EMTALA SUMMARY: OUTPATIENT PPS REGULATION
INTRODUCTION
The rule extends the reach of a hospital’s EMTALA obligations. Any off-site facility
that is treated as an outpatient department of the hospital for Medicare payment purposes
(“provider-based status”) is part of the hospital for EMTALA purposes. This means that
if an individual requests emergency service at an off-campus hospital outpatient
department, the hospital must assure that a medical screening examination and any
necessary stabilizing treatment is provided. The EMTALA obligation flows as a
consequence of the hospital receiving greater Medicare reimbursement for facilities with
provider-based status. A hospital must establish protocols for responding to individuals
with potential emergency medical conditions who request service at its off-campus
outpatient departments.
The definition of “comes to the emergency department” has also been expanded to
include the hospital campus. If an individual requests emergency service from the
hospital at a facility on-campus the hospital must assure that a screening and, if
necessary, stabilizing treatment is provided.
Currently, the only guidance available is the text of the regulation and the government’s
commentary in the preamble to the regulation. Revised interpretive guidelines for the
HCFA region offices and the state surveyors are expected early in 2001. The AHA will
be working with HCFA as the guidelines are developed and to suggest appropriate
clarifications. If you have any questions or would like to suggest areas needing
clarification, please contact Maureen Mudron, Washington Counsel, mmudron@aha.org,
or 202.626.2301.
The summary that follows is based on the text of the regulation. To the extent the
preamble includes an explanation of what was intended, or gives some insight on the
thinking behind the regulation, those comments are included in italics.
Hospital Responsibilities for Off-Campus Outpatient Department
Preamble: To the extent a hospital acquires or creates an off-campus location, identifies
it to HCFA and the public as a part of that hospital, and claims payment for services at
that location as hospital services, it is not unreasonable to expect that hospital also to
assume the obligations, including EMTALA, that flow from hospital status.
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Protocol Required
A hospital must establish protocols for handling individuals with potential emergency
conditions who present at off-campus outpatient departments. The capability of the
hospital as a whole, not just the outpatient department, must be available to the
individual. However, there is no obligation to locate additional staff or personnel to offcampus departments to be on standby for possible emergencies.
Preamble: The only off-campus facilities affected are outpatient departments.
Other facilities with provider-based status, e.g. skilled nursing facilities or home
health agencies, do not have EMTALA obligations since a patient coming to such
an entity would not have come to the hospital.
If an individual comes to an off-campus department and a request is made for
examination or treatment for a potential emergency medical condition, the
hospital incurs an obligation to provide, within its capability, an appropriate
medical screening examination and necessary stabilizing treatment. The patient
may need to be taken to the main campus. If so, the hospital is responsible for
moving or arranging safe transport.
There is no requirement that all areas of the hospital are equipped to provide
emergency care or that treatment always be provided outside the emergency area
or department. It also does not mean that every appearance by an individual at
an off-campus hospital department that does not offer services for emergency
medical conditions will necessarily trigger an EMTALA obligation. Individuals
come to these departments for many medical purposes that may not involve
potential emergency medical conditions.
The protocols must provide for direct contact between the off-campus department and
emergency personnel at the main hospital campus and may provide for dispatch of
practitioners, when appropriate, from the main hospital.
Preamble: The intent is to ensure timely exchange of information between the
two sites, and to allow the hospital the flexibility to bring emergency personnel to
the patient, rather than the opposite, where doing so is the best medical approach
to meeting the patient’s needs.

Department routinely staffed by physicians, RNs or LPNs
If the outpatient department is routinely staffed by physicians, RNs, or LPNs, they
must be trained and given protocols for handling emergencies. At least one
individual on duty during regular business hours must be designated a “qualified
medical person” (QMP). The QMP must initiate a screening and, if necessary,
arrange an appropriate transfer. The screening may be completed and any
necessary stabilizing treatment provided at the off-campus site if it has the
capability.
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EMTALA Summary/3

Department not staffed by physicians, RNs or LPNs
If the department is not routinely staffed by physicians, RNs, or LPNs, the
protocol must call for contact with emergency personnel at the main hospital
campus. Department staff must describe the patient’s appearance and report
symptoms and, if appropriate, arrange transport to the main hospital campus or for
appropriate transfer to another hospital.
This is not intended to delay an appropriate transfer. The contact with emergency
personnel at the main hospital campus should be made either after or
concurrently with, the actions needed to arrange an appropriate transfer if doing
otherwise would significantly jeopardize the individual’s life or health.
Transfer and Transport

Movement to main hospital.
If an individual requires more than what is available at the off-campus department
and is moved to the main hospital, it is not a transfer under EMTALA. The offcampus facility must assist in arranging for this movement.
To meet requirements for an off-campus site, procedures will be needed that
permit the staff to obtain prompt medical transport, by hospital-owned or other
ambulance or other appropriate vehicle, either to the main hospital campus or,
where an appropriate transfer is being provided, to another medical facility.
The capability of the hospital includes that of the hospital as a whole, not just the
capability of the off-campus facility. Except when the main hospital is without the
capability or the health of a patient would be jeopardized the obligation of a
hospital must be discharged within the hospital as a whole.

Transfer to another hospital.
If the condition of the patient warrants transfer to another hospital the EMTALA
transfer requirements must be met. The requirement to provide medical
treatment to minimize risks during transfer would be met by providing treatment
within the capability of the off-campus department.
Transfer to another hospital would be considered warranted if the main hospital
does not have the specialized capability required by the individual, or the
individual’s condition is deteriorating so rapidly that taking the time to move the
individual to the main hospital would significantly jeopardize the life or health of
the individual. The protocol must include procedures and agreements established
in advance with medical facilities in the area of the off-campus department to
facilitate appropriate transfers.
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Preamble: EMS personnel can play a valuable role in transporting patients to
appropriate sources of emergency care. A hospital may not, however, meet its
EMTALA obligations merely by summoning EMS personnel. EMS may be used
appropriately in conjunction with an appropriate hospital response to treat and
move an individual who is already on hospital property.
Hospital Responsibilities for on-campus facilities
If an individual is on hospital property and a request is made for examination or treatment
of a potential emergency medical condition the hospital must provide for an appropriate
medical screening and, if necessary, stabilizing treatment.

Hospital property means the entire main hospital campus, including the parking
lot, sidewalk, and driveway, as well as any hospital outpatient department that is
located off the main hospital campus.

Campus means the physical area immediately adjacent to the provider’s main
buildings, other areas and structures that are not strictly contiguous to the main
buildings but are located within 250 yards, and any other areas determined on an
individual case basis by the HCFA regional office.
Preamble: This definition would encompass not only institutions that are located
in self-contained, well-defined settings, but other locations, such as central city
areas, where there may be a group of buildings that function as a campus but are
not strictly contiguous and may even be crossed by public streets.
Advanced Beneficiary Notice Form
When a Medicare beneficiary is treated in a hospital outpatient department or a hospitalbased entity (other than a rural health clinic) that is not located on the main provider’s
campus, the hospital has a duty to provide written notice to the beneficiary, prior to the
delivery of services, of the amount of the beneficiary’s potential financial liability (that
is, of the fact that the beneficiary will incur a coinsurance liability for an outpatient visit
to the hospital as well as for the physician service, and of the amount of that liability).
In situations where EMTALA applies, hospitals are not required to deliver the notice
before screening and stabilizing a patient with an emergency medical condition. When
the exact type and extent of care needed is not known, the hospital may furnish a notice
that explains a coinsurance obligation will apply that the patient would not incur if the
facility were not provider-based, and an estimate based on typical or average charges
may be provided.
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Effective Date
The effective date has been extended from October 10, 2000 to January 10, 2001. A
formal announcement will be issued in the Federal Register. Watch the AHA web site
for updates.
9/26/00
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