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

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

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.