H*3889 Session 112 (1997-1998)
H*3889(Rat #0449, Act #0326 of 1998) General Bill, By Kelley, Barrett, Battle,
A.W. Byrd, Clyburn, Edge, J. Hines, Keegan, Knotts, Maddox, McKay, Miller,
Neilson, Robinson, Rodgers, Simrill, Whatley and Witherspoon
A BILL TO AMEND TITLE 38, CHAPTER 71, CODE OF LAWS OF SOUTH CAROLINA, 1976,
RELATING TO ACCIDENT AND HEALTH INSURANCE, BY ADDING ARTICLE 15 TO ENACT THE
"ACCESS TO EMERGENCY MEDICAL CARE ACT" SO AS TO PROVIDE THAT PRIOR TO
REQUIRING AUTHORIZATION FROM A MANAGED CARE ORGANIZATION FOR MEDICAL TREATMENT
AT AN EMERGENCY DEPARTMENT, THE PATIENT MUST BE SCREENED AND ANY EMERGENCY
CONDITION STABILIZED; AND TO REQUIRE A MANAGED CARE ORGANIZATION TO INFORM ITS
ENROLLEES AND AFFILIATED PROVIDERS OF ITS EMERGENCY MEDICAL CARE SERVICES AND
POLICIES, TO PAY FOR THE SERVICES THAT IT INCLUDES IN ITS POLICIES, NOT TO
RETROSPECTIVELY DENY OR REDUCE PAYMENTS IF THE EMERGENCY CONDITION WAS LATER
DETERMINED NOT TO BE AN EMERGENCY AND TO PROVIDE EXCEPTIONS, AND NOT TO
PROHIBIT OR DISCOURAGE THE APPROPRIATE USE OF THE 911 TELEPHONE
NUMBER.-AMENDED TITLE
04/09/97 House Introduced and read first time HJ-50
04/09/97 House Referred to Committee on Labor, Commerce and
Industry HJ-50
03/25/98 House Committee report: Favorable with amendment Labor,
Commerce and Industry HJ-14
03/26/98 House Amended HJ-22
03/26/98 House Read second time HJ-24
03/26/98 House Unanimous consent for third reading on next
legislative day HJ-24
03/27/98 House Read third time and sent to Senate HJ-2
03/31/98 Senate Introduced and read first time SJ-12
03/31/98 Senate Referred to Committee on Banking and Insurance SJ-12
04/22/98 Senate Banking and Insurance Committee Polled out no
report SJ-9
05/21/98 Senate Amended SJ-16
05/21/98 Senate Read second time SJ-16
05/26/98 Senate Read third time and returned to House with
amendments SJ-12
05/28/98 House Concurred in Senate amendment and enrolled HJ-108
06/04/98 Ratified R 449
06/08/98 Signed By Governor
06/08/98 Effective date 06/08/98
06/19/98 Copies available
06/19/98 Act No. 326
(A326, R449, H3889)
AN ACT TO AMEND TITLE 38, CHAPTER 71, CODE OF LAWS
OF SOUTH CAROLINA, 1976, RELATING TO ACCIDENT AND
HEALTH INSURANCE, BY ADDING ARTICLE 15 TO ENACT THE
ACCESS TO EMERGENCY MEDICAL CARE ACT SO AS TO
PROVIDE THAT PRIOR TO REQUIRING AUTHORIZATION FROM
A MANAGED CARE ORGANIZATION FOR MEDICAL
TREATMENT AT AN EMERGENCY DEPARTMENT, THE PATIENT
MUST BE SCREENED AND ANY EMERGENCY CONDITION
STABILIZED; AND TO REQUIRE A MANAGED CARE
ORGANIZATION TO INFORM ITS ENROLLEES AND AFFILIATED
PROVIDERS OF ITS EMERGENCY MEDICAL CARE SERVICES
AND POLICIES, TO PAY FOR THE SERVICES THAT IT INCLUDES
IN ITS POLICIES, NOT TO RETROSPECTIVELY DENY OR
REDUCE PAYMENTS IF THE EMERGENCY CONDITION WAS
LATER DETERMINED NOT TO BE AN EMERGENCY AND TO
PROVIDE EXCEPTIONS, AND NOT TO PROHIBIT OR
DISCOURAGE THE APPROPRIATE USE OF THE 911 TELEPHONE
NUMBER.
Be it enacted by the General Assembly of the State of South Carolina:
Access to emergency medical care; procedures under managed
care
SECTION 1. Title 38, Chapter 71 of the 1976 Code is amended by
adding:
"Article 15
Access to Emergency Medical Care
Section 38-71-1510. This article may be cited as the 'Access to
Emergency Medical Care Act'.
Section 38-71-1520. As used in this article:
(1) 'Emergency medical care' means those health care services
provided in a hospital emergency facility to evaluate and treat an
emergency medical condition.
(2) 'Emergency medical condition' means 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:
(a) 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;
(b) serious impairment to bodily functions; or
(c) serious dysfunction of any bodily organ or part.
(3) 'Emergency medical provider' means hospitals licensed by the
South Carolina Department of Health and Environmental Control,
hospital-based services, and physicians licensed by the State Board of
Medical Examiners who provide emergency medical care.
(4) 'Managed care organization' means a licensed insurance company,
a hospital or medical services plan contract, a health maintenance
organization, or any other entity which is subject to regulation by the
department and which operates a managed care plan.
(5) 'Managed care plan' means a plan operated by a managed care
organization which provides for the financing and delivery of health care
and treatment services to individuals enrolled in the plan through its own
employed health care providers or contracting with selected specific
providers that conform to explicit selection standards, or both. A
managed care plan also customarily has a formal organizational structure
for continual quality assurance, a certified utilization review program,
dispute resolution, and financial incentives for individual enrollees to use
the plan's participating providers and procedures.
Section 38-71-1530. (A) A patient who presents to an emergency
department, by the Federal Social Security Act, must be screened to
determine whether an emergency medical condition exists. This
evaluation may include, but is not limited to, diagnostic testing to assess
the extent of the condition, sickness, or injury and radiographic
procedures and interpretation.
(B) Appropriate intervention must be initiated by medical personnel
to stabilize any emergency medical condition before requesting
authorization for the treatment by a managed care organization.
(C) A managed care organization shall inform its insureds, enrollees,
patients, and affiliated providers about all policies related to emergency
medical care access, coverage, payment, and grievance procedures. It is
the ultimate responsibility of the managed care organization to inform any
contracted third party administrator, independent contractor, or primary
care provider about the emergency medical care provisions contained in
this subsection.
(D) A managed care organization which includes emergency medical
care services as part of its policy or contract shall provide coverage and
shall subsequently pay providers for emergency medical care services
provided to an insured, enrollee, or patient who presents an emergency
medical condition. This subsection must not be construed to require
coverage for illnesses, diseases, equipment, supplies, or procedures or
treatments which are not otherwise covered under the terms of the
insured's policy or contract.
(E) A managed care organization may not retrospectively deny or
reduce payments to providers for emergency medical care of an insured,
enrollee, or patient even if it is determined that the emergency medical
condition initially presented is later identified through screening not to be
an actual emergency, except in these cases:
(1) material misrepresentation, fraud, omission, or clerical error;
(2) a payment reduction due to applicable co-payments,
co-insurance, or deductibles which may be the responsibility of the
insured;
(3) cases in which the insured does not meet the emergency medical
condition definition, unless the insured has been referred to the
emergency department by the insured's primary care physician or other
agent acting on behalf of the insurer.
Section 38-71-1540. No managed care organization may engage in any
practice to prohibit or discourage the appropriate use of the 911
emergency telephone system which may adversely impact the health of
its enrollees.
Section 38-71-1550. If any provision of this article or the application
of any provision to any person or circumstance is held invalid, the
invalidity does not affect other provisions or applications of the article
which can be given effect without the invalid provision or application, and
to this end the provisions of this article are severable."
Time effective
SECTION 2. This act takes effect upon approval by the Governor.
Approved the 8th day of June, 1998. |