[Congressional Bills 106th Congress]
[From the U.S. Government Publishing Office]
[S. 517 Introduced in Senate (IS)]







106th CONGRESS
  1st Session
                                 S. 517

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


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             March 3, 1999

Mr. Graham (for himself, Mr. Chafee, Ms. Mikulski, Mr. DeWine, and Mr. 
Robb) introduced the following bill; which was read twice and referred 
       to the Committee on Health, Education, Labor, and Pensions

_______________________________________________________________________

                                 A BILL


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

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Access to Emergency Medical Services 
Act of 1999''.

SEC. 2. EMERGENCY SERVICES.

    (a) Coverage of Emergency Services.--
            (1) In general.--If a group health plan, or health 
        insurance coverage offered by a health insurance issuer, 
        provides any benefits with respect to emergency services (as 
        defined in paragraph (2)(B)), the plan or issuer shall cover 
        emergency services furnished under the plan or coverage--
                    (A) without the need for any prior authorization 
                determination;
                    (B) whether or not the health care provider 
                furnishing such services is a participating provider 
                with respect to such services;
                    (C) in a manner so that, if such services are 
                provided to a participant, beneficiary, or enrollee by 
                a nonparticipating health care provider, the 
                participant, beneficiary, or enrollee is not liable for 
                amounts that exceed the amounts of liability that would 
                be incurred if the services were provided by a 
                participating provider; and
                    (D) without regard to any other term or condition 
                of such plan or coverage (other than exclusion or 
                coordination of benefits, or an affiliation or waiting 
                period, permitted under section 2701 of the Public 
                Health Service Act (42 U.S.C. 300gg et seq.), section 
                701 of the Employee Retirement Income Security Act of 
                1974 (29 U.S.C. 1181 et seq.), or section 9801 of the 
                Internal Revenue Code of 1986, and other than 
                applicable cost sharing).
            (2) Definitions.--In this section:
                    (A) Emergency medical condition based on prudent 
                layperson standard.--The term ``emergency medical 
                condition'' means a medical condition manifesting 
                itself by acute symptoms of sufficient severity 
                (including severe pain) such that a prudent layperson, 
                who possesses an average knowledge of health and 
                medicine, could reasonably expect the absence of 
                immediate medical attention to result in a condition 
                described in clause (i), (ii), or (iii) of section 
                1867(e)(1)(A) of the Social Security Act (42 U.S.C. 
                1395dd(e)(1)(A)).
                    (B) Emergency services.--The term ``emergency 
                services'' means--
                            (i) a medical screening examination (as 
                        required under section 1867 of the Social 
                        Security Act (42 U.S.C. 1395dd)) that is within 
                        the capability of the emergency department of a 
                        hospital, including ancillary services 
                        routinely available to the emergency department 
                        to evaluate an emergency medical condition (as 
                        defined in subparagraph (A)); and
                            (ii) within the capabilities of the staff 
                        and facilities at the hospital, such further 
                        medical examination and treatment as are 
                        required under section 1867 of such Act to 
                        stabilize the patient.
                    (C) Stabilize.--The term ``to stabilize'' means, 
                with respect to an emergency medical condition, to 
                provide 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 a facility.
    (b) Reimbursement for Maintenance Care and Post-Stabilization 
Care.--In the case of services (other than emergency services) for 
which benefits are available under a group health plan, or under health 
insurance coverage offered by a health insurance issuer, the plan or 
issuer shall provide for reimbursement with respect to such services 
provided to a participant, beneficiary, or enrollee other than through 
a participating health care provider in a manner consistent with 
subsection (a)(1)(C) (and shall otherwise comply with the guidelines 
established under section 1852(d)(2) of the Social Security Act (42 
U.S.C. 1395w-22(d)(2)) (relating to promoting efficient and timely 
coordination of appropriate maintenance and post-stabilization care of 
an enrollee after an enrollee has been determined to be stable), or, in 
the absence of guidelines under such section, such guidelines as the 
Secretary shall establish to carry out this subsection), if the 
services are maintenance care or post-stabilization care covered under 
such guidelines.
    (c) Information for Participants, Beneficiaries, and Enrollees.--
            (1) Group health plans.--A group health plan shall--
                    (A) provide to participants and beneficiaries at 
                the time of initial coverage under the plan (or the 
                effective date of this Act, in the case of individuals 
                who are participants and beneficiaries as of such 
                date), at least annually thereafter, and at the 
                beginning of any open enrollment provided under the 
                plan, the information described in paragraph (3) in 
                printed form; and
                    (B) upon request, make available to participants 
                and beneficiaries, to the applicable authority, and to 
                prospective participants and beneficiaries the 
                information described in paragraph (3) in printed form.
            (2) Health insurance issuers.--A health insurance issuer, 
        in connection with the provision of health insurance coverage, 
        shall--
                    (A) provide to individuals enrolled under such 
                coverage at the time of enrollment, and at least 
                annually thereafter, (and to plan administrators of 
                group health plans in connection with which such 
                coverage is offered) the information described in 
                paragraph (3) in printed form; and
                    (B) upon request, make available to the applicable 
                authority, to individuals who are prospective 
                enrollees, to plan administrators of group health plans 
                that may obtain such coverage, and to the public the 
                information described in paragraph (3) in printed form.
            (3) Required information.--The information described in 
        this paragraph with respect to a group health plan or health 
        insurance coverage offered by a health insurance issuer is 
        information about the coverage of emergency services, 
        including--
                    (A) the appropriate use of emergency services, 
                including use of the 911 telephone system or its local 
                equivalent in emergency situations and an explanation 
                of what constitutes an emergency situation;
                    (B) the process and procedures of the plan or 
                issuer for obtaining emergency services;
                    (C) any cost-sharing applicable to emergency 
                services; and
                    (D) the locations of--
                            (i) emergency departments; and
                            (ii) other settings in which plan 
                        physicians and hospitals provide emergency 
                        services and post-stabilization care.
    (d) Definitions.--In this section:
            (1) Applicable authority.--The term ``applicable 
        authority'' means--
                    (A) in the case of a group health plan, the 
                Secretary of Health and Human Services and the 
                Secretary of Labor; and
                    (B) in the case of a health insurance issuer with 
                respect to a specific provision of this section, the 
                applicable State authority or the Secretary of Health 
                and Human Services if such Secretary is enforcing such 
                provisions under section 2722(a)(2) or 2761(a)(2) of 
                the Public Health Service Act (42 U.S.C. 300gg-
                22(a)(2), 300gg-61(a)(2)).
            (2) 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 a group health plan or health insurance 
        coverage, a health care provider that is not a participating 
        health care provider with respect to such items and services.
            (3) 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 a group health plan or health insurance coverage offered 
        by a health insurance issuer, a health care provider that 
        furnishes such items and services under a contract or other 
        arrangement with the plan or issuer.
            (4) Other terms.--The terms ``applicable State authority'', 
        ``beneficiary'', ``group health plan'', ``health insurance 
        coverage'', ``health insurance issuer'', and ``participant'' 
        shall have the meanings given to such terms in section 2791 of 
        the Public Health Service Act (42 U.S.C. 300gg-91).

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

    (a) Group Market.--Subpart 2 of part A of title XXVII of the Public 
Health Service Act, as amended by the Omnibus Consolidated and 
Emergency Supplemental Appropriations Act, 1999 (Public Law 105-277), 
is amended by adding at the end the following new section:

``SEC. 2707. EMERGENCY SERVICES.

    ``(a) In General.--Each group health plan (and each health 
insurance issuer offering group health insurance coverage in connection 
with such a plan) shall comply with the requirements of the Access to 
Emergency Medical Services Act of 1999, and such requirements shall be 
deemed to be incorporated into this subsection.
    ``(b) Notice.--A group health plan shall comply with the notice 
requirement under section 711(d) of the Employee Retirement Income 
Security Act with respect to the requirements referred to in subsection 
(a), and a health insurance issuer shall comply with such notice 
requirement as if such section applied to such issuer and such issuer 
were a group health plan.''.
    (b) Individual Market.--Subpart 3 of part B of title XXVII of the 
Public Health Service Act, as amended by the Omnibus Consolidated and 
Emergency Supplemental Appropriations Act, 1999 (Public Law 105-277), 
is amended by adding at the end the following new section:

``SEC. 2753. EMERGENCY SERVICES.

    ``(a) In General.--Each health insurance issuer shall comply with 
the requirements of the Access to Emergency Medical Services Act of 
1999 with respect to individual health insurance coverage it offers, 
and such requirements shall be deemed to be incorporated into this 
subsection.
    ``(b) Notice.--A health insurance issuer under this part shall 
comply with the notice requirement under section 711(d) of the Employee 
Retirement Income Security Act with respect to the requirements 
referred to in subsection (a) as if such section applied to such issuer 
and such issuer were a group health plan.''.

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

    (a) In General.--Subpart B of part 7 of subtitle B of title I of 
the Employee Retirement Income Security Act of 1974, as amended by the 
Omnibus Consolidated and Emergency Supplemental Appropriations Act, 
1999 (Public Law 105-277), is amended by adding at the end the 
following:

``SEC. 714. EMERGENCY SERVICES.

    ``(a) In General.--Subject to subsection (b), a group health plan 
(and a health insurance issuer offering group health insurance coverage 
in connection with such a plan) shall comply with the requirements of 
the Access to Emergency Medical Services Act of 1999, and such 
requirements shall be deemed to be incorporated into this subsection.
    ``(b) Satisfaction of Requirements.--For purposes of subsection 
(a), insofar as a group health plan provides benefits in the form of 
health insurance coverage through a health insurance issuer, the plan 
shall be treated as meeting the requirements of the Access to Emergency 
Medical Services Act of 1999 with respect to such benefits and not be 
considered as failing to meet such requirements because of a failure of 
the issuer to meet such requirements so long as the plan sponsor or its 
representatives did not cause such failure by the issuer.''.
    (b) Conforming Amendment.--Section 732(a) of the Employee 
Retirement Income Security Act of 1974 (29 U.S.C. 1191a(a)) is amended 
by striking ``section 711'' and inserting ``sections 711 and 714''.
    (c) Clerical Amendment.--The table of contents in section 1 of the 
Employee Retirement Income Security Act of 1974 is amended by inserting 
after the item relating to section 713 the following new item:

``Sec. 714. Emergency services.''.

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

    Subchapter B of chapter 100 of the Internal Revenue Code of 1986 is 
amended--
            (1) in the table of sections, by inserting after the item 
        relating to section 9812 the following new item:

``Sec. 9813. Standard relating to emergency services.''; and
            (2) by inserting after section 9812 the following:

``SEC. 9813. STANDARD RELATING TO EMERGENCY SERVICES.

    ``A group health plan shall comply with the requirements of the 
Access to Emergency Medical Services Act of 1999, and such requirements 
shall be deemed to be incorporated into this section.''.

SEC. 6. EFFECTIVE DATE.

    (a) Group Health Coverage.--
            (1) In general.--Subject to paragraph (2), the amendments 
        made by sections 3(a), 4, and 5 (and section 2 insofar as it 
        relates to such sections) shall apply to group health plans and 
        health insurance coverage offered in connection with group 
        health plans for plan years beginning on or after January 1, 
        2000.
            (2) Treatment of collective bargaining agreements.--In the 
        case of a group health plan maintained pursuant to 1 or more 
        collective bargaining agreements between employee 
        representatives and 1 or more employers ratified before the 
        date of the enactment of this Act, the amendments made by 
        sections 3(a), 4, and 5 (and section 2 insofar as it relates to 
        such sections) shall not apply to plan years beginning before 
        the later of--
                    (A) the date on which the last collective 
                bargaining agreement relating to the plan terminates 
                (determined without regard to any extension thereof 
                agreed to after the date of the enactment of this Act); 
                or
                    (B) January 1, 2000.
        For purposes of subparagraph (A), any plan amendment made 
        pursuant to a collective bargaining agreement relating to the 
        plan that amends the plan solely to conform to any requirement 
        of this Act shall not be treated as a termination of such 
        collective bargaining agreement.
    (b) Individual Market.--The amendment made by section 3(b) (and 
section 2 insofar as it relates to such section) shall apply with 
respect to health insurance coverage offered, sold, issued, renewed, in 
effect, or operated in the individual market on or after January 1, 
2000.
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