HB469INTRODUCED
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HB469
2JX7FII-1
By Representative Oliver
RFD: Insurance
First Read: 20-Mar-25
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5 2JX7FII-1 02/25/2025 JC (L)lg 2025-885
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First Read: 20-Mar-25
SYNOPSIS:
Currently, a provider that is not in a health
care insurer's network may bill an insured individual
for the balance of its retail charge for ground
ambulance service after it has received payment from
the insurer. This practice is called "balance" or
"surprise billing."
This bill would prohibit surprise billing by
setting a minimum rate for health insurers to pay
out-of-network ground ambulance providers, which would
be considered payment in full. This rate would be a
multiplier of the current Medicare reimbursement
amount. Under this bill, a ground ambulance provider
could directly charge an individual for no more than
the in-network cost-sharing amount under the insurance
contract.
This bill would further require health insurers
to directly pay the ambulance service and not the
covered individual.
A BILL
TO BE ENTITLED
AN ACT
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Relating to health insurance; to establish a minimum
reimbursement rate for out-of-network ground ambulance
services covered by health insurance plans; to provide that
the minimum reimbursement amount is payment in full for ground
ambulance services; to prohibit balance billing of insureds
who receive emergency transportation from out-of-network
ground ambulance services; and to provide for reimbursement
guidelines for health insurers and out-of-network ground
ambulance services.
BE IT ENACTED BY THE LEGISLATURE OF ALABAMA:
Section 1. For the purposes of this act, the following
words have the following meanings:
(1) CLEAN CLAIM. A reimbursement claim for covered
services which is submitted to a health care insurer and which
contains substantially all of the data and information
necessary for accurate adjudication, without the need for
additional information from the emergency medical provider
service or a third party.
(2) COLLECTION. Any written or oral communication made
to an enrollee for the purpose of obtaining payment for the
services rendered by an emergency medical service provider,
including invoicing and legal debt collection efforts.
(3) COST-SHARING AMOUNT. The enrollee's deductible,
coinsurance, copayment, or other amount due under a health
care benefit plan for covered services.
(4) COVERED SERVICES or COVERED SERVICE. Those services
provided by an emergency medical service provider which are
covered by an enrollee's health care benefit plan, including
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covered by an enrollee's health care benefit plan, including
the following:
a. EMERGENCY GROUND TRANSPORT. An emergency event in
which an enrollee is transported by an emergency medical
service provider to a hospital or definitive care facility as
defined in Section 22-18-1, Code of Alabama 1975, and which
may include basic life support or advanced life support.
b. TREAT IN PLACE. An emergency response event in which
an emergency medical provider service assesses an enrollee or
renders treatment, including basic life support or advanced
life support, to an enrollee, at his or her location without
emergency ground transport.
(5) EMERGENCY MEDICAL SERVICE PROVIDER or PROVIDER. Any
public or private organization that is licensed to provide
emergency medical services as defined in Section 22-18-1, Code
of Alabama 1975, including emergency ground transport and
treat in place.
(6) ENROLLEE. An individual who resides in the State of
Alabama who is covered by a health care benefit plan.
(7) HEALTH CARE BENEFIT PLAN. Any individual or group
plan, policy, or contract issued, delivered, or renewed in
this state by a health care insurer to provide, deliver,
arrange for, pay for, or reimburse health care services,
including those provided by an emergency medical service
provider, except for payments for health care made under
automobile or homeowners insurance plans, accident-only plans,
specified disease plans, long-term care plans, supplemental
hospital or fixed indemnity plans, dental and vision plans, or
Medicaid.
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Medicaid.
(8) HEALTH CARE INSURER. Any entity that issues or
administers a health care benefit plan, including a health
care insurer, a health care services plan incorporated under
Chapter 20 of Title 10A, Code of Alabama 1975, or a health
maintenance organization established under Chapter 21A of
Title 27, Code of Alabama 1975.
(9) IN-NETWORK. When an emergency medical service
provider is in a contract with the health care insurer to
provide covered services in the health care insurer's provider
network.
(10) OUT-OF-NETWORK. When an emergency medical service
provider does not have a contract with a health care insurer
to provide covered services in the health care insurer's
provider network.
Section 2. (a) The minimum reimbursement amount a
health care insurer shall pay to an emergency medical service
provider that is out-of-network for covered services is the
lesser of the emergency medical service provider's billed
charge or 325 percent of the Medicare rate that is in effect
for the geographic area in which the covered service,
including emergency ground transport or treat in place, is
provided as published by the Centers for Medicare & Medicaid
Services.
(b) If the Medicare benchmark provided in subsection
(a) is the applicable reimbursement and the covered service is
a treat in place, the rate shall be no less than the published
code in effect for providing emergency basic life support.
Section 3. (a)(1) Payment in accordance with Section 2
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Section 3. (a)(1) Payment in accordance with Section 2
shall be payment in full for covered services.
(2) An emergency medical service provider that is
out-of-network, including the provider's agent, contractor, or
assignee, may not bill or seek collection of any amount from
an enrollee which is in excess of the minimum reimbursement
amount as provided in Section 2, except for the enrollee's
in-network cost-sharing amount.
(3) The health care insurer shall certify an enrollee's
in-network cost sharing amount to the provider upon request.
(b)(1) Within 30 days after receipt of a clean claim
for reimbursement, a health care insurer shall remit payment
to an out-of-network emergency medical service provider and
shall not send payment to an enrollee.
(2) If a claim for reimbursement submitted by an
emergency medical service provider to a health care insurer is
not a clean claim, within 30 days the health care insurer
shall send the provider a written receipt acknowledging the
claim, accompanied with one of the following applicable
statements:
a. The insurer is declining to pay all or a part of the
claim and the specific reason for the denial.
b. Additional information is necessary to determine if
the claim is payable and the specific additional information
that is required.
(3) Any dispute between a health care insurer and an
emergency medical service provider over the amount to be paid
to the provider may be settled by one of the following means:
a. Affording the provider access to the insurer's
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a. Affording the provider access to the insurer's
internal forum for resolving provider disputes concerning
coverage and reimbursement amounts.
b. Selecting an internal dispute resolution contractor
mutually agreeable to the insurer and the provider.
(c) The enrollee shall not be included in any
communication between the health care insurer and the
out-of-network emergency medical service provider pursuant to
the insurer's payment of the provider, nor shall the enrollee
be a party in the resolution of any payment dispute between
the insurer and the provider.
Section 4. This act shall become effective on October
1, 2025.
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