
From the U.S. Code Online via GPO Access
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[Laws in effect as of January 23, 2000]
[Document not affected by Public Laws enacted between
  January 23, 2000 and December 4, 2001]
[CITE: 42USC1395dd]

 
                 TITLE 42--THE PUBLIC HEALTH AND WELFARE
 
                       CHAPTER 7--SOCIAL SECURITY
 
        SUBCHAPTER XVIII--HEALTH INSURANCE FOR AGED AND DISABLED
 
                    Part D--Miscellaneous Provisions
 
Sec. 1395dd. Examination and treatment for emergency medical 
        conditions and women in labor
        

(a) Medical screening requirement

    In the case of a hospital that has a hospital emergency department, 
if any individual (whether or not eligible for benefits under this 
subchapter) comes to the emergency department and a request is made on 
the individual's behalf for examination or treatment for a medical 
condition, the hospital must provide for an appropriate medical 
screening examination within the capability of the hospital's emergency 
department, including ancillary services routinely available to the 
emergency department, to determine whether or not an emergency medical 
condition (within the meaning of subsection (e)(1) of this section) 
exists.

(b) Necessary stabilizing treatment for emergency medical conditions and 
        labor

                           (1) In general

        If any individual (whether or not eligible for benefits under 
    this subchapter) comes to a hospital and the hospital determines 
    that the individual has an emergency medical condition, the hospital 
    must provide either--
            (A) within the staff and facilities available at the 
        hospital, for such further medical examination and such 
        treatment as may be required to stabilize the medical condition, 
        or
            (B) for transfer of the individual to another medical 
        facility in accordance with subsection (c) of this section.

                 (2) Refusal to consent to treatment

        A hospital is deemed to meet the requirement of paragraph (1)(A) 
    with respect to an individual if the hospital offers the individual 
    the further medical examination and treatment described in that 
    paragraph and informs the individual (or a person acting on the 
    individual's behalf) of the risks and benefits to the individual of 
    such examination and treatment, but the individual (or a person 
    acting on the individual's behalf) refuses to consent to the 
    examination and treatment. The hospital shall take all reasonable 
    steps to secure the individual's (or person's) written informed 
    consent to refuse such examination and treatment.

                 (3) Refusal to consent to transfer

        A hospital is deemed to meet the requirement of paragraph (1) 
    with respect to an individual if the hospital offers to transfer the 
    individual to another medical facility in accordance with subsection 
    (c) of this section and informs the individual (or a person acting 
    on the individual's behalf) of the risks and benefits to the 
    individual of such transfer, but the individual (or a person acting 
    on the individual's behalf) refuses to consent to the transfer. The 
    hospital shall take all reasonable steps to secure the individual's 
    (or person's) written informed consent to refuse such transfer.

(c) Restricting transfers until individual stabilized

                              (1) Rule

        If an individual at a hospital has an emergency medical 
    condition which has not been stabilized (within the meaning of 
    subsection (e)(3)(B) of this section), the hospital may not transfer 
    the individual unless--
            (A)(i) the individual (or a legally responsible person 
        acting on the individual's behalf) after being informed of the 
        hospital's obligations under this section and of the risk of 
        transfer, in writing requests transfer to another medical 
        facility,
            (ii) a physician (within the meaning of section 1395x(r)(1) 
        of this title) has signed a certification that \1\ based upon 
        the information available at the time of transfer, the medical 
        benefits reasonably expected from the provision of appropriate 
        medical treatment at another medical facility outweigh the 
        increased risks to the individual and, in the case of labor, to 
        the unborn child from effecting the transfer, or
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    \1\ So in original. Probably should be followed by a comma.
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            (iii) if a physician is not physically present in the 
        emergency department at the time an individual is transferred, a 
        qualified medical person (as defined by the Secretary in 
        regulations) has signed a certification described in clause (ii) 
        after a physician (as defined in section 1395x(r)(1) of this 
        title), in consultation with the person, has made the 
        determination described in such clause, and subsequently 
        countersigns the certification; and
            (B) the transfer is an appropriate transfer (within the 
        meaning of paragraph (2)) to that facility.

    A certification described in clause (ii) or (iii) of subparagraph 
    (A) shall include a summary of the risks and benefits upon which the 
    certification is based.

                      (2) Appropriate transfer

        An appropriate transfer to a medical facility is a transfer--
            (A) in which the transferring hospital provides the medical 
        treatment within its capacity which minimizes the risks to the 
        individual's health and, in the case of a woman in labor, the 
        health of the unborn child;
            (B) in which the receiving facility--
                (i) has available space and qualified personnel for the 
            treatment of the individual, and
                (ii) has agreed to accept transfer of the individual and 
            to provide appropriate medical treatment;

            (C) in which the transferring hospital sends to the 
        receiving facility all medical records (or copies thereof), 
        related to the emergency condition for which the individual has 
        presented, available at the time of the transfer, including 
        records related to the individual's emergency medical condition, 
        observations of signs or symptoms, preliminary diagnosis, 
        treatment provided, results of any tests and the informed 
        written consent or certification (or copy thereof) provided 
        under paragraph (1)(A), and the name and address of any on-call 
        physician (described in subsection (d)(1)(C) of this section) 
        who has refused or failed to appear within a reasonable time to 
        provide necessary stabilizing treatment;
            (D) in which the transfer is effected through qualified 
        personnel and transportation equipment, as required including 
        the use of necessary and medically appropriate life support 
        measures during the transfer; and
            (E) which meets such other requirements as the Secretary may 
        find necessary in the interest of the health and safety of 
        individuals transferred.

(d) Enforcement

                      (1) Civil money penalties

        (A) A participating hospital that negligently violates a 
    requirement of this section is subject to a civil money penalty of 
    not more than $50,000 (or not more than $25,000 in the case of a 
    hospital with less than 100 beds) for each such violation. The 
    provisions of section 1320a-7a of this title (other than subsections 
    (a) and (b)) shall apply to a civil money penalty under this 
    subparagraph in the same manner as such provisions apply with 
    respect to a penalty or proceeding under section 1320a-7a(a) of this 
    title.
        (B) Subject to subparagraph (C), any physician who is 
    responsible for the examination, treatment, or transfer of an 
    individual in a participating hospital, including a physician on-
    call for the care of such an individual, and who negligently 
    violates a requirement of this section, including a physician who--
            (i) signs a certification under subsection (c)(1)(A) of this 
        section that the medical benefits reasonably to be expected from 
        a transfer to another facility outweigh the risks associated 
        with the transfer, if the physician knew or should have known 
        that the benefits did not outweigh the risks, or
            (ii) misrepresents an individual's condition or other 
        information, including a hospital's obligations under this 
        section,

    is subject to a civil money penalty of not more than $50,000 for 
    each such violation and, if the violation is is \2\ gross and 
    flagrant or is repeated, to exclusion from participation in this 
    subchapter and State health care programs. The provisions of section 
    1320a-7a of this title (other than the first and second sentences of 
    subsection (a) and subsection (b)) shall apply to a civil money 
    penalty and exclusion under this subparagraph in the same manner as 
    such provisions apply with respect to a penalty, exclusion, or 
    proceeding under section 1320a-7a(a) of this title.
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    \2\ So in original.
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        (C) If, after an initial examination, a physician determines 
    that the individual requires the services of a physician listed by 
    the hospital on its list of on-call physicians (required to be 
    maintained under section 1395cc(a)(1)(I) of this title) and notifies 
    the on-call physician and the on-call physician fails or refuses to 
    appear within a reasonable period of time, and the physician orders 
    the transfer of the individual because the physician determines that 
    without the services of the on-call physician the benefits of 
    transfer outweigh the risks of transfer, the physician authorizing 
    the transfer shall not be subject to a penalty under subparagraph 
    (B). However, the previous sentence shall not apply to the hospital 
    or to the on-call physician who failed or refused to appear.

                        (2) Civil enforcement

        (A) Personal harm

            Any individual who suffers personal harm as a direct result 
        of a participating hospital's violation of a requirement of this 
        section may, in a civil action against the participating 
        hospital, obtain those damages available for personal injury 
        under the law of the State in which the hospital is located, and 
        such equitable relief as is appropriate.

        (B) Financial loss to other medical facility

            Any medical facility that suffers a financial loss as a 
        direct result of a participating hospital's violation of a 
        requirement of this section may, in a civil action against the 
        participating hospital, obtain those damages available for 
        financial loss, under the law of the State in which the hospital 
        is located, and such equitable relief as is appropriate.

        (C) Limitations on actions

            No action may be brought under this paragraph more than two 
        years after the date of the violation with respect to which the 
        action is brought.

           (3) Consultation with peer review organizations

        In considering allegations of violations of the requirements of 
    this section in imposing sanctions under paragraph (1), the 
    Secretary shall request the appropriate utilization and quality 
    control peer review organization (with a contract under part B of 
    subchapter XI of this chapter) to assess whether the individual 
    involved had an emergency medical condition which had not been 
    stabilized, and provide a report on its findings. Except in the case 
    in which a delay would jeopardize the health or safety of 
    individuals, the Secretary shall request such a review before 
    effecting a sanction under paragraph (1) and shall provide a period 
    of at least 60 days for such review.

(e) Definitions

    In this section:
        (1) The term ``emergency medical condition'' means--
            (A) a medical condition manifesting itself by acute symptoms 
        of sufficient severity (including severe pain) such that the 
        absence of immediate medical attention could reasonably be 
        expected to result in--
                (i) 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,
                (ii) serious impairment to bodily functions, or
                (iii) serious dysfunction of any bodily organ or part; 
            or

            (B) with respect to a pregnant women \3\ who is having 
        contractions--
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    \3\ So in original. Probably should be ``woman''.
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                (i) that there is inadequate time to effect a safe 
            transfer to another hospital before delivery, or
                (ii) that transfer may pose a threat to the health or 
            safety of the woman or the unborn child.

        (2) The term ``participating hospital'' means hospital that has 
    entered into a provider agreement under section 1395cc of this 
    title.
        (3)(A) The term ``to stabilize'' means, with respect to an 
    emergency medical condition described in paragraph (1)(A), to 
    provide such medical treatment of the condition as may be necessary 
    to assure, within reasonable medical probability, that no material 
    deterioration of the condition is likely to result from or occur 
    during the transfer of the individual from a facility, or, with 
    respect to an emergency medical condition described in paragraph 
    (1)(B), to deliver (including the placenta).
        (B) The term ``stabilized'' means, with respect to an emergency 
    medical condition described in paragraph (1)(A), that no material 
    deterioration of the condition is likely, within reasonable medical 
    probability, to result from or occur during the transfer of the 
    individual from a facility, or, with respect to an emergency medical 
    condition described in paragraph (1)(B), that the woman has 
    delivered (including the placenta).
        (4) The term ``transfer'' means the movement (including the 
    discharge) of an individual outside a hospital's facilities at the 
    direction of any person employed by (or affiliated or associated, 
    directly or indirectly, with) the hospital, but does not include 
    such a movement of an individual who (A) has been declared dead, or 
    (B) leaves the facility without the permission of any such person.
        (5) The term ``hospital'' includes a critical access hospital 
    (as defined in section 1395x(mm)(1) of this title).

(f) Preemption

    The provisions of this section do not preempt any State or local law 
requirement, except to the extent that the requirement directly 
conflicts with a requirement of this section.

(g) Nondiscrimination

    A participating hospital that has specialized capabilities or 
facilities (such as burn units, shock-trauma units, neonatal intensive 
care units, or (with respect to rural areas) regional referral centers 
as identified by the Secretary in regulation) shall not refuse to accept 
an appropriate transfer of an individual who requires such specialized 
capabilities or facilities if the hospital has the capacity to treat the 
individual.

(h) No delay in examination or treatment

    A participating hospital may not delay provision of an appropriate 
medical screening examination required under subsection (a) of this 
section or further medical examination and treatment required under 
subsection (b) of this section in order to inquire about the 
individual's method of payment or insurance status.

(i) Whistleblower protections

    A participating hospital may not penalize or take adverse action 
against a qualified medical person described in subsection 
(c)(1)(A)(iii) of this section or a physician because the person or 
physician refuses to authorize the transfer of an individual with an 
emergency medical condition that has not been stabilized or against any 
hospital employee because the employee reports a violation of a 
requirement of this section.

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1867, as added Pub. L. 99-
272, title IX, Sec. 9121(b), Apr. 7, 1986, 100 Stat. 164; amended Pub. 
L. 99-509, title IX, Sec. 9307(c)(4), Oct. 21, 1986, 100 Stat. 1996; 
Pub. L. 99-514, title XVIII, Sec. 1895(b)(4), Oct. 22, 1986, 100 Stat. 
2933; Pub. L. 100-203, title IV, Sec. 4009(a)(1), formerly 
Sec. 4009(a)(1), (2), Dec. 22, 1987, 101 Stat. 1330-56, 1330-57; Pub. L. 
100-360, title IV, Sec. 411(b)(8)(A)(i), July 1, 1988, 102 Stat. 772; 
Pub. L. 100-485, title VI, Sec. 608(d)(18)(E), Oct. 13, 1988, 102 Stat. 
2419; Pub. L. 101-239, title VI, Secs. 6003(g)(3)(D)(xiv), 6211(a)-(h), 
Dec. 19, 1989, 103 Stat. 2154, 2245-2248; Pub. L. 101-508, title IV, 
Secs. 4008(b)(1)-(3)(A), 4207(a)(1)(A), (2), (3), (k)(3), formerly 
4027(a)(1)(A), (2), (3), (k)(3), Nov. 5, 1990, 104 Stat. 1388-44, 1388-
117, 1388-124, renumbered and amended Pub. L. 103-432, title I, 
Sec. 160(d)(4), (5)(A), Oct. 31, 1994, 108 Stat. 4444; Pub. L. 105-33, 
title IV, Sec. 4201(c)(1), Aug. 5, 1997, 111 Stat. 373.)

                       References in Text

    Part B of subchapter XI of this chapter, referred to in subsec. 
(d)(3), is classified to section 1320c et seq. of this title.


                            Prior Provisions

    A prior section 1395dd, act Aug. 14, 1935, ch. 531, title XVIII, 
Sec. 1867, as added July 30, 1965, Pub. L. 89-97, title I, Sec. 102(a), 
79 Stat. 329; amended Jan. 2, 1968, Pub. L. 90-248, title I, 
Sec. 164(a), 81 Stat. 873; Oct. 30, 1972, Pub. L. 92-603, title II, 
Sec. 288, 86 Stat. 1457, related to creation, composition, meetings, and 
functions of the Health Insurance Benefits Advisory Council and the 
appointment of a Chairman and members thereto, and qualifications, terms 
of office, compensation, and reimbursement of travel expenses of 
members, prior to repeal by Pub. L. 98-369, div. B, title III, 
Sec. 2349(a), July 18, 1984, 98 Stat. 1097, eff. July 18, 1984.


                               Amendments

    1997--Subsec. (e)(5). Pub. L. 105-33 substituted ``critical access'' 
for ``rural primary care''.
    1994--Subsec. (d)(3). Pub. L. 103-432, Sec. 160(d)(5)(A), made 
technical amendment to Pub. L. 101-508, Sec. 4207(a)(1)(A). See 1990 
Amendment note below.
    1990--Subsec. (c)(2)(C). Pub. L. 101-508, Sec. 4008(b)(3)(A)(iii), 
substituted ``subsection (d)(1)(C)'' for ``subsection (d)(2)(C)''.
    Subsec. (d)(1). Pub. L. 101-508, Sec. 4008(b)(3)(A)(i), (ii), 
redesignated par. (2) as (1) and struck out former par. (1) which read 
as follows: ``If a hospital knowingly and willfully, or negligently, 
fails to meet the requirements of this section, such hospital is subject 
to--
        ``(A) termination of its provider agreement under this 
    subchapter in accordance with section 1395cc(b) of this title, or
        ``(B) at the option of the Secretary, suspension of such 
    agreement for such period of time as the Secretary determines to be 
    appropriate, upon reasonable notice to the hospital and to the 
    public.''
    Subsec. (d)(1)(B). Pub. L. 101-508, Sec. 4207(a)(2), (3), formerly 
Sec. 4027(a)(2), (3), as renumbered by Pub. L. 103-432, Sec. 160(d)(4), 
which directed amendment of par. (2)(B) by substituting ``negligently'' 
for ``knowingly'' and ``is gross and flagrant or is repeated'' for 
``knowing and willful or negligent'', was executed by making the 
substitutions in par. (1)(B) to reflect the probable intent of Congress 
and the intervening redesignation of par. (2) as (1) by Pub. L. 101-508, 
Sec. 4008(b)(3)(A)(ii). See above.
    Subsec. (d)(2). Pub. L. 101-508, Sec. 4008(b)(3)(A)(ii), 
redesignated par. (3) as (2). Former par. (2) redesignated (1).
    Subsec. (d)(2)(A). Pub. L. 101-508, Sec. 4008(b)(1), (2), 
substituted ``negligently'' for ``knowingly'' and inserted ``(or not 
more than $25,000 in the case of a hospital with less than 100 beds)'' 
after ``$50,000''.
    Subsec. (d)(3). Pub. L. 101-508, Sec. 4207(a)(1)(A), formerly 
Sec. 4027(a)(1)(A), as renumbered and amended by Pub. L. 103-432, 
Sec. 160(d)(4), (5)(A), added par. (3). Former par. (3) redesignated 
(2).
    Subsec. (i). Pub. L. 101-508, Sec. 4207(k)(3), formerly 
Sec. 4027(k)(3), as renumbered by Pub. L. 103-432, Sec. 160(d)(4), 
amended subsec. (i) generally. Prior to amendment, subsec. (i) read as 
follows: ``A participating hospital may not penalize or take adverse 
action against a physician because the physician refuses to authorize 
the transfer of an individual with an emergency medical condition that 
has not been stabilized.''
    1989--Pub. L. 101-239, Sec. 6211(h)(2)(A), struck out ``active'' 
before ``labor'' in section catchline.
    Subsec. (a). Pub. L. 101-239, Sec. 6211(h)(2)(B), which directed the 
amendment of subsec. (a) by striking out ``or to determine if the 
individual is in active labor (within the meaning of section (e)(2) of 
this section)'' was executed by striking out ``or to determine if the 
individual is in active labor (within the meaning of subsection (e)(2) 
of this section)'' after ``exists''.
    Pub. L. 101-239, Sec. 6211(a), substituted ``hospital's emergency 
department, including ancillary services routinely available to the 
emergency department,'' for ``hospital's emergency department''.
    Subsec. (b). Pub. L. 101-239, Sec. 6211(h)(2)(C), struck out 
``active'' before ``labor'' in heading.
    Subsec. (b)(1). Pub. L. 101-239, Sec. 6211(h)(2)(D)(i), struck out 
``or is in active labor'' after ``emergency medical condition'' in 
introductory provisions.
    Subsec. (b)(1)(A). Pub. L. 101-239, Sec. 6211(h)(2)(D)(ii), struck 
out ``or to provide for treatment of the labor'' after ``stabilize the 
medical condition''.
    Subsec. (b)(2). Pub. L. 101-239, Sec. 6211(b)(1), inserted ``and 
informs the individual (or a person acting on the individual's behalf) 
of the risks and benefits to the individual of such examination and 
treatment,'' after ``in that paragraph'', substituted ``and treatment.'' 
for ``or treatment.'', and inserted at end ``The hospital shall take all 
reasonable steps to secure the individual's (or person's) written 
informed consent to refuse such examination and treatment.''
    Subsec. (b)(3). Pub. L. 101-239, Sec. 6211(b)(2), inserted ``and 
informs the individual (or a person acting on the individual's behalf) 
of the risks and benefits to the individual of such transfer,'' after 
``subsection (c) of this section'' and inserted at end ``The hospital 
shall take all reasonable steps to secure the individual's (or person's) 
written informed consent to refuse such transfer.''
    Subsec. (c). Pub. L. 101-239, Sec. 6211(g)(1)(A), substituted 
``individual'' for ``patient'' in heading.
    Subsec. (c)(1). Pub. L. 101-239, Sec. 6211(c)(4), (g)(1)(B), 
(h)(2)(E), in introductory provisions, substituted ``an individual'' for 
``a patient'', ``subsection (e)(3)(B) of this section)'' for 
``subsection (e)(4)(B) of this section) or is in active labor'', and 
``the individual'' for ``the patient'', and inserted at end ``A 
certification described in clause (ii) or (iii) of subparagraph (A) 
shall include a summary of the risks and benefits upon which the 
certification is based.''
    Subsec. (c)(1)(A)(i). Pub. L. 101-239, Sec. 6211(c)(1), (g)(1)(B), 
substituted ``the individual'' for ``the patient'', ``the individual's 
behalf'' for ``the patient's behalf'', and ``after being informed of the 
hospital's obligations under this section and of the risk of transfer, 
in writing requests transfer to another medical facility'' for 
``requests that the transfer be effected''.
    Subsec. (c)(1)(A)(ii). Pub. L. 101-239, Sec. 6211(c)(2)(B), (3), 
(g)(1)(B), substituted ``has signed a certification that based upon the 
information available at the time of transfer'' for ``, or other 
qualified medical personnel when a physician is not readily available in 
the emergency department, has signed a certification that, based upon 
the reasonable risks and benefits to the patient, and based upon the 
information available at the time'' and ``individual and, in the case of 
labor, to the unborn child'' for ``individual's medical condition''.
    Subsec. (c)(1)(A)(iii). Pub. L. 101-239, Sec. 6211(c)(2)(A), (C), 
(D), added cl. (iii).
    Subsec. (c)(2)(A). Pub. L. 101-239, Sec. 6211(c)(5), added subpar. 
(A). Former subpar. (A) redesignated (B).
    Subsec. (c)(2)(B). Pub. L. 101-239, Sec. 6211(c)(5)(A), (g)(1)(B), 
redesignated subpar. (A) as (B) and substituted ``the individual'' for 
``the patient'' in cls. (i) and (ii). Former subpar. (B) redesignated 
(C).
    Subsec. (c)(2)(C). Pub. L. 101-239, Sec. 6211(c)(5)(A), (d), 
redesignated subpar. (B) as (C) and substituted ``sends to'' for 
``provides'' and ``all medical records (or copies thereof), related to 
the emergency condition for which the individual has presented, 
available at the time of the transfer, including records related to the 
individual's emergency medical condition, observations of signs or 
symptoms, preliminary diagnosis, treatment provided, results of any 
tests and the informed written consent or certification (or copy 
thereof) provided under paragraph (1)(A), and the name and address of 
any on-call physician (described in subsection (d)(2)(C) of this 
section) who has refused or failed to appear within a reasonable time to 
provide necessary stabilizing treatment'' for ``with appropriate medical 
records (or copies thereof) of the examination and treatment effected at 
the transferring hospital''. Former subpar. (C) redesignated (D).
    Subsec. (c)(2)(D). Pub. L. 101-239, Sec. 6211(c)(5)(A), redesignated 
subpar. (C) as (D). Former subpar. (D) redesignated (E).
    Subsec. (c)(2)(E). Pub. L. 101-239, Sec. 6211(c)(5)(A), (g)(1)(B), 
redesignated subpar. (D) as (E) and substituted ``individuals'' for 
``patients''.
    Subsec. (d)(2)(B). Pub. L. 101-239, Sec. 6211(e)(1), amended subpar. 
(B) generally. Prior to amendment, subpar. (B) read as follows: ``The 
responsible physician in a participating hospital with respect to the 
hospital's violation of a requirement of this subsection is subject to 
the sanctions described in section 1395u(j)(2) of this title, except 
that, for purposes of this subparagraph, the civil money penalty with 
respect to each violation may not exceed $50,000, rather than $2,000.''
    Subsec. (d)(2)(C). Pub. L. 101-239, Sec. 6211(e)(2), added subpar. 
(C) and struck out former subpar. (C) which read as follows: ``As used 
in this paragraph, the term `responsible physician' means, with respect 
to a hospital's violation of a requirement of this section, a physician 
who--
        ``(i) is employed by, or under contract with, the participating 
    hospital, and
        ``(ii) acting as such an employee or under such a contract, has 
    professional responsibility for the provision of examinations or 
    treatments for the individual, or transfers of the individual, with 
    respect to which the violation occurred.''
    Subsec. (e)(1). Pub. L. 101-239, Sec. 6211(h)(1)(A), substituted 
``means--'' and subpars. (A) and (B) for ``means a medical condition 
manifesting itself by acute symptoms of sufficient severity (including 
severe pain) such that the absence of immediate medical attention could 
reasonably be expected to result in--
        ``(A) placing the patient's health in serious jeopardy,
        ``(B) serious impairment to bodily functions, or
        ``(C) serious dysfunction of any bodily organ or part.''
    Subsec. (e)(2). Pub. L. 101-239, Sec. 6211(h)(1)(B), (E), 
redesignated par. (3) as (2) and struck out former par. (2) which 
defined ``active labor''.
    Subsec. (e)(3). Pub. L. 101-239, Sec. 6211(h)(1)(E), redesignated 
par. (4) as (3). Former par. (3) redesignated (2).
    Subsec. (e)(4). Pub. L. 101-239, Sec. 6211(h)(1)(E), redesignated 
par. (5) as (4). Former par. (4) redesignated (3).
    Subsec. (e)(4)(A). Pub. L. 101-239, Sec. 6211(h)(1)(C), substituted 
``emergency medical condition described in paragraph (1)(A)'' for 
``emergency medical condition'', ``likely to result from or occur 
during'' for ``likely to result from'', and ``from a facility, or, with 
respect to an emergency medical condition described in paragraph (1)(B), 
to deliver (including the placenta)'' for ``from a facility''.
    Subsec. (e)(4)(B). Pub. L. 101-239, Sec. 6211(h)(1)(D), inserted 
``described in paragraph (1)(A)'' after ``emergency medical condition'', 
``or occur during'' after ``to result from'', and ``, or, with respect 
to an emergency medical condition described in paragraph (1)(B), that 
the woman has delivered (including the placenta)'' after ``from a 
facility''.
    Subsec. (e)(5). Pub. L. 101-239, Sec. 6211(h)(1)(E), redesignated 
par. (6) as (5). Former par. (5) redesignated (4).
    Pub. L. 101-239, Sec. 6211(g)(2), substituted ``an individual'' for 
``a patient'' in two places.
    Subsec. (e)(6). Pub. L. 101-239, Sec. 6211(h)(1)(E), redesignated 
par. (6) as (5).
    Pub. L. 101-239, Sec. 6003(g)(3)(D)(xiv), added par. (6).
    Subsecs. (g) to (i). Pub. L. 101-239, Sec. 6211(f), added subsecs. 
(g) to (i).
    1988--Subsec. (d)(1). Pub. L. 100-360, Sec. 411(b)(8)(A)(i), amended 
Pub. L. 100-203, Sec. 4009(a)(2), see 1987 Amendment note below.
    Subsec. (d)(2). Pub. L. 100-360, Sec. 411(b)(8)(A)(i), as amended by 
Pub. L. 100-485, Sec. 608(d)(18)(E), amended Pub. L. 100-203, 
Sec. 4009(a)(1), see 1987 Amendment note below.
    1987--Subsec. (d)(1). Pub. L. 100-203, Sec. 4009(a)(2), which 
directed insertion of a provision related to imposing the sanction 
described in section 1395u(j)(2)(A) of this title, was amended generally 
by Pub. L. 100-360, Sec. 411(b)(8)(A)(i), so that it does not amend par. 
(1).
    Subsec. (d)(2). Pub. L. 100-203, Sec. 4009(a)(1), as amended by Pub. 
L. 100-360, Sec. 411(b)(8)(A)(i), as amended by Pub. L. 100-485, 
Sec. 608(d)(18)(E), substituted subpars. (A) and (B) for ``In addition 
to the other grounds for imposition of a civil money penalty under 
section 1320a-7a(a) of this title, a participating hospital that 
knowingly violates a requirement of this section and the responsible 
physician in the hospital with respect to such a violation are each 
subject, under that section, to a civil money penalty of not more than 
$25,000 for each such violation.'', designated second sentence as 
subpar. (C), substituted ``this paragraph'' for ``the previous 
sentence'', and redesignated former subpars. (A) and (B) as cls. (i) and 
(ii), respectively, of subpar. (C).
    1986--Subsec. (b)(2), (3). Pub. L. 99-509 struck out ``legally 
responsible'' after ``individual (or a''.
    Subsec. (e)(3). Pub. L. 99-514 struck out ``and has, under the 
agreement, obligated itself to comply with the requirements of this 
section'' after ``section 1395cc of this title''.


                    Effective Date of 1997 Amendment

    Amendment by Pub. L. 105-33 applicable to services furnished on or 
after Oct. 1, 1997, see section 4201(d) of Pub. L. 105-33, set out as a 
note under section 1395f of this title.


                    Effective Date of 1990 Amendment

    Amendment by section 4008(b)(1)-(3)(A) of Pub. L. 101-508 applicable 
to actions occurring on or after the first day of the sixth month 
beginning after Nov. 5, 1990, see section 4008(b)(4) of Pub. L. 101-508, 
set out as a note under section 1395cc of this title.
    Amendment by section 4207(a)(1)(A) of Pub. L. 101-508 effective on 
the first day of the first month beginning more than 60 days after Nov. 
5, 1990, see section 4207(a)(1)(C) of Pub. L. 101-508, as amended, set 
out as a note under section 1320c-3 of this title.
    Section 4207(a)(4), formerly 4027(a)(4), of Pub. L. 101-508, as 
renumbered and amended by Pub. L. 103-432, title I, Sec. 160(d)(4), 
(5)(B), Oct. 31, 1994, 108 Stat. 4444, provided that: ``The amendments 
made by paragraphs (2) and (3) [amending this section] shall apply to 
actions occurring on or after the first day of the sixth month beginning 
after the date of the enactment of this Act [Nov. 5, 1990].''


                    Effective Date of 1989 Amendment

    Section 6211(i) of Pub. L. 101-239 provided that: ``The amendments 
made by this section [amending this section] shall take effect on the 
first day of the first month that begins more than 180 days after the 
date of the enactment of this Act [Dec. 19, 1989], without regard to 
whether regulations to carry out such amendments have been promulgated 
by such date.''


                    Effective Date of 1988 Amendments

    Amendment by Pub. L. 100-485 effective as if included in the 
enactment of the Medicare Catastrophic Coverage Act of 1988, Pub. L. 
100-360, see section 608(g)(1) of Pub. L. 100-485, set out as a note 
under section 704 of this title.
    Except as specifically provided in section 411 of Pub. L. 100-360, 
amendment by Pub. L. 100-360, as it relates to a provision in the 
Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-203, effective as 
if included in the enactment of that provision in Pub. L. 100-203, see 
section 411(a) of Pub. L. 100-360, set out as a Reference to OBRA; 
Effective Date note under section 106 of Title 1, General Provisions.


                    Effective Date of 1987 Amendment

    Section 4009(a)(2), formerly Sec. 4009(a)(3), of Pub. L. 100-203, as 
redesignated by Pub. L. 100-360, title IV, Sec. 411(b)(8)(A)(ii), July 
1, 1988, 102 Stat. 772, provided that: ``The amendments made by this 
subsection [amending this section] shall apply to actions occurring on 
or after the date of the enactment of this Act [Dec. 22, 1987].''


                    Effective Date of 1986 Amendment

    Amendment by Pub. L. 99-514 effective, except as otherwise provided, 
as if included in enactment of the Consolidated Omnibus Budget 
Reconciliation Act of 1985, Pub. L. 99-272, see section 1895(e) of Pub. 
L. 99-514, set out as a note under section 162 of Title 26, Internal 
Revenue Code.


                             Effective Date

    Section 9121(c) of Pub. L. 99-272 provided that: ``The amendments 
made by this section [enacting this section and amending section 1395cc 
of this title] shall take effect on the first day of the first month 
that begins at least 90 days after the date of the enactment of this Act 
[Apr. 7, 1986].''


    Inspector General Study of Prohibition on Hospital Employment of 
                               Physicians

    Section 4008(c) of Pub. L. 101-508 directed Secretary of Health and 
Human Services (acting through Inspector General of Department of Health 
and Human Services) to conduct a study of the effect of State laws 
prohibiting the employment of physicians by hospitals on the 
availability and accessibility of trauma and emergency care services, 
and include in such study an analysis of the effect of such laws on the 
ability of hospitals to meet the requirements of section 1867 of the 
Social Security Act (this section) relating to the examination and 
treatment of individuals with an emergency medical condition and women 
in labor, with Secretary to submit a report to Congress on the study not 
later than 1 year after Nov. 5, 1990.

                  Section Referred to in Other Sections

    This section is referred to in sections 300d-13, 1320c-3, 1395w-22, 
1395cc of this title.
