[Congressional Bills 105th Congress]
[From the U.S. Government Publishing Office]
[S. 356 Introduced in Senate (IS)]

  1st Session
                                 S. 356

 To amend the Internal Revenue Code of 1986, the Public Health Service 
 Act, the Employee Retirement Income Security Act of 1974, and titles 
XVIII and XIX of the Social Security Act to assure access to emergency 
 medical services under group health plans, health insurance coverage, 
                and the medicare and medicaid programs.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                           February 25, 1997

Mr. Graham (for himself, Mr. Hutchinson, Ms. Mikulski, and Mr. Chafee) 
introduced the following bill; which was read twice and referred to the 
                          Committee on Finance

_______________________________________________________________________

                                 A BILL


 
 To amend the Internal Revenue Code of 1986, the Public Health Service 
 Act, the Employee Retirement Income Security Act of 1974, and titles 
XVIII and XIX of the Social Security Act to assure access to emergency 
 medical services under group health plans, health insurance coverage, 
                and the medicare and medicaid programs.

    Be it enacted by the Senate and House of Representatives 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 1997''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
Sec. 2. Amendments to the Internal Revenue Code of 1986.
Sec. 3. Amendments to the Employee Retirement Income Security Act of 
                            1974.
Sec. 4. Amendments to the Public Health Service Act relating to the 
                            group market.
Sec. 5. Amendments to the Public Health Service Act relating to the 
                            individual market.
Sec. 6. Application to private coverage for medicare and medicaid 
                            beneficiaries.
Sec. 7. Establishment of guidelines.

SEC. 2. AMENDMENTS TO THE INTERNAL REVENUE CODE OF 1986.

    (a) In General.--Subtitle K of the Internal Revenue Code of 1986 
(as added by section 401(a) of the Health Insurance Portability and 
Accountability Act of 1996) is amended--
            (1) by striking all that precedes section 9801 and 
        inserting the following:

              ``Subtitle K--Group Health Plan Requirements

                              ``Chapter 100. Group health plan 
                                        requirements.

             ``CHAPTER 100--GROUP HEALTH PLAN REQUIREMENTS

                              ``Subchapter A. Requirements relating to 
                                        portability, access, and 
                                        renewability.
                              ``Subchapter B. Other requirements.
                              ``Subchapter C. General provisions.

   ``Subchapter A--Requirements Relating to Portability, Access, and 
                              Renewability

                              ``Sec. 9801. Increased portability 
                                        through limitation on 
                                        preexisting condition 
                                        exclusions.
                              ``Sec. 9802. Prohibiting discrimination 
                                        against individual participants 
                                        and beneficiaries based on 
                                        health status.
                              ``Sec. 9803. Guaranteed renewability in 
                                        multiemployer plans and certain 
                                        multiple employer welfare 
                                        arrangements.'',
            (2) by redesignating sections 9804, 9805, and 9806 as 
        sections 9831, 9832, and 9833, respectively,
            (3) by inserting before section 9831 (as so redesignated) 
        the following:

                   ``Subchapter C--General Provisions

                              ``Sec. 9831. General exceptions.
                              ``Sec. 9832. Definitions.
                              ``Sec. 9833. Regulations.'', and
            (4) by inserting after section 9803 the following:

                   ``Subchapter B--Other Requirements

                              ``Sec. 9811. Assuring equitable coverage 
                                        of emergency services, 
                                        maintenance care, and post-
                                        stabilization care.

``SEC. 9811. ASSURING EQUITABLE COVERAGE OF EMERGENCY SERVICES, 
              MAINTENANCE CARE, AND POST-STABILIZATION CARE.

    ``(a) Prohibition of Certain Restrictions on Coverage of Emergency 
Services.--
            ``(1) In general.--If a group health plan provides any 
        benefits with respect to emergency services (as defined in 
        paragraph (2)(B)), the plan (and any health insurance issuer 
        offering health insurance coverage in connection with such a 
        plan) shall cover emergency services furnished to a participant 
        or beneficiary of the plan--
                    ``(A) without the need for any prior authorization 
                determination,
                    ``(B) subject to paragraph (3), whether or not the 
                physician or provider furnishing such services is a 
                participating physician or provider with respect to 
                such services, and
                    ``(C) subject to paragraph (3), without regard to 
                any other term or condition of such plan or coverage 
                (other than an exclusion of benefits, or an affiliation 
                or waiting period, permitted under section 9801).
            ``(2) Emergency services; emergency medical condition.--For 
        purposes of this section--
                    ``(A) Emergency medical condition based on prudent 
                layperson.--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--
                            ``(i) placing the health of the individual 
                        (or, with respect to a pregnant woman, the 
                        health of the woman or her unborn child) in 
                        serious jeopardy,
                            ``(ii) serious impairment to bodily 
                        functions, or
                            ``(iii) serious dysfunction of any bodily 
                        organ or part.
                    ``(B) Emergency services.--The term `emergency 
                services' means--
                            ``(i) a medical screening examination (as 
                        required under section 1867 of the Social 
                        Security Act) 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 available at the hospital, such 
                        further medical examination and treatment as 
                        are required under section 1867 of the Social 
                        Security Act to stabilize the patient.
                    ``(C) Trauma and burn centers.--The provisions of 
                clause (ii) of subparagraph (B) apply to a trauma or 
                burn center, in a hospital, that--
                            ``(i) is designated by the State, a 
                        regional authority of the State, or by the 
                        designee of the State, or
                            ``(ii) is in a State that has not made such 
                        designations and meets medically recognized 
                        national standards.
            ``(3) Application of network restriction permitted in 
        certain cases.--
                    ``(A) In general.--Except as provided in 
                subparagraph (B), if a group health plan (and an issuer 
                of health insurance coverage in connection with such a 
                plan) denies, limits, or otherwise differentiates in 
                coverage or payment for benefits other than emergency 
                services on the basis that the physician or provider of 
                such services is a nonparticipating physician or 
                provider, the plan and issuer may deny, limit, or 
                differentiate in coverage or payment for emergency 
                services on such basis.
                    ``(B) Network restrictions not permitted in certain 
                exceptional cases.--The denial or limitation of, or 
                differentiation in, coverage or payment of benefits for 
                emergency services under subparagraph (A) shall not 
apply in the following cases:
                            ``(i) Circumstances beyond control of 
                        participant or beneficiary.--The participant or 
                        beneficiary is unable to go to a participating 
                        hospital for such services due to circumstances 
                        beyond the control of the participant or 
                        beneficiary (as determined consistent with 
                        guidelines and subparagraph (C)).
                            ``(ii) Likelihood of an adverse health 
                        consequence based on layperson's judgment.--A 
                        prudent layperson possessing an average 
                        knowledge of health and medicine could 
                        reasonably believe that, under the 
                        circumstances and consistent with guidelines, 
                        the time required to go to a participating 
                        hospital for such services could result in any 
                        of the adverse health consequences described in 
                        a clause of subsection (a)(2)(A).
                            ``(iii) Physician referral.--A 
                        participating physician or other person 
                        authorized by the plan refers the participant 
                        or beneficiary to an emergency department of a 
                        hospital and does not specify an emergency 
                        department of a hospital that is a 
                        participating hospital with respect to such 
                        services.
                    ``(C) Application of `beyond control' standards.--
                For purposes of applying subparagraph (B)(i), receipt 
                of emergency services from a nonparticipating hospital 
                shall be treated under the guidelines as being `due to 
                circumstances beyond the control of the participant or 
                beneficiary' if any of the following conditions are 
                met:
                            ``(i) Unconscious.--The participant or 
                        beneficiary was unconscious or in an otherwise 
                        altered mental state at the time of initiation 
                        of the services.
                            ``(ii) Ambulance delivery.--The participant 
                        or beneficiary was transported by an ambulance 
                        or other emergency vehicle directed by a person 
                        other than the participant or beneficiary to 
                        the nonparticipating hospital in which the 
                        services were provided.
                            ``(iii) Natural disaster.--A natural 
                        disaster or civil disturbance prevented the 
                        participant or beneficiary from presenting to a 
                        participating hospital for the provision of 
                        such services.
                            ``(iv) No good faith effort to inform of 
                        change in participation during a contract 
                        year.--The status of the hospital changed from 
                        a participating hospital to a nonparticipating 
                        hospital with respect to emergency services 
                        during a contract year and the plan or issuer 
                        failed to make a good faith effort to notify 
                        the participant or beneficiary involved of such 
                        change.
                            ``(v) Other conditions.--There were other 
                        factors (such as those identified in 
                        guidelines) that prevented the participant or 
                        beneficiary from controlling selection of the 
                        hospital in which the services were provided.
    ``(b) Assuring Coordinated Coverage of Maintenance Care and Post-
Stabilization Care.--
            ``(1) In general.--In the case of a participant or 
        beneficiary who is covered under a group health plan (or under 
        health insurance coverage issued by a health insurance issuer 
        offered in connection with such a plan) and who has received 
        emergency services pursuant to a screening evaluation conducted 
        (or supervised) by a treating physician at a hospital that is a 
        nonparticipating provider with respect to emergency services, 
        if--
                    ``(A) pursuant to such evaluation, the physician 
                identifies post-stabilization care (as defined in 
                paragraph (3)(B)) that is required by the participant 
                or beneficiary,
                    ``(B) the plan or coverage provides benefits with 
                respect to the care so identified and the plan requires 
                (but for this subsection) an affirmative prior 
                authorization determination as a condition of coverage 
                of such care, and
                    ``(C) the treating physician (or another individual 
                acting on behalf of such physician) initiates, not 
                later than 30 minutes after the time the treating 
                physician determines that the condition of the 
                participant or beneficiary is stabilized, a good faith 
                effort to contact a physician or other person 
                authorized by the plan or issuer (by telephone or other 
                means) to obtain an affirmative prior authorization 
                determination with respect to the care,
        then, without regard to terms and conditions specified in 
        paragraph (2) the plan or issuer shall cover maintenance care 
        (as defined in paragraph (3)(A)) furnished to the participant 
        or beneficiary during the period specified in paragraph (4) and 
        shall cover post-stabilization care furnished to the 
        participant or beneficiary during the period beginning under 
        paragraph (5) and ending under paragraph (6).
            ``(2) Terms and conditions waived.--The terms and 
        conditions (of a plan or coverage) described in this paragraph 
        that are waived under paragraph (1) are as follows:
                    ``(A) The need for any prior authorization 
                determination.
                    ``(B) Any limitation on coverage based on whether 
                or not the physician or provider furnishing the care is 
                a participating physician or provider with respect to 
                such care.
                    ``(C) Any other term or condition of the plan or 
                coverage (other than an exclusion of benefits, or an 
                affiliation or waiting period, permitted under section 
                9801 and other than a requirement relating to medical 
                necessity for coverage of benefits).
            ``(3) Maintenance care and post-stabilization care 
        defined.--In this subsection:
                    ``(A) Maintenance care.--The term `maintenance 
                care' means, with respect to an individual who is 
                stabilized after provision of emergency services, 
                medically necessary items and services (other than 
                emergency services) that are required by the individual 
                to ensure that the individual remains stabilized during 
                the period described in paragraph (4).
                    ``(B) Post-stabilization care.--The term `post-
                stabilization care' means, with respect to an 
                individual who is determined to be stable pursuant to a 
                medical screening examination or who is stabilized 
                after provision of emergency services, medically 
                necessary items and services (other than emergency 
                services and other than maintenance care) that are 
                required by the individual.
            ``(4) Period of required coverage of maintenance care.--The 
        period of required coverage of maintenance care of an 
        individual under this subsection begins at the time of the 
        request (or the initiation of the good faith effort to make the 
        request) under paragraph (1)(C) and ends when--
                    ``(A) the individual is discharged from the 
                hospital;
                    ``(B) a physician (designated by the plan or issuer 
                involved) and with privileges at the hospital involved 
                arrives at the emergency department of the hospital and 
                assumes responsibility with respect to the treatment of 
                the individual; or
                    ``(C) the treating physician and the plan or issuer 
                agree to another arrangement with respect to the care 
                of the individual.
            ``(5) When post-stabilization care required to be 
        covered.--
                    ``(A) When treating physician unable to communicate 
                request.--If the treating physician or other individual 
                makes the good faith effort to request authorization 
                under paragraph (1)(C) but is unable to communicate the 
                request directly with an authorized person referred to 
                in such paragraph within 30 minutes after the time of 
                initiating such effort, then post-stabilization care is 
                required to be covered under this subsection beginning 
                at the end of such 30-minute period.
                    ``(B) When able to communicate request, and no 
                timely response.--
                            ``(i) In general.--If the treating 
                        physician or other individual under paragraph 
                        (1)(C) is able to communicate the request 
                        within the 30-minute period described in 
                        subparagraph (A), the post-stabilization care 
                        requested is required to be covered under this 
                        subsection beginning 30 minutes after the time 
                        when the plan or issuer receives the request 
                        unless a person authorized by the plan or 
                        issuer involved communicates (or makes a good 
                        faith effort to communicate) a denial of the 
                        request for the prior authorization 
                        determination within 30 minutes of the time 
                        when the plan or issuer receives the request 
                        and the treating physician does not request 
                        under clause (ii) to communicate directly with 
                        an authorized physician concerning the denial.
                            ``(ii) Request for direct physician-to-
                        physician communication concerning denial.--If 
                        a denial of a request is communicated under 
                        clause (i), the treating physician may request 
                        to communicate respecting the denial directly 
                        with a physician who is authorized by the plan 
                        or issuer to deny or affirm such a denial.
                    ``(C) When no timely response to request for 
                physician-to-physician communication.--If a request for 
                physician-to-physician communication is made under 
                subparagraph (B)(ii), the post-stabilization care 
                requested is required to be covered under this 
                subsection beginning 30 minutes after the time when the 
                plan or issuer receives the request from a treating 
                physician unless a physician, who is authorized by the 
                plan or issuer to reverse or affirm the initial denial 
                of the care, communicates (or makes a good faith effort 
                to communicate) directly with the treating physician 
                within such 30-minute period.
                    ``(D) Disagreements over post-stabilization care.--
                If, after a direct physician-to-physician communication 
                under subparagraph (C), the denial of the request for 
                the post-stabilization care is not reversed and the 
                treating physician communicates to the plan or issuer 
                involved a disagreement with such decision, the post-
                stabilization care requested is required to be covered 
                under this subsection beginning as follows:
                            ``(i) Delay to allow for prompt arrival of 
                        physician assuming responsibility.--If the plan 
                        or issuer communicates that a physician 
                        (designated by the plan or issuer) with 
                        privileges at the hospital involved will arrive 
                        promptly (as determined under guidelines) at 
                        the emergency department of the hospital in 
                        order to assume responsibility with respect to 
                        the treatment of the participant or beneficiary 
                        involved, the required coverage of the post-
                        stabilization care begins after the passage of 
                        such time period as would allow the prompt 
                        arrival of such a physician.
                            ``(ii) Other cases.--If the plan or issuer 
                        does not so communicate, the required coverage 
                        of the post-stabilization care begins 
                        immediately.
            ``(6) No requirement of coverage of post-stabilization care 
        if alternate plan of treatment.--
                    ``(A) In general.--Coverage of post-stabilization 
                care is not required under this subsection with respect 
                to an individual when--
                            ``(i) subject to subparagraph (B), a 
                        physician (designated by the plan or issuer 
                        involved) and with privileges at the hospital 
                        involved arrives at the emergency department of 
                        the hospital and assumes responsibility with 
                        respect to the treatment of the individual; or
                            ``(ii) the treating physician and the plan 
                        or issuer agree to another arrangement with 
                        respect to the post-stabilization care (such as 
                        an appropriate transfer of the individual 
                        involved to another facility or an appointment 
                        for timely followup treatment for the 
                        individual).
                    ``(B) Special rule where once care initiated.--
                Required coverage of requested post-stabilization care 
                shall not end by reason of subparagraph (A)(i) during 
                an episode of care (as determined by guidelines) if the 
                treating physician initiated such care (consistent with 
                a previous paragraph) before the arrival of a physician 
                described in such subparagraph.
            ``(7) Construction.--Nothing in this subsection shall be 
        construed as--
                    ``(A) preventing a plan or issuer from authorizing 
                coverage of maintenance care or post-stabilization care 
                in advance or at any time; or
                    ``(B) preventing a treating physician or other 
                individual described in paragraph (1)(C) and a plan or 
                issuer from agreeing to modify any of the time periods 
                specified in paragraphs (5) as it relates to cases 
                involving such persons.
    ``(c) Limits on Cost-Sharing for Services Furnished in Emergency 
Departments.--If a group health plan provides any benefits with respect 
to emergency services, the plan (or a health insurance issuer offering 
health insurance coverage in connection with such a plan) may impose 
cost sharing with respect to such services only if the following 
conditions are met:
            ``(1) Limitations on cost-sharing differential for 
        nonparticipating providers.--
                    ``(A) No differential for certain services.--In the 
                case of services furnished under the circumstances 
                described in clause (i), (ii), or (iii) of subsection 
                (a)(3)(B) (relating to circumstances beyond the control 
                of the beneficiary, the likelihood of an adverse health 
                consequence based on layperson's judgment, and 
                physician referral), the cost-sharing for such services 
                provided by a nonparticipating provider or physician 
                does not exceed the cost-sharing for such services 
                provided by a participating provider or physician.
                    ``(B) Only reasonable differential for other 
                services.--In the case of other emergency services, any 
                differential by which the cost-sharing for such 
                services provided by a nonparticipating provider or 
                physician exceeds the cost-sharing for such services 
                provided by a participating provider or physician is 
                reasonable (as determined under guidelines).
            ``(2) Only reasonable differential between emergency 
        services and other services.--Any differential by which the 
        cost-sharing for services furnished in an emergency department 
        exceeds the cost-sharing for such services furnished in another 
        setting is reasonable (as determined under guidelines).
            ``(3) Construction.--Nothing in paragraph (1)(B) or (2) 
        shall be construed as authorizing guidelines other than 
        guidelines that establish maximum cost-sharing differentials.
    ``(d) Information on Access to Emergency Services.--A group health 
plan (or a health insurance issuer, to the extent a health insurance 
issuer offers group health insurance coverage in connection with such a 
plan) shall provide education to participants and beneficiaries of the 
plan on--
            ``(1) coverage of emergency services (as defined in 
        subsection (a)(2)(B)) by the plan in accordance with the 
        provisions of this section,
            ``(2) the appropriate use of emergency services, including 
        use of the 911 telephone system or its local equivalent,
            ``(3) any cost sharing applicable to emergency services,
            ``(4) the process and procedures of the plan for obtaining 
        emergency services, and
            ``(5) the locations of--
                    ``(A) emergency departments, and
                    ``(B) other settings,
        in which participating physicians and hospitals provide 
        emergency services and post-stabilization care.
    ``(e) General Definitions.--For purposes of this section:
            ``(1) Cost sharing.--The term `cost sharing' means any 
        deductible, coinsurance amount, copayment or other out-of-
        pocket payment (other than premiums or enrollment fees) that a 
        group health plan (or a health insurance issuer offering group 
        health insurance issuer in connection with such a plan) imposes 
        on participants and beneficiaries of the plan with respect to 
        the coverage of benefits.
            ``(2) Good faith effort.--The term `good faith effort' has 
        the meaning given such term in guidelines and requires such 
        appropriate documentation as is specified under such 
        guidelines.
            ``(3) Guidelines.--The term `guidelines' means guidelines 
        established in accordance with section 7 of the Access to 
        Emergency Medical Services Act of 1997.
            ``(4) Nonparticipating physician or provider.--The term 
        `nonparticipating physician or provider' means, with respect to 
        health care items and services furnished to a participant or 
        beneficiary of a group health plan, a physician or provider 
        that is not a participating physician or provider for such 
        services.
            ``(5) Participating physician or provider.--The term 
        `participating physician or provider' means, with respect to 
        health care items and services furnished to a participant or 
        beneficiary of a group health plan, a physician or provider 
        that furnishes such items and services under a contract or 
        other arrangement with such plan (or with a health insurance 
        issuer offering group health insurance coverage in connection 
        with such a plan).
            ``(6) Prior authorization determination.--The term `prior 
        authorization determination' means, with respect to items and 
        services for which coverage may be provided under a group 
        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) of whether or not such items and 
        services will be covered under the plan.
            ``(7) Stabilize.--The term `to stabilize' means, with 
        respect to an emergency medical condition, to provide (in 
        complying with section 1867 of the Social Security Act) such 
        medical treatment of the condition as may be necessary to 
        assure, within reasonable medical probability, that no material 
        deterioration of the condition is likely to result from or 
        occur during the transfer of the individual from the facility.
            ``(8) Stabilized.--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 from or occur before an 
        individual can be transferred from the facility, in compliance 
        with the requirements of section 1867 of the Social Security 
        Act.
            ``(9) Treating physician.--The term `treating physician' 
        includes a treating health care professional who is licensed 
        under State law to provide emergency services other than under 
        the supervision of a physician.''
    (b) Conforming Amendments.--
            (1) Chapter 100 of such Code (as added by section 401 of 
        the Health Insurance Portability and Accountability Act of 1996 
        and as previously amended by this section) is further amended--
                    (A) in the last sentence of section 9801(c)(1), by 
                striking ``section 9805(c)'' and inserting ``section 
                9832(c)'';
                    (B) in section 9831(b), by striking ``9805(c)(1)'' 
                and inserting ``9832(c)(1)'';
                    (C) in section 9831(c)(1), by striking 
                ``9805(c)(2)'' and inserting ``9832(c)(2)'';
                    (D) in section 9831(c)(2), by striking 
                ``9805(c)(3)'' and inserting ``9832(c)(3)''; and
                    (E) in section 9831(c)(3), by striking 
                ``9805(c)(4)'' and inserting ``9832(c)(4)''.
            (2) Section 4980D of such Code (as added by section 402 of 
        the Health Insurance Portability and Accountability Act of 
        1996) is amended--
                    (A) in subsection (c)(3)(B)(i)(I), by striking 
                ``9805(d)(3)'' and inserting ``9832(d)(3)'';
                    (B) in subsection (d)(1), by inserting ``(other 
                than a failure attributable to section 9811)'' after 
                ``on any failure'';
                    (C) in subsection (d)(3), by striking ``9805'' and 
                inserting ``9832'';
                    (D) in subsection (f)(1), by striking ``9805(a)'' 
                and inserting ``9832(a)''.
            (3) The table of subtitles for such Code is amended by 
        striking the item relating to subtitle K (as added by section 
        401(b) of the Health Insurance Portability and Accountability 
        Act of 1996) and inserting the following new item:

                              ``Subtitle K. Group health plan 
                                        requirements.''
    (c) Effective Date.--(1) Subject to paragraph (2), the amendments 
made by this section shall apply to group health plans for plan years 
beginning on or after 18 months after the date of the enactment of this 
Act.
    (2) 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 enactment of this 
Act, the amendments made by this section shall not apply to plan years 
beginning before the later of--
            (A) the date on which the last collective bargaining 
        agreements relating to the plan terminates (determined without 
        regard to any extension thereof agreed to after the date of 
        enactment of this Act), or
            (B) 18 months after the date of the enactment of this Act.
For purposes of subparagraph (A), any plan amendment made pursuant to a 
collective bargaining agreement relating to the plan which amends the 
plan solely to conform to any requirement added by this section shall 
not be treated as a termination of such collective bargaining 
agreement.

SEC. 3. AMENDMENTS TO 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. 713. ASSURING EQUITABLE COVERAGE OF EMERGENCY SERVICES, 
              MAINTENANCE CARE, AND POST-STABILIZATION CARE.

    ``(a) Prohibition of Certain Restrictions on Coverage of Emergency 
Services.--
            ``(1) In general.--If a group health plan provides any 
        benefits with respect to emergency services (as defined in 
        paragraph (2)(B)), the plan (and any health insurance issuer 
        offering health insurance coverage in connection with such a 
        plan) shall cover emergency services furnished to a participant 
        or beneficiary of the plan--
                    ``(A) without the need for any prior authorization 
                determination,
                    ``(B) subject to paragraph (3), whether or not the 
                physician or provider furnishing such services is a 
                participating physician or provider with respect to 
                such services, and
                    ``(C) subject to paragraph (3), without regard to 
                any other term or condition of such plan or coverage 
                (other than an exclusion of benefits, or an affiliation 
                or waiting period, permitted under section 701).
            ``(2) Emergency services; emergency medical condition.--For 
        purposes of this section--
                    ``(A) Emergency medical condition based on prudent 
                layperson.--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--
                            ``(i) placing the health of the individual 
                        (or, with respect to a pregnant woman, the 
                        health of the woman or her unborn child) in 
                        serious jeopardy,
                            ``(ii) serious impairment to bodily 
                        functions, or
                            ``(iii) serious dysfunction of any bodily 
                        organ or part.
                    ``(B) Emergency services.--The term `emergency 
                services' means--
                            ``(i) a medical screening examination (as 
                        required under section 1867 of the Social 
                        Security Act) 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 available at the hospital, such 
                        further medical examination and treatment as 
                        are required under section 1867 of the Social 
                        Security Act to stabilize the patient.
                    ``(C) Trauma and burn centers.--The provisions of 
                clause (ii) of subparagraph (B) apply to a trauma or 
                burn center, in a hospital, that--
                            ``(i) is designated by the State, a 
                        regional authority of the State, or by the 
                        designee of the State, or
                            ``(ii) is in a State that has not made such 
                        designations and meets medically recognized 
                        national standards.
            ``(3) Application of network restriction permitted in 
        certain cases.--
                    ``(A) In general.--Except as provided in 
                subparagraph (B), if a group health plan (and an issuer 
                of health insurance coverage in connection with such a 
                plan) denies, limits, or otherwise differentiates in 
                coverage or payment for benefits other than emergency 
                services on the basis that the physician or provider of 
                such services is a nonparticipating physician or 
                provider, the plan and issuer may deny, limit, or 
                differentiate in coverage or payment for emergency 
                services on such basis.
                    ``(B) Network restrictions not permitted in certain 
                exceptional cases.--The denial or limitation of, or 
                differentiation in, coverage or payment of benefits for 
                emergency services under subparagraph (A) shall not 
                apply in the following cases:
                            ``(i) Circumstances beyond control of 
                        participant or beneficiary.--The participant or 
                        beneficiary is unable to go to a participating 
                        hospital for such services due to circumstances 
                        beyond the control of the participant or 
                        beneficiary (as determined consistent with 
                        guidelines and subparagraph (C)).
                            ``(ii) Likelihood of an adverse health 
                        consequence based on layperson's judgment.--A 
                        prudent layperson possessing an average 
                        knowledge of health and medicine could 
reasonably believe that, under the circumstances and consistent with 
guidelines, the time required to go to a participating hospital for 
such services could result in any of the adverse health consequences 
described in a clause of subsection (a)(2)(A).
                            ``(iii) Physician referral.--A 
                        participating physician or other person 
                        authorized by the plan refers the participant 
                        or beneficiary to an emergency department of a 
                        hospital and does not specify an emergency 
                        department of a hospital that is a 
                        participating hospital with respect to such 
                        services.
                    ``(C) Application of `beyond control' standards.--
                For purposes of applying subparagraph (B)(i), receipt 
                of emergency services from a nonparticipating hospital 
                shall be treated under the guidelines as being `due to 
                circumstances beyond the control of the participant or 
                beneficiary' if any of the following conditions are 
                met:
                            ``(i) Unconscious.--The participant or 
                        beneficiary was unconscious or in an otherwise 
                        altered mental state at the time of initiation 
                        of the services.
                            ``(ii) Ambulance delivery.--The participant 
                        or beneficiary was transported by an ambulance 
                        or other emergency vehicle directed by a person 
                        other than the participant or beneficiary to 
                        the nonparticipating hospital in which the 
                        services were provided.
                            ``(iii) Natural disaster.--A natural 
                        disaster or civil disturbance prevented the 
                        participant or beneficiary from presenting to a 
                        participating hospital for the provision of 
                        such services.
                            ``(iv) No good faith effort to inform of 
                        change in participation during a contract 
                        year.--The status of the hospital changed from 
                        a participating hospital to a nonparticipating 
                        hospital with respect to emergency services 
                        during a contract year and the plan or issuer 
                        failed to make a good faith effort to notify 
                        the participant or beneficiary involved of such 
                        change.
                            ``(v) Other conditions.--There were other 
                        factors (such as those identified in 
                        guidelines) that prevented the participant or 
                        beneficiary from controlling selection of the 
                        hospital in which the services were provided.
    ``(b) Assuring Coordinated Coverage of Maintenance Care and Post-
Stabilization Care.--
            ``(1) In general.--In the case of a participant or 
        beneficiary who is covered under a group health plan (or under 
        health insurance coverage issued by a health insurance issuer 
        offered in connection with such a plan) and who has received 
        emergency services pursuant to a screening evaluation conducted 
        (or supervised) by a treating physician at a hospital that is a 
        nonparticipating provider with respect to emergency services, 
        if--
                    ``(A) pursuant to such evaluation, the physician 
                identifies post-stabilization care (as defined in 
                paragraph (3)(B)) that is required by the participant 
                or beneficiary,
                    ``(B) the plan or coverage provides benefits with 
                respect to the care so identified and the plan requires 
                (but for this subsection) an affirmative prior 
                authorization determination as a condition of coverage 
                of such care, and
                    ``(C) the treating physician (or another individual 
                acting on behalf of such physician) initiates, not 
                later than 30 minutes after the time the treating 
                physician determines that the condition of the 
                participant or beneficiary is stabilized, a good faith 
                effort to contact a physician or other person 
                authorized by the plan or issuer (by telephone or other 
                means) to obtain an affirmative prior authorization 
                determination with respect to the care,
        then, without regard to terms and conditions specified in 
        paragraph (2) the plan or issuer shall cover maintenance care 
        (as defined in paragraph (3)(A)) furnished to the participant 
        or beneficiary during the period specified in paragraph (4) and 
        shall cover post-stabilization care furnished to the 
        participant or beneficiary during the period beginning under 
        paragraph (5) and ending under paragraph (6).
            ``(2) Terms and conditions waived.--The terms and 
        conditions (of a plan or coverage) described in this paragraph 
        that are waived under paragraph (1) are as follows:
                    ``(A) The need for any prior authorization 
                determination.
                    ``(B) Any limitation on coverage based on whether 
                or not the physician or provider furnishing the care is 
                a participating physician or provider with respect to 
                such care.
                    ``(C) Any other term or condition of the plan or 
                coverage (other than an exclusion of benefits, or an 
                affiliation or waiting period, permitted under section 
                701 and other than a requirement relating to medical 
                necessity for coverage of benefits).
            ``(3) Maintenance care and post-stabilization care 
        defined.--In this subsection:
                    ``(A) Maintenance care.--The term `maintenance 
                care' means, with respect to an individual who is 
                stabilized after provision of emergency services, 
                medically necessary items and services (other than 
                emergency services) that are required by the individual 
                to ensure that the individual remains stabilized during 
                the period described in paragraph (4).
                    ``(B) Post-stabilization care.--The term `post-
                stabilization care' means, with respect to an 
                individual who is determined to be stable pursuant to a 
                medical screening examination or who is stabilized 
                after provision of emergency services, medically 
                necessary items and services (other than emergency 
                services and other than maintenance care) that are 
                required by the individual.
            ``(4) Period of required coverage of maintenance care.--The 
        period of required coverage of maintenance care of an 
        individual under this subsection begins at the time of the 
        request (or the initiation of the good faith effort to make the 
        request) under paragraph (1)(C) and ends when--
                    ``(A) the individual is discharged from the 
                hospital;
                    ``(B) a physician (designated by the plan or issuer 
                involved) and with privileges at the hospital involved 
                arrives at the emergency department of the hospital and 
                assumes responsibility with respect to the treatment of 
                the individual; or
                    ``(C) the treating physician and the plan or issuer 
                agree to another arrangement with respect to the care 
                of the individual.
            ``(5) When post-stabilization care required to be 
        covered.--
                    ``(A) When treating physician unable to communicate 
                request.--If the treating physician or other individual 
                makes the good faith effort to request authorization 
                under paragraph (1)(C) but is unable to communicate the 
                request directly with an authorized person referred to 
                in such paragraph within 30 minutes after the time of 
                initiating such effort, then post-stabilization care is 
                required to be covered under this subsection beginning 
                at the end of such 30-minute period.
                    ``(B) When able to communicate request, and no 
                timely response.--
                            ``(i) In general.--If the treating 
                        physician or other individual under paragraph 
                        (1)(C) is able to communicate the request 
                        within the 30-minute period described in 
                        subparagraph (A), the post-stabilization care 
                        requested is required to be covered under this 
                        subsection beginning 30 minutes after the time 
                        when the plan or issuer receives the request 
                        unless a person authorized by the plan or 
                        issuer involved communicates (or makes a good 
                        faith effort to communicate) a denial of the 
                        request for the prior authorization 
                        determination within 30 minutes of the time 
                        when the plan or issuer receives the request 
                        and the treating physician does not request 
                        under clause (ii) to communicate directly with 
                        an authorized physician concerning the denial.
                            ``(ii) Request for direct physician-to-
                        physician communication concerning denial.--If 
                        a denial of a request is communicated under 
                        clause (i), the treating physician may request 
                        to communicate respecting the denial directly 
                        with a physician who is authorized by the plan 
                        or issuer to deny or affirm such a denial.
                    ``(C) When no timely response to request for 
                physician-to-physician communication.--If a request for 
                physician-to-physician communication is made under 
                subparagraph (B)(ii), the post-stabilization care 
                requested is required to be covered under this 
                subsection beginning 30 minutes after the time when the 
                plan or issuer receives the request from a treating 
                physician unless a physician, who is authorized by the 
                plan or issuer to reverse or affirm the initial denial 
                of the care, communicates (or makes a good faith effort 
                to communicate) directly with the treating physician 
                within such 30-minute period.
                    ``(D) Disagreements over post-stabilization care.--
                If, after a direct physician-to-physician communication 
                under subparagraph (C), the denial of the request for 
                the post-stabilization care is not reversed and the 
                treating physician communicates to the plan or issuer 
                involved a disagreement with such decision, the post-
                stabilization care requested is required to be covered 
                under this subsection beginning as follows:
                            ``(i) Delay to allow for prompt arrival of 
                        physician assuming responsibility.--If the plan 
                        or issuer communicates that a physician 
                        (designated by the plan or issuer) with 
                        privileges at the hospital involved will arrive 
                        promptly (as determined under guidelines) at 
                        the emergency department of the hospital in 
                        order to assume responsibility with respect to 
                        the treatment of the participant or beneficiary 
                        involved, the required coverage of the post-
                        stabilization care begins after the passage of 
                        such time period as would allow the prompt 
                        arrival of such a physician.
                            ``(ii) Other cases.--If the plan or issuer 
                        does not so communicate, the required coverage 
                        of the post-stabilization care begins 
                        immediately.
            ``(6) No requirement of coverage of post-stabilization care 
        if alternate plan of treatment.--
                    ``(A) In general.--Coverage of post-stabilization 
                care is not required under this subsection with respect 
                to an individual when--
                            ``(i) subject to subparagraph (B), a 
                        physician (designated by the plan or issuer 
                        involved) and with privileges at the hospital 
                        involved arrives at the emergency department of 
                        the hospital and assumes responsibility with 
                        respect to the treatment of the individual; or
                            ``(ii) the treating physician and the plan 
                        or issuer agree to another arrangement with 
                        respect to the post-stabilization care (such as 
                        an appropriate transfer of the individual 
                        involved to another facility  or an appointment 
for timely followup treatment for the individual).
                    ``(B) Special rule where once care initiated.--
                Required coverage of requested post-stabilization care 
                shall not end by reason of subparagraph (A)(i) during 
                an episode of care (as determined by guidelines) if the 
                treating physician initiated such care (consistent with 
                a previous paragraph) before the arrival of a physician 
                described in such subparagraph.
            ``(7) Construction.--Nothing in this subsection shall be 
        construed as--
                    ``(A) preventing a plan or issuer from authorizing 
                coverage of maintenance care or post-stabilization care 
                in advance or at any time; or
                    ``(B) preventing a treating physician or other 
                individual described in paragraph (1)(C) and a plan or 
                issuer from agreeing to modify any of the time periods 
                specified in paragraphs (5) as it relates to cases 
                involving such persons.
    ``(c) Limits on Cost-Sharing for Services Furnished in Emergency 
Departments.--If a group health plan provides any benefits with respect 
to emergency services, the plan (or a health insurance issuer offering 
health insurance coverage in connection with such a plan) may impose 
cost sharing with respect to such services only if the following 
conditions are met:
            ``(1) Limitations on cost-sharing differential for 
        nonparticipating providers.--
                    ``(A) No differential for certain services.--In the 
                case of services furnished under the circumstances 
                described in clause (i), (ii), or (iii) of subsection 
                (a)(3)(B) (relating to circumstances beyond the control 
                of the beneficiary, the likelihood of an adverse health 
                consequence based on layperson's judgment, and 
                physician referral), the cost-sharing for such services 
                provided by a nonparticipating provider or physician 
                does not exceed the cost-sharing for such services 
                provided by a participating provider or physician.
                    ``(B) Only reasonable differential for other 
                services.--In the case of other emergency services, any 
                differential by which the cost-sharing for such 
                services provided by a nonparticipating provider or 
                physician exceeds the cost-sharing for such services 
                provided by a participating provider or physician is 
                reasonable (as determined under guidelines).
            ``(2) Only reasonable differential between emergency 
        services and other services.--Any differential by which the 
        cost-sharing for services furnished in an emergency department 
        exceeds the cost-sharing for such services furnished in another 
        setting is reasonable (as determined under guidelines).
            ``(3) Construction.--Nothing in paragraph (1)(B) or (2) 
        shall be construed as authorizing guidelines other than 
        guidelines that establish maximum cost-sharing differentials.
    ``(d) Information on Access to Emergency Services.--A group health 
plan (or a health insurance issuer, to the extent a health insurance 
issuer offers group health insurance coverage in connection with such a 
plan) shall provide education to participants and beneficiaries of the 
plan on--
            ``(1) coverage of emergency services (as defined in 
        subsection (a)(2)(B)) by the plan in accordance with the 
        provisions of this section,
            ``(2) the appropriate use of emergency services, including 
        use of the 911 telephone system or its local equivalent,
            ``(3) any cost sharing applicable to emergency services,
            ``(4) the process and procedures of the plan for obtaining 
        emergency services, and
            ``(5) the locations of--
                    ``(A) emergency departments, and
                    ``(B) other settings,
        in which participating physicians and hospitals provide 
        emergency services and post-stabilization care.
    ``(e) General Definitions.--For purposes of this section:
            ``(1) Cost sharing.--The term `cost sharing' means any 
        deductible, coinsurance amount, copayment or other out-of-
        pocket payment (other than premiums or enrollment fees) that a 
        group health plan (or a health insurance issuer offering group 
        health insurance issuer in connection with such a plan) imposes 
        on participants and beneficiaries of the plan with respect to 
        the coverage of benefits.
            ``(2) Good faith effort.--The term `good faith effort' has 
        the meaning given such term in guidelines and requires such 
        appropriate documentation as is specified under such 
        guidelines.
            ``(3) Guidelines.--The term `guidelines' means guidelines 
        established in accordance with section 7 of the Access to 
        Emergency Medical Services Act of 1997.
            ``(4) Nonparticipating physician or provider.--The term 
        `nonparticipating physician or provider' means, with respect to 
        health care items and services furnished to a participant or 
        beneficiary of a group health plan, a physician or provider 
        that is not a participating physician or provider for such 
        services.
            ``(5) Participating physician or provider.--The term 
        `participating physician or provider' means, with respect to 
        health care items and services furnished to a participant or 
        beneficiary of a group health plan, a physician or provider 
        that furnishes such items and services under a contract or 
        other arrangement with such plan (or with a health insurance 
        issuer offering group health insurance coverage in connection 
        with such a plan).
            ``(6) Prior authorization determination.--The term `prior 
        authorization determination' means, with respect to items and 
        services for which coverage may be provided under a group 
        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) of whether or not such items and 
        services will be covered under the plan.
            ``(7) Stabilize.--The term `to stabilize' means, with 
        respect to an emergency medical condition, to provide (in 
        complying with section 1867 of the Social Security Act) such 
        medical treatment of the condition as may be necessary to 
        assure, within reasonable medical probability, that no material 
        deterioration of the condition is likely to result from or 
        occur during the transfer of the individual from the facility.
            ``(8) Stabilized.--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 from or occur before an 
        individual can be transferred from the facility, in compliance 
        with the requirements of section 1867 of the Social Security 
        Act.
            ``(9) Treating physician.--The term `treating physician' 
        includes a treating health care professional who is licensed 
        under State law to provide emergency services other than under 
        the supervision of a physician.
    ``(f) Continued Applicability of State Law With Respect to Health 
Insurance Issuers.--The provisions of section 731(a) (relating to State 
authority to provide for standards and requirements for health 
insurance issuers to the extent the standards and requirements do not 
prevent the application of a requirement of this part) apply with 
respect to the requirements of this section.''.
    (b) Conforming Amendments.--
            (1) Section 731(c) of such Act (29 U.S.C. 1191(c)), as 
        amended by section 603(b)(1) of Public Law 104-204, is amended 
        by striking ``section 711'' and inserting ``sections 711 and 
        713''.
            (2) Section 732(a) of such Act (29 U.S.C. 1191a(a)), as 
        amended by section 603(b)(2) of Public Law 104-204, is amended 
        by striking ``section 711'' and inserting ``sections 711 and 
        713''.
            (3) The table of contents in section 1 of such Act is 
        amended by inserting after the item relating to section 712 the 
        following new item:

``Sec. 713. Assuring equitable coverage of emergency services, 
                            maintenance care, and post-stabilization 
                            care.''.
    (c) Effective Date.--(1) Subject to paragraph (2), the amendments 
made by this section shall apply to group health plans for plan years 
beginning on or after the date that is 18 months after the date of the 
enactment of this Act.
    (2) 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 enactment of this 
Act, the amendments made by this section shall not apply to plan years 
beginning before the later of--
            (A) the date on which the last collective bargaining 
        agreements relating to the plan terminates (determined without 
        regard to any extension thereof agreed to after the date of 
        enactment of this Act), or
            (B) 18 months after the date of the enactment of this Act.
For purposes of subparagraph (A), any plan amendment made pursuant to a 
collective bargaining agreement relating to the plan which amends the 
plan solely to conform to any requirement added by this section shall 
not be treated as a termination of such collective bargaining 
agreement.

SEC. 4. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT RELATING TO THE 
              GROUP MARKET.

    (a) In General.--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. 2706. ASSURING EQUITABLE COVERAGE OF EMERGENCY SERVICES, 
              MAINTENANCE CARE, AND POST-STABILIZATION CARE.

    ``(a) Prohibition of Certain Restrictions on Coverage of Emergency 
Services.--
            ``(1) In general.--If a group health plan provides any 
        benefits with respect to emergency services (as defined in 
        paragraph (2)(B)), the plan (and any health insurance issuer 
        offering health insurance coverage in connection with such a 
        plan) shall cover emergency services furnished to a participant 
        or beneficiary of the plan--
                    ``(A) without the need for any prior authorization 
                determination,
                    ``(B) subject to paragraph (3), whether or not the 
                physician or provider furnishing such services is a 
                participating physician or provider with respect to 
                such services, and
                    ``(C) subject to paragraph (3), without regard to 
                any other term or condition of such plan or coverage 
                (other than an exclusion of benefits, or an affiliation 
                or waiting period, permitted under section 2701).
            ``(2) Emergency services; emergency medical condition.--For 
        purposes of this section--
                    ``(A) Emergency medical condition based on prudent 
                layperson.--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--
                            ``(i) placing the health of the individual 
                        (or, with respect to a pregnant woman, the 
                        health of the woman or her unborn child) in 
                        serious jeopardy,
                            ``(ii) serious impairment to bodily 
                        functions, or
                            ``(iii) serious dysfunction of any bodily 
                        organ or part.
                    ``(B) Emergency services.--The term `emergency 
                services' means--
                            ``(i) a medical screening examination (as 
                        required under section 1867 of the Social 
                        Security Act) 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 available at the hospital, such 
                        further medical examination and treatment as 
                        are required under section 1867 of the Social 
                        Security Act to stabilize the patient.
                    ``(C) Trauma and burn centers.--The provisions of 
                clause (ii) of subparagraph (B) apply to a trauma or 
                burn center, in a hospital, that--
                            ``(i) is designated by the State, a 
                        regional authority of the State, or by the 
                        designee of the State, or
                            ``(ii) is in a State that has not made such 
                        designations and meets medically recognized 
                        national standards.
            ``(3) Application of network restriction permitted in 
        certain cases.--
                    ``(A) In general.--Except as provided in 
                subparagraph (B), if a group health plan (and an issuer 
                of health insurance coverage in connection with such a 
                plan) denies, limits, or otherwise differentiates in 
                coverage or payment for benefits other than emergency 
                services on the basis that the physician or provider of 
                such services is a nonparticipating physician or 
                provider, the plan and issuer may deny, limit, or 
                differentiate in coverage or payment for emergency 
                services on such basis.
                    ``(B) Network restrictions not permitted in certain 
                exceptional cases.--The denial or limitation of, or 
                differentiation in, coverage or payment of benefits for 
                emergency services under subparagraph (A) shall not 
                apply in the following cases:
                            ``(i) Circumstances beyond control of 
                        participant or beneficiary.--The participant or 
                        beneficiary is unable to go to a participating 
                        hospital for such services due to circumstances 
                        beyond the control of the participant or 
                        beneficiary (as determined consistent with 
                        guidelines and subparagraph (C)).
                            ``(ii) Likelihood of an adverse health 
                        consequence based on layperson's judgment.--A 
                        prudent layperson possessing an average 
                        knowledge of health and medicine could 
reasonably believe that, under the circumstances and consistent with 
guidelines, the time required to go to a participating hospital for 
such services could result in any of the adverse health consequences 
described in a clause of subsection (a)(2)(A).
                            ``(iii) Physician referral.--A 
                        participating physician or other person 
                        authorized by the plan refers the participant 
                        or beneficiary to an emergency department of a 
                        hospital and does not specify an emergency 
                        department of a hospital that is a 
                        participating hospital with respect to such 
                        services.
                    ``(C) Application of `beyond control' standards.--
                For purposes of applying subparagraph (B)(i), receipt 
                of emergency services from a nonparticipating hospital 
                shall be treated under the guidelines as being `due to 
                circumstances beyond the control of the participant or 
                beneficiary' if any of the following conditions are 
                met:
                            ``(i) Unconscious.--The participant or 
                        beneficiary was unconscious or in an otherwise 
                        altered mental state at the time of initiation 
                        of the services.
                            ``(ii) Ambulance delivery.--The participant 
                        or beneficiary was transported by an ambulance 
                        or other emergency vehicle directed by a person 
                        other than the participant or beneficiary to 
                        the nonparticipating hospital in which the 
                        services were provided.
                            ``(iii) Natural disaster.--A natural 
                        disaster or civil disturbance prevented the 
                        participant or beneficiary from presenting to a 
                        participating hospital for the provision of 
                        such services.
                            ``(iv) No good faith effort to inform of 
                        change in participation during a contract 
                        year.--The status of the hospital changed from 
                        a participating hospital to a nonparticipating 
                        hospital with respect to emergency services 
                        during a contract year and the plan or issuer 
                        failed to make a good faith effort to notify 
                        the participant or beneficiary involved of such 
                        change.
                            ``(v) Other conditions.--There were other 
                        factors (such as those identified in 
                        guidelines) that prevented the participant or 
                        beneficiary from controlling selection of the 
                        hospital in which the services were provided.
    ``(b) Assuring Coordinated Coverage of Maintenance Care and Post-
Stabilization Care.--
            ``(1) In general.--In the case of a participant or 
        beneficiary who is covered under a group health plan (or under 
        health insurance coverage issued by a health insurance issuer 
        offered in connection with such a plan) and who has received 
        emergency services pursuant to a screening evaluation conducted 
        (or supervised) by a treating physician at a hospital that is a 
        nonparticipating provider with respect to emergency services, 
        if--
                    ``(A) pursuant to such evaluation, the physician 
                identifies post-stabilization care (as defined in 
                paragraph (3)(B)) that is required by the participant 
                or beneficiary,
                    ``(B) the plan or coverage provides benefits with 
                respect to the care so identified and the plan requires 
                (but for this subsection) an affirmative prior 
                authorization determination as a condition of coverage 
                of such care, and
                    ``(C) the treating physician (or another individual 
                acting on behalf of such physician) initiates, not 
                later than 30 minutes after the time the treating 
                physician determines that the condition of the 
                participant or beneficiary is stabilized, a good faith 
                effort to contact a physician or other person 
                authorized by the plan or issuer (by telephone or other 
                means) to obtain an affirmative prior authorization 
                determination with respect to the care,
        then, without regard to terms and conditions specified in 
        paragraph (2) the plan or issuer shall cover maintenance care 
        (as defined in paragraph (3)(A)) furnished to the participant 
        or beneficiary during the period specified in paragraph (4) and 
        shall cover post-stabilization care furnished to the 
        participant or beneficiary during the period beginning under 
        paragraph (5) and ending under paragraph (6).
            ``(2) Terms and conditions waived.--The terms and 
        conditions (of a plan or coverage) described in this paragraph 
        that are waived under paragraph (1) are as follows:
                    ``(A) The need for any prior authorization 
                determination.
                    ``(B) Any limitation on coverage based on whether 
                or not the physician or provider furnishing the care is 
                a participating physician or provider with respect to 
                such care.
                    ``(C) Any other term or condition of the plan or 
                coverage (other than an exclusion of benefits, or an 
                affiliation or waiting period, permitted under section 
                2701 and other than a requirement relating to medical 
                necessity for coverage of benefits).
            ``(3) Maintenance care and post-stabilization care 
        defined.--In this subsection:
                    ``(A) Maintenance care.--The term `maintenance 
                care' means, with respect to an individual who is 
                stabilized after provision of emergency services, 
                medically necessary items and services (other than 
                emergency services) that are required by the individual 
                to ensure that the individual remains stabilized during 
                the period described in paragraph (4).
                    ``(B) Post-stabilization care.--The term `post-
                stabilization care' means, with respect to an 
                individual who is determined to be stable pursuant to a 
                medical screening examination or who is stabilized 
                after provision of emergency services, medically 
                necessary items and services (other than emergency 
                services and other than maintenance care) that are 
                required by the individual.
            ``(4) Period of required coverage of maintenance care.--The 
        period of required coverage of maintenance care of an 
        individual under this subsection begins at the time of the 
        request (or the initiation of the good faith effort to make the 
        request) under paragraph (1)(C) and ends when--
                    ``(A) the individual is discharged from the 
                hospital;
                    ``(B) a physician (designated by the plan or issuer 
                involved) and with privileges at the hospital involved 
                arrives at the emergency department of the hospital and 
                assumes responsibility with respect to the treatment of 
                the individual; or
                    ``(C) the treating physician and the plan or issuer 
                agree to another arrangement with respect to the care 
                of the individual.
            ``(5) When post-stabilization care required to be 
        covered.--
                    ``(A) When treating physician unable to communicate 
                request.--If the treating physician or other individual 
                makes the good faith effort to request authorization 
                under paragraph (1)(C) but is unable to communicate the 
                request directly with an authorized person referred to 
                in such paragraph within 30 minutes after the time of 
                initiating such effort, then post-stabilization care is 
                required to be covered under this subsection beginning 
                at the end of such 30-minute period.
                    ``(B) When able to communicate request, and no 
                timely response.--
                            ``(i) In general.--If the treating 
                        physician or other individual under paragraph 
                        (1)(C) is able to communicate the request 
                        within the 30-minute period described in 
                        subparagraph (A), the post-stabilization care 
                        requested is required to be covered under this 
                        subsection beginning 30 minutes after the time 
                        when the plan or issuer receives the request 
                        unless a person authorized by the plan or 
                        issuer involved communicates (or makes a good 
                        faith effort to communicate) a denial of the 
                        request for the prior authorization 
                        determination within 30 minutes of the time 
                        when the plan or issuer receives the request 
                        and the treating physician does not request 
                        under clause (ii) to communicate directly with 
                        an authorized physician concerning the denial.
                            ``(ii) Request for direct physician-to-
                        physician communication concerning denial.--If 
                        a denial of a request is communicated under 
                        clause (i), the treating physician may request 
                        to communicate respecting the denial directly 
                        with a physician who is authorized by the plan 
                        or issuer to deny or affirm such a denial.
                    ``(C) When no timely response to request for 
                physician-to-physician communication.--If a request for 
                physician-to-physician communication is made under 
                subparagraph (B)(ii), the post-stabilization care 
                requested is required to be covered under this 
                subsection beginning 30 minutes after the time when the 
                plan or issuer receives the request from a treating 
                physician unless a physician, who is authorized by the 
                plan or issuer to reverse or affirm the initial denial 
                of the care, communicates (or makes a good faith effort 
                to communicate) directly with the treating physician 
                within such 30-minute period.
                    ``(D) Disagreements over post-stabilization care.--
                If, after a direct physician-to-physician communication 
                under subparagraph (C), the denial of the request for 
                the post-stabilization care is not reversed and the 
                treating physician communicates to the plan or issuer 
                involved a disagreement with such decision, the post-
                stabilization care requested is required to be covered 
                under this subsection beginning as follows:
                            ``(i) Delay to allow for prompt arrival of 
                        physician assuming responsibility.--If the plan 
                        or issuer communicates that a physician 
                        (designated by the plan or issuer) with 
                        privileges at the hospital involved will arrive 
                        promptly (as determined under guidelines) at 
                        the emergency department of the hospital in 
                        order to assume responsibility with respect to 
                        the treatment of the participant or beneficiary 
                        involved, the required coverage of the post-
                        stabilization care begins after the passage of 
                        such time period as would allow the prompt 
                        arrival of such a physician.
                            ``(ii) Other cases.--If the plan or issuer 
                        does not so communicate, the required coverage 
                        of the post-stabilization care begins 
                        immediately.
            ``(6) No requirement of coverage of post-stabilization care 
        if alternate plan of treatment.--
                    ``(A) In general.--Coverage of post-stabilization 
                care is not required under this subsection with respect 
                to an individual when--
                            ``(i) subject to subparagraph (B), a 
                        physician (designated by the plan or issuer 
                        involved) and with privileges at the hospital 
                        involved arrives at the emergency department of 
                        the hospital and assumes responsibility with 
                        respect to the treatment of the individual; or
                            ``(ii) the treating physician and the plan 
                        or issuer agree to another arrangement with 
                        respect to the post-stabilization care (such as 
                        an appropriate transfer of the individual 
                        involved to another facility or an appointment 
for timely followup treatment for the individual).
                    ``(B) Special rule where once care initiated.--
                Required coverage of requested post-stabilization care 
                shall not end by reason of subparagraph (A)(i) during 
                an episode of care (as determined by guidelines) if the 
                treating physician initiated such care (consistent with 
                a previous paragraph) before the arrival of a physician 
                described in such subparagraph.
            ``(7) Construction.--Nothing in this subsection shall be 
        construed as--
                    ``(A) preventing a plan or issuer from authorizing 
                coverage of maintenance care or post-stabilization care 
                in advance or at any time; or
                    ``(B) preventing a treating physician or other 
                individual described in paragraph (1)(C) and a plan or 
                issuer from agreeing to modify any of the time periods 
                specified in paragraphs (5) as it relates to cases 
                involving such persons.
    ``(c) Limits on Cost-Sharing for Services Furnished in Emergency 
Departments.--If a group health plan provides any benefits with respect 
to emergency services, the plan (or a health insurance issuer offering 
health insurance coverage in connection with such a plan) may impose 
cost sharing with respect to such services only if the following 
conditions are met:
            ``(1) Limitations on cost-sharing differential for 
        nonparticipating providers.--
                    ``(A) No differential for certain services.--In the 
                case of services furnished under the circumstances 
                described in clause (i), (ii), or (iii) of subsection 
                (a)(3)(B) (relating to circumstances beyond the control 
                of the beneficiary, the likelihood of an adverse health 
                consequence based on layperson's judgment, and 
                physician referral), the cost-sharing for such services 
                provided by a nonparticipating provider or physician 
                does not exceed the cost-sharing for such services 
                provided by a participating provider or physician.
                    ``(B) Only reasonable differential for other 
                services.--In the case of other emergency services, any 
                differential by which the cost-sharing for such 
                services provided by a nonparticipating provider or 
                physician exceeds the cost-sharing for such services 
                provided by a participating provider or physician is 
                reasonable (as determined under guidelines).
            ``(2) Only reasonable differential between emergency 
        services and other services.--Any differential by which the 
        cost-sharing for services furnished in an emergency department 
        exceeds the cost-sharing for such services furnished in another 
        setting is reasonable (as determined under guidelines).
            ``(3) Construction.--Nothing in paragraph (1)(B) or (2) 
        shall be construed as authorizing guidelines other than 
        guidelines that establish maximum cost-sharing differentials.
    ``(d) Information on Access to Emergency Services.--A group health 
plan (or a health insurance issuer, to the extent a health insurance 
issuer offers group health insurance coverage in connection with such a 
plan) shall provide education to participants and beneficiaries of the 
plan on--
            ``(1) coverage of emergency services (as defined in 
        subsection (a)(2)(B)) by the plan in accordance with the 
        provisions of this section,
            ``(2) the appropriate use of emergency services, including 
        use of the 911 telephone system or its local equivalent,
            ``(3) any cost sharing applicable to emergency services,
            ``(4) the process and procedures of the plan for obtaining 
        emergency services, and
            ``(5) the locations of--
                    ``(A) emergency departments, and
                    ``(B) other settings,
        in which participating physicians and hospitals provide 
        emergency services and post-stabilization care.
    ``(e) General Definitions.--For purposes of this section:
            ``(1) Cost sharing.--The term `cost sharing' means any 
        deductible, coinsurance amount, copayment or other out-of-
        pocket payment (other than premiums or enrollment fees) that a 
        group health plan (or a health insurance issuer offering group 
        health insurance issuer in connection with such a plan) imposes 
        on participants and beneficiaries of the plan with respect to 
        the coverage of benefits.
            ``(2) Good faith effort.--The term `good faith effort' has 
        the meaning given such term in guidelines and requires such 
        appropriate documentation as is specified under such 
        guidelines.
            ``(3) Guidelines.--The term `guidelines' means guidelines 
        established in accordance with section 7 of the Access to 
        Emergency Medical Services Act of 1997.
            ``(4) Nonparticipating physician or provider.--The term 
        `nonparticipating physician or provider' means, with respect to 
        health care items and services furnished to a participant or 
        beneficiary of a group health plan, a physician or provider 
        that is not a participating physician or provider for such 
        services.
            ``(5) Participating physician or provider.--The term 
        `participating physician or provider' means, with respect to 
        health care items and services furnished to a participant or 
        beneficiary of a group health plan, a physician or provider 
        that furnishes such items and services under a contract or 
        other arrangement with such plan (or with a health insurance 
        issuer offering group health insurance coverage in connection 
        with such a plan).
            ``(6) Prior authorization determination.--The term `prior 
        authorization determination' means, with respect to items and 
        services for which coverage may be provided under a group 
        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) of whether or not such items and 
        services will be covered under the plan.
            ``(7) Stabilize.--The term `to stabilize' means, with 
        respect to an emergency medical condition, to provide (in 
        complying with section 1867 of the Social Security Act) such 
        medical treatment of the condition as may be necessary to 
        assure, within reasonable medical probability, that no material 
        deterioration of the condition is likely to result from or 
        occur during the transfer of the individual from the facility.
            ``(8) Stabilized.--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 from or occur before an 
        individual can be transferred from the facility, in compliance 
        with the requirements of section 1867 of the Social Security 
        Act.
            ``(9) Treating physician.--The term `treating physician' 
        includes a treating health care professional who is licensed 
        under State law to provide emergency services other than under 
        the supervision of a physician.
    ``(f) Continued Applicability of State Law With Respect to Health 
Insurance Issuers.--The provisions of section 2723(a) (relating to 
State authority to provide for standards and requirements for health 
insurance issuers to the extent the standards and requirements do not 
prevent the application of a requirement of this part) apply with 
respect to the requirements of this section.''.
    (b) Conforming Amendment.--Section 2723(c) of such Act (42 U.S.C. 
300gg-23(c)), as amended by section 604(b)(2) of Public Law 104-204, is 
amended by striking ``section 2704'' and inserting ``sections 2704 and 
2706''.
    (c) Effective Date.--(1) Subject to paragraph (2), the amendments 
made by this section shall apply to group health plans for plan years 
beginning on or after the date that is 18 months after the date of the 
enactment of this Act.
    (2) 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 enactment of this 
Act, the amendments made by this section shall not apply to plan years 
beginning before the later of--
            (A) the date on which the last collective bargaining 
        agreements relating to the plan terminates (determined without 
        regard to any extension thereof agreed to after the date of 
        enactment of this Act), or
            (B) 18 months after the date of the enactment of this Act.
For purposes of subparagraph (A), any plan amendment made pursuant to a 
collective bargaining agreement relating to the plan which amends the 
plan solely to conform to any requirement added by this section shall 
not be treated as a termination of such collective bargaining 
agreement.

SEC. 5. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT RELATING TO THE 
              INDIVIDUAL MARKET.

    (a) In General.--Part B of title XXVII of the Public Health Service 
Act is amended--
            (1) by redesignating the subpart 3 relating to other 
        requirements as subpart 2, and
            (2) by adding at the end of such subpart the following new 
        section:

``SEC. 2752. ASSURING EQUITABLE COVERAGE OF EMERGENCY SERVICES, 
              MAINTENANCE CARE, AND POST-STABILIZATION CARE.

    ``(a) In General.--The provisions of section 2706 shall apply to 
health insurance coverage offered by a health insurance issuer in the 
individual market in the same manner as it applies to health insurance 
coverage offered by a health insurance issuer in connection with a 
group plan. In applying the previous sentence, the reference in section 
2706(b)(2)(C) to section 2701 is deemed a reference to subpart 1 of 
this part.
    ``(b) Continued Applicability of State Law With Respect to Health 
Insurance Issuers.--The provisions of section 2762 (relating to State 
authority to provide for standards and requirements for health 
insurance issuers to the extent the standards and requirements do not 
prevent the application of a requirement of this part) apply with 
respect to the requirements of this section.''.
    (b) Conforming Amendment.--Section 2763(b)(2) of such Act (42 
U.S.C. 300gg-63(b)(2)), as added by section 605(b)(3)(B) of Public Law 
104-204, is amended by striking ``section 2751'' and inserting 
``sections 2751 and 2752''.
    (c) Effective Date.--The amendments made by this section shall 
apply with respect to health insurance coverage offered, sold, issued, 
renewed, in effect, or operated in the individual market on or after 
the date that is 18 months after the date of the enactment of this Act.

SEC. 6. APPLICATION TO PRIVATE COVERAGE FOR MEDICARE AND MEDICAID 
              BENEFICIARIES.

    (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 2706 of the Public 
        Health Service Act with respect to individuals enrolled with 
        the organization under this section.''.
    (b) Medicaid.--Title XIX of such Act (42 U.S.C. 1396 et seq.) is 
amended by inserting after section 1908 the following new section:

 ``access to emergency services for beneficiaries enrolled in private 
                              health plans

    ``Sec. 1909. (a) In General.--A State plan may not be approved 
under this title unless the plan requires each health insurance issuer 
or other entity with a contract with such plan to provide coverage or 
benefits to individuals eligible for medical assistance under the plan 
to comply with the provisions of section 2706 of the Public Health 
Service Act with respect to such coverage or benefits.
    ``(b) Cost Sharing.--Nothing in this section or section 2706(c) of 
the Public Health Service Act shall be construed as authorizing a 
health insurance issuer or entity to impose cost sharing with respect 
to the coverage or benefits described in subsection (a) that is 
inconsistent with the cost sharing that is otherwise permitted under 
this title.
    ``(c) Waivers Prohibited.--The requirement of subsection (a) may 
not be waived under section 1115 or section 1915(b) of the Social 
Security Act.''.
    (c) Medicare Select Policies.--Section 1882(t)(1) of such Act (42 
U.S.C. 1395ss(t)(1)) is amended--
            (1) in subparagraph (B), by inserting ``subject to 
        subparagraph (G),'' after ``(B)'',
            (2) by striking ``and'' at the end of subparagraph (E),
            (3) by striking the period at the end of subparagraph (F) 
        and inserting ``; and'', and
            (4) by adding at the end the following new subparagraph:
            ``(G) the issuer of the policy complies with the 
        requirements of section 2752 of the Public Health Service Act 
        with respect to enrollees under this subsection.''.
    (d) Effective Dates.--
            (1) Medicare.--The amendment made by subsection (a) shall 
        apply to eligible organizations under section 1876 of the 
        Social Security Act for contract years beginning on or after 
        the date that is 18 months after the date of the enactment of 
        this Act.
            (2) Medicaid.--The amendment made by subsection (b) shall 
        apply to State plans under title XIX of the Social Security Act 
        for contract years beginning on or after the date that is 18 
        months after the date of the enactment of this Act.
            (3) Medicare select.--The amendments made by subsection (c) 
        shall apply to policies for contract years beginning on or 
        after the date that is 18 months after the date of the 
        enactment of this Act.

SEC. 7. ESTABLISHMENT OF GUIDELINES.

    (a) In General.--The Secretary of Labor, the Secretary of Health 
and Human Services, and the Secretary of the Treasury (in this section 
referred to as ``the Secretaries'') shall, in accordance with the 
process described in subsection (b), jointly establish guidelines to 
carry out section 9811 of the Internal Revenue Code of 1986, section 
713 of the Employee Retirement Income Security Act of 1974, and 
sections 2706 and 2752 of the Public Health Service Act, including all 
such guidelines as may be referred to in such sections.
    (b) Process.--
            (1) Advisory panel.--Not later than 90 days after the date 
        of the enactment of this Act, the Secretaries shall jointly 
        establish an advisory panel to assist in the development of the 
        guidelines referred to in subsection (a). The members of the 
        panel shall include individuals representing--
                    (A) emergency medical personnel, including 
                emergency physicians, emergency nurses, and other 
                appropriate emergency health care professionals;
                    (B) health insurance issuers, including at least 
                one health maintenance organization;
                    (C) hospitals;
                    (D) employers;
                    (E) the States; and
                    (F) consumers.
            (2) Notice and comment.--Not later than 180 days after the 
        date of the enactment of this Act, the Secretaries shall 
        jointly cause to have published in the Federal Register notice 
        of proposed rulemaking on the guidelines referred to in 
        subsection (a). Not later than 60 days after the close of the 
        period for public comment on such guidelines, the Secretaries 
        shall jointly cause to have published in the Federal Register a 
        final rule establishing such guidelines.
                                 <all>