II 104th congress S.2121 2d Session To ensure medicare beneficiaries participating- in managed care have access to emergency and urgent care. IN THE SENATE OF THE UNITED STATES September 25, 1996 Mr. Graham (for himself, Mr. Grassley, Ms. Moseley-Braun, Mr. Chafee, Mr. Jeffords, Mr. Baucus, Mr. Simon, Mr. Rollings, and Mr. Wellstone) introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To ensure medicare beneficiaries participating in managed care have access to emergency and urgent care. 1 Be it enacted hy the Senate and House ofEepresenta- 2 tives ofthe United States ofAmerica in Congress assembled, 3 SECTION 1. SHORV^ TITLE. 4 This Act may be cited as the "Medicare Access to 5 Emergency Medical Care Act of 1996". 6 SEC. 2. REQUIREMENTS FOR MEDICARE MANAGED CARE. — 7 (a) Access to Emergency Services. Section 8 1876(c) of the Social Security Act (42 U.S.C. 1395mm(c)) 9 is amended by adding at the end the following: — — 2 A 1 "(9)(A) risk-sharing contract under this section 2 shall require an eligible organization that provides any 3 coverage with respect to emergency services to cover emer- 4 gency services furnished to a member enrolled with the 5 organization 6 "(i) without regard to whether or not the pro- 7 vider furnishing the emergency services has a con- 8 tractual or other arrangement with the organization 9 for the provision of such services to such members, 10 and 11 ''(ii) without regard to prior authorization. A 12 "(B)(i) risk-sharing contract under this section 13 shall require an eligible organization that provides any 14 coverage with respect to emergency services 15 "(I) to determine and make prompt payment 16 (within the meaning of subsection (g)(6)(A)) in a 17 reasonable and appropriate amount for such services 18 (including services required to be provided under 19 section 1867), and 20 "(II) subject to clause (ii), to not impose cost- 21 sharing for services furnished in a hospital emer- 22 gency department that is calculated in a manner 23 (such as the use of a different percentage) that im- 24 poses greater cost sharing with respect to such serv- es 2121 IS 3 1 ices compared to comparable services furnished in 2 other settings. 3 "(ii) An ehgible organization may impose a reason- 4 able copa3ni[ient (as determined in accordance with stand- 5 ards established by the Secretary) in lieu of coinsurance 6 to deter inappropriate use of services of hospital emer- 7 gency departments. 8 "(C) In this paragraph, the term 'emergency services' 9 has the same meaning as in paragraph (10)(D).". 10 (b) Timely Authorization for Promptly Need- 11 ED Cake Identified as a Result of Required — 12 Screening Evaluation. Section 1876(c) of such Act 13 (42 U.S.C. 1395mm(c)), as amended by subsection (a), 14 is amended by adding at the end the following: 15 "(10)(A) The organization must provide access 24 16 hours a day, 7 days a week to individuals who are author- 17 ized to make any prior authorizations required by the or- 18 ganization for coverage of items and services (other than 19 emergency services) that a treating physician or other 20 emergency department personnel identify, pursuant to a 21 screening evaluation required under section 1867(a), as 22 being needed promptly by an individual enrolled with the 23 organization under this part. 24 "(B) The organization is deemed to have approved 25 a request for such promptly needed items and semces if •S 2121 IS —— 4 1 the physician or other emergency department personnel in- 2 volved 3 "(i) has made a reasonable effort to contact an 4 individual described in subparagraph (A) for author- 5 ization to provide an appropriate referral for such 6 items and services or to provide the items and serv- 7 ices to the individual and access to the person has 8 not been provided (as required in subparagraph 9 (A)), or 10 "(ii) has requested such authorization from the 1 1 person and the person has not denied the authoriza- 12 tion within 30 minutes after the time the request is 13 made. 14 "(C) Approval of a request for a prior authorization 15 determination (including a deemed approval under sub- 16 paragraph (B)) shall be treated as approval of a request 17 for any items and services that are required to treat the 18 medical condition identified pursuant to the required 19 screening evaluation. 20 "(D) In this paragraph, the term 'emergency services' 21 means 22 "(i) health care items and services furnished in 23 the emergency department of a hospital (including a 24 trauma center), and >S 2121 IS — e5 1 "(ii) ancillary services routinely available to 2 such department, 3 to the extent they are required to evaluate and treat an 4 emergency medical condition (as defined in subparagraph 5 (E)) until the condition is stabiUzed (as defined in sub- 6 paragraph (F)). 7 "(E) In subparagraph (D), the term 'emergency med- 8 ical condition' means a medical condition, the onset of 9 which is sudden, that manifests itself by symptoms of suf- 10 ficient severity, including severe pain, that a prudent 1 1 layperson, who possesses an average knowledge of health 12 and medicine, could reasonably expect the absence of im- 13 mediate medical attention to result in 14 "(i) placing the person's health in serious jeop- 15 ardy, 16 "(ii) serious impairment to bodily functions, or 17 "(iii) serious dysfunction of any bodily organ or 18 part. 19 "(F) In subparagraph (D), the term 'stabihzed' 20 means, with respect to an emergency medical condition, 21 that no material deterioration of the condition is likely, 22 Avithin reasonable medical probability, to result or occur 23 before an individual can be transferred in compliance with 24 the requirements of section 1867.". •S 2121 IS 6 — 1 (c) Conforming Amendment. Section 2 1876(c)(4)(B) of such Act (42 U.S.C. 1395mm(c)(4)(B)) 3 is amended by inserting* "subject to paragraphs (9) and 4 (10)," before "provide". — 5 (d) Effective Date. The amendments made by 6 subsections (a) and (b) shall be effective for contract years 7 beginning on or after the date of the enactment of this 8 Act. O j ! ! >S 2121 IS ! \ ens LIBRARY ams iaE3fl e