to prior authorization.
    ``(B)(i) A risk-sharing contract under this section shall require 
an eligible organization that provides any coverage with respect to 
emergency services--
            ``(I) to determine and make prompt payment (within the 
        meaning of subsection (g)(6)(A)) in a reasonable and 
        appropriate amount for such services (including services 
        required to be provided under section 1867), and
            ``(II) subject to clause (ii), to not impose cost-sharing 
        for services furnished in a hospital emergency department that 
        is calculated in a manner (such as the use of a different 
        percentage) that imposes greater cost sharing with respect to 
        such services compared to comparable services furnished in 
        other settings.
    ``(ii) An eligible organization may impose a reasonable copayment 
(as determined in accordance with standards established by the 
Secretary) in lieu of coinsurance to deter inappropriate use of 
services of hospital emergency departments.
    ``(C) In this paragraph, the term `emergency services' has the same 
meaning as in paragraph (10)(D).''.
    (b) Timely Authorization for Promptly Needed Care Identified as a 
Result of Required Screening Evaluation.--Section 1876(c) of such Act 
(42 U.S.C. 1395mm(c)), as amended by subsection (a), is amended by 
adding at the end the following:
    ``(10)(A) The organization must provide access 24 hours a day, 7 
days a week to individuals who are authorized to make any prior 
authorizations required by the organization for coverage of items and 
services (other than emergency services) that a treating physician or 
other emergency department personnel identify, pursuant to a screening 
evaluation required under section 1867(a), as being needed promptly by 
an individual enrolled with the organization under this part.
    ``(B) The organization is deemed to have approved a request for 
such promptly needed items and services if the physician or other 
emergency department personnel involved--
            ``(i) has made a reasonable effort to contact an individual 
        described in subparagraph (A) for authorization to provide an 
        appropriate referral for such items and services or to provide 
        the items and services to the individual and access to the 
        person has not been provided (as required in subparagraph (A)), 
        or
            ``(ii) has requested such authorization from the person and 
        the person has not denied the authorization within 30 minutes 
        after the time the request is made.
    ``(C) Approval of a request for a prior authorization determination 
(including a deemed approval under subparagraph (B)) shall be treated 
as approval of a request for any items and services that are required 
to treat the medical condition identified pursuant to the required 
screening evaluation.
    ``(D) In this paragraph, the term `emergency services' means--
            ``(i) health care items and services furnished in the 
        emergency department of a hospital (including a trauma center), 
        and
            ``(ii) ancillary services routinely available to such 
        department,
to the extent they are required to evaluate and treat an emergency 
medical condition (as defined in subparagraph (E)) until the condition 
is stabilized (as defined in subparagraph (F)).
    ``(E) In subparagraph (D), the term `emergency medical condition' 
means a medical 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 
medicine, could reasonably expect the absence of immediate medical 
attention to result in--
            ``(i) placing the person's health in serious jeopardy,
            ``(ii) serious impairment to bodily functions, or
            ``(iii) serious dysfunction of any bodily organ or part.
    ``(F) In subparagraph (D), the term `stabilized' means, with 
respect to an emergency medical condition, that no material 
deterioration of the condition is likely, within reasonable medical 
probability, to result or occur before an individual can be transferred 
in compliance with the requirements of section 1867.''.
    (c) Conforming Amendment.--Section 1876(c)(4)(B) of such Act (42 
U.S.C. 1395mm(c)(4)(B)) is amended by inserting ``subject to paragraphs 
(9) and (10),'' before ``provide''.
    (d) Effective Date.--The amendments made by subsections (a) and (b) 
shall be effective for contract years beginning on or after the date of 
the enactment of this Act.
                                 <all>