Coverage and reimbursement of emergency ambulance services under health insurance policies and plans. (FE)

A rate that is mutually agreed upon by the plan and the ambulance service provider.

A rate that is set or approved by a local governmental entity in the jurisdiction in which the emergency ambulance services originated.

A rate that is 350 percent of the Medicare program’s published rate for the services in the same geographic area or a rate that is equivalent to the rate billed by the ambulance service provider for the services, whichever is less.

The bill provides that an ambulance service provider that is reimbursed at the applicable rate may not charge an enrollee an additional amount for the emergency ambulance services except for any cost-sharing responsibility, such as a copayment, coinsurance, or deductible. The bill also prohibits the plan from imposing a cost-sharing amount on an enrollee that is greater than the amount that would have applied had the ambulance service provider been a participating provider.

The bill further requires that a health insurance policy or self-insured governmental health plan respond to claims for covered emergency ambulance services within 30 days by remitting payment directly to the ambulance service provider or by notifying the provider of any defect with the claim. The bill also provides that the policy or plan must remit payment for the transportation of a patient by ambulance (including transport from one facility to another to receive services not available at the first) as a medically necessary emergency ambulance service at a rate as described above if the ambulance service provider includes with its claim for payment a medical necessity certification statement signed by an individual who meets criteria established by federal regulations.