[Congressional Record Volume 143, Number 21 (Tuesday, February 25, 1997)]
[Extensions of Remarks]
[Pages E310-E311]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]




  INTRODUCTION OF THE ACCESS TO EMERGENCY MEDICAL SERVICES ACT OF 1997

                                 ______
                                 

                        HON. BENJAMIN L. CARDIN

                              of maryland

                    in the house of representatives

                       Tuesday, February 25, 1997

  Mr. CARDIN. Mr. Speaker, I rise today with my colleague Marge Roukema 
to introduce the Access to Emergency Medical Services Act of 1997. 
Companion legislation is being introduced in the Senate by Senators Bob 
Graham, Tim Hutchison, and Barbara Mikulski.
  The Access to Emergency Medical Services Act of 1997 would enact a 
national definition of emergency known as the ``prudent layperson'' 
definition. The bill would ensure that health plans cover emergency 
care based on a patient's symptoms rather than the final diagnosis. 
Enactment of this definition would end the phenomena of health plans 
denying coverage for emergency care when chest pains turned out to be 
indigestion rather than a heart attack.
  As you may recall, we first introduced this legislation in the 104th 
Congress. We ended 1996 with 154 cosponsors and had portions of the 
bill favorably reported by the Commerce Committee and the full Senate.
  This year, the legislation has been redrafted to amend the Health 
Insurance Portability and Accountability Act. The goals of the bill are 
the same. Again, it would establish the ``prudent layperson'' 
definition of emergency as the standard for coverage under group health 
plans, health insurers, and the Medicare and Medicaid programs. It 
would also forbid any requirement for preauthorization for emergency 
care. A new addition to this legislation

[[Page E311]]

is that it will go into much greater detail about requirements for 
health plans and emergency physicians to work together to coordinate 
any necessary followup care to the emergency visit. A summary of the 
bill appears at the conclusion of this statement.
  In developing this legislation, we once again worked closely with the 
American College of Emergency Physicians and the Maryland chapter of 
their organization. I would like to thank them for all of their 
assistance during this drafting process.
  This year we have an important new supporter of our legislation: 
Kaiser Permanente, one of our Nation's oldest, largest, and most 
respected managed care plans. I want to underscore the significance of 
Kaiser's support. As far as I know, this is the first time that a 
managed care plan has worked to develop a Federal standard for managed 
care practices. Kaiser has taken this bold step because they agree with 
us--when a person presents at an emergency room with what they believe 
is a true emergency, it is in the health plan's best interest to cover 
that visit, not to penalize their member if the condition does not turn 
out to be a true emergency.

  Kaiser would like our bill to preempt States' abilities to further 
regulate coverage of emergency care--and we will continue to discuss 
that issue. Kaiser's perspective is that the best policy would be to 
have one uniform set of standards on emergency for all States. However, 
the bill introduced today does not preempt further State action. Our 
bill is consistent with the rest of the Health Insurance Portability 
and Accountability Act in that it only preempts State law where that 
law prohibits the application of the Federal law. States are absolutely 
allowed to go further.
  In addition to Kaiser Permanente and the American College of 
Emergency Physicians, our legislation is endorsed by a broad spectrum 
of interests. These organizations include: the American Medical 
Association, Citizen Action, the American Hospital Association, 
Families USA, the American Heart Association, the Coalition for 
American Trauma Care, the American Osteopathic Association, the Center 
for Patient Advocacy, and the American Association of Neurological 
Surgeons.
  This year's Access to Emergency Medical Services Act is a new and 
improved version of the legislation we introduced in the last Congress 
and as you can see, we have already gathered broad-ranging support. 
Again, this bill would enable those in need to be assured access to 
emergency medical care--without the fear that their health plan will 
deny them coverage.
  Access to emergency care is fundamental to ensuring a viable health 
care system. What is at stake here is not an issue of governmental 
regulation, but an issue of protecting patient safety. I urge each of 
my colleagues to join me in supporting the Access to Emergency Medical 
Services Act and help us enact this protection into law.

    Short Summary--Access to Emergency Medical Services Act of 1997

       The bill would 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. If enacted, this bill would guarantee that 
     consumers are covered for legitimate emergency department 
     visits. For health plans that offer coverage for emergency 
     services, including the Medicare and Medicaid programs, the 
     bill would require payment for emergency services consistent 
     with the ``prudent layperson'' standard. Patients would not 
     be required to obtain prior authorization for emergency 
     services. Health plans would be required to cover and pay for 
     emergency care based upon the patient's presenting symptoms, 
     rather than the final diagnosis. The bill also establishes a 
     process in which the emergency department and health plan 
     work together to assure that the patient receives appropriate 
     follow-up care.
       Key provisions of the bill:
       Establishes a uniform definition of emergency based upon 
     the ``prudent layperson'' standard. Health plans would be 
     required to cover emergency services if the patient presents 
     with symptoms that a prudent layperson, possessing an average 
     knowledge of health and medicine, could reasonably expect to 
     result in serious impairment to the patient's health. Health 
     plans would not be required to reimburse for services 
     provided to patients that do not meet the ``prudent 
     layperson'' standard.
       Plans would be prohibited from requiring, as a condition 
     for coverage, that patients obtain prior authorization from 
     the health plan before seeking emergency care.
       Establishes coverage standards for out-of-plan emergency 
     care to protect patients who, under reasonable circumstances, 
     seek care in an out-of-plan emergency department.
       Allows health plans to establish reasonable cost-sharing 
     differentials for emergency care when a patient chooses an 
     emergency setting over a non-emergency setting, or an out-of-
     plan emergency setting over an in-plan emergency setting.
       Provides a process for coordination of post-stabilization 
     care. Treating emergency physicians and health plans would be 
     required to make timely communications concerning any 
     medically necessary post-stabilization care identified as a 
     result of a federally required screening examination. Plans, 
     in conjunction with the treating physician, may arrange for 
     an alternative treatment plan that allows the health plan to 
     assume care of the patient after stabilization.
       Health plans would be required to educate their members on 
     emergency care coverage and the appropriate use of emergency 
     medical services, including the use of the 911 system.
       There would be no preemption of state law as long as the 
     state law does not prevent the application of the federal 
     law.
       In general, requirements of the bill would be enforced in 
     the same manner as the requirements of the ``Health Insurance 
     Portability and Accountability Act of 1996.''
       Applies to all health plans that offer coverage for 
     emergency care, whether licensed or self-insured, including 
     the Medicare and Medicaid programs. Effective for plan years 
     beginning on or after 18 months after the date of enactment.

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