[Federal Register Volume 77, Number 22 (Thursday, February 2, 2012)]
[Proposed Rules]
[Pages 5213-5217]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2012-2287]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Part 489

[CMS-1350-NC]
RIN 0938-AQ51


Medicare Program; Emergency Medical Treatment and Labor Act 
(EMTALA): Applicability to Hospital Inpatients and Hospitals With 
Specialized Capabilities

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Request for comments.

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SUMMARY: This request for comments addresses the applicability of the 
Emergency Medical Treatment and Labor Act (EMTALA) to hospital 
inpatients.

DATES: Comment Date: To be assured consideration, comments on the 
Applicability of EMTALA to Hospitals with Specialized Capabilities 
(section II.B. of this document) must be received at one of the 
addresses provided below, no later than 5 p.m. EST on April 2, 2012.

ADDRESSES: In commenting, please refer to file code CMS-1350-NC. 
Because of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission.
    You may submit comments in one of four ways (please choose only one 
of the ways listed):
    1. Electronically. You may submit electronic comments on this 
regulation to http://www.regulations.gov. Follow the ``Submit a 
comment'' instructions.
    2. By regular mail. You may mail written comments to the following 
address ONLY: Centers for Medicare & Medicaid Services, Department of 
Health and Human Services, Attention: CMS-1350-NC, P.O. Box 8013, 
Baltimore, MD 21244-8013.
    Please allow sufficient time for mailed comments to be received 
before the close of the comment period.
    3. By express or overnight mail. You may send written comments to 
the following address ONLY: Centers for Medicare & Medicaid Services, 
Department of Health and Human Services, Attention: CMS-1350-NC, Mail 
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
    4. By hand or courier. If you prefer, you may deliver (by hand or 
courier) your written comments before the close of the comment period 
to either of the following addresses:
    a. For delivery in Washington, DC--Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, Room 445-G, Hubert 
H. Humphrey Building, 200 Independence Avenue SW., Washington, DC 20201
    (Because access to the interior of the Hubert H. Humphrey Building 
is not readily available to persons without Federal government 
identification, commenters are encouraged to leave their comments in 
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing 
by stamping in and retaining an extra copy of the comments being 
filed.)
    b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid 
Services, Department of Health and Human Services, 7500 Security 
Boulevard, Baltimore, MD 21244-1850.
    If you intend to deliver your comments to the Baltimore address, 
please call telephone number (410) 786-1066 in advance to schedule your 
arrival with one of our staff members.
    Comments mailed to the addresses indicated as appropriate for hand 
or courier delivery may be delayed and received after the comment 
period.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Renate Dombrowski, (410) 786-4645, 
Ankit Patel, (410) 786-4537.

SUPPLEMENTARY INFORMATION: 
    Inspection of Public Comments: All comments received before the 
close of the comment period are available for viewing by the public, 
including any personally identifiable or confidential business 
information that is included in a comment. We post all comments 
received before the close of the comment period on the following Web 
site as soon as possible after they have been received: http://www.regulations.gov. Follow the search instructions on that Web site to 
view public comments.
    Comments received timely will also be available for public 
inspection as they are received, generally beginning approximately 3 
weeks after publication

[[Page 5214]]

of a document, at the headquarters of the Centers for Medicare & 
Medicaid Services, 7500 Security Boulevard, Baltimore, Maryland 21244, 
Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule 
an appointment to view public comments, phone 1-800-743-3951.

I. Background

    Sections 1866(a)(1)(I), 1866(a)(1)(N), and 1867 of the Social 
Security Act (the Act) were enacted as parts of the Emergency Medical 
Treatment and Labor Act (EMTALA). These statutory provisions impose 
specific obligations on certain Medicare-participating hospitals and 
critical access hospitals (CAHs). (Throughout this document, when we 
reference the obligation of a ``hospital'' under these sections of the 
Act and in our regulations, we mean to include CAHs as well.) These 
obligations concern individuals who come to a hospital's ``dedicated 
emergency department'' (as defined at 42 CFR 489.24(b)) and request 
examination or treatment for a medical condition and apply to all of 
these individuals regardless of whether they are beneficiaries of any 
program under the Act.
    EMTALA, also known as the patient antidumping statute, was passed 
in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act 
of 1985 (COBRA), Public Law 99-272. Congress incorporated these 
antidumping provisions within the Social Security Act to ensure that 
any individual with an emergency medical condition (EMC), regardless of 
the individual's insurance coverage, is not denied essential lifesaving 
services. Under section 1866(a)(1)(I)(i) of the Act, a hospital that 
fails to fulfill its EMTALA obligations under these provisions may be 
subject to termination of its Medicare provider agreement which would 
result in the loss of Medicare and Medicaid payments. In addition, 
section 1867(d) of the Act provides for the imposition of civil 
monetary penalties on a hospital or physician who negligently violates 
a requirement of EMTALA under section 1867 of the Act.
    Section 1867 of the Act sets forth requirements for medical 
screening examinations for individuals who come to the emergency 
department of a hospital and request examination or treatment for a 
medical condition. The statute further provides that, if a hospital 
finds that such an individual has an EMC, it is obligated to provide 
that individual with either necessary stabilizing treatment or an 
appropriate transfer to another medical facility where stabilization 
can occur. The EMTALA statute also separately outlines the obligation 
of hospitals to receive appropriate transfers from other hospitals. 
Section 1867(g) of the Act states that ``A participating hospital that 
has specialized capabilities or facilities (such as burn units, shock-
trauma units, neonatal intensive care units, or (with respect to rural 
areas) regional referral centers as identified by the Secretary in 
regulation) shall not refuse to accept an appropriate transfer of an 
individual who requires such specialized capabilities or facilities if 
the hospital has the capacity to treat the individual.'' The 
regulations implementing section 1867 of the Act are found at 42 CFR 
489.24. The regulations at 42 CFR 489.20(l), (m), (q), and (r) also 
refer to certain EMTALA requirements outlined in section 1866 of the 
Act. The Interpretive Guidelines concerning EMTALA are found at 
Appendix V of the CMS State Operations Manual: http://www.cms.gov/manuals/Downloads/som107ap_v_emerg.pdf.

A. Applicability of EMTALA to Hospital Inpatients

    The focus of EMTALA routinely involves the treatment of individuals 
who ``come to the emergency department,'' as we have defined that term 
at 42 CFR 489.24(b); that is, the individual is in a hospital-owned and 
operated ambulance or ``has presented at a hospital's dedicated 
emergency department * * * and requests examination or treatment for a 
medical condition, or has such a request made on his or her behalf [or] 
[h]as presented on hospital property * * * other than the dedicated 
emergency department, and requests examination or treatment for what 
may be an emergency medical condition, or has such a request made on 
his or her behalf.''
    However, concerns have also arisen about the continuing 
applicability of EMTALA to hospital inpatients. We have previously 
discussed the applicability of EMTALA to hospital inpatients in the May 
9, 2002 (67 FR 31475) Hospital Inpatient Prospective Payment System 
(IPPS) proposed rule entitled ``Medicare Program; Changes to the 
Hospital Inpatient Prospective Payment Systems and Fiscal Year 2003 
Rates'' (hereinafter referred to as the FY 2003 IPPS proposed rule) and 
the September 9, 2003 (68 FR 53243) stand-alone final rule on EMTALA 
entitled ``Medicare Program; Clarifying Policies Related to the 
Responsibilities of Medicare-Participating Hospitals in Treating 
Individuals With Emergency Medical Conditions'' (hereinafter referred 
to as the 2003 EMTALA final rule). As we noted in these prior proposed 
and final rules, in 1999, the United States Supreme Court considered a 
case (Roberts v. Galen of Virginia, 525 U.S. 249 (1999)) that involved, 
in part, the question of whether EMTALA applies to hospital inpatients. 
In the context of that case, the United States Solicitor General 
advised the Court that HHS would develop a regulation clarifying its 
position on this issue. In the FY 2003 IPPS proposed rule, we proposed 
that EMTALA continues to apply to admitted individuals who are not 
stabilized (who presented under EMTALA), but that it would not 
otherwise apply to inpatients. We indicated that individuals whose 
conditions go in and out of apparent stability rapidly and frequently 
would not be considered ``stabilized'' and the hospital would continue 
to have an obligation to such individuals even after they are admitted. 
However, for all other inpatients we stated that EMTALA was intended to 
provide protection to individuals coming to a hospital to seek care for 
an EMC. Therefore, we stated that we believe the EMTALA requirements do 
not extend to stabilized inpatients even if they subsequently become 
unstable because those inpatients are protected by a number of Medicare 
conditions of participation (CoPs) as well as the hospital's other 
legal, licensing, and professional obligations with respect to the 
continued proper care and treatment of its patients.
    In the 2003 EMTALA final rule, we refined this position to state 
that a hospital's obligation under EMTALA ends either when the 
individual is stabilized or when that hospital, in good faith, admits 
an individual with an EMC as an inpatient in order to provide 
stabilizing treatment. That is, we stated that EMTALA does not apply to 
any inpatient, even one who was admitted through the dedicated 
emergency department and for whom the hospital had initially incurred 
an EMTALA obligation to stabilize an EMC, and who remained unstabilized 
after admission as an inpatient. We noted that other patient safeguards 
protect all inpatients, including the hospital CoPs as well as State 
malpractice law. In addition, we noted that judicial interpretation of 
the matter and comments we received on the proposed rule helped shape 
the policy articulated in the final rule. However, we also stated in 
the rule that a hospital could not escape liability under EMTALA by 
admitting an individual with no intention of treating the individual 
and then inappropriately

[[Page 5215]]

transferring or discharging that individual without having met the 
stabilization requirement.

B. EMTALA Technical Advisory Group Recommendation Regarding 
Responsibilities of Hospitals With Specialized Capabilities

    Section 945 of the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (MMA), Public Law 108-173, required the 
Secretary to establish a Technical Advisory Group (TAG) to advise the 
Secretary on issues related to the regulations and implementation of 
EMTALA. The EMTALA TAG's functions, as identified in the charter for 
the EMTALA TAG, were as follows:
     Review EMTALA regulations.
     Provide advice and recommendations to the Secretary 
concerning these regulations and their application to hospitals and 
physicians.
     Solicit comments and recommendations from hospitals, 
physicians, and the public regarding the implementation of such 
regulations.
     Disseminate information concerning the application of 
these regulations to hospitals, physicians, and the public.
    The TAG met 7 times during its 30-month term, which ended on 
September 30, 2007. At its meetings, the TAG heard testimony from 
representatives of physician groups, hospital associations, and others 
regarding EMTALA issues and concerns. During each meeting, 
recommendations developed by subcommittees established by the TAG were 
discussed and voted on by members of the TAG. One of these 
recommendations, presented by the TAG to CMS during its September 2007 
meeting, called for CMS to revise its regulations to address the 
situation of an individual who: (1) Presents to a hospital that has a 
dedicated emergency department and is determined to have an EMC; (2) is 
admitted to the hospital as an inpatient for purposes of stabilizing 
the EMC; and (3) subsequently needs a transfer to a hospital with 
specialized capabilities to receive stabilizing treatment that cannot 
be provided by the referring hospital that originally admitted the 
individual. This recommendation can be found at the following Web site: 
http://www.cms.gov/EMTALA/Downloads/EMTALA_Final_Report_Summary.pdf.

C. Applicability of EMTALA to Hospital Inpatients and Responsibilities 
of Hospitals With Specialized Capabilities

    To further clarify our position on the applicability of EMTALA and 
the responsibilities of hospitals with specialized capabilities to 
accept appropriate transfers, the agency included as part of the April 
30, 2008 Hospital IPPS proposed rule (73 FR 23669) entitled, ``Medicare 
Program; Proposed Changes to the Hospital Inpatient Prospective Payment 
Systems and Fiscal Year 2009 Rates; Proposed Changes to Disclosure of 
Physician Ownership in Hospitals and Physician Self-Referral Rules; 
Proposed Collection of Information Regarding Financial Relationships 
Between Hospitals and Physicians'' (hereinafter referred to as the FY 
2009 IPPS proposed rule), two proposals that addressed the issue of 
hospital inpatients. First, we stated that we believe that the 
obligation of EMTALA does not end for all hospitals once an individual 
is admitted as an inpatient to the hospital where the individual first 
presented with a medical condition that was determined to be an EMC. 
Rather, once the individual is admitted, the admission only affects the 
EMTALA obligation of the hospital where the individual first presented 
(the admitting hospital). In the FY 2009 IPPS proposed rule (73 FR 
23670), we stated that section 1867(g) of the Act (which refers to 
responsibilities of hospitals with specialized capabilities)

* * * requires a receiving hospital with specialized capabilities to 
accept a request to transfer an individual with an unstable 
emergency medical condition as long as the hospital has the capacity 
to treat that individual, regardless of whether the individual had 
been an inpatient at the admitting hospital.

    We stated that we believe that permitting inpatient admission at 
the admitting hospital to end EMTALA obligations for another hospital 
would seemingly contradict the intent of section 1867(g) of the Act to 
ensure that hospitals with specialized capabilities provide medical 
treatment to individuals with EMCs in order to stabilize those 
conditions. We further noted that while a hospital inpatient is 
protected under Medicare CoPs and may also have additional protections 
under State law, the obligations of another hospital under the CoPs 
apply only to that hospital's patients, and there is no CoP that 
requires a hospital to accept the transfer of a patient from another 
facility. We proposed to interpret section 1867(g) of the Act as 
creating an obligation on hospitals with specialized capabilities to 
accept appropriate transfers of individuals for whom the admitting 
hospital originally had an EMTALA obligation under section 1867 of the 
Act, if the hospital with specialized capabilities has the capacity to 
treat the individuals. Thus, in the FY 2009 IPPS proposed rule (73 FR 
23670), we proposed to amend the regulations

* * * to add a provision to state that when an individual covered by 
EMTALA was admitted as an inpatient and remains unstabilized with an 
emergency medical condition, a receiving hospital with specialized 
capabilities has an EMTALA obligation to accept that individual, 
assuming that the transfer of the individual is an appropriate 
transfer and the participating hospital with specialized 
capabilities has the capacity to treat the individual.

    We received many comments opposing the proposal concerning 
hospitals with specialized capabilities included in the FY 2009 IPPS 
proposed rule. The commenters stated that the proposed rule would 
effectively ``reopen'' EMTALA for the admitting hospital by extending 
EMTALA's requirements for an ``appropriate transfer'' despite the fact 
that the admitting hospital's general EMTALA obligations ended, under 
regulation, when it admitted an individual as an inpatient. The 
commenters also stated that, because the original admitting hospital 
may claim that it lacks the capability to stabilize the individual's 
EMC, finalizing the proposed policy would result in an increase in 
patient dumping and inappropriate transfers, especially to teaching 
hospitals, tertiary care centers, and urban safety net hospitals. 
Commenters further asserted that finalizing CMS' policy as proposed 
would exacerbate confusion surrounding the determination of whether an 
individual is considered stable. That is, the hospital would be 
required to continuously monitor the individual to determine if at any 
point in the emergency department or even as an inpatient, the 
individual experienced a period of stability since such stability would 
end EMTALA obligations for all hospitals that might otherwise have 
obligations under the law. Under this scenario, the commenters asserted 
that the hospital with specialized capabilities would be forced to 
accept the transfer of an individual, potentially increasing the number 
of inappropriate or unnecessary transfers, because that hospital would 
be unable, with complete certainty, to determine whether the individual 
being transferred had ever experienced a period of stability.
    As a result, in the August 19, 2008 IPPS final rule (73 FR 48659) 
entitled, ``Medicare Program; Changes to the Hospital Inpatient 
Prospective Payment Systems and Fiscal Year 2009 Rates; Payments for 
Graduate Medical Education in Certain Emergency Situations; Changes to 
Disclosure of

[[Page 5216]]

Physician Ownership in Hospitals and Physician Self-Referral Rules; 
Updates to the Long-Term Care Prospective Payment System; Updates to 
Certain IPPS-Excluded Hospitals; and Collection of Information 
Regarding Financial Relationships Between Hospitals'' (hereinafter 
referred to as the FY 2009 IPPS final rule) we stated that,

Due to the many concerns that the commenters raised which are noted 
above, we believe it is appropriate to finalize a policy to state 
that if an individual with an unstable emergency medical condition 
is admitted, the EMTALA obligation has ended for the admitting 
hospital and even if the individual's emergency medical condition 
remains unstabilized and the individual requires special services 
only available at another hospital, the hospital with specialized 
capabilities does not have an EMTALA obligation to accept an 
appropriate transfer of that individual.

    Put another way, we finalized a policy that a hospital with 
specialized capabilities does not have an EMTALA obligation to accept 
an appropriate transfer of an individual who has been admitted in good 
faith as an inpatient at the first hospital. In the FY 2009 IPPS final 
rule (73 FR 48659), we stated that we believe that,

* * * finalizing the policy as proposed may negatively impact 
patient care, due to an increase in inappropriate transfers which 
could be detrimental to the physical and psychological health and 
well-being of patients [and we were] concerned that finalizing our 
proposed rule could further burden the emergency services system and 
may force hospitals providing emergency care to limit their services 
or close, reducing access to emergency care.

In addition, we stated that we were concerned about the possible 
disparate treatment of inpatients under the proposed policy because an 
individual who presented to a hospital under EMTALA might have 
different transfer rights than an inpatient who was admitted for an 
elective procedure. In the FY 2009 IPPS final rule (73 FR 48659) we 
stated--

    [W]e believe that, in the case where an individual is admitted 
and later found to be in need of specialized care not available at 
the admitting hospital, hospitals with specialized capabilities 
generally do accept the transfer, even in the absence of a legal 
requirement to do so.

    Finally, while we adopted a final rule that limits the EMTALA 
responsibilities of a hospital with specialized capabilities (73 FR 
48661), we

* * * encourage[d] the public to make CMS aware if this 
interpretation of section 1867(g) of the Act should result in 
harmful refusals by hospitals with specialized capabilities to 
accept the transfer of inpatients whose emergency medical condition 
remains unstabilized, or any other unintended consequences.

D. Litigation Related to the Applicability of EMTALA to Hospital 
Inpatients

    We are aware that there continues to be a range of opinions, even 
at the Federal circuit court level, on the topic of EMTALA's 
application to inpatients. For example, in Thornton v. Southwest 
Detroit Hospital, 895 F.2d 1131, 1134 (6th Cir. 1990), the Sixth 
Circuit stated that, ``once a patient is found to suffer from an [EMC] 
in the emergency room, she cannot be discharged until the condition is 
stabilized * * *.'' However, other courts have concluded that a 
hospital's obligations under EMTALA end at the time that a hospital 
admits an individual to the facility as an inpatient. (See Bryan v. 
Rectors and Visitors of the University of Virginia, 95 F.3d 349 (4th 
Cir. 1996) and Bryant v. Adventist Health System/West, 289 F.3d 1162 
(9th Cir. 2002)). More recently, in Moses v. Providence Hospital and 
Medical Centers Inc., 561 F.3d 573 (6th Cir. 2009), the Sixth noted 
that the policy articulated in the 2003 EMTALA final rule that a 
hospital's obligation under EMTALA would end when that hospital, in 
good faith, admits an individual with an EMC as an inpatient was 
contrary to the plain language of the EMTALA statute. Rather, the court 
stated that a hospital's EMTALA obligations to an individual continue 
until that individual's EMC is stabilized regardless of the 
individual's status as an inpatient or outpatient.

E. Advance Notice of Proposed Rulemaking: Applicability of EMTALA to 
Hospital Inpatients and Hospitals With Specialized Capabilities

    In 2010, United States Solicitor General advised the Supreme Court 
that HHS had committed to initiating a rulemaking process to reconsider 
the policy articulated in its current regulations, which state that a 
hospital's EMTALA obligations end upon the good faith admission as an 
inpatient of an individual with an EMC. In the December 23, 2010 
Federal Register (75 FR 80762), we published an advance notice of 
proposed rulemaking (ANPRM) entitled ``Medicare Program; Emergency 
Medical Treatment and Labor Act: Applicability to Hospital and Critical 
Access Hospital Inpatients and Hospitals With Specialized 
Capabilities'' to solicit comments regarding whether we should revisit 
the policies established in the 2003 EMTALA final rule and the FY 2009 
IPPS final rule. In addition, we sought real world examples that would 
inform our understanding of the current policy's impact on patients' 
access to care for an EMC. We noted that we would find it particularly 
helpful whether commenters could submit specific real-world examples 
that demonstrate if it would be beneficial to revisit these policies. 
We stated (75 FR 80765) that we--

* * * are interested in hearing whether commenters are aware of 
situations where an individual who presented under EMTALA with an 
unstable EMC was admitted to the hospital where he or she first 
presented and was then transferred to another facility, even though 
the admitting hospital had the capacity and capability to treat that 
individual's EMC.

    We further stated (75 FR 80765) that we were ``* * * interested in 
receiving information regarding the accuracy of our statement in the 
August 19, 2008 IPPS final rule that a hospital with specialized 
capabilities would accept the transfer of an inpatient with an 
unstabilized EMC absent an EMTALA obligation.'' Lastly, we stated (75 
FR 80765) that we were interested in learning whether commenters were 
``* * * aware of situations where an individual with an unstabilized 
EMC was admitted as an inpatient and continued to have an unstabilized 
EMC requiring the services of a hospital with specialized capabilities 
that refused to accept the transfer of the individual because current 
policy does not obligate hospitals with specialized capabilities to do 
so.''

II. Provisions of the Request for Comments

A. Applicability of EMTALA to Hospital Inpatients

    In the 2003 EMTALA final rule, we took the position that a 
hospital's obligation under EMTALA ends when that hospital, in good 
faith, admits an individual with an unstable emergency medical 
condition as an inpatient to that hospital. In that rule, we noted that 
other patient safeguards including the CoPs as well as State 
malpractice law protect inpatients. In response to our request for 
comments in the ANPRM as to whether we should revisit the policies that 
were established in the 2003 EMTALA final rule, very few commenters 
took the position that the admitting hospital should continue to have 
an EMTALA obligation after the individual is admitted as an inpatient. 
While some commenters advocated extending EMTALA to inpatients who do 
not experience a period of stability, the commenters did not provide 
any evidence that the existing policy has resulted in patients being 
admitted and then subsequently discharged before

[[Page 5217]]

they were stable, adversely affecting the clinical outcome of those 
patients. Most commenters expressed support for the current policy that 
EMTALA does not apply to any inpatient of a hospital, even a patient 
who was admitted through that hospital's dedicated emergency department 
and continues to be unstable. These commenters referred to our 2003 
EMTALA final rule and concurred with our assessment that, under our 
existing policy, the numerous hospital CoPs that protect inpatients as 
well as inpatients' rights under State law afford individuals admitted 
to a hospital with sufficient protection. Moreover, commenters 
appreciated the clarity and predictability of a bright line policy. 
Commenters also noted that our current policy regarding inpatients is 
achieving Congress' intent by ensuring that every individual, 
regardless of their ability to pay for emergency services, should have 
access to hospital services provided in hospitals with emergency 
departments.
    Therefore, in light of the comments we received regarding the 
extension of the EMTALA obligations for hospitals admitting an 
individual through their dedicated emergency departments, we are not 
proposing to change the current EMTALA requirements for these 
hospitals. That is, we are maintaining our current policy that, if an 
individual ``comes to the [hospital's] emergency department,'' as we 
have defined that term in regulation, and the hospital provides an 
appropriate medical screening examination and determines that an EMC 
exists, and then admits the individual in good faith in order to 
stabilize the EMC, that hospital has satisfied its EMTALA obligation 
towards that patient. We continue to believe that this policy is a 
reasonable interpretation of the EMTALA statute and is supported by 
several Federal courts that have held that an individual's EMTALA 
protections end upon admission as a hospital inpatient. For further 
explanation, we refer readers to the 2003 EMTALA final rule (68 FR 
53244), in which we finalized the policy that a hospital's EMTALA 
obligations end upon admission.

B. Applicability of EMTALA to Hospitals With Specialized Capabilities

    The second issue upon which the ANPRM solicited comment was, 
whether EMTALA should apply to situations where a hospital seeks to 
transfer an individual, who was admitted by that hospital as an 
inpatient after coming to the hospital's dedicated emergency department 
with an EMC, to a hospital with specialized capabilities because the 
admitted inpatient continues to have an unstabilized EMC that requires 
specialized treatment not available at the admitting hospital. Under 
current regulations, if an individual comes to the hospital's dedicated 
emergency department, is determined to have an EMC, is admitted as an 
inpatient, and continues to have an unstabilized EMC which requires the 
specialized capabilities of another hospital, the EMTALA obligation for 
the admitting hospital has ended and a hospital with specialized 
capabilities also does not have an EMTALA obligation towards that 
individual.
    Although we received some comments that supported amending the 
current regulations to require hospitals with specialized capabilities 
to accept the appropriate transfer of an inpatient who had presented to 
the admitting hospital under EMTALA and requires specialized 
capabilities to stabilize his or her EMC not available at the admitting 
hospital, most comments supported making no change to the current 
policies regarding the applicability of EMTALA to hospitals with 
specialized capabilities.
    Therefore, at this time, we are making no proposals with respect to 
our policies regarding the applicability of EMTALA to hospitals with 
specialized capabilities. However, we will continue to monitor whether 
it may be appropriate in the future to reconsider this issue. Thus, we 
are providing a 60-day comment period to allow the public to submit 
data or real world examples that are relevant to this issue.

III. Response to Comments

    Because of the large number of public comments we normally receive 
on Federal Register documents, we are not able to acknowledge or 
respond to them individually. We will consider all comments we receive 
by the date and time specified in the DATES section of this preamble. 
If we proceed to issue a subsequent document on the issues raised 
therein, we will respond to those comments in the preamble to that 
document.

(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare--Hospital Insurance; and Program No. 93.774)

    Dated: January 9, 2012.
Marilyn Tavenner,
Acting Administrator, Centers for Medicare & Medicaid Services.
    Approved: January 26, 2012.
Kathleen Sebelius,
Secretary, Department of Health and Human Services.
[FR Doc. 2012-2287 Filed 1-31-12; 4:15 pm]
BILLING CODE 4120-01-P