BILL ANALYSIS


                                                        S.B. 1361
                                                      By: Shapiro
                                             Economic Development
                                                         04-27-95
                                     Committee Report (Unamended)
BACKGROUND

The Department of Insurance has received numerous complaints from
citizens that carriers or managed care plans have refused to
reimburse emergency care providers for services which the patient
believed to be a medical emergency. Hospitals and emergency
physicians report frequent refusals to reimburse for emergency
services which would appear to reasonable persons to constitute an
emergency medical condition. Such refusals are frequently made on
the grounds that the patient had sufficient time to present himself
or herself to the emergency hospital with which the managed care
plan had a contract or that, following the emergency physician's
screening examination or treatment, the physician's diagnosis
indicated no emergency medical condition existed.

PURPOSE

As proposed, S.B. 1361 redefines the terms "emergency medical
care," "emergency care," and "emergency services."

RULEMAKING AUTHORITY

It is the committee's opinion that this bill does not grant any
additional rulemaking authority to a state officer, institution, or
agency.

SECTION BY SECTION ANALYSIS

SECTION 1. Amends Article 3.70-2(I), Insurance Code, as follows:

     (I)(1) Requires an individual or group policy of accident and
     sickness insurance that provides any emergency care benefit
     including policies issued by companies subject to Chapter 20,
     Insurance Code, delivered or issued for delivery in this state
     to define "emergency care" as emergency services provided
     after the recent onset of a medical condition manifesting
     itself by acute symptoms of sufficient severity, such that the
     absence of immediate medical attention could reasonably be
     expected by a prudent layperson 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.
     
     (2) Provides that "emergency care" also means emergency
       services provided to a pregnant woman who is having
       contractions and there is inadequate time to effect a safe
       transfer to another hospital before delivery, or transfer
       may pose a threat to the health or safety of the woman or
       the unborn child.
       
       SECTION 2.   Amends Article 20A.02(t), Insurance Code, to make
conforming changes.

SECTION 3. Amends Section 311.021, Health and Safety Code, as
follows:

     Sec. 311.021. (1)(A) Defines "emergency service" as services
     that are usually and customarily available at a hospital and
     must be provided after the recent onset of a medical condition
     manifesting itself by acute symptoms of sufficient severity,
     such that the absence of immediate medical attention could
     reasonably be expected 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.
     
     (2) Provides that "emergency service" also means services
       provided to a pregnant woman who is having contractions, and
       there is inadequate time to effect a safe transfer to
       another hospital before delivery, or transfer may pose a
       threat to the health or safety of the woman or the unborn
       child. Makes nonsubstantive and conforming changes.
SECTION 4. Amends Section 773.003(19), Health and Safety Code to
redefine "emergency medical care" to make conforming changes.

SECTION 5. Emergency clause.
           Effective date: 90 days after adjournment.