Rescinded 1975
SSR 68-25: Sections 1814(f) and 1862(a)(4).—Hospital Insurance Benefits—Emergency Inpatient Hospital Services in Hospitals Outside the United States
20 CFR 405.153, 405.313
SSR 68-25
Held, section 1814(f) of the Act, which provides that under certain conditions emergency inpatient hospital services rendered outside the United States are covered under Part A of title XVIII, permits payment to be made where the insured individual is inside the United States near a foreign border when a medical emergency requiring hospitalization occurs, the individual leaves the United States to obtain treatment, and the nearest or most accessible hospital is across the border.
Further held, payment may not be made under section 1814(f) for emergency inpatient hospital services rendered outside the United States where the individual left the United States for purposes other than to obtain medical treatment, even though the medical emergency occurred within the United States; nor will payment be made for emergency inpatient hospital services in foreign countries not geographically adjacent to United States territory.
Section 1862(a) of the Social Security Act excludes from coverage under the health insurance program established by title XVIII of the Act all expenses incurred for items or services—
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(4) which are not provided within the United States (except for emergency inpatient hospital services furnished outside the United States under the conditions described in section 1814(f)) * * *.
Section 1814(f) of the Act provides as follows:
The authority contained in subsection (d) [section 1814(d) of the Act, which authorizes payment under Part A of title XVIII for emergency inpatient hospital services in certain hospitals which do not meet all the requirements of section 1861(e) of the Act to participate in the hospital insurance program] shall be applicable to emergency inpatient hospital services furnished an individual by a hospital located outside the United States if—
(1) such individual was physically present in a place within the United States at the time the emergency which necessitated such inpatient hospital services occurred; and
(2) such hospital was closer to, or substantially more accessible from, such place than the nearest hospital within the United States which was adequately equipped to deal with, and was available for the treatment of, such individual's illness or injury.
A question has arisen as to when emergency inpatient hospital services in a foreign hospital are covered under the provisions of section 1862(a)(4) and 1814(f), supra, where the insured individual while on a vacation or business trip was taken sick or injured immediately after boarding a plane or ship departing the United States and had no opportunity to disembark until reaching the foreign country. The resolution of this question depends, in part, on the meaning of the phrase "physically present in a place within the United States" which occurs in section 1814(f)(1), supra.
The term "United States" is defined by sections 1861(x) and 210(i) of the Act as meaning the States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam, and American Samoa; by reference to precedents establishing American territorial limits,[1] the term also includes American territorial waters and the airspace above such waters.
However, the phrase "physically present in a place within the United States" should be interpreted in view of its context and legislative background. Section 1814(f)(2), in specifying that the foreign hospital be closer to the place where the medical emergency occurred or more accessible than the nearest adequately-equipped and available hospital in the United States, contemplates the situation where an emergency occurs relatively close to a foreign border (e.g., the Canadian frontier), and a physician or other responsible person could not conscientiously permit the delay which would be entailed in sending the individual to a hospital in the United States. Another requirement of section 1814(f), implicit but obvious, is that the medical difficulty be a genuine emergency.
The sequence thus required by the statute is that an individual suffer an emergency medical situation while he is within the United States, and that he leave the United States for the purpose of obtaining emergency hospital treatment in a foreign hospital because the foreign hospital either is closer than a hospital in the United States or is more accessible from the place within the United States where the emergency occurred.
Therefore, if the individual's reason for leaving the United States is to obtain prompt treatment at a hospital nearer, or more accessible, than the nearest adequate American hospital, his situation is clearly that contemplated by the statute. On the other hand, if his departure is part of a trip abroad, so that the hospital is more "accessible" simply because he was involved in the processes of such travel (e.g., the airplane on which he was traveling was already enroute and so could not readily return to permit his removal), the situation is not that contemplated by the statute, and in such a situation services in a foreign hospital would not be covered by section 1814(f) even though the individual was within the "United States" when the emergency occurred.
This construction of the statute is enforced by reference to the practical considerations unrestricted foreign coverage would present. Payment to Canadian or Mexican hospitals close to the border entails certain problems, yet these problems are insignificant when compared with those to which a broad extension of coverage in foreign hospitals would have, involving dealings with foreign hospitals separated from the United States by great barriers of distance, language, fiscal differences, and major variants dictated the general exclusion, in section 1862(a)(4), of services not provided within the United States.
Accordingly, it is held that, other requirements being met, payment may be made under section 1814(f) of the Act for emergency inpatient hospital services rendered outside the United States where the insured individual is inside the United States near a foreign border when a medical emergency requiring hospitalization occurs, the individual leaves the United States to obtain treatment, and the nearest or most accessible hospital is across the border.
It is further held that payment may not be made under section 1814(f) of the Act for emergency inpatient hospital services rendered outside the United States where the individual left the United States for purposes other than to obtain medical treatment even though the medical emergency occurred within the United States; nor will payment be made for emergency inpatient hospital services in foreign countries not geographically adjacent to United States territory.
[1]United States v. State of California, 381 U.S. 139, 85 S. Ct. 1401 (1965); the Submerged Lands Act, 43 U.S.C. §§1301ff.; C.A.B. v. Island Airlines, Inc., 235 F. Supp. 990 (D. Hawaii, 1964); Ross v. McIntyre, 140 U.S. 453, 11 S. Ct. 897 (1891).