The text, verbatim
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§ 489.24(a)(1) The duty — screening, then stabilising or transfer
Effective 1994-06-22
(a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must— (i) Provide 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 exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of § 482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital's obligation under this section ends, as specified in paragraph (d)(2) of this section.
Official text
The two limbs are joined by "and": screening comes first, and the second limb only applies once an emergency medical condition "is determined to exist". Clause (a)(1)(i) requires the examination to be conducted by someone "determined qualified by hospital bylaws or rules and regulations" who also "meets the requirements of Sec. 482.55 ... concerning emergency services personnel and direction". Section 482.55 sits in part 482, the conditions of participation for hospitals; a critical access hospital is certified against part 485 subpart F instead. The cross-reference is reproduced as written and is not resolved here — see the 482.55 entry.
§ 489.24(a)(2) The 1135 waiver — and the 72 hours it lasts
Effective 2021-01-01
(2) (i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual's source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act.
Official text
Five conditions, lettered (A) through (E). The waiver is limited to 72 hours beginning on implementation of a hospital disaster protocol, except that for a pandemic infectious disease it continues until the public health emergency declaration ends. Amended by 85 FR 78762 (Dec. 2, 2020) to add the pandemic provision; the 72-hour limit is unchanged.
§ 489.24(b)-Comes_to_ED Definition — comes to the emergency department
Effective 1986-07-17
Comes to the emergency department means, with respect to an individual who is not a patient (as defined in this section), the individual— (1) Has presented at a hospital's dedicated emergency department, as defined in this section, and requests examination or treatment for a medical condition, or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment for a medical condition; (2) Has presented on hospital property, as defined in this section, other than the dedicated emergency department, and requests examination or treatment for what may be an emergency medical condition, or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs emergency examination or treatment; (3) Is in a ground or air ambulance owned and operated by the hospital for purposes of examination and treatment for a medical condition at a hospital's dedicated emergency department, even if the ambulance is not on hospital grounds. However, an individual in an ambulance owned and operated by the hospital is not considered to have “come to the hospital's emergency department” if— (i) The ambulance is operated under communitywide emergency medical service (EMS) protocols that direct it to transport the individual to a hospital other than the hospital that owns the ambulance; for example, to the closest appropriate facility. In this case, the individual is considered to have come to the emergency department of the hospital to which the individual is transported, at the time the individual is brought onto hospital property; (ii) The ambulance is operated at the direction of a physician who is not employed or otherwise affiliated with the hospital that owns the ambulance; or (4) Is in a ground or air nonhospital-owned ambulance on hospital property for presentation for examination and treatment for a medical condition at a hospital's dedicated emergency department. However, an individual in a nonhospital-owned ambulance off hospital property is not considered to have come to the hospital's emergency department, even if a member of the ambulance staff contacts the hospital by telephone or telemetry communications and informs the hospital that they want to transport the individual to the hospital for examination and treatment. The hospital may direct the ambulance to another facility if it is in “diversionary status,” that is, it does not have the staff or facilities to accept any additional emergency patients. If, however, the ambulance staff disregards the hospital's diversion instructions and transports the individual onto hospital property, the individual is considered to have come to the emergency department.
Official text
The opening words do as much work as the list: this definition applies only "with respect to an individual who is not a patient". Once someone is a patient under this section, the trigger has already been pulled and this definition stops doing anything. Where no request is made, one is deemed to exist if "a prudent layperson observer" would believe the individual needs examination or treatment — the test is what a layperson would think, not what a clinician later concludes. Subparagraph (4) also preserves diversion: a hospital in diversionary status may direct a nonhospital-owned ambulance elsewhere, but if the ambulance comes onto hospital property anyway the individual is treated as having come to the emergency department.
§ 489.24(b)-Dedicated_ED Definition — dedicated emergency department
Effective 1986-07-17
Dedicated emergency department means any department or facility of the hospital, regardless of whether it is located on or off the main hospital campus, that meets at least one of the following requirements: (1) It is licensed by the State in which it is located under applicable State law as an emergency room or emergency department; (2) It is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or (3) During the calendar year immediately preceding the calendar year in which a determination under this section is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment.
Official text
Three routes, and only one of them needs a State licence. A department that is merely held out to the public as providing emergency care, or that in fact provided one-third of its outpatient visits for emergency conditions, is a dedicated emergency department whether or not it is licensed as one. The third route is measured over the calendar year immediately preceding the year of determination.
§ 489.24(b)-EMC Definition — emergency medical condition
Effective 1986-07-17
Emergency medical condition means— (1) A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) 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 (2) With respect to a pregnant woman who is having contractions— (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.
Official text
"including severe pain" is in the statute, as are "psychiatric disturbances and/or symptoms of substance abuse". The test is prospective and probabilistic — what could reasonably be expected to happen without immediate attention — not what did happen.
§ 489.24(b)-Patient Definition — patient: who no longer triggers the duty
Effective 1986-07-17
Patient means— (1) An individual who has begun to receive outpatient services as part of an encounter, as defined in § 410.2 of this chapter, other than an encounter that the hospital is obligated by this section to provide; (2) An individual who has been admitted as an inpatient, as defined in this section.
Official text
The definition that closes the gate. "Comes to the emergency department" is defined only for someone who is not a patient, so an inpatient cannot trigger section 489.24 — which is what makes paragraph (d)(2) necessary rather than redundant. Note the carved-out phrase in subparagraph (1): an encounter that the hospital is obligated by THIS section to provide does not make the individual a patient. Without that phrase, providing the screening would switch the duty off.
§ 489.24(b)-Stabilized Definition — stabilized, and to stabilize
Effective 1986-07-17
Stabilized means, with respect to an “emergency medical condition” as defined in this section under paragraph (1) of that definition, 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” as defined in this section under paragraph (2) of that definition, that the woman has delivered the child and the placenta. To stabilize means, with respect to an “emergency medical condition” as defined in this section under paragraph (1) of that definition, to provide such medical treatment of the condition 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 that, with respect to an “emergency medical condition” as defined in this section under paragraph (2) of that definition, the woman has delivered the child and the placenta.
Official text
Both definitions are keyed to a transfer that may never happen. "Stabilized" does not mean treated, cured, or improved: it means the condition is not likely to materially deteriorate during a move. "To stabilize" is defined the same way, so the treatment the hospital must provide under (d)(1)(i) is treatment sufficient to reach that threshold, not treatment sufficient to resolve the condition. The two definitions are printed as one slice because they are adjacent and share their structure.
§ 489.24(b)-Inpatient Definition — inpatient (the second definition in the CFR)
Effective 1986-07-17
Inpatient means an individual who is admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services as described in § 409.10(a) of this chapter with the expectation that he or she will remain at least overnight and occupy a bed even though the situation later develops that the individual can be discharged or transferred to another hospital and does not actually use a hospital bed overnight.
Official text
This definition carries no "for purposes of payment" opening, unlike Sec. 412.3(a). It nonetheless defines inpatient services by reference to Sec. 409.10(a), and that provision defines services as those "furnished to an inpatient" — see the 409.10 entry. The closing clause does real work: the individual counts as an inpatient even if the situation later develops that they can be discharged or transferred and they never actually use a bed overnight. The expectation is measured when they are admitted.
§ 489.24(c) A clearly non-emergency request — the reduced screening
Effective 1986-07-17
(c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital's dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition.
Official text
The screening duty scales down but does not switch off. The standard becomes "such screening as would be appropriate for any individual presenting in that manner", and its purpose is stated: to determine that the individual does not have an emergency medical condition. The trigger is the nature of the REQUEST, not the condition later found.
§ 489.24(d)(1) What stabilising means here — treat, or transfer
Effective 1986-07-17
(d) Necessary stabilizing treatment for emergency medical conditions — (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either— (i) Within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For transfer of the individual to another medical facility in accordance with paragraph (e) of this section.
Official text
Two alternatives, and the hospital chooses. Both are bounded by "within the capabilities of the staff and facilities available at the hospital" — the duty is not absolute, it is measured against that hospital on that day. The opening words make the whole paragraph subject to (d)(2).
§ 489.24(d)(2) When the duty ends — admission in good faith
Effective 1986-07-17
(2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual. (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation.
Official text
Three clauses and they are not variants of each other. (i) is the way out: admit in good faith to stabilise and this section is satisfied. (ii) says the section never applied to someone admitted for elective care. (iii) points elsewhere entirely — the care of inpatients is governed by the part 482 conditions of participation, not by this section. Admission does not end the hospital's obligations; it ends the obligations created by THIS section, and (iii) names what they become.
§ 489.24(d)(3) Refusal of treatment — what the record must show
Effective 1986-07-17
(3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section 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 the examination and treatment, but the individual (or a person acting on the individual's behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual's written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both.
Official text
The hospital meets (d)(1)(i) by offering and being refused, but only on three conditions, and two of them are documentary: all reasonable steps to secure written informed refusal, and a description in the medical record. The written document "should" indicate the person was informed of the risks and benefits — "should", where the surrounding verbs are "must".
§ 489.24(d)(4) Delay — what may not happen first, and what still may
Effective 1986-07-17
(4) Delay in examination or treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual's method of payment or insurance status. (ii) A participating hospital may not seek, or direct an individual to seek, authorization from the individual's insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual's physician at any time to seek advice regarding the individual's medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. (iv) Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation.
Official text
The paragraph is often quoted as two prohibitions; it is four provisions and the last two cut back the first two. (iii) permits consulting the individual's own physician at any time. (iv) permits registration processes — expressly including asking whether the individual is insured and what the insurance is — provided the inquiry does not delay screening or treatment, and adds that reasonable registration "may not unduly discourage individuals from remaining for further evaluation". The line is delay and discouragement, not the question itself.
§ 489.24(d)(5) Refusal of transfer — the parallel condition
Effective 1986-07-17
(5) Refusal to consent to transfer. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual's behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual's written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual's refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual.
Official text
Structurally identical to (d)(3) with one addition not present there: the written document must also state the reasons for the refusal. Both provisions turn a refusal into compliance only if the paperwork exists.
§ 489.24(e)(3) Adverse action — the federal provision that protects an employee
Effective 1986-07-17
(3) A participating hospital may not penalize or take adverse action against a physician or a qualified medical person described in paragraph (e)(1)(ii)(C) of this section because the physician or qualified medical person 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.
Official text
The second clause is the one that reaches a nurse. It is not limited to physicians: "any hospital employee". Its scope is narrow in a different way — the report must concern "a violation of a requirement of this section", meaning section 489.24. A report about understaffing, about chapter 258 overtime, or about anything else is outside it. This is the provision the anti-retaliation cell could not reach, because that cell searched subpart F of part 485 and this sentence is in part 489.
§ 489.24(f) The receiving hospital
Effective 1986-07-17
(f) Recipient hospital responsibilities. A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive case units, or, with respect to rural areas, regional referral centers (which, for purposes of this subpart, mean hospitals meeting the requirements of referral centers found at § 412.96 of this chapter)) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. (1) The provisions of this paragraph (f) apply to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. (2) The provisions of this paragraph (f) do not apply to an individual who has been admitted to a referring hospital under the provisions of paragraph (d)(2)(i) of this section.
Official text
The duty runs both ways, and (1) removes the usual precondition: a hospital with specialized capabilities owes this even without a dedicated emergency department. It is still conditioned on "capacity", which takes its meaning from the (b) definition and therefore includes "numbers and availability of qualified staff". (2) disapplies it for someone already admitted in good faith to stabilise.
§ 489.24(g) The consequence
Effective 1986-07-17
(g) Termination of provider agreement. If a hospital fails to meet the requirements of paragraph (a) through (f) of this section, CMS may terminate the provider agreement in accordance with § 489.53.
Official text
The only consequence stated in the section, and it runs against the hospital rather than to any individual. No damages, no private right of action and no deadline appear anywhere in section 489.24. Civil monetary penalties and the individual right to sue are in section 1867 of the Act, which this page does not collect.
§ 482.55 The personnel standard the screening requirement points at
Effective 2025-07-01
§ 482.55 Condition of participation: Emergency services. The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. (a) Standard: Organization and direction. If emergency services are provided at the hospital— (1) The services must be organized under the direction of a qualified member of the medical staff; (2) The services must be integrated with other departments of the hospital; (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. (b) Standard: Personnel. (1) The emergency services must be supervised by a qualified member of the medical staff. (2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. (c) Standard: Emergency services readiness. Effective July 1, 2025, in accordance with the complexity and scope of services offered, there must be adequate provisions and protocols to meet the emergency needs of patients. (1) Protocols. Protocols must be consistent with nationally recognized and evidence-based guidelines for the care of patients with emergency conditions, including but not limited to patients with obstetrical emergencies, complications, and immediate post-delivery care. (2) Provisions. Provisions include equipment, supplies, and medication used in treating emergency cases. Such provisions must be kept at the hospital and be readily available for treating emergency cases to meet the needs of patients. The available provisions must include the following: (i) Drugs, blood and blood products, and biologicals commonly used in life-saving procedures; (ii) Equipment and supplies commonly used in life-saving procedures; and (iii) Each emergency services treatment area must have a call-in-system for each patient. (3) Staff training. Applicable staff, as identified by the hospital, must be trained annually on the protocols and provisions implemented pursuant to this section. (i) The governing body must identify and document which staff must complete such training. (ii) The hospital must document in the staff personnel records that the training was successfully completed. (iii) The hospital must be able to demonstrate staff knowledge on the topics implemented pursuant to this section. (iv) The hospital must use findings from its QAPI program, as required at § 482.21, to inform staff training needs and any additions, revisions, or updates to training topics on an ongoing basis.
Official text
Reproduced because 489.24(a)(1)(i) requires the person conducting the screening to meet this section's requirements "concerning emergency services personnel and direction". Two things a reader should see. First, this is part 482 — the conditions of participation for hospitals — while a critical access hospital is certified against part 485 subpart F, where the emergency services personnel rule is 485.618(d). Section 489.24 applies to a CAH, because (b) defines Hospital to include one, and it points at a part 482 standard to say who may screen. This page reproduces both and does not resolve which applies. Second, paragraph (c) took effect July 1 2025 (89 FR 94592, Nov. 27, 2024), so protocols, provisions and annual training are recent additions to this standard.
§ 409.10(a) The inpatient services definition that the inpatient definition points at
Effective 1986-07-17
§ 409.10 Included services. (a) Subject to the conditions, limitations, and exceptions set forth in this subpart, the term “inpatient hospital or inpatient CAH services” means the following services furnished to an inpatient of a participating hospital or of a participating CAH or, in the case of emergency services or services in foreign hospitals, to an inpatient of a qualified hospital: (1) Bed and board. (2) Nursing services and other related services. (3) Use of hospital or CAH facilities. (4) Medical social services. (5) Drugs, biologicals, supplies, appliances, and equipment. (6) Certain other diagnostic or therapeutic services. (7) Medical or surgical services provided by certain interns or residents-in-training. (8) Transportation services, including transport by ambulance.
Official text
Section 489.24(b) defines an inpatient by the services the admission is for, and sends the reader here for those services. This provision defines "inpatient hospital or inpatient CAH services" as services furnished "to an inpatient of a participating hospital" — it uses the word it is being used to explain. The definition of WHO an inpatient is therefore is not completed here; it is carried elsewhere, to 412.3(a), which supplies one "for purposes of payment under Medicare Part A". Three provisions pass the question along and none of them is a general definition of inpatient status.
§ 485.618(d)(2) The CAH rule that says a registered nurse may conduct the screening
Effective 1986-07-17
(2) A registered nurse with training and experience in emergency care can be utilized to conduct specific medical screening examinations only if— (i) The registered nurse is on site and immediately available at the CAH when a patient requests medical care; and (ii) The nature of the patient's request for medical care is within the scope of practice of a registered nurse and consistent with applicable State laws and the CAH's bylaws or rules and regulations.
Official text
This is the provision that meets 489.24(a)(1)(i) on the CAH side, and it is worth reading slowly. It does not say a registered nurse is on duty in the emergency department; it says an RN may be UTILISED to conduct SPECIFIC medical screening examinations, and only if the RN is on site and immediately available and the request is within the nurse's scope. Two consequences follow. First, the word is "specific": the paragraph is not authority for an RN to conduct every screening. Second, paragraph (d)(1) requires only that a doctor, PA, NP or CNS be ON CALL and available on site within 30 minutes — so for a CAH the two personnel rules answer the presence question differently, and it is the RN route that requires the person to already be in the building. Where the RN is not on site, this paragraph does not authorise the screening it describes, and 489.24(a)(1)(i) is not discharged by a practitioner who is thirty minutes away. The on-call cell sets out the full paragraph, including the 60-minute frontier exception at (d)(1)(ii) and the temporary RN substitution at (d)(3).