An EMTALA (Emergency Medical Treatment and Labor Act) compliance program is the set of written policies, logs, forms and audit tools that lets a Medicare hospital with an emergency department meet 42 CFR 489.24, the Medicare regulation accompanying section 1867 of the Social Security Act, and related duties in 42 CFR 489.20. Integral Healthcare Solutions (IHS) drafts that set for hospitals, including critical access hospitals.
Your physicians approve the clinical content.
Last updated: November 2026
What does 42 CFR 489.24 require of a hospital emergency department?
A hospital with a dedicated emergency department must give an appropriate medical screening examination to any individual who comes to the emergency department and, if an emergency medical condition exists, provide stabilizing treatment or an appropriate transfer, whether or not the individual is eligible for Medicare and regardless of ability to pay (paragraph (a)(1)). Text is from the current eCFR as rebuilt November 4, 2026 (title 42 last amended October 8, 2026), opened November 5, 2026.
- Who is covered. An individual comes to the emergency department by requesting examination or treatment for a medical condition there, or for what may be an emergency medical condition elsewhere on hospital property (the main campus, including its parking lot, sidewalk and driveway, but not areas such as physician offices or entities that participate separately under Medicare), or by having the request made for them. Arrival by ambulance can also count (paragraph (b)). With no request, one is treated as made when a prudent layperson observer would believe, from appearance or behavior, that the individual needs it.
- Dedicated emergency department. A department or facility of the hospital, on or off campus, that meets at least one test: State-licensed as an emergency room or department; held out to the public as a place for emergency care on an urgent basis without a previously scheduled appointment; or, by representative sample, at least one-third of its outpatient visits in the calendar year before a determination were for emergency medical conditions on an urgent basis without a previously scheduled appointment.
- Screening. The examination is within the capability of the emergency department, including ancillary services routinely available to it, and determines whether an emergency medical condition exists. It is done by individuals the hospital's bylaws or rules and regulations qualify and who meet 42 CFR 482.55.
- Stabilizing and refusals. The hospital must provide, within the capabilities of its staff and facilities, the treatment required to stabilize the condition, or transfer under paragraph (e); a good-faith inpatient admission in order to stabilize satisfies the hospital's duty. If the hospital offers treatment or a transfer and informs the individual of the risks and benefits but the individual declines, it must take all reasonable steps to secure a written informed refusal ((d)(2), (d)(3), (d)(5)).
- Transferring an unstabilized individual. The hospital may not transfer unless the transfer is appropriate and one of three things is in place: the individual's (or a legally responsible person's) written request after being informed of the hospital's obligations and the risk of transfer, giving reasons and showing awareness of risks and benefits; a physician's signed certification, with a summary of risks and benefits, that on the information available at the time of transfer the medical benefits reasonably expected from treatment elsewhere outweigh the increased risks to the individual or, for a woman in labor, to the woman or unborn child; or, if no physician is physically present in the emergency department at the time of transfer, a signed certification by a qualified medical person (as the hospital's bylaws or rules determine), after a physician in consultation agrees with it and subsequently countersigns (paragraph (e)(1)).
- An appropriate transfer. It is appropriate only in those cases in which the sender provides treatment within its capacity that minimizes health risks; the receiving facility has available space and qualified personnel and has agreed to accept the individual and provide appropriate treatment; the related records available at the time of transfer go along; and qualified personnel and transportation equipment carry it out (paragraph (e)(2)).
- Recipient hospitals. A participating hospital with specialized capabilities or facilities may not refuse an appropriate transfer of an individual who requires them if it has the capacity to treat, unless the referring hospital admitted the individual as an inpatient under (d)(2)(i) ((f)).
- On-call policies. A hospital must have written policies to respond when a specialty is not available or the on-call physician cannot respond for reasons beyond the physician's control, and to keep emergency services available if it chooses to let on-call physicians schedule elective surgery while on call, have simultaneous on-call duties or join a formal community call plan ((j)).
What signage, log, on-call list and record duties come with it?
Under 42 CFR 489.20, the hospital posts conspicuously a sign on rights under section 1867 of the Act, in the form the Secretary specifies, and Medicaid participation information (paragraph (q)). It keeps transfer records for 5 years from the date of transfer, an on-call list of physicians available to provide treatment necessary after the initial examination to stabilize individuals, in accordance with the hospital's resources, and a central log on each individual who comes to the emergency department seeking assistance, noting whether the person refused or was refused treatment, or was transferred, admitted and treated, stabilized and transferred, or discharged (paragraph (r)).
What happens when a hospital falls short?
CMS may terminate the provider agreement of a hospital with an emergency department that fails to comply with 489.24(a) through (e) or 489.20(m), (q) and (r) (42 CFR 489.53(b)). For a violation of 489.24(a) through (f) that CMS determines poses immediate jeopardy, CMS gives a preliminary notice that the agreement will end in 23 days if the hospital does not correct the deficiencies or refute the finding, and a final notice at least 2 but not more than 4 days before the effective date (489.53(d)(2)(i)). After a citation, see plan of correction steps.
Separately, OIG may penalize a participating hospital with an emergency department or specialized capabilities for each negligent violation of section 1867 or 489.24 other than 489.24(j), and may exclude a responsible physician for a gross and flagrant, or repeated, violation (42 CFR 1003.500). The HHS table at 45 CFR 102.3 lists 2025 maximums of 136,886 dollars for a hospital with 100 beds or more or a responsible physician, and 68,445 dollars for a hospital with fewer than 100 beds; it adjusts yearly. OIG's EMTALA enforcement list showed 114 actions on November 5, 2026; the 20 newest, February 2025 to August 2026, are settlements for alleged violations (15 screening, 4 stabilizing treatment, 5 transfers; some cite more than one) of 40,000 to 350,000 dollars.
How do surveyors test EMTALA compliance?
CMS tells surveyors to review at least 20 records in depth (at least 10 on revisit surveys), chosen from the emergency department log and other information such as patient charts, and not by hospital staff (State Operations Manual, Appendix V, Rev. 191, July 19, 2019). The selection list: individuals transferred out; gaps, returns or non-sequential log entries; refusals of examination, treatment or transfer; patients who left against medical advice or without being seen; and returns within 48 hours. The IHS log audit applies that selection to your records.
Who needs an EMTALA compliance program, and what starts the work?
The CMS survey manual states that hospitals with dedicated emergency departments, including critical access hospitals, are required to adopt and enforce policies and procedures to comply with 42 CFR 489.24. In IHS's reading, triggers include a new department, a change in bylaws or on-call coverage, and a complaint or citation.
How does IHS help with an EMTALA compliance program?
IHS turns 42 CFR 489.24 and the related 489.20 duties into policies, forms and audit tools. Thomas G. Goddard, JD, PhD, IHS founder and former URAC Chief Operating Officer and General Counsel, leads the work. This program sits in Compliance Services, one of three IHS practice lines.
What IHS drafts
Screening, stabilization and transfer policies and forms written to the paragraph text; an on-call policy; a central log template; and a log audit on a sample from your own log.
What you supply
Your bylaws, policies, transfer agreements, on-call lists, central log, and physician approval of clinical content.
The real limit
Your clinicians decide clinical content and your counsel decides legal questions. IHS does not communicate with CMS, OIG or a state agency for you.
What to have ready
- Current screening, stabilization and transfer policies (489.24(a), (d), (e)).
- The bylaws or rules that say who may perform the screening ((a)(1)(i)).
- Every department or facility, on or off campus, that may meet a dedicated emergency department test ((b)).
- Transfer forms and agreements, and specialized capabilities you offer other hospitals ((e), (f)).
- On-call policies and the on-call list with individual physician names ((j); 489.20(r)(2)).
- Your central log and sign locations (489.20(q), (r)).
With the list in hand, the free introductory call is where IHS walks through it with you.
How does an EMTALA program compare with other approaches?
A log audit adds a test on a sample from your log; that is an IHS method. A review directed by counsel is legal analysis, which IHS does not provide.
What does an EMTALA compliance program cost?
IHS scopes each engagement after a free introductory call. Scope drivers are the number of campuses and dedicated emergency departments, how many transfer agreements you have, and whether you want the log audit.
What this is not
- It is not legal advice or a guarantee of any outcome with CMS or OIG. IHS is a consulting firm, not a law firm.
- It does not decide how state law applies to emergency care. CMS's page for QSO-21-22-Hospitals, a memo on patients who are pregnant or experiencing pregnancy loss, states that CMS rescinded it effective May 29, 2025.
Frequently asked questions
Does EMTALA apply to critical access hospitals and rural emergency hospitals?
Yes. Paragraph (b) of 42 CFR 489.24 says hospital includes a critical access hospital (section 1861(mm)(1) of the Act) and a rural emergency hospital (section 1861(kkk)(2)).
Does EMTALA reach off-campus departments?
Yes, if it meets a dedicated emergency department test; the definition covers departments on or off the main campus.
Who may perform the medical screening examination?
Individuals the hospital's bylaws or rules qualify (paragraph (a)(1)(i)). The State Operations Manual says the designation should be in a document approved by the governing body; informal appointments that could frequently change are not acceptable.
Can registration staff ask about insurance in the emergency department?
Registration may ask whether an individual is insured and what the insurance is, if the inquiry does not delay screening or treatment and registration does not unduly discourage the individual from staying (paragraph (d)(4)(iv)). It may not seek insurer authorization until after the screening and after it has initiated the treatment needed to stabilize (paragraph (d)(4)(ii)).
Does EMTALA cover psychiatric emergencies and women in labor?
Yes. The emergency medical condition definition names psychiatric disturbances and symptoms of substance abuse among the acute symptoms, and covers a pregnant woman having contractions when there is inadequate time for a safe transfer before delivery or transfer may threaten the health or safety of the woman or unborn child.
What must the on-call list show?
The State Operations Manual says it must be up to date and list current medical staff members or physicians with privileges, plus, if the hospital participates in a community call plan, physicians at other hospitals who are on call under it. It names individual physicians with accurate contact information, not groups.
Does OIG penalty authority reach the on-call policy paragraph?
Section 1003.500(a) authorizes a hospital penalty for each negligent violation of section 1867 or 42 CFR 489.24 other than 489.24(j). CMS termination is separate: 489.53(b)(2) covers 489.20(r), which includes the on-call list.
Does IHS approve screening content or contact CMS, OIG or the state?
No to both. Your physicians approve every clinical element, and your hospital handles any survey, complaint or agency contact.