Relief for hospitals – Insurance must pay for EMTALA care

By Jennifer A. Stiller
December 29, 2009
Revised March 23, 2010

A federal law called the Emergency Medical Treatment and Labor Act ("EMTALA") has since 1985 required virtually all American hospitals to provide basic assessment and treatment services to deal with true medical emergencies regardless of whether the patient is able to pay for care.

The law requires all hospitals that participate in Medicare and have an emergency department to medically screen anyone who "comes to the emergency department" seeking treatment for a medical condition so as to determine whether an "emergency medical condition" exists. If it does, the hospital must either stabilize the patient's condition or arrange for a transfer. (EMTALA also prohibits a transfer unless the medical benefits of the transfer outweigh its risks or the patient specifically requests it.)

EMTALA applies to everybody – not just people covered by Medicare – but nothing in it required health insurance to actually pay the hospitals for the screening and stabilizations they provide.

Now that has changed. With the enactment on March 23, 2010 of the Patient Protection and Affordable Care Act, federal law now bars insurance companies from imposing pre-authorization requirements on EMTALA care. It also requires insurers to pay hospitals not under contract with them for EMTALA services on the same basis as they pay their own in-network hospitals.

Specifically, insurance plans must not –

• Require a prior authorization for screening and stabilization services as defined under EMTALA;
  
  
• Impose any requirement or condition on a non-contracted hospital that is more restrictive than those it imposes on hospitals with contracts;
  
  
• Impose different coinsurance or copayment requirements on non-network hospitals than they impose on in-network hospitals; or
  
  
• Apply any other coverage restriction (other than otherwise permissible cost-sharing and pre-existing condition exclusions).

The services to which these conditions apply are the emergency department screening and stabilization services required by EMTALA, which, depending on the patient's condition, could be quite extensive. The new provision does not apply to services provided in an emergency department not required to determine whether an "emergency medical condition" exists and to stabilize such a condition. "Emergency medical condition" is defined to mean –

A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in —

• Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
  
  
• Serious impairment to bodily functions, or
  
  
• Serious dysfunction of any bodily organ or part

The new requirements for insurance payment for EMTALA services become effective on or after September 23, 2010. The new law applies to all group and individual insurance plans for any plan year that starts on or after that date.