Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted in 1986 in response to increasing concerns about hospitals refusing care to poor or uninsured patients, a practice known as “patient dumping.” Signed into law by President Ronald Reagan as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, EMTALA established a federal mandate to ensure public access to emergency services regardless of an individual's ability to pay.
Historic cases underscore the necessity of this legislation:
- 1954: Laura Lingo, a 5-month-old girl, sustained severe burns from boiling water. Her mother sought care at a hospital, but the child was transferred to another hospital due to the family’s inability to pay. She later died from her injuries.
- 1976: Michael Jessee, a 13-year-old boy with a life-threatening arterial injury, was transferred from a private hospital to a county facility because he was considered a “charity case.” The delay in treatment resulted in permanent damage to his leg.
These were not isolated incidents. Estimates suggest that prior to the EMTALA mandate, up to 250,000 patients were transferred annually due to inability to pay.
Core EMTALA Requirements:
Hospitals that receive Medicare funding and operate emergency departments must:
- Provide a Medical Screening Examination (MSE): Every individual presenting to an emergency department requesting to be seen must receive an MSE to determine if an Emergency Medical Condition (EMC) exists. This evaluation must not be delayed for administrative purposes.
- Stabilize or Transfer: If an EMC is identified, the hospital must either stabilize the individual or arrange an appropriate transfer to a facility capable of providing the necessary care.
- Appropriate Transfers: The transferring hospital must provide treatment within its capacity to minimize health risks. The receiving facility must agree to accept the transfer and provide appropriate care.
When Do EMTALA Obligations Begin and End?
EMTALA obligations commence when an individual presents to a dedicated emergency department and requests an exam or treatment.
EMTALA obligations end when:
- The MSE determines that no EMC exists or,
- The EMC is stabilized even if ongoing care is needed, or
- The individual is admitted to the hospital as an inpatient (not in observation status), or
- The individual is safely transferred to another facility that assumes EMTALA obligation, or
- The individual refuses care.
Transfers and Documentation
Transfers may occur under two conditions:
- At the individual’s request, the individual must be informed of the transfer's associated risks and the hospital’s EMTALA obligations. These risks must be documented in the patient’s medical record.
- When medically necessary: A physician must certify that the benefits of transfer outweigh the risks. If the physician is not present, a Qualified Medical Professional (QMP) may sign the certification after consulting with the physician. The physician must later sign the certification in a timely manner (as set forth in facility policy). A copy of the certification must be placed in the medical record and a copy must be sent to the receiving facility.
Additional requirements of transfer include:
- Providing treatment to minimize transfer risks to the individual.
- Sending all relevant medical records to the receiving facility.
- Using appropriate personnel, transportation, and life support equipment based on the individual's medical needs.
- Retaining all transfer records for at least five years, or longer if required by state law.
Facilities may not take adverse actions against Physicians or QMPs who refuse to transfer an individual due to an unstabilized EMC.
Refusal of Care/Transfer
If an individual refuses care or transfer, the refusal must be documented in the medical record. Documentation should include:
- The care or transfer offered and refused.
- The risks associated with refusal.
- A signed acknowledgment from the patient indicating understanding of the risks (or documentation of refusal to sign).
Improper Transfer
If a receiving facility suspects an improper transfer, it must report the incident to CMS or the appropriate State Agency within 72 hours.
Facilities Without Emergency Services
Facilities lacking an emergency department must maintain written policies and procedures for:
- Appraisal of emergencies
- Initial treatment of emergencies
- Appropriate referral
Key Definitions
Emergency Medical Condition (EMC): A condition with acute symptoms that could seriously jeopardize health or bodily functions without immediate medical attention. For pregnant individuals, this includes active labor where transfer is unsafe.
Dedicated Emergency Department: A hospital department or facility (on or off-campus) that meets at least one of the following criteria: licensed as an emergency department by the state, is held out to the public as providing emergency care, or treats a significant number of emergency medical conditions on an urgent basis.
Medical Screening Examination (MSE): A documented process to determine the presence of an EMC. It may range from a basic assessment to complex diagnostics. Triage alone does not qualify as an MSE.
Qualified Medical Person (QMP): A non-physician practitioner authorized by hospital policy to perform MSEs.
Registration Process: May include collecting emergency contacts, medical history, and insurance details, provided it does not delay the MSE or treatment.
Stabilizing Treatment: Care that ensures, within reasonable medical probability, that the patient’s condition will not materially deteriorate or that the EMC has been resolved.
References
- 42 CFR 489.24 (up to date as of 7/06/2025) -Special responsibilities of Medicare hospitals in emergency cases.
- State Operations Manual (SOM) Appendix V
- https://law.justia.com/cases/arizona/supreme-court/1984/16634-pr-2.html
- https://time.com/archive/6869306/medicine-the-baby-the-rules/
- https://www.emra.org/books/advocacy-handbook/emtala-story
For questions or to learn more, contact the C&A team at 704-573-4535 or email us at info@courtemanche-assocs.com.
