[Congressional Record Volume 145, Number 33 (Wednesday, March 3, 1999)]
[Senate]
[Page S2212]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. GRAHAM (for himself, Mr. Chafee, Ms. Mikulski, Mr. DeWine, 
        and Mr. Robb):
  S. 517. A bill to assure access under group health plans and health 
insurance coverage to covered emergency medical services; to the 
Committee on Health, Education, Labor and Pensions.


            ACCESS TO EMERGENCY MEDICAL SERVICES ACT OF 1999

  Mr. GRAHAM. Mr. President, I rise today with my colleagues Senators 
Chafee, Robb, and Mikulski, to introduce the Emergency Medical Services 
Act of 1999. Americans today are routinely denied coverage by their 
managed care plans for visits to the emergency department for 
legitimate emergency medical conditions. This legislation establishes a 
national definition, known as the prudent layperson standard, for the 
purposes of receiving emergency room treatment. The Balanced Budget Act 
of 1997 applied this definition to the Medicaid and Medicare programs. 
The proposal would simply ensure that all private health plans afford 
their consumers the same kinds of protections available to Medicaid and 
Medicare beneficiaries.
  Mr. President, current law places patients in the unreasonable 
position of fearing that payment for emergency room visits will be 
denied even when conditions appear to both the patient and emergency 
room personnel to require urgent treatment. For example, a patient who 
is experiencing chest pains and believes that she is having a heart 
attack may not be covered by a health plan if the diagnosis later turns 
out to be indigestion. Enactment of the ``prudent layperson'' 
definition would end this phenomena by ensuring coverage when a 
reasonable person, who believes that she is in need of care, presents 
herself at an emergency room and is treated.
  Federal law, the Emergency Medical Treatment and Active Labor Act 
(EMTALA), already requires that all persons who come to a hospital for 
emergency care be given a screening examination to determine if they 
are experiencing a medical emergency, and if so, that they receive 
stabilizing treatment before being discharged or moved to another 
facility. As a result, emergency, room doctors and hospitals face a 
catch-22. Practitioners are required by EMTALA and their own 
professional ethics to perform diagnostic tests and exams to rule out 
emergency conditions, but may be denied reimbursement due to HMO prior 
authorization requirements or a finding after diagnosis that the 
condition was not of an emergency.

  This legislation also provides a process for the coordination of 
post-stabilization care. Consider this example: a patient goes into the 
emergency room complaining of chest pains, in an obvious emergent 
condition. Subsequently, the chest pains subside, therefore, the 
patient is considered clinically ``stabilized.'' However, this does not 
mean that the patient is out of danger. At that point the emergency 
room physician may recommend a follow up test, such as an EKG, but is 
frequently unable to get the health plan to authorize any follow-up 
care.
  This portion of the bill would require that treating emergency 
physicians and health plans timely communicate with each other to 
determine what the necessary post-stabilization care should be. Health 
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. For instance, the plan may 
recommend that the patient by transferred to an in-network hospital, or 
it may agree to cover the tests recommended by the emergency room 
physician.
  Our legislation has been strongly endorsed by Kaiser Permanente, one 
of our nation's oldest, largest, and most respected managed care plans, 
and the American College of Emergency Physicians. The legislation has 
also received the strong support of the American Osteopathic 
Association, the Federation of American Health Systems, and the 
National Council of Senior Citizens, among many others.
  I would ask that my colleagues join us in supporting this important 
legislation.
                                 ______