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.