OFFICE OF FISCAL ANALYSIS
Legislative Office Building, Room 5200
Hartford, CT 06106 (860) 240-0200
http://www.cga.ct.gov/ofa
sSB-179
AN ACT CONCERNING RATES FOR AMBULANCE AND
PARAMEDIC SERVICES.
Primary Analyst: MP 3/12/24
Contributing Analyst(s): LD, LG, NN, JP
Reviewer: JS
OFA Fiscal Note
State Impact:
Agency Affected Fund-Effect FY 25 $ FY 26 $
State Comptroller - Fringe
Benefits
1
GF - Cost Potential Potential
Resources of the General Fund;
Social Services, Dept.
GF - Cost Potential Potential
Note: GF=General Fund
Municipal Impact:
Municipalities Effect FY 25 $ FY 26 $
Various Municipalities Cost Potential Potential
Various Municipalities Savings Potential Potential
Explanation
The bill results in potential costs to the state and municipalities and
potential savings for certain municipalities beginning in FY 25.
The bill requires health carriers to cover medically necessary
ambulance services in line with the rate schedule that the Department
of Public Health (DPH) already sets for these services. Under current
practice, carriers often negotiate lower rates than the “maximum
allowable rates” published by DPH. The bill's provision may result in
higher costs for health carriers (including the state employees and some
1
The fringe benefit costs for most state employees are budgeted centrally in accounts
administered by the Comptroller. The estimated active employee fringe benefit cost
associated with most personnel changes is 41.25% of payroll in FY 25. 2024SB-00179-R000017-FN.DOCX Page 2 of 5
municipal plans) and savings to towns.
Additionally, the bill appears to expand the existing mandate for
medically necessary ambulance services to include paramedic intercept
services, for which providers can seek direct reimbursement under the
bill.
2
This component of the bill may result in costs to the plans and
associated with the Exchange.
To the extent the bill also mandates coverage for certain treatment at
the scene when there is no ambulance transport, the bill results in
potentially significant costs for the state employee plan, fully insured
municipalities, and associated with exchange enrollees, as that is not
currently a mandated or typically provided coverage.
Potential Costs to the Office of the State Comptroller – Fringe
Benefits and Municipalities
The bill results in a potential cost to the State Comptroller – Fringe
Benefits account associated with new mandated coverage of paramedic
intercept services, and potentially different reimbursement rates under
the plan. The state employee health plan uses reimbursement rates for
emergency medical services (EMS) up to DPH's current maximum
allowable rate. The cost to the plan will depend on the difference
between current reimbursement rates for EMS and the rates utilized
under the bill, as well as the number of EMS claims.
Certain municipalities with either self or fully insured health plans or
participation in the Partnership plan will see a potential cost to the
extent the plans do not currently fully reimburse the maximum
allowable rates for EMS, including the potentially mandated coverage
of treatment without medical conveyance, subject to the
Commissioner's rate schedule. Due to federal law, municipalities with
2
Paramedic intercept services are advanced life support (ALS) services provided by a
paramedic from a separate organization to a patient being transported by an
ambulance service. At the ambulance services’ request, an outside paramedic meets
the ambulance via a separate vehicle and rides inside to provide services for more
serious cases. 2024SB-00179-R000017-FN.DOCX Page 3 of 5
self-insured health plans are exempt from state health insurance benefit
mandates, so potential costs are contingent on the plan electing to adopt
the mandate.
Potential Costs Related to Exchange Enrollees
The bill could result in a cost to the state to defray additional
premium costs for enrollees purchasing health insurance on the state’s
exchange, to the extent the requirement for “paramedic intercept
services” is determined to increase premiums and constitute a new state
benefit mandate.
Typically under current law, the provider of the ambulance transport
service bills the insurance company for a higher level of care made
possible by the paramedic intercept service and then reimburses the
provider of paramedic intercept services at an agreed upon rate. It is not
clear to what extent the bill will result in coverage for services not
already being partially covered through such combined billing
arrangements. The plain average of DPH’s 2024 rate schedule for
paramedic intercept services is $1,088, for basic life support (BLS) is
$945, and for advanced life support (ALS) is $1,611.
3
The bill could also result in additional costs to defray premiums for
exchange enrollees to the extent there is an additional new mandate for
treatment without conveyance that is determined to require defrayal.
Under the Affordable Care Act (ACA), states are allowed to mandate
benefits in excess of the essential health benefits but must pay for the
excess coverage. Federal regulations require the state to defray the cost
of additional benefits related to specific care, treatment or services
mandated by state action after December 31, 2011 (except to comply
with federal requirements) for all plans sold on the exchange.
4
There
are currently 130,141 enrollees in qualified health plans on the exchange,
3
DPH Office of Emergency Medical Services, 2022-2024 Allowable Rates by EMS
Organizations
4
45 CFR 155.170 2024SB-00179-R000017-FN.DOCX Page 4 of 5
including 29,687 in Covered Connecticut.
To the extent the bill is determined to include one or two new state
benefit mandates that require defrayal, there would be a cost to the state
beginning January 1, 2025.
5
Full year costs would begin in FY 26 and
continue annually.
Defrayal costs for Covered Connecticut enrollees would be incurred
by the Department of Social Services (DSS), to the extent the bill raises
premiums for those enrollees. The bill could also increase Covered
Connecticut costs to the extent it increases the negotiated
reimbursement rates for already covered ambulance services, however,
that impact would be limited due to the way federal subsidies for those
enrollees would increase as well.
It is not clear how or when the ACA defrayal rules will be enforced
for non-Covered Connecticut enrollees. Recently proposed federal
regulations, if finalized, would provide a means for the state to integrate
existing state benefit mandates in essential health benefit categories into
Connecticut’s benchmark plan, which could alleviate some federal
premium defrayal requirements in the out years.
6
Potential Municipal Savings
The bill could result in a savings to various municipalities beginning
in FY 25 to the extent insurance providers reimburse ambulance
companies at a higher rate and extend the coverage to include
paramedic intercept services.
Funding structure for ambulance services varies widely by
municipality. Municipalities that provide their own paid ambulance
service will likely see the largest impact as a greater portion of operating
expenses may be covered by the insurance providers. Municipalities
5
After determining if the mandate is subject to defrayal, states must reimburse the
carriers or the insureds for the excess coverage. The premium costs are to be quantified
by each insurer on the exchange and reported to the state.
6
88 FR 82510 2024SB-00179-R000017-FN.DOCX Page 5 of 5
that do not provide any expenditures for ambulance services will have
no impact.
Insurance providers currently negotiate a reimbursement percentage
for ambulance services based on the maximum allowable rate set by
DPH. Removing the maximum allowable language may allow
ambulance services to negotiate based on a higher rate or receive the full
DPH rate.
For example, an insurance company that currently reimburses an
ambulance provider at 80% of the average statewide rate set by DPH
might instead be required to reimburse at 100% of that rate. For a service
such as basic life support (BLS), the ambulance provider would see an
increase of approximately $190 for each instance when they provide
BLS.
7
This revenue increase for ambulance services may result in a
corresponding savings to municipalities.
Municipalities may also see a corresponding savings to the extent
insurance providers reimburse ambulance companies for paramedic
intercept services.
The Out Years
The annualized ongoing fiscal impact identified above would
continue into the future subject to inflation, the DPH EMS rate schedule,
carrier negotiated rates, the number of QHP enrollees on the exchange,
federal regulations concerning defrayal, and the methods municipalities
use to provide and fund ambulance services.
Sources: Department of Public Health 2022 Office of Emergency Medical Services Annual
Report
Department of Public Health https://portal.ct.gov/DPH/Emergency-Medical-
Services/EMS/Office-of-Emergency-Medical-Services-Homepage
Office of Health Strategy All Payer Claims Database
7
Basic life support (BLS) is defined by the Connecticut Department of Public Health's
Office of Emergency Medical Services as transportation by ground ambulance vehicle
where the vehicle is staffed by an individual who is qualified as an EMT-basic.