[Congressional Bills 107th Congress]
[From the U.S. Government Publishing Office]
[H.R. 1648 Introduced in House (IH)]
107th CONGRESS
1st Session
H. R. 1648
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 1, 2001
Mr. Upton (for himself and Mr. Towns) introduced the following bill;
which was referred to the Committee on Energy and Commerce, and in
addition to the Committees on Education and the Workforce, and Ways and
Means, for a period to be subsequently determined by the Speaker, in
each case for consideration of such provisions as fall within the
jurisdiction of the committee concerned
_______________________________________________________________________
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 2001''.
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.''.
(B) 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''.
(2) 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.''.
(3) 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 section 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, 2002.
(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 by 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, 2002.
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.
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