| 1 | | - | Assembly Bill No. 716 CHAPTER 454An act to add Sections 1371.56, 1797.124, and 1797.233 to, and to repeal Section 1367.11 of, the Health and Safety Code, and to add Section 10126.66 to, and to repeal Section 10352 of, the Insurance Code, relating to medical transportation. [ Approved by Governor October 08, 2023. Filed with Secretary of State October 08, 2023. ] LEGISLATIVE COUNSEL'S DIGESTAB 716, Boerner. Ground medical transportation. Existing law creates the Emergency Medical Services Authority to coordinate various state activities concerning emergency medical services. Existing law requires the authority to report specified information, including reporting ambulance patient offload time twice per year to the Commission on Emergency Medical Services.This bill would require the authority to annually report the allowable maximum rates for ground ambulance transportation services in each county, including trending the rates by county, as specified.Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires that health care service plan contracts and health insurance policies provide coverage for certain services and treatments, including medical transportation services, and requires a policy or contract to provide for the direct reimbursement of a covered medical transportation services provider if the provider has not received payment from another source.This bill would delete that direct reimbursement requirement and would require a health care service plan contract or a health insurance policy issued, amended, or renewed on or after January 1, 2024, to require an enrollee or insured who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the enrollee or insured would pay for the same covered services received from a contracting ground ambulance provider. The bill would prohibit a noncontracting ground ambulance provider from sending to collections a higher amount, would limit the amount an enrollee or insured owes a noncontracting ground ambulance provider to no more than the in-network cost-sharing amount, and would prohibit a ground ambulance provider from billing an uninsured or self-pay patient more than the established payment by Medi-Cal or Medicare fee-for-service amount, whichever is greater. The bill would require a plan or insurer to directly reimburse a noncontracting ground ambulance provider for ground ambulance services the difference between the in-network cost-sharing amount and an amount described, as specified, unless it reaches another agreement with the noncontracting ground ambulance provider. Because a willful violation of the bills requirements relative to a health care service plan would be a crime, the bill would impose a state-mandated local program.The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.This bill would provide that no reimbursement is required by this act for a specified reason.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: YES Bill TextThe people of the State of California do enact as follows:SECTION 1. Section 1367.11 of the Health and Safety Code is repealed.SEC. 2. Section 1371.56 is added to the Health and Safety Code, to read:1371.56. (a) (1) Unless otherwise required by this chapter, a health care service plan contract issued, amended, or renewed on or after January 1, 2024, shall require an enrollee who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the enrollee would pay for the same covered services received from a contracting ground ambulance provider. This amount shall be referred to as the in-network cost-sharing amount.(2) An enrollee shall not owe the noncontracting ground ambulance provider more than the in-network cost-sharing amount for services subject to this section. At the time of payment by the plan to the noncontracting provider, the plan shall inform the enrollee and the noncontracting provider of the in-network cost-sharing amount owed by the enrollee and shall disclose whether or not the enrollees coverage is regulated by the department or if the coverage is not state-regulated.(b) (1) The in-network cost-sharing amount paid by the enrollee pursuant to this section shall count toward the limit on annual out-of-pocket expenses established under Section 1367.006.(2) Cost sharing arising pursuant to this section shall count toward any deductible in the same manner as cost sharing would be attributed to a contracting provider.(3) The in-network cost-sharing amount paid by the enrollee pursuant to this section shall satisfy the enrollees obligation to pay cost sharing for the health service.(c) A noncontracting ground ambulance provider shall only advance to collections the in-network cost-sharing amount, as determined by the plan pursuant to subdivision (a), that the enrollee failed to pay.(1) A noncontracting ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the enrollee for a minimum of 12 months after the initial billing regarding amounts owed by the enrollee pursuant to subdivision (a).(2) With respect to an enrollee, a noncontracting ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section.(d) (1) Unless otherwise agreed to by the noncontracting ground ambulance provider and the health care service plan, the plan shall directly reimburse a noncontracting ground ambulance provider for ground ambulance services the difference between the in-network cost-sharing amount and an amount described, as follows:(A) If there is a rate established or approved by a local government, at the rate established or approved by the governing body of the local government having jurisdiction for that area or subarea, including an exclusive operating area pursuant to Section 1797.85.(B) If the local government having jurisdiction where the service was provided does not have an established or approved rate for that service, the amount established by Section 1300.71 (a)(3)(B) of Title 28 of the California Code of Regulations.(2) A local government has jurisdiction over the ground ambulance transport if either of the following applies:(A) The ground ambulance transport is initiated within the boundaries of the local governments regulatory jurisdiction.(B) In the case of ground ambulance transports provided on a mutual or automatic aid basis into another jurisdiction, the local government where the noncontracting ground ambulance provider is based.(3) A payment made by the health care service plan to the noncontracting ground ambulance provider for services as required in subdivision (a), plus the applicable cost sharing owed by the enrollee, shall constitute payment in full for services rendered.(4) Notwithstanding any other law, the amounts paid by a health care service plan for services under this section shall not constitute the prevailing or customary charges, the usual fees to the general public, or other charges for other payers for an individual ground ambulance provider.(e) A health care service plan or a provider may seek relief in any appropriate court for the purpose of resolving a payment dispute. A ground ambulance provider may use a health care service plans existing dispute resolution processes.(f) Ground ambulance service providers remain subject to the balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code.(g) This section does not apply to a Medi-Cal managed health care service plan or any entity that enters into a contract with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), and Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code.SEC. 3. Section 1797.124 is added to the Health and Safety Code, to read:1797.124. (a) On or before March 1, 2024, and on or before each January 1 thereafter, the authority shall annually develop and publish on its internet website a report showing the allowable maximum rates for ground ambulance transportation services in each county, including trending the rates by county. If feasible, this report shall include the applicable Medicare rate for the year.(b) The authority shall annually submit each report to the Department of Insurance and the Department of Managed Health Care for purposes of rate review, as well as to the Office of Health Care Affordability.SEC. 4. Section 1797.233 is added to the Health and Safety Code, to read:1797.233. (a) A ground ambulance provider shall not require an uninsured patient or self-pay patient to pay an amount more than the established payment by Medi-Cal or Medicare fee-for-service amount, whichever is greater.(b) (1) A ground ambulance provider shall only advance to collections the Medicare or Medi-Cal payment amount, as determined pursuant to subdivision (a), that the uninsured or self-pay patient failed to pay.(2) The ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the individual for a minimum of 12 months after the initial billing regarding amounts owed by the individual pursuant to subdivision (a).(3) With respect to an uninsured patient or self-pay patient, the ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section.(c) Ground ambulance service providers remain subject to balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code.SEC. 5. Section 10126.66 is added to the Insurance Code, to read:10126.66. (a) (1) Unless otherwise required by this chapter, a health insurance policy issued, amended, or renewed on or after January 1, 2024, shall require an insured who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the insured would pay for the same covered services received from a contracting ground ambulance provider. This amount shall be referred to as the in-network cost-sharing amount. (2) An insured shall not owe the noncontracting ground ambulance provider more than the in-network cost-sharing amount for services subject to this section. At the time of payment by the insurer to the noncontracting provider, the insurer shall inform the insured and the noncontracting provider of the in-network cost-sharing amount owed by the insured and shall disclose whether or not the insureds coverage is regulated by the department or if the coverage is not state-regulated.(b) (1) The in-network cost-sharing amount paid by the insured pursuant to this section shall count toward the limit on annual out-of-pocket expenses established under Section 10112.28.(2) Cost sharing arising pursuant to this section shall count toward any deductible in the same manner as cost sharing would be attributed to a contracting provider.(3) The in-network cost-sharing amount paid by the insured pursuant to this section shall satisfy the insureds obligation to pay cost sharing for the health service.(c) A noncontracting ground ambulance provider shall only advance to collections the in-network cost-sharing amount, as determined by the insurer pursuant to subdivision (a), that the insured failed to pay.(1) A noncontracting ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the insured for a minimum of 12 months after the initial billing regarding amounts owed by the insured pursuant to subdivision (a).(2) With respect to an insured, a noncontracting ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section.(d) (1) Unless otherwise agreed to by the noncontracting ground ambulance provider and the health insurer, the insurer shall directly reimburse a noncontracting ground ambulance provider for ground ambulance services the difference between the in-network cost-sharing amount and an amount described, as follows:(A) If there is a rate established or approved by a local government, at the rate established or approved by the governing body of the local government having jurisdiction for that area or subarea, including an exclusive operating area pursuant to Section 1797.85 of the Health and Safety Code.(B) If the local government having jurisdiction where the service was provided does not have an established or approved rate for that service, the reasonable and customary value for the services rendered, based upon statistically credible information that is updated at least annually and takes into consideration all of the following:(i) The ambulance providers training, qualifications, and length of time in practice.(ii) The nature of the services provided.(iii) The fees usually charged by the ambulance provider.(iv) Prevailing ground ambulance provider rates charged in the general geographic areas in which the services were rendered.(v) Other aspects of the economics of the ambulance providers practice that are relevant.(vi) Any unusual circumstances in the case.(2) A local government has jurisdiction over the ground ambulance transport if either of the following applies:(A) The ground ambulance transport is initiated within the boundaries of the local governments regulatory jurisdiction. (B) In the case of ground ambulance transports provided on a mutual or automatic aid basis into another jurisdiction, the local government where the noncontracting ground ambulance provider is based.(3) A payment made by the health insurer to the noncontracting ground ambulance provider for services as required in subdivision (a), plus the applicable cost sharing owed by the insured, shall constitute payment in full for services rendered.(4) Notwithstanding any other law, the amounts paid by a health insurer for services under this section shall not constitute the prevailing or customary charges, the usual fees to the general public, or other charges for other payers for an individual ground ambulance provider.(e) A health insurer or ground ambulance provider may seek relief in any appropriate court for the purpose of resolving a payment dispute. A ground ambulance provider may use a health insurers existing dispute resolution process under Section 10123.137.(f) This section does not affect the balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code.SEC. 6. Section 10352 of the Insurance Code is repealed.SEC. 7. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution. |
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| 1 | + | Enrolled September 14, 2023 Passed IN Senate September 11, 2023 Passed IN Assembly September 12, 2023 Amended IN Senate September 06, 2023 Amended IN Senate July 10, 2023 Amended IN Senate June 26, 2023 Amended IN Assembly May 02, 2023 Amended IN Assembly April 19, 2023 CALIFORNIA LEGISLATURE 20232024 REGULAR SESSION Assembly Bill No. 716Introduced by Assembly Member Boerner(Coauthor: Assembly Member Wood)(Coauthor: Senator Wiener)February 13, 2023An act to add Sections 1371.56, 1797.124, and 1797.233 to, and to repeal Section 1367.11 of, the Health and Safety Code, and to add Section 10126.66 to, and to repeal Section 10352 of, the Insurance Code, relating to medical transportation.LEGISLATIVE COUNSEL'S DIGESTAB 716, Boerner. Ground medical transportation. Existing law creates the Emergency Medical Services Authority to coordinate various state activities concerning emergency medical services. Existing law requires the authority to report specified information, including reporting ambulance patient offload time twice per year to the Commission on Emergency Medical Services.This bill would require the authority to annually report the allowable maximum rates for ground ambulance transportation services in each county, including trending the rates by county, as specified.Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires that health care service plan contracts and health insurance policies provide coverage for certain services and treatments, including medical transportation services, and requires a policy or contract to provide for the direct reimbursement of a covered medical transportation services provider if the provider has not received payment from another source.This bill would delete that direct reimbursement requirement and would require a health care service plan contract or a health insurance policy issued, amended, or renewed on or after January 1, 2024, to require an enrollee or insured who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the enrollee or insured would pay for the same covered services received from a contracting ground ambulance provider. The bill would prohibit a noncontracting ground ambulance provider from sending to collections a higher amount, would limit the amount an enrollee or insured owes a noncontracting ground ambulance provider to no more than the in-network cost-sharing amount, and would prohibit a ground ambulance provider from billing an uninsured or self-pay patient more than the established payment by Medi-Cal or Medicare fee-for-service amount, whichever is greater. The bill would require a plan or insurer to directly reimburse a noncontracting ground ambulance provider for ground ambulance services the difference between the in-network cost-sharing amount and an amount described, as specified, unless it reaches another agreement with the noncontracting ground ambulance provider. Because a willful violation of the bills requirements relative to a health care service plan would be a crime, the bill would impose a state-mandated local program.The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.This bill would provide that no reimbursement is required by this act for a specified reason.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: YES Local Program: YES Bill TextThe people of the State of California do enact as follows:SECTION 1. Section 1367.11 of the Health and Safety Code is repealed.SEC. 2. Section 1371.56 is added to the Health and Safety Code, to read:1371.56. (a) (1) Unless otherwise required by this chapter, a health care service plan contract issued, amended, or renewed on or after January 1, 2024, shall require an enrollee who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the enrollee would pay for the same covered services received from a contracting ground ambulance provider. This amount shall be referred to as the in-network cost-sharing amount.(2) An enrollee shall not owe the noncontracting ground ambulance provider more than the in-network cost-sharing amount for services subject to this section. At the time of payment by the plan to the noncontracting provider, the plan shall inform the enrollee and the noncontracting provider of the in-network cost-sharing amount owed by the enrollee and shall disclose whether or not the enrollees coverage is regulated by the department or if the coverage is not state-regulated.(b) (1) The in-network cost-sharing amount paid by the enrollee pursuant to this section shall count toward the limit on annual out-of-pocket expenses established under Section 1367.006.(2) Cost sharing arising pursuant to this section shall count toward any deductible in the same manner as cost sharing would be attributed to a contracting provider.(3) The in-network cost-sharing amount paid by the enrollee pursuant to this section shall satisfy the enrollees obligation to pay cost sharing for the health service.(c) A noncontracting ground ambulance provider shall only advance to collections the in-network cost-sharing amount, as determined by the plan pursuant to subdivision (a), that the enrollee failed to pay.(1) A noncontracting ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the enrollee for a minimum of 12 months after the initial billing regarding amounts owed by the enrollee pursuant to subdivision (a).(2) With respect to an enrollee, a noncontracting ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section.(d) (1) Unless otherwise agreed to by the noncontracting ground ambulance provider and the health care service plan, the plan shall directly reimburse a noncontracting ground ambulance provider for ground ambulance services the difference between the in-network cost-sharing amount and an amount described, as follows:(A) If there is a rate established or approved by a local government, at the rate established or approved by the governing body of the local government having jurisdiction for that area or subarea, including an exclusive operating area pursuant to Section 1797.85.(B) If the local government having jurisdiction where the service was provided does not have an established or approved rate for that service, the amount established by Section 1300.71 (a)(3)(B) of Title 28 of the California Code of Regulations.(2) A local government has jurisdiction over the ground ambulance transport if either of the following applies:(A) The ground ambulance transport is initiated within the boundaries of the local governments regulatory jurisdiction.(B) In the case of ground ambulance transports provided on a mutual or automatic aid basis into another jurisdiction, the local government where the noncontracting ground ambulance provider is based.(3) A payment made by the health care service plan to the noncontracting ground ambulance provider for services as required in subdivision (a), plus the applicable cost sharing owed by the enrollee, shall constitute payment in full for services rendered.(4) Notwithstanding any other law, the amounts paid by a health care service plan for services under this section shall not constitute the prevailing or customary charges, the usual fees to the general public, or other charges for other payers for an individual ground ambulance provider.(e) A health care service plan or a provider may seek relief in any appropriate court for the purpose of resolving a payment dispute. A ground ambulance provider may use a health care service plans existing dispute resolution processes.(f) Ground ambulance service providers remain subject to the balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code.(g) This section does not apply to a Medi-Cal managed health care service plan or any entity that enters into a contract with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), and Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code.SEC. 3. Section 1797.124 is added to the Health and Safety Code, to read:1797.124. (a) On or before March 1, 2024, and on or before each January 1 thereafter, the authority shall annually develop and publish on its internet website a report showing the allowable maximum rates for ground ambulance transportation services in each county, including trending the rates by county. If feasible, this report shall include the applicable Medicare rate for the year.(b) The authority shall annually submit each report to the Department of Insurance and the Department of Managed Health Care for purposes of rate review, as well as to the Office of Health Care Affordability.SEC. 4. Section 1797.233 is added to the Health and Safety Code, to read:1797.233. (a) A ground ambulance provider shall not require an uninsured patient or self-pay patient to pay an amount more than the established payment by Medi-Cal or Medicare fee-for-service amount, whichever is greater.(b) (1) A ground ambulance provider shall only advance to collections the Medicare or Medi-Cal payment amount, as determined pursuant to subdivision (a), that the uninsured or self-pay patient failed to pay.(2) The ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the individual for a minimum of 12 months after the initial billing regarding amounts owed by the individual pursuant to subdivision (a).(3) With respect to an uninsured patient or self-pay patient, the ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section.(c) Ground ambulance service providers remain subject to balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code.SEC. 5. Section 10126.66 is added to the Insurance Code, to read:10126.66. (a) (1) Unless otherwise required by this chapter, a health insurance policy issued, amended, or renewed on or after January 1, 2024, shall require an insured who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the insured would pay for the same covered services received from a contracting ground ambulance provider. This amount shall be referred to as the in-network cost-sharing amount. (2) An insured shall not owe the noncontracting ground ambulance provider more than the in-network cost-sharing amount for services subject to this section. At the time of payment by the insurer to the noncontracting provider, the insurer shall inform the insured and the noncontracting provider of the in-network cost-sharing amount owed by the insured and shall disclose whether or not the insureds coverage is regulated by the department or if the coverage is not state-regulated.(b) (1) The in-network cost-sharing amount paid by the insured pursuant to this section shall count toward the limit on annual out-of-pocket expenses established under Section 10112.28.(2) Cost sharing arising pursuant to this section shall count toward any deductible in the same manner as cost sharing would be attributed to a contracting provider.(3) The in-network cost-sharing amount paid by the insured pursuant to this section shall satisfy the insureds obligation to pay cost sharing for the health service.(c) A noncontracting ground ambulance provider shall only advance to collections the in-network cost-sharing amount, as determined by the insurer pursuant to subdivision (a), that the insured failed to pay.(1) A noncontracting ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the insured for a minimum of 12 months after the initial billing regarding amounts owed by the insured pursuant to subdivision (a).(2) With respect to an insured, a noncontracting ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section.(d) (1) Unless otherwise agreed to by the noncontracting ground ambulance provider and the health insurer, the insurer shall directly reimburse a noncontracting ground ambulance provider for ground ambulance services the difference between the in-network cost-sharing amount and an amount described, as follows:(A) If there is a rate established or approved by a local government, at the rate established or approved by the governing body of the local government having jurisdiction for that area or subarea, including an exclusive operating area pursuant to Section 1797.85 of the Health and Safety Code.(B) If the local government having jurisdiction where the service was provided does not have an established or approved rate for that service, the reasonable and customary value for the services rendered, based upon statistically credible information that is updated at least annually and takes into consideration all of the following:(i) The ambulance providers training, qualifications, and length of time in practice.(ii) The nature of the services provided.(iii) The fees usually charged by the ambulance provider.(iv) Prevailing ground ambulance provider rates charged in the general geographic areas in which the services were rendered.(v) Other aspects of the economics of the ambulance providers practice that are relevant.(vi) Any unusual circumstances in the case.(2) A local government has jurisdiction over the ground ambulance transport if either of the following applies:(A) The ground ambulance transport is initiated within the boundaries of the local governments regulatory jurisdiction. (B) In the case of ground ambulance transports provided on a mutual or automatic aid basis into another jurisdiction, the local government where the noncontracting ground ambulance provider is based.(3) A payment made by the health insurer to the noncontracting ground ambulance provider for services as required in subdivision (a), plus the applicable cost sharing owed by the insured, shall constitute payment in full for services rendered.(4) Notwithstanding any other law, the amounts paid by a health insurer for services under this section shall not constitute the prevailing or customary charges, the usual fees to the general public, or other charges for other payers for an individual ground ambulance provider.(e) A health insurer or ground ambulance provider may seek relief in any appropriate court for the purpose of resolving a payment dispute. A ground ambulance provider may use a health insurers existing dispute resolution process under Section 10123.137.(f) This section does not affect the balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code.SEC. 6. Section 10352 of the Insurance Code is repealed.SEC. 7. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution. |
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| 14 | 28 | | |
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| 15 | 29 | | LEGISLATIVE COUNSEL'S DIGEST |
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| 16 | 30 | | |
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| 17 | 31 | | ## LEGISLATIVE COUNSEL'S DIGEST |
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| 18 | 32 | | |
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| 19 | 33 | | AB 716, Boerner. Ground medical transportation. |
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| 20 | 34 | | |
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| 21 | 35 | | Existing law creates the Emergency Medical Services Authority to coordinate various state activities concerning emergency medical services. Existing law requires the authority to report specified information, including reporting ambulance patient offload time twice per year to the Commission on Emergency Medical Services.This bill would require the authority to annually report the allowable maximum rates for ground ambulance transportation services in each county, including trending the rates by county, as specified.Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires that health care service plan contracts and health insurance policies provide coverage for certain services and treatments, including medical transportation services, and requires a policy or contract to provide for the direct reimbursement of a covered medical transportation services provider if the provider has not received payment from another source.This bill would delete that direct reimbursement requirement and would require a health care service plan contract or a health insurance policy issued, amended, or renewed on or after January 1, 2024, to require an enrollee or insured who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the enrollee or insured would pay for the same covered services received from a contracting ground ambulance provider. The bill would prohibit a noncontracting ground ambulance provider from sending to collections a higher amount, would limit the amount an enrollee or insured owes a noncontracting ground ambulance provider to no more than the in-network cost-sharing amount, and would prohibit a ground ambulance provider from billing an uninsured or self-pay patient more than the established payment by Medi-Cal or Medicare fee-for-service amount, whichever is greater. The bill would require a plan or insurer to directly reimburse a noncontracting ground ambulance provider for ground ambulance services the difference between the in-network cost-sharing amount and an amount described, as specified, unless it reaches another agreement with the noncontracting ground ambulance provider. Because a willful violation of the bills requirements relative to a health care service plan would be a crime, the bill would impose a state-mandated local program.The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.This bill would provide that no reimbursement is required by this act for a specified reason. |
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| 22 | 36 | | |
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| 23 | 37 | | Existing law creates the Emergency Medical Services Authority to coordinate various state activities concerning emergency medical services. Existing law requires the authority to report specified information, including reporting ambulance patient offload time twice per year to the Commission on Emergency Medical Services. |
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| 24 | 38 | | |
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| 25 | 39 | | This bill would require the authority to annually report the allowable maximum rates for ground ambulance transportation services in each county, including trending the rates by county, as specified. |
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| 26 | 40 | | |
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| 27 | 41 | | Existing law, the Knox-Keene Health Care Service Plan Act of 1975, provides for the licensure and regulation of health care service plans by the Department of Managed Health Care and makes a willful violation of the act a crime. Existing law also provides for the regulation of health insurers by the Department of Insurance. Existing law requires that health care service plan contracts and health insurance policies provide coverage for certain services and treatments, including medical transportation services, and requires a policy or contract to provide for the direct reimbursement of a covered medical transportation services provider if the provider has not received payment from another source. |
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| 28 | 42 | | |
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| 29 | 43 | | This bill would delete that direct reimbursement requirement and would require a health care service plan contract or a health insurance policy issued, amended, or renewed on or after January 1, 2024, to require an enrollee or insured who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the enrollee or insured would pay for the same covered services received from a contracting ground ambulance provider. The bill would prohibit a noncontracting ground ambulance provider from sending to collections a higher amount, would limit the amount an enrollee or insured owes a noncontracting ground ambulance provider to no more than the in-network cost-sharing amount, and would prohibit a ground ambulance provider from billing an uninsured or self-pay patient more than the established payment by Medi-Cal or Medicare fee-for-service amount, whichever is greater. The bill would require a plan or insurer to directly reimburse a noncontracting ground ambulance provider for ground ambulance services the difference between the in-network cost-sharing amount and an amount described, as specified, unless it reaches another agreement with the noncontracting ground ambulance provider. Because a willful violation of the bills requirements relative to a health care service plan would be a crime, the bill would impose a state-mandated local program. |
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| 30 | 44 | | |
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| 31 | 45 | | The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement. |
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| 32 | 46 | | |
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| 33 | 47 | | This bill would provide that no reimbursement is required by this act for a specified reason. |
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| 34 | 48 | | |
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| 35 | 49 | | ## Digest Key |
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| 36 | 50 | | |
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| 37 | 51 | | ## Bill Text |
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| 38 | 52 | | |
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| 39 | 53 | | The people of the State of California do enact as follows:SECTION 1. Section 1367.11 of the Health and Safety Code is repealed.SEC. 2. Section 1371.56 is added to the Health and Safety Code, to read:1371.56. (a) (1) Unless otherwise required by this chapter, a health care service plan contract issued, amended, or renewed on or after January 1, 2024, shall require an enrollee who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the enrollee would pay for the same covered services received from a contracting ground ambulance provider. This amount shall be referred to as the in-network cost-sharing amount.(2) An enrollee shall not owe the noncontracting ground ambulance provider more than the in-network cost-sharing amount for services subject to this section. At the time of payment by the plan to the noncontracting provider, the plan shall inform the enrollee and the noncontracting provider of the in-network cost-sharing amount owed by the enrollee and shall disclose whether or not the enrollees coverage is regulated by the department or if the coverage is not state-regulated.(b) (1) The in-network cost-sharing amount paid by the enrollee pursuant to this section shall count toward the limit on annual out-of-pocket expenses established under Section 1367.006.(2) Cost sharing arising pursuant to this section shall count toward any deductible in the same manner as cost sharing would be attributed to a contracting provider.(3) The in-network cost-sharing amount paid by the enrollee pursuant to this section shall satisfy the enrollees obligation to pay cost sharing for the health service.(c) A noncontracting ground ambulance provider shall only advance to collections the in-network cost-sharing amount, as determined by the plan pursuant to subdivision (a), that the enrollee failed to pay.(1) A noncontracting ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the enrollee for a minimum of 12 months after the initial billing regarding amounts owed by the enrollee pursuant to subdivision (a).(2) With respect to an enrollee, a noncontracting ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section.(d) (1) Unless otherwise agreed to by the noncontracting ground ambulance provider and the health care service plan, the plan shall directly reimburse a noncontracting ground ambulance provider for ground ambulance services the difference between the in-network cost-sharing amount and an amount described, as follows:(A) If there is a rate established or approved by a local government, at the rate established or approved by the governing body of the local government having jurisdiction for that area or subarea, including an exclusive operating area pursuant to Section 1797.85.(B) If the local government having jurisdiction where the service was provided does not have an established or approved rate for that service, the amount established by Section 1300.71 (a)(3)(B) of Title 28 of the California Code of Regulations.(2) A local government has jurisdiction over the ground ambulance transport if either of the following applies:(A) The ground ambulance transport is initiated within the boundaries of the local governments regulatory jurisdiction.(B) In the case of ground ambulance transports provided on a mutual or automatic aid basis into another jurisdiction, the local government where the noncontracting ground ambulance provider is based.(3) A payment made by the health care service plan to the noncontracting ground ambulance provider for services as required in subdivision (a), plus the applicable cost sharing owed by the enrollee, shall constitute payment in full for services rendered.(4) Notwithstanding any other law, the amounts paid by a health care service plan for services under this section shall not constitute the prevailing or customary charges, the usual fees to the general public, or other charges for other payers for an individual ground ambulance provider.(e) A health care service plan or a provider may seek relief in any appropriate court for the purpose of resolving a payment dispute. A ground ambulance provider may use a health care service plans existing dispute resolution processes.(f) Ground ambulance service providers remain subject to the balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code.(g) This section does not apply to a Medi-Cal managed health care service plan or any entity that enters into a contract with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), and Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code.SEC. 3. Section 1797.124 is added to the Health and Safety Code, to read:1797.124. (a) On or before March 1, 2024, and on or before each January 1 thereafter, the authority shall annually develop and publish on its internet website a report showing the allowable maximum rates for ground ambulance transportation services in each county, including trending the rates by county. If feasible, this report shall include the applicable Medicare rate for the year.(b) The authority shall annually submit each report to the Department of Insurance and the Department of Managed Health Care for purposes of rate review, as well as to the Office of Health Care Affordability.SEC. 4. Section 1797.233 is added to the Health and Safety Code, to read:1797.233. (a) A ground ambulance provider shall not require an uninsured patient or self-pay patient to pay an amount more than the established payment by Medi-Cal or Medicare fee-for-service amount, whichever is greater.(b) (1) A ground ambulance provider shall only advance to collections the Medicare or Medi-Cal payment amount, as determined pursuant to subdivision (a), that the uninsured or self-pay patient failed to pay.(2) The ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the individual for a minimum of 12 months after the initial billing regarding amounts owed by the individual pursuant to subdivision (a).(3) With respect to an uninsured patient or self-pay patient, the ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section.(c) Ground ambulance service providers remain subject to balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code.SEC. 5. Section 10126.66 is added to the Insurance Code, to read:10126.66. (a) (1) Unless otherwise required by this chapter, a health insurance policy issued, amended, or renewed on or after January 1, 2024, shall require an insured who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the insured would pay for the same covered services received from a contracting ground ambulance provider. This amount shall be referred to as the in-network cost-sharing amount. (2) An insured shall not owe the noncontracting ground ambulance provider more than the in-network cost-sharing amount for services subject to this section. At the time of payment by the insurer to the noncontracting provider, the insurer shall inform the insured and the noncontracting provider of the in-network cost-sharing amount owed by the insured and shall disclose whether or not the insureds coverage is regulated by the department or if the coverage is not state-regulated.(b) (1) The in-network cost-sharing amount paid by the insured pursuant to this section shall count toward the limit on annual out-of-pocket expenses established under Section 10112.28.(2) Cost sharing arising pursuant to this section shall count toward any deductible in the same manner as cost sharing would be attributed to a contracting provider.(3) The in-network cost-sharing amount paid by the insured pursuant to this section shall satisfy the insureds obligation to pay cost sharing for the health service.(c) A noncontracting ground ambulance provider shall only advance to collections the in-network cost-sharing amount, as determined by the insurer pursuant to subdivision (a), that the insured failed to pay.(1) A noncontracting ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the insured for a minimum of 12 months after the initial billing regarding amounts owed by the insured pursuant to subdivision (a).(2) With respect to an insured, a noncontracting ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section.(d) (1) Unless otherwise agreed to by the noncontracting ground ambulance provider and the health insurer, the insurer shall directly reimburse a noncontracting ground ambulance provider for ground ambulance services the difference between the in-network cost-sharing amount and an amount described, as follows:(A) If there is a rate established or approved by a local government, at the rate established or approved by the governing body of the local government having jurisdiction for that area or subarea, including an exclusive operating area pursuant to Section 1797.85 of the Health and Safety Code.(B) If the local government having jurisdiction where the service was provided does not have an established or approved rate for that service, the reasonable and customary value for the services rendered, based upon statistically credible information that is updated at least annually and takes into consideration all of the following:(i) The ambulance providers training, qualifications, and length of time in practice.(ii) The nature of the services provided.(iii) The fees usually charged by the ambulance provider.(iv) Prevailing ground ambulance provider rates charged in the general geographic areas in which the services were rendered.(v) Other aspects of the economics of the ambulance providers practice that are relevant.(vi) Any unusual circumstances in the case.(2) A local government has jurisdiction over the ground ambulance transport if either of the following applies:(A) The ground ambulance transport is initiated within the boundaries of the local governments regulatory jurisdiction. (B) In the case of ground ambulance transports provided on a mutual or automatic aid basis into another jurisdiction, the local government where the noncontracting ground ambulance provider is based.(3) A payment made by the health insurer to the noncontracting ground ambulance provider for services as required in subdivision (a), plus the applicable cost sharing owed by the insured, shall constitute payment in full for services rendered.(4) Notwithstanding any other law, the amounts paid by a health insurer for services under this section shall not constitute the prevailing or customary charges, the usual fees to the general public, or other charges for other payers for an individual ground ambulance provider.(e) A health insurer or ground ambulance provider may seek relief in any appropriate court for the purpose of resolving a payment dispute. A ground ambulance provider may use a health insurers existing dispute resolution process under Section 10123.137.(f) This section does not affect the balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code.SEC. 6. Section 10352 of the Insurance Code is repealed.SEC. 7. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution. |
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| 40 | 54 | | |
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| 41 | 55 | | The people of the State of California do enact as follows: |
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| 42 | 56 | | |
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| 43 | 57 | | ## The people of the State of California do enact as follows: |
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| 44 | 58 | | |
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| 45 | 59 | | SECTION 1. Section 1367.11 of the Health and Safety Code is repealed. |
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| 46 | 60 | | |
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| 47 | 61 | | SECTION 1. Section 1367.11 of the Health and Safety Code is repealed. |
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| 48 | 62 | | |
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| 49 | 63 | | ### SECTION 1. |
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| 50 | 64 | | |
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| 51 | 65 | | |
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| 52 | 66 | | |
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| 53 | 67 | | SEC. 2. Section 1371.56 is added to the Health and Safety Code, to read:1371.56. (a) (1) Unless otherwise required by this chapter, a health care service plan contract issued, amended, or renewed on or after January 1, 2024, shall require an enrollee who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the enrollee would pay for the same covered services received from a contracting ground ambulance provider. This amount shall be referred to as the in-network cost-sharing amount.(2) An enrollee shall not owe the noncontracting ground ambulance provider more than the in-network cost-sharing amount for services subject to this section. At the time of payment by the plan to the noncontracting provider, the plan shall inform the enrollee and the noncontracting provider of the in-network cost-sharing amount owed by the enrollee and shall disclose whether or not the enrollees coverage is regulated by the department or if the coverage is not state-regulated.(b) (1) The in-network cost-sharing amount paid by the enrollee pursuant to this section shall count toward the limit on annual out-of-pocket expenses established under Section 1367.006.(2) Cost sharing arising pursuant to this section shall count toward any deductible in the same manner as cost sharing would be attributed to a contracting provider.(3) The in-network cost-sharing amount paid by the enrollee pursuant to this section shall satisfy the enrollees obligation to pay cost sharing for the health service.(c) A noncontracting ground ambulance provider shall only advance to collections the in-network cost-sharing amount, as determined by the plan pursuant to subdivision (a), that the enrollee failed to pay.(1) A noncontracting ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the enrollee for a minimum of 12 months after the initial billing regarding amounts owed by the enrollee pursuant to subdivision (a).(2) With respect to an enrollee, a noncontracting ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section.(d) (1) Unless otherwise agreed to by the noncontracting ground ambulance provider and the health care service plan, the plan shall directly reimburse a noncontracting ground ambulance provider for ground ambulance services the difference between the in-network cost-sharing amount and an amount described, as follows:(A) If there is a rate established or approved by a local government, at the rate established or approved by the governing body of the local government having jurisdiction for that area or subarea, including an exclusive operating area pursuant to Section 1797.85.(B) If the local government having jurisdiction where the service was provided does not have an established or approved rate for that service, the amount established by Section 1300.71 (a)(3)(B) of Title 28 of the California Code of Regulations.(2) A local government has jurisdiction over the ground ambulance transport if either of the following applies:(A) The ground ambulance transport is initiated within the boundaries of the local governments regulatory jurisdiction.(B) In the case of ground ambulance transports provided on a mutual or automatic aid basis into another jurisdiction, the local government where the noncontracting ground ambulance provider is based.(3) A payment made by the health care service plan to the noncontracting ground ambulance provider for services as required in subdivision (a), plus the applicable cost sharing owed by the enrollee, shall constitute payment in full for services rendered.(4) Notwithstanding any other law, the amounts paid by a health care service plan for services under this section shall not constitute the prevailing or customary charges, the usual fees to the general public, or other charges for other payers for an individual ground ambulance provider.(e) A health care service plan or a provider may seek relief in any appropriate court for the purpose of resolving a payment dispute. A ground ambulance provider may use a health care service plans existing dispute resolution processes.(f) Ground ambulance service providers remain subject to the balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code.(g) This section does not apply to a Medi-Cal managed health care service plan or any entity that enters into a contract with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), and Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code. |
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| 54 | 68 | | |
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| 55 | 69 | | SEC. 2. Section 1371.56 is added to the Health and Safety Code, to read: |
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| 56 | 70 | | |
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| 57 | 71 | | ### SEC. 2. |
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| 58 | 72 | | |
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| 59 | 73 | | 1371.56. (a) (1) Unless otherwise required by this chapter, a health care service plan contract issued, amended, or renewed on or after January 1, 2024, shall require an enrollee who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the enrollee would pay for the same covered services received from a contracting ground ambulance provider. This amount shall be referred to as the in-network cost-sharing amount.(2) An enrollee shall not owe the noncontracting ground ambulance provider more than the in-network cost-sharing amount for services subject to this section. At the time of payment by the plan to the noncontracting provider, the plan shall inform the enrollee and the noncontracting provider of the in-network cost-sharing amount owed by the enrollee and shall disclose whether or not the enrollees coverage is regulated by the department or if the coverage is not state-regulated.(b) (1) The in-network cost-sharing amount paid by the enrollee pursuant to this section shall count toward the limit on annual out-of-pocket expenses established under Section 1367.006.(2) Cost sharing arising pursuant to this section shall count toward any deductible in the same manner as cost sharing would be attributed to a contracting provider.(3) The in-network cost-sharing amount paid by the enrollee pursuant to this section shall satisfy the enrollees obligation to pay cost sharing for the health service.(c) A noncontracting ground ambulance provider shall only advance to collections the in-network cost-sharing amount, as determined by the plan pursuant to subdivision (a), that the enrollee failed to pay.(1) A noncontracting ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the enrollee for a minimum of 12 months after the initial billing regarding amounts owed by the enrollee pursuant to subdivision (a).(2) With respect to an enrollee, a noncontracting ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section.(d) (1) Unless otherwise agreed to by the noncontracting ground ambulance provider and the health care service plan, the plan shall directly reimburse a noncontracting ground ambulance provider for ground ambulance services the difference between the in-network cost-sharing amount and an amount described, as follows:(A) If there is a rate established or approved by a local government, at the rate established or approved by the governing body of the local government having jurisdiction for that area or subarea, including an exclusive operating area pursuant to Section 1797.85.(B) If the local government having jurisdiction where the service was provided does not have an established or approved rate for that service, the amount established by Section 1300.71 (a)(3)(B) of Title 28 of the California Code of Regulations.(2) A local government has jurisdiction over the ground ambulance transport if either of the following applies:(A) The ground ambulance transport is initiated within the boundaries of the local governments regulatory jurisdiction.(B) In the case of ground ambulance transports provided on a mutual or automatic aid basis into another jurisdiction, the local government where the noncontracting ground ambulance provider is based.(3) A payment made by the health care service plan to the noncontracting ground ambulance provider for services as required in subdivision (a), plus the applicable cost sharing owed by the enrollee, shall constitute payment in full for services rendered.(4) Notwithstanding any other law, the amounts paid by a health care service plan for services under this section shall not constitute the prevailing or customary charges, the usual fees to the general public, or other charges for other payers for an individual ground ambulance provider.(e) A health care service plan or a provider may seek relief in any appropriate court for the purpose of resolving a payment dispute. A ground ambulance provider may use a health care service plans existing dispute resolution processes.(f) Ground ambulance service providers remain subject to the balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code.(g) This section does not apply to a Medi-Cal managed health care service plan or any entity that enters into a contract with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), and Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code. |
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| 60 | 74 | | |
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| 61 | 75 | | 1371.56. (a) (1) Unless otherwise required by this chapter, a health care service plan contract issued, amended, or renewed on or after January 1, 2024, shall require an enrollee who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the enrollee would pay for the same covered services received from a contracting ground ambulance provider. This amount shall be referred to as the in-network cost-sharing amount.(2) An enrollee shall not owe the noncontracting ground ambulance provider more than the in-network cost-sharing amount for services subject to this section. At the time of payment by the plan to the noncontracting provider, the plan shall inform the enrollee and the noncontracting provider of the in-network cost-sharing amount owed by the enrollee and shall disclose whether or not the enrollees coverage is regulated by the department or if the coverage is not state-regulated.(b) (1) The in-network cost-sharing amount paid by the enrollee pursuant to this section shall count toward the limit on annual out-of-pocket expenses established under Section 1367.006.(2) Cost sharing arising pursuant to this section shall count toward any deductible in the same manner as cost sharing would be attributed to a contracting provider.(3) The in-network cost-sharing amount paid by the enrollee pursuant to this section shall satisfy the enrollees obligation to pay cost sharing for the health service.(c) A noncontracting ground ambulance provider shall only advance to collections the in-network cost-sharing amount, as determined by the plan pursuant to subdivision (a), that the enrollee failed to pay.(1) A noncontracting ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the enrollee for a minimum of 12 months after the initial billing regarding amounts owed by the enrollee pursuant to subdivision (a).(2) With respect to an enrollee, a noncontracting ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section.(d) (1) Unless otherwise agreed to by the noncontracting ground ambulance provider and the health care service plan, the plan shall directly reimburse a noncontracting ground ambulance provider for ground ambulance services the difference between the in-network cost-sharing amount and an amount described, as follows:(A) If there is a rate established or approved by a local government, at the rate established or approved by the governing body of the local government having jurisdiction for that area or subarea, including an exclusive operating area pursuant to Section 1797.85.(B) If the local government having jurisdiction where the service was provided does not have an established or approved rate for that service, the amount established by Section 1300.71 (a)(3)(B) of Title 28 of the California Code of Regulations.(2) A local government has jurisdiction over the ground ambulance transport if either of the following applies:(A) The ground ambulance transport is initiated within the boundaries of the local governments regulatory jurisdiction.(B) In the case of ground ambulance transports provided on a mutual or automatic aid basis into another jurisdiction, the local government where the noncontracting ground ambulance provider is based.(3) A payment made by the health care service plan to the noncontracting ground ambulance provider for services as required in subdivision (a), plus the applicable cost sharing owed by the enrollee, shall constitute payment in full for services rendered.(4) Notwithstanding any other law, the amounts paid by a health care service plan for services under this section shall not constitute the prevailing or customary charges, the usual fees to the general public, or other charges for other payers for an individual ground ambulance provider.(e) A health care service plan or a provider may seek relief in any appropriate court for the purpose of resolving a payment dispute. A ground ambulance provider may use a health care service plans existing dispute resolution processes.(f) Ground ambulance service providers remain subject to the balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code.(g) This section does not apply to a Medi-Cal managed health care service plan or any entity that enters into a contract with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), and Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code. |
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| 62 | 76 | | |
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| 63 | 77 | | 1371.56. (a) (1) Unless otherwise required by this chapter, a health care service plan contract issued, amended, or renewed on or after January 1, 2024, shall require an enrollee who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the enrollee would pay for the same covered services received from a contracting ground ambulance provider. This amount shall be referred to as the in-network cost-sharing amount.(2) An enrollee shall not owe the noncontracting ground ambulance provider more than the in-network cost-sharing amount for services subject to this section. At the time of payment by the plan to the noncontracting provider, the plan shall inform the enrollee and the noncontracting provider of the in-network cost-sharing amount owed by the enrollee and shall disclose whether or not the enrollees coverage is regulated by the department or if the coverage is not state-regulated.(b) (1) The in-network cost-sharing amount paid by the enrollee pursuant to this section shall count toward the limit on annual out-of-pocket expenses established under Section 1367.006.(2) Cost sharing arising pursuant to this section shall count toward any deductible in the same manner as cost sharing would be attributed to a contracting provider.(3) The in-network cost-sharing amount paid by the enrollee pursuant to this section shall satisfy the enrollees obligation to pay cost sharing for the health service.(c) A noncontracting ground ambulance provider shall only advance to collections the in-network cost-sharing amount, as determined by the plan pursuant to subdivision (a), that the enrollee failed to pay.(1) A noncontracting ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the enrollee for a minimum of 12 months after the initial billing regarding amounts owed by the enrollee pursuant to subdivision (a).(2) With respect to an enrollee, a noncontracting ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section.(d) (1) Unless otherwise agreed to by the noncontracting ground ambulance provider and the health care service plan, the plan shall directly reimburse a noncontracting ground ambulance provider for ground ambulance services the difference between the in-network cost-sharing amount and an amount described, as follows:(A) If there is a rate established or approved by a local government, at the rate established or approved by the governing body of the local government having jurisdiction for that area or subarea, including an exclusive operating area pursuant to Section 1797.85.(B) If the local government having jurisdiction where the service was provided does not have an established or approved rate for that service, the amount established by Section 1300.71 (a)(3)(B) of Title 28 of the California Code of Regulations.(2) A local government has jurisdiction over the ground ambulance transport if either of the following applies:(A) The ground ambulance transport is initiated within the boundaries of the local governments regulatory jurisdiction.(B) In the case of ground ambulance transports provided on a mutual or automatic aid basis into another jurisdiction, the local government where the noncontracting ground ambulance provider is based.(3) A payment made by the health care service plan to the noncontracting ground ambulance provider for services as required in subdivision (a), plus the applicable cost sharing owed by the enrollee, shall constitute payment in full for services rendered.(4) Notwithstanding any other law, the amounts paid by a health care service plan for services under this section shall not constitute the prevailing or customary charges, the usual fees to the general public, or other charges for other payers for an individual ground ambulance provider.(e) A health care service plan or a provider may seek relief in any appropriate court for the purpose of resolving a payment dispute. A ground ambulance provider may use a health care service plans existing dispute resolution processes.(f) Ground ambulance service providers remain subject to the balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code.(g) This section does not apply to a Medi-Cal managed health care service plan or any entity that enters into a contract with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), and Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code. |
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| 64 | 78 | | |
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| 65 | 79 | | |
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| 66 | 80 | | |
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| 67 | 81 | | 1371.56. (a) (1) Unless otherwise required by this chapter, a health care service plan contract issued, amended, or renewed on or after January 1, 2024, shall require an enrollee who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the enrollee would pay for the same covered services received from a contracting ground ambulance provider. This amount shall be referred to as the in-network cost-sharing amount. |
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| 68 | 82 | | |
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| 69 | 83 | | (2) An enrollee shall not owe the noncontracting ground ambulance provider more than the in-network cost-sharing amount for services subject to this section. At the time of payment by the plan to the noncontracting provider, the plan shall inform the enrollee and the noncontracting provider of the in-network cost-sharing amount owed by the enrollee and shall disclose whether or not the enrollees coverage is regulated by the department or if the coverage is not state-regulated. |
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| 70 | 84 | | |
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| 71 | 85 | | (b) (1) The in-network cost-sharing amount paid by the enrollee pursuant to this section shall count toward the limit on annual out-of-pocket expenses established under Section 1367.006. |
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| 72 | 86 | | |
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| 73 | 87 | | (2) Cost sharing arising pursuant to this section shall count toward any deductible in the same manner as cost sharing would be attributed to a contracting provider. |
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| 74 | 88 | | |
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| 75 | 89 | | (3) The in-network cost-sharing amount paid by the enrollee pursuant to this section shall satisfy the enrollees obligation to pay cost sharing for the health service. |
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| 76 | 90 | | |
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| 77 | 91 | | (c) A noncontracting ground ambulance provider shall only advance to collections the in-network cost-sharing amount, as determined by the plan pursuant to subdivision (a), that the enrollee failed to pay. |
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| 78 | 92 | | |
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| 79 | 93 | | (1) A noncontracting ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the enrollee for a minimum of 12 months after the initial billing regarding amounts owed by the enrollee pursuant to subdivision (a). |
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| 80 | 94 | | |
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| 81 | 95 | | (2) With respect to an enrollee, a noncontracting ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section. |
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| 82 | 96 | | |
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| 83 | 97 | | (d) (1) Unless otherwise agreed to by the noncontracting ground ambulance provider and the health care service plan, the plan shall directly reimburse a noncontracting ground ambulance provider for ground ambulance services the difference between the in-network cost-sharing amount and an amount described, as follows: |
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| 84 | 98 | | |
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| 85 | 99 | | (A) If there is a rate established or approved by a local government, at the rate established or approved by the governing body of the local government having jurisdiction for that area or subarea, including an exclusive operating area pursuant to Section 1797.85. |
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| 86 | 100 | | |
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| 87 | 101 | | (B) If the local government having jurisdiction where the service was provided does not have an established or approved rate for that service, the amount established by Section 1300.71 (a)(3)(B) of Title 28 of the California Code of Regulations. |
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| 88 | 102 | | |
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| 89 | 103 | | (2) A local government has jurisdiction over the ground ambulance transport if either of the following applies: |
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| 90 | 104 | | |
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| 91 | 105 | | (A) The ground ambulance transport is initiated within the boundaries of the local governments regulatory jurisdiction. |
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| 92 | 106 | | |
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| 93 | 107 | | (B) In the case of ground ambulance transports provided on a mutual or automatic aid basis into another jurisdiction, the local government where the noncontracting ground ambulance provider is based. |
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| 94 | 108 | | |
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| 95 | 109 | | (3) A payment made by the health care service plan to the noncontracting ground ambulance provider for services as required in subdivision (a), plus the applicable cost sharing owed by the enrollee, shall constitute payment in full for services rendered. |
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| 96 | 110 | | |
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| 97 | 111 | | (4) Notwithstanding any other law, the amounts paid by a health care service plan for services under this section shall not constitute the prevailing or customary charges, the usual fees to the general public, or other charges for other payers for an individual ground ambulance provider. |
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| 98 | 112 | | |
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| 99 | 113 | | (e) A health care service plan or a provider may seek relief in any appropriate court for the purpose of resolving a payment dispute. A ground ambulance provider may use a health care service plans existing dispute resolution processes. |
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| 100 | 114 | | |
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| 101 | 115 | | (f) Ground ambulance service providers remain subject to the balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code. |
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| 102 | 116 | | |
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| 103 | 117 | | (g) This section does not apply to a Medi-Cal managed health care service plan or any entity that enters into a contract with the State Department of Health Care Services pursuant to Chapter 7 (commencing with Section 14000), Chapter 8 (commencing with Section 14200), and Chapter 8.75 (commencing with Section 14591) of Part 3 of Division 9 of the Welfare and Institutions Code. |
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| 104 | 118 | | |
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| 105 | 119 | | SEC. 3. Section 1797.124 is added to the Health and Safety Code, to read:1797.124. (a) On or before March 1, 2024, and on or before each January 1 thereafter, the authority shall annually develop and publish on its internet website a report showing the allowable maximum rates for ground ambulance transportation services in each county, including trending the rates by county. If feasible, this report shall include the applicable Medicare rate for the year.(b) The authority shall annually submit each report to the Department of Insurance and the Department of Managed Health Care for purposes of rate review, as well as to the Office of Health Care Affordability. |
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| 106 | 120 | | |
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| 107 | 121 | | SEC. 3. Section 1797.124 is added to the Health and Safety Code, to read: |
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| 108 | 122 | | |
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| 109 | 123 | | ### SEC. 3. |
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| 110 | 124 | | |
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| 111 | 125 | | 1797.124. (a) On or before March 1, 2024, and on or before each January 1 thereafter, the authority shall annually develop and publish on its internet website a report showing the allowable maximum rates for ground ambulance transportation services in each county, including trending the rates by county. If feasible, this report shall include the applicable Medicare rate for the year.(b) The authority shall annually submit each report to the Department of Insurance and the Department of Managed Health Care for purposes of rate review, as well as to the Office of Health Care Affordability. |
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| 112 | 126 | | |
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| 113 | 127 | | 1797.124. (a) On or before March 1, 2024, and on or before each January 1 thereafter, the authority shall annually develop and publish on its internet website a report showing the allowable maximum rates for ground ambulance transportation services in each county, including trending the rates by county. If feasible, this report shall include the applicable Medicare rate for the year.(b) The authority shall annually submit each report to the Department of Insurance and the Department of Managed Health Care for purposes of rate review, as well as to the Office of Health Care Affordability. |
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| 114 | 128 | | |
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| 115 | 129 | | 1797.124. (a) On or before March 1, 2024, and on or before each January 1 thereafter, the authority shall annually develop and publish on its internet website a report showing the allowable maximum rates for ground ambulance transportation services in each county, including trending the rates by county. If feasible, this report shall include the applicable Medicare rate for the year.(b) The authority shall annually submit each report to the Department of Insurance and the Department of Managed Health Care for purposes of rate review, as well as to the Office of Health Care Affordability. |
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| 116 | 130 | | |
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| 117 | 131 | | |
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| 118 | 132 | | |
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| 119 | 133 | | 1797.124. (a) On or before March 1, 2024, and on or before each January 1 thereafter, the authority shall annually develop and publish on its internet website a report showing the allowable maximum rates for ground ambulance transportation services in each county, including trending the rates by county. If feasible, this report shall include the applicable Medicare rate for the year. |
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| 120 | 134 | | |
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| 121 | 135 | | (b) The authority shall annually submit each report to the Department of Insurance and the Department of Managed Health Care for purposes of rate review, as well as to the Office of Health Care Affordability. |
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| 122 | 136 | | |
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| 123 | 137 | | SEC. 4. Section 1797.233 is added to the Health and Safety Code, to read:1797.233. (a) A ground ambulance provider shall not require an uninsured patient or self-pay patient to pay an amount more than the established payment by Medi-Cal or Medicare fee-for-service amount, whichever is greater.(b) (1) A ground ambulance provider shall only advance to collections the Medicare or Medi-Cal payment amount, as determined pursuant to subdivision (a), that the uninsured or self-pay patient failed to pay.(2) The ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the individual for a minimum of 12 months after the initial billing regarding amounts owed by the individual pursuant to subdivision (a).(3) With respect to an uninsured patient or self-pay patient, the ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section.(c) Ground ambulance service providers remain subject to balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code. |
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| 124 | 138 | | |
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| 125 | 139 | | SEC. 4. Section 1797.233 is added to the Health and Safety Code, to read: |
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| 126 | 140 | | |
|---|
| 127 | 141 | | ### SEC. 4. |
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| 128 | 142 | | |
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| 129 | 143 | | 1797.233. (a) A ground ambulance provider shall not require an uninsured patient or self-pay patient to pay an amount more than the established payment by Medi-Cal or Medicare fee-for-service amount, whichever is greater.(b) (1) A ground ambulance provider shall only advance to collections the Medicare or Medi-Cal payment amount, as determined pursuant to subdivision (a), that the uninsured or self-pay patient failed to pay.(2) The ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the individual for a minimum of 12 months after the initial billing regarding amounts owed by the individual pursuant to subdivision (a).(3) With respect to an uninsured patient or self-pay patient, the ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section.(c) Ground ambulance service providers remain subject to balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code. |
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| 130 | 144 | | |
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| 131 | 145 | | 1797.233. (a) A ground ambulance provider shall not require an uninsured patient or self-pay patient to pay an amount more than the established payment by Medi-Cal or Medicare fee-for-service amount, whichever is greater.(b) (1) A ground ambulance provider shall only advance to collections the Medicare or Medi-Cal payment amount, as determined pursuant to subdivision (a), that the uninsured or self-pay patient failed to pay.(2) The ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the individual for a minimum of 12 months after the initial billing regarding amounts owed by the individual pursuant to subdivision (a).(3) With respect to an uninsured patient or self-pay patient, the ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section.(c) Ground ambulance service providers remain subject to balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code. |
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| 132 | 146 | | |
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| 133 | 147 | | 1797.233. (a) A ground ambulance provider shall not require an uninsured patient or self-pay patient to pay an amount more than the established payment by Medi-Cal or Medicare fee-for-service amount, whichever is greater.(b) (1) A ground ambulance provider shall only advance to collections the Medicare or Medi-Cal payment amount, as determined pursuant to subdivision (a), that the uninsured or self-pay patient failed to pay.(2) The ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the individual for a minimum of 12 months after the initial billing regarding amounts owed by the individual pursuant to subdivision (a).(3) With respect to an uninsured patient or self-pay patient, the ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section.(c) Ground ambulance service providers remain subject to balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code. |
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| 134 | 148 | | |
|---|
| 135 | 149 | | |
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| 136 | 150 | | |
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| 137 | 151 | | 1797.233. (a) A ground ambulance provider shall not require an uninsured patient or self-pay patient to pay an amount more than the established payment by Medi-Cal or Medicare fee-for-service amount, whichever is greater. |
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| 138 | 152 | | |
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| 139 | 153 | | (b) (1) A ground ambulance provider shall only advance to collections the Medicare or Medi-Cal payment amount, as determined pursuant to subdivision (a), that the uninsured or self-pay patient failed to pay. |
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| 140 | 154 | | |
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| 141 | 155 | | (2) The ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the individual for a minimum of 12 months after the initial billing regarding amounts owed by the individual pursuant to subdivision (a). |
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| 142 | 156 | | |
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| 143 | 157 | | (3) With respect to an uninsured patient or self-pay patient, the ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section. |
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| 144 | 158 | | |
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| 145 | 159 | | (c) Ground ambulance service providers remain subject to balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code. |
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| 146 | 160 | | |
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| 147 | 161 | | SEC. 5. Section 10126.66 is added to the Insurance Code, to read:10126.66. (a) (1) Unless otherwise required by this chapter, a health insurance policy issued, amended, or renewed on or after January 1, 2024, shall require an insured who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the insured would pay for the same covered services received from a contracting ground ambulance provider. This amount shall be referred to as the in-network cost-sharing amount. (2) An insured shall not owe the noncontracting ground ambulance provider more than the in-network cost-sharing amount for services subject to this section. At the time of payment by the insurer to the noncontracting provider, the insurer shall inform the insured and the noncontracting provider of the in-network cost-sharing amount owed by the insured and shall disclose whether or not the insureds coverage is regulated by the department or if the coverage is not state-regulated.(b) (1) The in-network cost-sharing amount paid by the insured pursuant to this section shall count toward the limit on annual out-of-pocket expenses established under Section 10112.28.(2) Cost sharing arising pursuant to this section shall count toward any deductible in the same manner as cost sharing would be attributed to a contracting provider.(3) The in-network cost-sharing amount paid by the insured pursuant to this section shall satisfy the insureds obligation to pay cost sharing for the health service.(c) A noncontracting ground ambulance provider shall only advance to collections the in-network cost-sharing amount, as determined by the insurer pursuant to subdivision (a), that the insured failed to pay.(1) A noncontracting ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the insured for a minimum of 12 months after the initial billing regarding amounts owed by the insured pursuant to subdivision (a).(2) With respect to an insured, a noncontracting ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section.(d) (1) Unless otherwise agreed to by the noncontracting ground ambulance provider and the health insurer, the insurer shall directly reimburse a noncontracting ground ambulance provider for ground ambulance services the difference between the in-network cost-sharing amount and an amount described, as follows:(A) If there is a rate established or approved by a local government, at the rate established or approved by the governing body of the local government having jurisdiction for that area or subarea, including an exclusive operating area pursuant to Section 1797.85 of the Health and Safety Code.(B) If the local government having jurisdiction where the service was provided does not have an established or approved rate for that service, the reasonable and customary value for the services rendered, based upon statistically credible information that is updated at least annually and takes into consideration all of the following:(i) The ambulance providers training, qualifications, and length of time in practice.(ii) The nature of the services provided.(iii) The fees usually charged by the ambulance provider.(iv) Prevailing ground ambulance provider rates charged in the general geographic areas in which the services were rendered.(v) Other aspects of the economics of the ambulance providers practice that are relevant.(vi) Any unusual circumstances in the case.(2) A local government has jurisdiction over the ground ambulance transport if either of the following applies:(A) The ground ambulance transport is initiated within the boundaries of the local governments regulatory jurisdiction. (B) In the case of ground ambulance transports provided on a mutual or automatic aid basis into another jurisdiction, the local government where the noncontracting ground ambulance provider is based.(3) A payment made by the health insurer to the noncontracting ground ambulance provider for services as required in subdivision (a), plus the applicable cost sharing owed by the insured, shall constitute payment in full for services rendered.(4) Notwithstanding any other law, the amounts paid by a health insurer for services under this section shall not constitute the prevailing or customary charges, the usual fees to the general public, or other charges for other payers for an individual ground ambulance provider.(e) A health insurer or ground ambulance provider may seek relief in any appropriate court for the purpose of resolving a payment dispute. A ground ambulance provider may use a health insurers existing dispute resolution process under Section 10123.137.(f) This section does not affect the balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code. |
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| 148 | 162 | | |
|---|
| 149 | 163 | | SEC. 5. Section 10126.66 is added to the Insurance Code, to read: |
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| 150 | 164 | | |
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| 151 | 165 | | ### SEC. 5. |
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| 152 | 166 | | |
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| 153 | 167 | | 10126.66. (a) (1) Unless otherwise required by this chapter, a health insurance policy issued, amended, or renewed on or after January 1, 2024, shall require an insured who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the insured would pay for the same covered services received from a contracting ground ambulance provider. This amount shall be referred to as the in-network cost-sharing amount. (2) An insured shall not owe the noncontracting ground ambulance provider more than the in-network cost-sharing amount for services subject to this section. At the time of payment by the insurer to the noncontracting provider, the insurer shall inform the insured and the noncontracting provider of the in-network cost-sharing amount owed by the insured and shall disclose whether or not the insureds coverage is regulated by the department or if the coverage is not state-regulated.(b) (1) The in-network cost-sharing amount paid by the insured pursuant to this section shall count toward the limit on annual out-of-pocket expenses established under Section 10112.28.(2) Cost sharing arising pursuant to this section shall count toward any deductible in the same manner as cost sharing would be attributed to a contracting provider.(3) The in-network cost-sharing amount paid by the insured pursuant to this section shall satisfy the insureds obligation to pay cost sharing for the health service.(c) A noncontracting ground ambulance provider shall only advance to collections the in-network cost-sharing amount, as determined by the insurer pursuant to subdivision (a), that the insured failed to pay.(1) A noncontracting ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the insured for a minimum of 12 months after the initial billing regarding amounts owed by the insured pursuant to subdivision (a).(2) With respect to an insured, a noncontracting ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section.(d) (1) Unless otherwise agreed to by the noncontracting ground ambulance provider and the health insurer, the insurer shall directly reimburse a noncontracting ground ambulance provider for ground ambulance services the difference between the in-network cost-sharing amount and an amount described, as follows:(A) If there is a rate established or approved by a local government, at the rate established or approved by the governing body of the local government having jurisdiction for that area or subarea, including an exclusive operating area pursuant to Section 1797.85 of the Health and Safety Code.(B) If the local government having jurisdiction where the service was provided does not have an established or approved rate for that service, the reasonable and customary value for the services rendered, based upon statistically credible information that is updated at least annually and takes into consideration all of the following:(i) The ambulance providers training, qualifications, and length of time in practice.(ii) The nature of the services provided.(iii) The fees usually charged by the ambulance provider.(iv) Prevailing ground ambulance provider rates charged in the general geographic areas in which the services were rendered.(v) Other aspects of the economics of the ambulance providers practice that are relevant.(vi) Any unusual circumstances in the case.(2) A local government has jurisdiction over the ground ambulance transport if either of the following applies:(A) The ground ambulance transport is initiated within the boundaries of the local governments regulatory jurisdiction. (B) In the case of ground ambulance transports provided on a mutual or automatic aid basis into another jurisdiction, the local government where the noncontracting ground ambulance provider is based.(3) A payment made by the health insurer to the noncontracting ground ambulance provider for services as required in subdivision (a), plus the applicable cost sharing owed by the insured, shall constitute payment in full for services rendered.(4) Notwithstanding any other law, the amounts paid by a health insurer for services under this section shall not constitute the prevailing or customary charges, the usual fees to the general public, or other charges for other payers for an individual ground ambulance provider.(e) A health insurer or ground ambulance provider may seek relief in any appropriate court for the purpose of resolving a payment dispute. A ground ambulance provider may use a health insurers existing dispute resolution process under Section 10123.137.(f) This section does not affect the balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code. |
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| 154 | 168 | | |
|---|
| 155 | 169 | | 10126.66. (a) (1) Unless otherwise required by this chapter, a health insurance policy issued, amended, or renewed on or after January 1, 2024, shall require an insured who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the insured would pay for the same covered services received from a contracting ground ambulance provider. This amount shall be referred to as the in-network cost-sharing amount. (2) An insured shall not owe the noncontracting ground ambulance provider more than the in-network cost-sharing amount for services subject to this section. At the time of payment by the insurer to the noncontracting provider, the insurer shall inform the insured and the noncontracting provider of the in-network cost-sharing amount owed by the insured and shall disclose whether or not the insureds coverage is regulated by the department or if the coverage is not state-regulated.(b) (1) The in-network cost-sharing amount paid by the insured pursuant to this section shall count toward the limit on annual out-of-pocket expenses established under Section 10112.28.(2) Cost sharing arising pursuant to this section shall count toward any deductible in the same manner as cost sharing would be attributed to a contracting provider.(3) The in-network cost-sharing amount paid by the insured pursuant to this section shall satisfy the insureds obligation to pay cost sharing for the health service.(c) A noncontracting ground ambulance provider shall only advance to collections the in-network cost-sharing amount, as determined by the insurer pursuant to subdivision (a), that the insured failed to pay.(1) A noncontracting ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the insured for a minimum of 12 months after the initial billing regarding amounts owed by the insured pursuant to subdivision (a).(2) With respect to an insured, a noncontracting ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section.(d) (1) Unless otherwise agreed to by the noncontracting ground ambulance provider and the health insurer, the insurer shall directly reimburse a noncontracting ground ambulance provider for ground ambulance services the difference between the in-network cost-sharing amount and an amount described, as follows:(A) If there is a rate established or approved by a local government, at the rate established or approved by the governing body of the local government having jurisdiction for that area or subarea, including an exclusive operating area pursuant to Section 1797.85 of the Health and Safety Code.(B) If the local government having jurisdiction where the service was provided does not have an established or approved rate for that service, the reasonable and customary value for the services rendered, based upon statistically credible information that is updated at least annually and takes into consideration all of the following:(i) The ambulance providers training, qualifications, and length of time in practice.(ii) The nature of the services provided.(iii) The fees usually charged by the ambulance provider.(iv) Prevailing ground ambulance provider rates charged in the general geographic areas in which the services were rendered.(v) Other aspects of the economics of the ambulance providers practice that are relevant.(vi) Any unusual circumstances in the case.(2) A local government has jurisdiction over the ground ambulance transport if either of the following applies:(A) The ground ambulance transport is initiated within the boundaries of the local governments regulatory jurisdiction. (B) In the case of ground ambulance transports provided on a mutual or automatic aid basis into another jurisdiction, the local government where the noncontracting ground ambulance provider is based.(3) A payment made by the health insurer to the noncontracting ground ambulance provider for services as required in subdivision (a), plus the applicable cost sharing owed by the insured, shall constitute payment in full for services rendered.(4) Notwithstanding any other law, the amounts paid by a health insurer for services under this section shall not constitute the prevailing or customary charges, the usual fees to the general public, or other charges for other payers for an individual ground ambulance provider.(e) A health insurer or ground ambulance provider may seek relief in any appropriate court for the purpose of resolving a payment dispute. A ground ambulance provider may use a health insurers existing dispute resolution process under Section 10123.137.(f) This section does not affect the balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code. |
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| 156 | 170 | | |
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| 157 | 171 | | 10126.66. (a) (1) Unless otherwise required by this chapter, a health insurance policy issued, amended, or renewed on or after January 1, 2024, shall require an insured who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the insured would pay for the same covered services received from a contracting ground ambulance provider. This amount shall be referred to as the in-network cost-sharing amount. (2) An insured shall not owe the noncontracting ground ambulance provider more than the in-network cost-sharing amount for services subject to this section. At the time of payment by the insurer to the noncontracting provider, the insurer shall inform the insured and the noncontracting provider of the in-network cost-sharing amount owed by the insured and shall disclose whether or not the insureds coverage is regulated by the department or if the coverage is not state-regulated.(b) (1) The in-network cost-sharing amount paid by the insured pursuant to this section shall count toward the limit on annual out-of-pocket expenses established under Section 10112.28.(2) Cost sharing arising pursuant to this section shall count toward any deductible in the same manner as cost sharing would be attributed to a contracting provider.(3) The in-network cost-sharing amount paid by the insured pursuant to this section shall satisfy the insureds obligation to pay cost sharing for the health service.(c) A noncontracting ground ambulance provider shall only advance to collections the in-network cost-sharing amount, as determined by the insurer pursuant to subdivision (a), that the insured failed to pay.(1) A noncontracting ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the insured for a minimum of 12 months after the initial billing regarding amounts owed by the insured pursuant to subdivision (a).(2) With respect to an insured, a noncontracting ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section.(d) (1) Unless otherwise agreed to by the noncontracting ground ambulance provider and the health insurer, the insurer shall directly reimburse a noncontracting ground ambulance provider for ground ambulance services the difference between the in-network cost-sharing amount and an amount described, as follows:(A) If there is a rate established or approved by a local government, at the rate established or approved by the governing body of the local government having jurisdiction for that area or subarea, including an exclusive operating area pursuant to Section 1797.85 of the Health and Safety Code.(B) If the local government having jurisdiction where the service was provided does not have an established or approved rate for that service, the reasonable and customary value for the services rendered, based upon statistically credible information that is updated at least annually and takes into consideration all of the following:(i) The ambulance providers training, qualifications, and length of time in practice.(ii) The nature of the services provided.(iii) The fees usually charged by the ambulance provider.(iv) Prevailing ground ambulance provider rates charged in the general geographic areas in which the services were rendered.(v) Other aspects of the economics of the ambulance providers practice that are relevant.(vi) Any unusual circumstances in the case.(2) A local government has jurisdiction over the ground ambulance transport if either of the following applies:(A) The ground ambulance transport is initiated within the boundaries of the local governments regulatory jurisdiction. (B) In the case of ground ambulance transports provided on a mutual or automatic aid basis into another jurisdiction, the local government where the noncontracting ground ambulance provider is based.(3) A payment made by the health insurer to the noncontracting ground ambulance provider for services as required in subdivision (a), plus the applicable cost sharing owed by the insured, shall constitute payment in full for services rendered.(4) Notwithstanding any other law, the amounts paid by a health insurer for services under this section shall not constitute the prevailing or customary charges, the usual fees to the general public, or other charges for other payers for an individual ground ambulance provider.(e) A health insurer or ground ambulance provider may seek relief in any appropriate court for the purpose of resolving a payment dispute. A ground ambulance provider may use a health insurers existing dispute resolution process under Section 10123.137.(f) This section does not affect the balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code. |
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| 158 | 172 | | |
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| 159 | 173 | | |
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| 160 | 174 | | |
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| 161 | 175 | | 10126.66. (a) (1) Unless otherwise required by this chapter, a health insurance policy issued, amended, or renewed on or after January 1, 2024, shall require an insured who receives covered services from a noncontracting ground ambulance provider to pay no more than the same cost-sharing amount that the insured would pay for the same covered services received from a contracting ground ambulance provider. This amount shall be referred to as the in-network cost-sharing amount. |
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| 162 | 176 | | |
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| 163 | 177 | | (2) An insured shall not owe the noncontracting ground ambulance provider more than the in-network cost-sharing amount for services subject to this section. At the time of payment by the insurer to the noncontracting provider, the insurer shall inform the insured and the noncontracting provider of the in-network cost-sharing amount owed by the insured and shall disclose whether or not the insureds coverage is regulated by the department or if the coverage is not state-regulated. |
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| 164 | 178 | | |
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| 165 | 179 | | (b) (1) The in-network cost-sharing amount paid by the insured pursuant to this section shall count toward the limit on annual out-of-pocket expenses established under Section 10112.28. |
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| 166 | 180 | | |
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| 167 | 181 | | (2) Cost sharing arising pursuant to this section shall count toward any deductible in the same manner as cost sharing would be attributed to a contracting provider. |
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| 168 | 182 | | |
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| 169 | 183 | | (3) The in-network cost-sharing amount paid by the insured pursuant to this section shall satisfy the insureds obligation to pay cost sharing for the health service. |
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| 170 | 184 | | |
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| 171 | 185 | | (c) A noncontracting ground ambulance provider shall only advance to collections the in-network cost-sharing amount, as determined by the insurer pursuant to subdivision (a), that the insured failed to pay. |
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| 172 | 186 | | |
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| 173 | 187 | | (1) A noncontracting ground ambulance provider, or an entity acting on its behalf, including a debt buyer or assignee of the debt, shall not report adverse information to a consumer credit reporting agency or commence civil action against the insured for a minimum of 12 months after the initial billing regarding amounts owed by the insured pursuant to subdivision (a). |
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| 174 | 188 | | |
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| 175 | 189 | | (2) With respect to an insured, a noncontracting ground ambulance provider, or an entity acting on its behalf, including an assignee of the debt, shall not use wage garnishments or liens on primary residences as a means of collecting unpaid bills pursuant to this section. |
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| 176 | 190 | | |
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| 177 | 191 | | (d) (1) Unless otherwise agreed to by the noncontracting ground ambulance provider and the health insurer, the insurer shall directly reimburse a noncontracting ground ambulance provider for ground ambulance services the difference between the in-network cost-sharing amount and an amount described, as follows: |
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| 178 | 192 | | |
|---|
| 179 | 193 | | (A) If there is a rate established or approved by a local government, at the rate established or approved by the governing body of the local government having jurisdiction for that area or subarea, including an exclusive operating area pursuant to Section 1797.85 of the Health and Safety Code. |
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| 180 | 194 | | |
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| 181 | 195 | | (B) If the local government having jurisdiction where the service was provided does not have an established or approved rate for that service, the reasonable and customary value for the services rendered, based upon statistically credible information that is updated at least annually and takes into consideration all of the following: |
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| 182 | 196 | | |
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| 183 | 197 | | (i) The ambulance providers training, qualifications, and length of time in practice. |
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| 184 | 198 | | |
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| 185 | 199 | | (ii) The nature of the services provided. |
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| 186 | 200 | | |
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| 187 | 201 | | (iii) The fees usually charged by the ambulance provider. |
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| 188 | 202 | | |
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| 189 | 203 | | (iv) Prevailing ground ambulance provider rates charged in the general geographic areas in which the services were rendered. |
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| 190 | 204 | | |
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| 191 | 205 | | (v) Other aspects of the economics of the ambulance providers practice that are relevant. |
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| 192 | 206 | | |
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| 193 | 207 | | (vi) Any unusual circumstances in the case. |
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| 194 | 208 | | |
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| 195 | 209 | | (2) A local government has jurisdiction over the ground ambulance transport if either of the following applies: |
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| 196 | 210 | | |
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| 197 | 211 | | (A) The ground ambulance transport is initiated within the boundaries of the local governments regulatory jurisdiction. |
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| 198 | 212 | | |
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| 199 | 213 | | (B) In the case of ground ambulance transports provided on a mutual or automatic aid basis into another jurisdiction, the local government where the noncontracting ground ambulance provider is based. |
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| 200 | 214 | | |
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| 201 | 215 | | (3) A payment made by the health insurer to the noncontracting ground ambulance provider for services as required in subdivision (a), plus the applicable cost sharing owed by the insured, shall constitute payment in full for services rendered. |
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| 202 | 216 | | |
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| 203 | 217 | | (4) Notwithstanding any other law, the amounts paid by a health insurer for services under this section shall not constitute the prevailing or customary charges, the usual fees to the general public, or other charges for other payers for an individual ground ambulance provider. |
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| 204 | 218 | | |
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| 205 | 219 | | (e) A health insurer or ground ambulance provider may seek relief in any appropriate court for the purpose of resolving a payment dispute. A ground ambulance provider may use a health insurers existing dispute resolution process under Section 10123.137. |
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| 206 | 220 | | |
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| 207 | 221 | | (f) This section does not affect the balance billing protections for Medi-Cal beneficiaries under Section 14019.4 of the Welfare and Institutions Code. |
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| 208 | 222 | | |
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| 209 | 223 | | SEC. 6. Section 10352 of the Insurance Code is repealed. |
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| 210 | 224 | | |
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| 211 | 225 | | SEC. 6. Section 10352 of the Insurance Code is repealed. |
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| 212 | 226 | | |
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| 213 | 227 | | ### SEC. 6. |
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| 214 | 228 | | |
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| 215 | 229 | | |
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| 216 | 230 | | |
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| 217 | 231 | | SEC. 7. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution. |
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| 218 | 232 | | |
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| 219 | 233 | | SEC. 7. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution. |
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| 220 | 234 | | |
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| 221 | 235 | | SEC. 7. No reimbursement is required by this act pursuant to Section 6 of Article XIIIB of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIIIB of the California Constitution. |
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| 222 | 236 | | |
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| 223 | 237 | | ### SEC. 7. |
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