HB478INTRODUCED
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HB478
JPI5SYN-1
By Representative Oliver
RFD: Insurance
First Read: 20-Mar-25
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5 JPI5SYN-1 03/20/2025 JC (L)lg 2025-1301
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First Read: 20-Mar-25
SYNOPSIS:
This bill would regulate the provision of
emergency ambulance services in the state for a period
of approximately four years, by imposing requirements
on reimbursement by health insurers for ambulance
providers that depend on whether the provider is
in-network or out-of-network.
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 bill would prohibit this practice and
limit the charge to an enrollee to no more than the
in-network cost-sharing amount under the insurance
contract.
This bill would require health insurers to
reimburse an ambulance service within 30 days of
receiving the claim.
During the first two years that the requirements
of this bill would be in effect, the Alabama Department
of Public Health would be required to study its impact
on the responsiveness and availability of ambulance
services, especially in rural areas of the state.
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A BILL
TO BE ENTITLED
AN ACT
Relating to health insurance; to set requirements on
reimbursement rates for ambulance services covered by health
insurance plans; to prohibit balance billing of insureds who
receive emergency transportation; to regulate cost-sharing for
insureds and to require reimbursement within a defined period;
to require the Alabama Department of Public Health to conduct
a study on the effects of this act on ambulance services in
the state; and to provide for the repeal of this act.
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) COST-SHARING AMOUNT. The enrollee's deductible,
coinsurance, copayment, or other amount due under a health
care benefit plan for covered services.
(3) COVERED SERVICES or COVERED SERVICE. Those services
provided by an emergency medical service provider which are
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provided by an emergency medical service provider which are
covered by an enrollee's health care benefit plan, including
emergency ground transport.
(4) EMERGENCY MEDICAL SERVICE 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.
(5) ENROLLEE. An individual who resides in the State of
Alabama who is covered by a health care benefit plan.
(6) 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.
(7) HEALTH CARE INSURER. Any entity that issues or
administers a health care benefit plan, including a health
care insurer, a nonprofit health care services plan
incorporated under Chapter 20, Title 10A, Code of Alabama
1975, or a health maintenance organization established under
Chapter 21A, Title 27, Code of Alabama 1975.
(8) 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.
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network.
(9) 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) Every health care insurer shall provide
an option for the emergency medical service provider to be
in-network.
(b) Negotiated or contracted in-network rates shall not
decrease after October 1, 2025.
(c) Negotiated or contracted in-network rates shall be
and remain a percentage of the current published rate for
ambulance services as established by the Centers for Medicare
and Medicaid Services under Title XVIII of the Social Security
Act for the same service provided in the same geographic area.
Section 3. (a) The minimum reimbursement rate for
covered services under any health care benefit plan issued by
a health insurer to an out-of-network emergency medical
service provider shall be 185 percent of the current published
rate for ambulance services as established by the Centers for
Medicare and Medicaid Services under Title XVIII of the Social
Security Act for the same service provided in the same
geographic area.
(b) The cost-sharing amounts shall not exceed the
in-network cost-sharing amounts for the covered health care
services received by an enrollee when the services are
provided by an out-of-network emergency ambulance service
provider.
Section 4. The reimbursement rate to an emergency
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Section 4. The reimbursement rate to an emergency
medical service provider for covered services under any health
care benefit plan issued by a health care insurer shall be the
greater of the following:
(1) The negotiated or contract rate for being
in-network as provided in Section 2.
(2) The minimum reimbursement rate for covered services
for an out-of-network emergency medical service provider as
provided in Section 3.
Section 5. (a) Payment made in accordance with Section
4 shall be considered payment in full for the covered services
provided, except for any cost-sharing amount, noncovered
service, or service considered not medically necessary
required to be paid by an enrollee.
(b) An emergency medical service provider is prohibited
from balance billing an enrollee for any additional amounts
for paid covered services.
Section 6. A health care insurer shall not require any
prior authorization for services provided by an emergency
medical services provider or follow the same practices
established by the Centers for Medicare and Medicaid Services
under Section 1834 of Title XVIII of the Social Security Act.
Section 7. (a)(1) Within 30 days after receipt of a
clean claim for reimbursement, a health care insurer shall
remit payment to the emergency medical service provider and
shall not send payment to an enrollee.
(2) A health care insurer shall remit payment with a
specific remark code to indicate that the claim has been paid
under the provisions of this act.
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under the provisions of this act.
(b)(1) 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 notice acknowledging the
date of receipt of 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 or reasons for the denial.
b. Additional information is necessary to determine if
the claim is payable and the specific additional information
that is required.
(2) On any claim denial, the emergency medical service
provider may bill the enrollee for all billed charges.
Section 8. (a) The Alabama Department of Public Health
shall conduct a comprehensive study to determine the
effectiveness of reimbursement payments paid in accordance
with this act and determine whether: (i) the average response
time for ambulance services in Alabama has decreased; and (ii)
the number of ambulances in Alabama, especially in rural
areas, has increased.
(b) All costs and expenses of the study shall be paid
by a nonprofit health care services plan incorporated under
Chapter 20, Title 10A, Code of Alabama 1975.
(c) The results of this study shall be provided to Blue
Cross Blue Shield of Alabama and the Alabama Association of
Ambulance Services no later than January 1, 2028.
Section 9. This act is repealed on June 1, 2029.
Section 10. This act shall become effective on October
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Section 10. This act shall become effective on October
1, 2025.169