Chapter 28. Access to Emergency Medical Services.

§ 31–2801. Definitions.

For the purposes of this chapter, the term:

(1) “Ancillary services” means standard medical procedures that are reasonably necessary for the diagnosis and treatment of a patient.

(2) “Emergency services” means:

(A) Health care services furnished in the emergency department of a hospital for the treatment of a medical emergency;

(B) Ancillary services routinely available to the emergency department of a hospital for the treatment of a medical emergency; and

(3) “Medical emergency” means the sudden onset or sudden worsening of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent lay person, who possesses an average knowledge of health and medicine, to result in:

(A) Placing the patient’s health in serious jeopardy;

(B) Serious impairment to bodily functions; or

§ 31–2802. Covered services.

(a)(1) All health insurers, hospitals or medical services corporations, and health maintenance organizations shall reimburse for emergency services that are due to a medical emergency.

(2) Reimbursement for pre-hospital medical care and transport delivered pursuant to paragraph (1) of this subsection by the Fire and Emergency Medical Services Department ("Department") or a third party contracted by the District to provide such services pursuant to § 5-401(b), shall be at the fee rate authorized by the Council pursuant to § 5-416(a).

(3) This subsection shall not apply to any group health plan or multiple employer welfare arrangement to the extent the plan or arrangement is not subject to state insurance regulation under section 514 of the Employee Retirement Income Security Act of 1974, approved September 2, 1974 (88 Stat. 897; 29 U.S.C. § 1144).

(b) A hospital emergency department or emergency medical service transporter shall provide a health insurer, hospital or medical services corporation, or health maintenance organization with any claim for reimbursement of services, and information on the presenting symptoms of the insured as well as the services provided.

(c) A health insurer, hospital or medical services corporation, or health maintenance organization shall consider both the presenting symptoms and the services provided in processing a claim for reimbursement of emergency services.

(d) A health insurer, hospital or medical services corporation, or health maintenance organization may not deny reimbursement, except for co-payments, deductibles, and co-insurance, for the provision of emergency services that are due to a medical emergency solely because the member failed to obtain pre-authorization for emergency services from the health insurer, hospital or medical services corporation, or health maintenance organization.

§ 31–2803. Emergency department HIV screening.

(a) For the purposes of this section, the term.

(1) “Health benefit plan,” “health insurer,” and “insured” shall have the same meanings as provided in § 31-3001.

(2) “HIV screening test” shall mean the testing for the human immunodeficiency virus or any other identified causative agent of the acquired immune deficiency syndrome by:

(A) Conducting a rapid-result test by means of the swabbing of a patient’s gums, finger-prick blood test, or other suitable rapid-result test; and

(B) If the result is positive, conducting an additional blood test for submission to a laboratory to confirm the results of the rapid-result test.

(b) A health benefit plan shall reimburse the cost of a voluntary HIV screening test performed on its insured while the insured is receiving emergency medical services, other than HIV screening, at a hospital emergency department, whether or not the HIV screening test is necessary for the treatment of the medical emergency which caused the insured to seek emergency services.

(1) Include at least one annual emergency department HIV screening test;

(2) Reimburse the costs of administering such a test, all laboratory expenses to analyze the test, and the costs of communicating to the patient the results of the test and any applicable follow-up instructions for obtaining health care and supportive services; and

(3) Not be subject to any annual or coinsurance deductible or any co-payment other than the co-payment that the insured would have to pay for the applicable hospital emergency department visit.

(d) A representative of the emergency department of a hospital that provides emergency department HIV screening shall advise any patient between 13 and 64 years of age:

(1) That unless a patient, or in the case of a minor, the patient’s parent, legal guardian, or other person authorized to make health care decisions for the minor, chooses to withhold consent, an HIV screening test will be performed at the time he or she receives emergency medical treatment;

(2) That, if the patient is covered by a health benefit plan issued by a health insurer, the cost of at least one annual emergency department HIV screening test is a covered benefit;

(3) That the test results are confidential, except that a positive test result will be reported to the Department of Health for statistical and public health purposes; and

(4) In the case of a positive test result, where the patient may obtain appropriate health care and supportive services.

(e) A health insurer shall not:

(1) Require an insured or applicant for insurance to pay a higher deductible, copayment, or coinsurance, require a longer waiting period, or impose any other condition for coverage of benefits solely because an insured or applicant for insurance used the benefits covered by this section;

(2) Refuse to issue a health benefit plan solely because an applicant may use the benefits covered by this section; or

(3) Cancel or refuse to renew a health benefit plan solely because an insured has used the benefits covered by this section.

(f) The Mayor, pursuant to subchapter I of Chapter 5 of Title 2, may issue rules to implement the provisions of this section.