[Congressional Bills 106th Congress]
[From the U.S. Government Publishing Office]
[H.R. 1777 Introduced in House (IH)]







106th CONGRESS
  1st Session
                                H. R. 1777

To amend the Public Health Service Act, the Employee Retirement Income 
 Security Act of 1974, and the Internal Revenue Code of 1986 to assure 
 access to covered emergency hospital services and emergency ambulance 
 services under a prudent layperson test under group health plans and 
                       health insurance coverage.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                              May 12, 1999

  Mr. Upton (for himself, Mr. Towns, and Mrs. Emerson) introduced the 
following bill; which was referred to the Committee on Commerce, and in 
  addition to the Committees on Ways and Means, and Education and the 
 Workforce, for a period to be subsequently determined by the Speaker, 
 in each case for consideration of such provisions as fall within the 
                jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL


 
To amend the Public Health Service Act, the Employee Retirement Income 
 Security Act of 1974, and the Internal Revenue Code of 1986 to assure 
 access to covered emergency hospital services and emergency ambulance 
 services under a prudent layperson test under group health plans and 
                       health insurance coverage.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Emergency Ambulance Services Access 
Assurance Act of 1999''.

SEC. 2. ASSURING ACCESS TO EMERGENCY SERVICES.

    (a) Group Health Plans.--
            (1) Public health service act amendments.--Subpart 2 of 
        part A of title XXVII of the Public Health Service Act is 
        amended by adding at the end the following new section:

``SEC. 2707. STANDARD RELATING TO ACCESS TO EMERGENCY SERVICES AND 
              EMERGENCY AMBULANCE SERVICES.

    ``(a) Coverage of Emergency Services.--
            ``(1) In general.--If a group health plan, or health 
        insurance coverage offered in connection with a health 
        insurance issuer, provides any benefits with respect to 
        emergency services (as defined in paragraph (2)(B)), the plan 
        or issuer shall cover emergency services furnished under the 
        plan or coverage--
                    ``(A) without the need for any prior authorization 
                determination;
                    ``(B) whether or not the health care provider 
                furnishing such services is a participating provider 
                with respect to such services;
                    ``(C) in a manner so that, if such services are 
                provided to a participant, beneficiary, or enrollee by 
                a nonparticipating health care provider without prior 
                authorization by the plan or issuer, the participant, 
                beneficiary, or enrollee is not liable for amounts that 
                exceed the amounts of liability that would be incurred 
                if the services were provided by a participating health 
                care provider with prior authorization by the plan or 
                issuer; and
                    ``(D) without regard to any other term or condition 
                of such coverage (other than exclusion or coordination 
                of benefits, or an affiliation or waiting period, 
                permitted under section 2701 of this Act, section 701 
                of the Employee Retirement Income Security Act of 1974, 
                or section 9801 of the Internal Revenue Code of 1986, 
                and other than applicable cost-sharing).
            ``(2) Definitions.--In this section:
                    ``(A) Emergency medical condition based on prudent 
                layperson standard.--The term `emergency medical 
                condition' means a medical condition manifesting itself 
                by acute symptoms of sufficient severity (including 
                severe pain) such that a prudent layperson, who 
                possesses an average knowledge of health and medicine, 
                could reasonably expect the absence of immediate 
                medical attention to result in a condition described in 
                clause (i), (ii), or (iii) of section 1867(e)(1)(A) of 
                the Social Security Act.
                    ``(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 such Act to 
                        stabilize the patient.
                    ``(C) Nonparticipating.--The term 
                `nonparticipating' means, with respect to a health care 
                provider that provides health care items and services 
to a participant, beneficiary, or enrollee under group health plan or 
health insurance coverage, a health care provider that is not a 
participating health care provider with respect to such items and 
services.
                    ``(D) Participating.--The term `participating' 
                means, with respect to a health care provider that 
                provides health care items and services to a 
                participant, beneficiary, or enrollee under group 
                health plan or health insurance coverage offered by a 
                health insurance issuer, a health care provider that 
                furnishes such items and services under a contract or 
                other arrangement with the plan or issuer.
    ``(b) Coverage of Emergency Ambulance Services.--
            ``(1) In general.--If a group health plan, or health 
        insurance coverage offered in connection with a group health 
        plan by a health insurance issuer, provides any benefits with 
        respect to ambulance services and emergency services, the plan 
        or issuer shall cover emergency ambulance services (as defined 
        in paragraph (2))) furnished under the plan or coverage under 
        the same terms and conditions under subparagraphs (A) through 
        (D) of subsection (a)(1) under which coverage is provided for 
        emergency services.
            ``(2) Emergency ambulance services.--For purposes of this 
        subsection, the term `emergency ambulance services' means 
        ambulance services (as defined for purposes of section 
        1861(s)(7) of the Social Security Act) furnished to transport 
        an individual who has an emergency medical condition (as 
        defined in subsection (a)(2)(A)) to a hospital for the receipt 
        of emergency services (as defined in subsection (a)(2)(B)) in a 
        case in which the emergency services are covered under the plan 
        or coverage pursuant to subsection (a)(1) and a prudent 
        layperson, with an average knowledge of health and medicine, 
        could reasonably expect that the absence of such transport 
        would result in placing the health of the individual in serious 
        jeopardy, serious impairment of bodily function, or serious 
        dysfunction of any bodily organ or part.
    ``(c) Notice.--A group health plan under this part shall comply 
with the notice requirement under section 714(b) of the Employee 
Retirement Income Security Act of 1974 with respect to the requirements 
of this section as if such section applied to such plan.''.
            (2) Section 2723(c) of such Act (42 U.S.C. 300gg-23(c)) is 
        amended by striking ``section 2704'' and inserting ``sections 
        2704 and 2707''.
            (3) ERISA amendments.--(A) Subpart B of part 7 of subtitle 
        B of title I of the Employee Retirement Income Security Act of 
        1974 is amended by adding at the end the following new section:

``SEC. 714. STANDARD RELATING TO ACCESS TO EMERGENCY SERVICES AND 
              EMERGENCY AMBULANCE SERVICES.

    ``(a) Coverage of Emergency Services.--
            ``(1) In general.--If a group health plan, or health 
        insurance coverage offered in connection with a health 
        insurance issuer, provides any benefits with respect to 
        emergency services (as defined in paragraph (2)(B)), the plan 
        or issuer shall cover emergency services furnished under the 
        plan or coverage--
                    ``(A) without the need for any prior authorization 
                determination;
                    ``(B) whether or not the health care provider 
                furnishing such services is a participating provider 
                with respect to such services;
                    ``(C) in a manner so that, if such services are 
                provided to a participant, beneficiary, or enrollee by 
                a nonparticipating health care provider without prior 
                authorization by the plan or issuer, the participant, 
                beneficiary, or enrollee is not liable for amounts that 
                exceed the amounts of liability that would be incurred 
                if the services were provided by a participating health 
                care provider with prior authorization by the plan or 
                issuer; and
                    ``(D) without regard to any other term or condition 
                of such coverage (other than exclusion or coordination 
                of benefits, or an affiliation or waiting period, 
                permitted under section 2701 of the Public Health 
                Service Act, section 701 of this Act, or section 9801 
                of the Internal Revenue Code of 1986, and other than 
                applicable cost-sharing).
            ``(2) Definitions.--In this section:
                    ``(A) Emergency medical condition based on prudent 
                layperson standard.--The term `emergency medical 
                condition' means a medical condition manifesting itself 
                by acute symptoms of sufficient severity (including 
                severe pain) such that a prudent layperson, who 
                possesses an average knowledge of health and medicine, 
                could reasonably expect the absence  of immediate 
medical attention to result in a condition described in clause (i), 
(ii), or (iii) of section 1867(e)(1)(A) of the Social Security Act.
                    ``(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 such Act to 
                        stabilize the patient.
                    ``(C) Nonparticipating.--The term 
                `nonparticipating' means, with respect to a health care 
                provider that provides health care items and services 
                to a participant, beneficiary, or enrollee under group 
                health plan or health insurance coverage, a health care 
                provider that is not a participating health care 
                provider with respect to such items and services.
                    ``(D) Participating.--The term `participating' 
                means, with respect to a health care provider that 
                provides health care items and services to a 
                participant, beneficiary, or enrollee under group 
                health plan or health insurance coverage offered by a 
                health insurance issuer, a health care provider that 
                furnishes such items and services under a contract or 
                other arrangement with the plan or issuer.
    ``(b) Coverage of Emergency Ambulance Services.--
            ``(1) In general.--If a group health plan, or health 
        insurance coverage offered in connection with a group health 
        plan by a health insurance issuer, provides any benefits with 
        respect to ambulance services and emergency services, the plan 
        or issuer shall cover emergency ambulance services (as defined 
        in paragraph (2))) furnished under the plan or coverage under 
        the same terms and conditions under subparagraphs (A) through 
        (D) of subsection (a)(1) under which coverage is provided for 
        emergency services.
            ``(2) Emergency ambulance services.--For purposes of this 
        subsection, the term `emergency ambulance services' means 
        ambulance services (as defined for purposes of section 
        1861(s)(7) of the Social Security Act) furnished to transport 
        an individual who has an emergency medical condition (as 
        defined in subsection (a)(2)(A)) to a hospital for the receipt 
        of emergency services (as defined in subsection (a)(2)(B)) in a 
        case in which the emergency services are covered under the plan 
        or coverage pursuant to subsection (a)(1) and a prudent 
        layperson, with an average knowledge of health and medicine, 
        could reasonably expect that the absence of such transport 
        would result in placing the health of the individual in serious 
        jeopardy, serious impairment of bodily function, or serious 
        dysfunction of any bodily organ or part.
    ``(c) Notice Under Group Health Plan.--The imposition of the 
requirement of this section shall be treated as a material modification 
in the terms of the plan described in section 102(a)(1), for purposes 
of assuring notice of such requirements under the plan; except that the 
summary description required to be provided under the last sentence of 
section 104(b)(1) with respect to such modification shall be provided 
by not later than 60 days after the first day of the first plan year in 
which such requirement apply.''.
            (B) Section 731(c) of such Act (29 U.S.C. 1191(c)) is 
        amended by striking ``section 711'' and inserting ``sections 
        711 and 714''.
            (C) The table of contents in section 1 of such Act is 
        amended by inserting after the item relating to section 713 the 
        following new item:

``Sec. 714. Standard relating to access to emergency services and 
                            emergency ambulance services.''.
            (4) Internal revenue code amendments.--
                    (A) In general.--Subchapter B of chapter 100 of the 
                Internal Revenue Code of 1986 is amended by inserting 
                after section 9812 the following new section:

``SEC. 9813. STANDARD RELATING TO ACCESS TO EMERGENCY SERVICES AND 
              EMERGENCY AMBULANCE SERVICES.

    ``(a) 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 shall cover emergency services 
        furnished under the plan--
                    ``(A) without the need for any prior authorization 
                determination;
                    ``(B) whether or not the health care provider 
                furnishing such services is a participating provider 
                with respect to such services;
                    ``(C) in a manner so that, if such services are 
                provided to a participant or beneficiary by a 
                nonparticipating health care provider without prior 
                authorization by the plan, the participant or 
                beneficiary is not liable for amounts that exceed the 
                amounts of liability that would be incurred if the 
                services were provided by a participating health care 
                provider with prior authorization by the plan; and
                    ``(D) without regard to any other term or condition 
                of such coverage (other than exclusion or coordination 
                of benefits, or an affiliation or waiting period, 
                permitted under section 2701 of the Public Health 
                Service Act, section 701 of the Employee Retirement 
                Income Security Act of 1974, or section 9801 of this 
                Code, and other than applicable cost-sharing).
            ``(2) Definitions.--In this section:
                    ``(A) Emergency medical condition based on prudent 
                layperson standard.--The term `emergency medical 
                condition' means a medical condition manifesting itself 
                by acute symptoms of sufficient severity (including 
                severe pain) such that a prudent layperson, who 
                possesses an average knowledge of health and medicine, 
                could reasonably expect the absence of immediate 
                medical attention to result in a condition described in 
                clause (i), (ii), or (iii) of section 1867(e)(1)(A) of 
                the Social Security Act.
                    ``(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 such Act to 
                        stabilize the patient.
                    ``(C) Nonparticipating.--The term 
                `nonparticipating' means, with respect to a health care 
                provider that provides health care items and services 
                to a participant or beneficiary under group health 
                plan, a health care provider that is not a 
                participating health care provider with respect to such 
                items and services.
                    ``(D) Participating.--The term `participating' 
                means, with respect to a health care provider that 
                provides health care items and services to a 
                participant or beneficiary under group health plan, a 
                health care provider that furnishes such items and 
                services under a contract or other arrangement with the 
                plan.
    ``(b) Coverage of Emergency Ambulance Services.--
            ``(1) In general.--If a group health plan provides any 
        benefits with respect to ambulance services and emergency 
        services, the plan shall cover emergency ambulance services (as 
        defined in paragraph (2))) furnished under the coverage under 
        the same terms and conditions under subparagraphs (A) through 
        (D) of subsection (a)(1) under which coverage is provided for 
        emergency services.
            ``(2) Emergency ambulance services.--For purposes of this 
        subsection, the term `emergency ambulance services' means 
        ambulance services (as defined for purposes of section 
        1861(s)(7) of the Social Security Act) furnished to transport 
        an individual who has an emergency medical condition (as 
        defined in subsection (a)(2)(A)) to a hospital for the receipt 
        of emergency services (as defined in subsection (a)(2)(B)) in a 
        case in which the emergency services are covered under the plan 
        pursuant to subsection (a)(1) and a prudent layperson, with an 
        average knowledge of health and medicine, could reasonably 
        expect that the absence of such transport would result in 
        placing the health of the individual in serious jeopardy, 
        serious impairment of bodily function, or serious dysfunction 
        of any bodily organ or part.''.
                    (B) Clerical amendment.--The table of sections of 
                such subchapter is amended by inserting after the item 
                relating to section 9812 the following new item:

                              ``Sec. 9813. Standard relating to access 
                                        to emergency services and 
                                        emergency ambulance 
                                        services.''.
    (b) Individual Health Insurance.--(1) Part B of title XXVII of the 
Public Health Service Act is amended by inserting after section 2752 
the following new section:

``SEC. 2753. STANDARD RELATING TO ACCESS TO EMERGENCY SERVICES AND 
              EMERGENCY AMBULANCE SERVICES.

    ``(a) In General.--The provisions of subsections (a) and (b) of 
section 2707 shall apply to health insurance coverage offered by a 
health insurance issuer in the individual market in the same manner as 
they apply to health insurance coverage offered by a health insurance 
issuer in connection with a group health plan in the small or large 
group market.
    ``(b) Notice.--A health insurance issuer under this part shall 
comply with the notice requirement under section 714(b) of the Employee 
Retirement Income Security Act of 1974 with respect to the requirements 
referred to in subsection (a) as if such section applied to such issuer 
and such issuer were a group health plan.''.
    (2) Section 2762(b)(2) of such Act (42 U.S.C. 300gg-62(b)(2)) is 
amended by striking ``section 2751'' and inserting ``sections 2751 and 
2753''.
    (c) Effective Dates.--
            (1) Group health plans and group health insurance 
        coverage.--Subject to paragraph (3), the amendments made by 
        subsection (a)  apply with respect to group health plans for 
plan years beginning on or after January 1, 2000.
            (2) Individual health insurance coverage.--The amendments 
        made by subsection (b) apply with respect to health insurance 
        coverage offered, sold, issued, renewed, in effect, or operated 
        in the individual market on or after such date.
            (3) Collective bargaining exception.--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 subsection (a) 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) January 1, 2000.
        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 subsection (a) shall not be treated as a termination 
        of such collective bargaining agreement.
            (4) Limitation on enforcement actions.--No enforcement 
        action shall be taken, pursuant to the amendments made by this 
        subsections (a) and (b), against a group health plan or health 
        insurance issuer with respect to a violation of a requirement 
        imposed by such amendments, to the extent that violation or 
        failure occurs before the date of issuance of regulations 
        issued in connection with such requirement, if the plan or 
        issuer has sought to comply in good faith with such 
        requirement.
    (d) Coordination of Administration.--The Secretary of Labor, the 
Secretary of the Treasury, and the Secretary of Health and Human 
Services shall ensure, through the execution of an interagency 
memorandum of understanding among such Secretaries, that--
            (1) regulations, rulings, and interpretations issued by 
        such Secretaries relating to the same matter over which two or 
        more such Secretaries have responsibility under the provisions 
        of this Act (and the amendments made thereby) are administered 
        so as to have the same effect at all times; and
            (2) coordination of policies relating to enforcing the same 
        requirements through such Secretaries in order to have a 
        coordinated enforcement strategy that avoids duplication of 
        enforcement efforts and assigns priorities in enforcement.
                                 <all>