WASHINGTON -- At a press conference signaling strong bipartisan support, Rep. Benjamin L. Cardin (D-MD) announced the reintroduction of the Access to Emergency Medical Services Act, HR 1674, and called upon Congress and the President to enact its provisions this year. Rep. Marge Roukema of New Jersey is the lead Republican sponsor. A companion bill will be introduced today by Senators Bob Graham (D-FL) and Lincoln Chafee (R-RI).

This bill would establish the "prudent layperson" standard for emergency services under group health plans and health insurers. Cardin's legislation requires plans to pay for emergency treatment and stabilization based on the patient's symptoms rather than the final diagnosis. In addition, it prevents plans from forcing patients to obtain prior authorization before seeking emergency care, and it prohibits them from imposing excessive copayments for treatment in out-of-network emergency rooms. The bill also promotes quality and cost-effectiveness by requiring that health plans and emergency physicians work together to coordinate necessary follow-up care.

"We've all heard of far too many cases when health plans denied payment for emergency care because a patient's chest pains didn't turn out to be a heart attack. This legislation will end that practice once and for all by standardizing the definition of an emergency," said Rep. Cardin. "Access to emergency care, including ambulance services, is one of the most basic patient protections. Individuals should be guaranteed coverage for treatment when they need it. Today we are joined by a coalition of consumer groups, physicians, nurses, hospitals, and managed care plans, who all recognize how important the prudent layperson standard is to quality care."

"Maryland was the first state to enact the prudent layperson definition in 1993, followed by 31 other states and the District of Columbia. But health plan enrollees in 28 other states and 50 million persons in ERISA self-insured plans across the nation are still not covered by these protections. It's time to make the ‘prudent layperson' standard the law for all Americans," Cardin said.

Rep. Cardin first introduced the Access to Emergency Medical Services Act in 1995 during the 104th Congress, and he reintroduced similar legislation in the 105th and 106th Congresses. The 1997 Balanced Budget Act guaranteed emergency care protections to the Medicare and Medicaid programs, and a 1998 Executive Order extended them to members of FEHBP, veterans', and military health plans. The "prudent layperson" provision is now an essential element of comprehensive managed care reform legislation.

SHORT SUMMARY

THE ACCESS TO EMERGENCY MEDICAL SERVICES ACT OF 2001

The bill would amend the Internal Revenue Code of 1986, the Public Health Service Act, and the Employee Retirement Income Security Act of 1974. If enacted, the bill would guarantee that consumers are covered for legitimate emergency department visits. For health plans that offer coverage for emergency services, 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 through which the emergency department and health plan work together to ensure that the patient receives appropriate follow-up care. This standard has been in effect since 1997 for all Medicare and Medicaid managed care enrollees, and since 1998 for all federal employees, military health plan enrollees and veterans.

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 that do not meet the "prudent layperson" standard.
• Applies the "prudent layperson" standard to coverage of emergency ambulance services.
• Plans would be prohibited from requiring, as a condition of coverage, that patients obtain prior authorization from the health plan before seeking emergency care.
• Establishes coverage standards for out-of-network emergency care to protect patients who, under reasonable circumstances, seek care in such an emergency department.
• 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 may arrange for an alternative treatment plan that allows the 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 911 system.
• There would be no preemption of the state law as long as the state law does not prevent the application of the federal law.
• Applies to all health plans that offer coverage for emergency care, whether fully-insured or self-insured.