Introduced Version
SENATE BILL No. 135
_____
DIGEST OF INTRODUCED BILL
Citations Affected: IC 16-18-2-13; IC 16-31-14.
Synopsis: Ambulance fee dispute resolution. Provides that: (1) when
an individual covered by a health plan is provided emergency
ambulance service by a nonparticipating ambulance service provider,
the health plan operator shall pay toward the compensation of the
nonparticipating ambulance service provider the amount that the health
plan operator considers reasonable compensation for the emergency
ambulance service; and (2) after the health plan operator pays this
amount and after any deductible, copayment, and coinsurance amount
is paid, neither the nonparticipating ambulance service provider nor the
health plan operator may seek to obtain any further amount from the
covered individual. Provides that if the nonparticipating ambulance
service provider considers the amount paid to be insufficient, the
nonparticipating ambulance service provider: (1) may initiate
negotiations with the health plan operator; and (2) if negotiations do
not produce a result satisfactory to the nonparticipating ambulance
service provider, may initiate arbitration of the ambulance fee dispute.
Provides for the selection of an arbitrator and establishes a procedure
by which the arbitrator determines a figure representing fair
compensation for the emergency ambulance service. Provides that an
arbitrator's determination as to fair compensation is binding on the
parties and is admissible in any court proceeding. Empowers the
insurance commissioner to reprimand, impose a civil penalty on, or
suspend the certificate of authority of a health plan operator that fails
upon request to provide information on compensation paid to
participating ambulance service providers, refuses to negotiate in good
(Continued next page)
Effective: July 1, 2022.
Ford Jon
January 4, 2022, read first time and referred to Committee on Health and Provider
Services.
2022 IN 135—LS 6436/DI 55 Digest Continued
faith, or refuses to compensate a nonparticipating ambulance service
provider in accordance with an arbitrator's determination. Requires the
Indiana emergency medical services commission to adopt rules
concerning the certification of arbitrators and the administration of the
ambulance fee dispute resolution process.
2022 IN 135—LS 6436/DI 552022 IN 135—LS 6436/DI 55 Introduced
Second Regular Session of the 122nd General Assembly (2022)
PRINTING CODE. Amendments: Whenever an existing statute (or a section of the Indiana
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between statutes enacted by the 2021 Regular Session of the General Assembly.
SENATE BILL No. 135
A BILL FOR AN ACT to amend the Indiana Code concerning
health.
Be it enacted by the General Assembly of the State of Indiana:
1 SECTION 1. IC 16-18-2-13 IS AMENDED TO READ AS
2 FOLLOWS [EFFECTIVE JULY 1, 2022]: Sec. 13. "Ambulance", for
3 purposes of IC 16-31, except IC 16-31-14, means a conveyance on:
4 (1) land;
5 (2) sea; or
6 (3) air;
7 that is used or is intended to be used for the purpose of responding to
8 emergency life-threatening situations and providing emergency
9 transportation service.
10 SECTION 2. IC 16-31-14 IS ADDED TO THE INDIANA CODE
11 AS A NEW CHAPTER TO READ AS FOLLOWS [EFFECTIVE
12 JULY 1, 2022]:
13 Chapter 14. Resolution of Ambulance Fee Disputes
14 Sec. 1. As used in this chapter, "ambulance" refers only to a
15 vehicle that is used to provide emergency ambulance service on
2022 IN 135—LS 6436/DI 55 2
1 land.
2 Sec. 2. As used in this chapter, "ambulance fee dispute" means
3 a dispute as to the compensation to be paid to an ambulance service
4 provider for emergency ambulance service.
5 Sec. 3. As used in this chapter, "ambulance service provider"
6 means a person that:
7 (1) provides emergency ambulance service; and
8 (2) holds a valid certificate issued by the commission under
9 IC 16-31-3 authorizing the person to provide emergency
10 ambulance service.
11 Sec. 4. As used in this chapter, "arbitrator" means a person that
12 holds a certificate issued by the commission under this chapter to
13 authorize the person to resolve ambulance fee disputes under this
14 chapter.
15 Sec. 5. As used in this chapter, "commission" refers to the
16 Indiana emergency medical services commission created by
17 IC 16-31-2-1.
18 Sec. 6. As used in this chapter, "cost sharing" means the total
19 amount paid:
20 (1) by a covered individual; or
21 (2) on behalf of a covered individual by any person other than
22 the health plan under which the individual is covered;
23 in the form of a deductible, copayment, or coinsurance, for
24 emergency ambulance service provided to the covered individual.
25 Sec. 7. As used in this chapter, "emergency ambulance service"
26 has the same meaning as "emergency ambulance services" set
27 forth in IC 16-18-2-107.
28 Sec. 8. As used in this chapter, "health plan" means any of the
29 following:
30 (1) A self-insurance program established under IC 5-10-8-7(b)
31 to provide group coverage.
32 (2) A prepaid health care delivery plan through which health
33 services are provided under IC 5-10-8-7(c).
34 (3) A policy of accident and sickness insurance as defined in
35 IC 27-8-5-1, but not including any insurance, plan, or policy
36 set forth in IC 27-8-5-2.5(a).
37 (4) An individual contract (as defined in IC 27-13-1-21) or a
38 group contract (as defined in IC 27-13-1-16) with a health
39 maintenance organization that provides coverage for basic
40 health care services (as defined in IC 27-13-1-4).
41 Sec. 9. As used in this chapter, "health plan operator" means
42 the following:
2022 IN 135—LS 6436/DI 55 3
1 (1) In the case of a health plan described in section 8(1) or 8(2)
2 of this chapter, the state of Indiana.
3 (2) In the case of a health plan described in section 8(3) of this
4 chapter, the insurer that issued the policy.
5 (3) In the case of a health plan described in section 8(4) of this
6 chapter, the health maintenance organization that entered
7 into the contract.
8 Sec. 10. For purposes of this chapter:
9 (1) an ambulance service provider that provides emergency
10 ambulance service to an individual covered by a health plan
11 is "nonparticipating" with respect to the health plan if the
12 ambulance service provider has not, by contract, affiliation,
13 agreement, or any other means, agreed to be compensated by
14 the health plan at no more than a certain amount or rate for
15 the emergency ambulance service; and
16 (2) an ambulance service provider that provides emergency
17 ambulance service to an individual covered by a health plan
18 is "participating" with respect to the health plan if the
19 ambulance service provider has agreed to be compensated by
20 the health plan at no more than a certain amount or rate for
21 the emergency ambulance service.
22 Sec. 11. As used in this chapter, "person" means an individual,
23 a corporation, a limited liability company, a partnership, or
24 another legal entity.
25 Sec. 12. As used in this chapter, the "usual and customary cost"
26 for emergency ambulance service provided in a particular case
27 means the eightieth percentile of charges recorded in the data base
28 maintained according to the rules adopted under section 13(6) of
29 this chapter for emergency ambulance services provided in the
30 same geographical area in which the particular emergency
31 ambulance service was provided.
32 Sec. 13. Before January 1, 2023, the commission shall adopt
33 rules under IC 4-22-2 to implement this chapter, including rules
34 concerning the following:
35 (1) The procedure for initiating and conducting negotiations
36 under section 16 of this chapter.
37 (2) The procedure for initiating arbitration, selecting an
38 arbitrator, and resolving an ambulance fee dispute through
39 arbitration under section 17 of this chapter, and for payment
40 of fair compensation to the arbitrator.
41 (3) The minimum qualifications that a person must meet to be
42 certified as an arbitrator under this chapter.
2022 IN 135—LS 6436/DI 55 4
1 (4) The certification of persons who apply for certification as
2 arbitrators and meet the qualifications established under
3 subdivision (3).
4 (5) The creation and publication on the Internet of a roster of
5 certified arbitrators.
6 (6) The establishment and maintenance of a data base of
7 information on compensation paid for emergency ambulance
8 service provided in particular geographical areas of Indiana.
9 (7) The use of the data base maintained under subdivision (6)
10 to determine the usual and customary cost of emergency
11 ambulance service in particular geographical areas of Indiana
12 for the purposes of section 17(c)(6) of this chapter.
13 Sec. 14. (a) If a health plan provides coverage for emergency
14 ambulance service, and if an individual covered by the health plan
15 is provided emergency ambulance service by a nonparticipating
16 ambulance service provider, the health plan operator shall pay
17 toward the compensation of the nonparticipating ambulance
18 service provider the amount that the health plan operator
19 considers:
20 (1) its legal obligation to pay; and
21 (2) reasonable compensation;
22 for the emergency ambulance service, minus the cost sharing paid
23 by or on behalf of the covered individual.
24 (b) The entire amount paid by a health plan to a
25 nonparticipating ambulance service provider:
26 (1) under subsection (a); and
27 (2) if applicable, at the conclusion of:
28 (A) negotiations under section 16 of this chapter; or
29 (B) arbitration under section 17 of this chapter;
30 shall be paid directly to the nonparticipating ambulance service
31 provider and shall not be remitted to the covered individual for
32 payment by the covered individual to the nonparticipating
33 ambulance service provider.
34 (c) After:
35 (1) the health plan operator pays toward the compensation of
36 the nonparticipating ambulance service provider the amount
37 required under subsection (a); and
38 (2) the full amount of cost sharing is paid to the
39 nonparticipating ambulance service provider by or on behalf
40 of the covered individual;
41 neither the nonparticipating ambulance service provider nor the
42 health plan operator may seek to obtain any further amount from
2022 IN 135—LS 6436/DI 55 5
1 the covered individual in compensation for the emergency
2 ambulance service provided to the covered individual by the
3 nonparticipating ambulance service provider.
4 Sec. 15. (a) For purposes of:
5 (1) evaluating the sufficiency of the amount paid by a health
6 plan operator under section 14(a) of this chapter; and
7 (2) preparing for and conducting:
8 (A) negotiations under section 16 of this chapter; or
9 (B) arbitration under section 17 of this chapter;
10 a nonparticipating ambulance service provider may obtain from
11 the health plan operator, and the health plan operator shall
12 provide to the nonparticipating ambulance service provider upon
13 request, information on compensation that the health plan
14 operator has paid to participating ambulance service providers for
15 emergency ambulance service.
16 (b) If a health plan operator fails or refuses to provide
17 information on compensation paid to participating ambulance
18 service providers for emergency ambulance service as required by
19 subsection (a), the insurance commissioner appointed under
20 IC 27-1-1-2 may:
21 (1) reprimand; or
22 (2) in the case of a health plan operator described in section
23 9(2) or 9(3) of this chapter, after notice and hearing under
24 IC 4-21.5:
25 (A) impose a civil penalty on; or
26 (B) suspend the certificate of authority of;
27 the health plan operator.
28 Sec. 16. (a) If a nonparticipating ambulance service provider
29 considers the amount paid by a health plan operator under section
30 14(a) of this chapter, in addition to any cost sharing paid by or on
31 behalf of the covered individual, to be insufficient compensation
32 for the emergency ambulance service provided to the covered
33 individual, the nonparticipating ambulance service provider may
34 initiate negotiations with the health plan operator according to the
35 rules adopted under section 13(1) of this chapter concerning the
36 adequacy of the amount paid by the health plan operator.
37 (b) In negotiations initiated under subsection (a), a health plan
38 operator shall negotiate in good faith and shall consider the facts
39 advanced by the nonparticipating ambulance service provider in
40 support of its position that the amount paid by a health plan
41 operator is insufficient compensation for the emergency ambulance
42 service provided to the covered individual.
2022 IN 135—LS 6436/DI 55 6
1 (c) If a health plan operator fails or refuses to negotiate in good
2 faith in negotiations initiated under subsection (a) or section
3 17(b)(3) of this chapter, the insurance commissioner appointed
4 under IC 27-1-1-2 may:
5 (1) reprimand; or
6 (2) in the case of a health plan operator described in section
7 9(2) or 9(3) of this chapter, after notice and hearing under
8 IC 4-21.5:
9 (A) impose a civil penalty on; or
10 (B) suspend the certificate of authority of;
11 the health plan operator.
12 (d) If, fifteen (15) days after negotiations are initiated under this
13 section, the negotiations do not result in an agreement to pay to the
14 nonparticipating ambulance service provider an amount that the
15 nonparticipating ambulance service provider considers sufficient,
16 the nonparticipating ambulance service provider may initiate
17 arbitration of the ambulance fee dispute under section 17 of this
18 chapter.
19 Sec. 17. (a) If a nonparticipating ambulance service provider, in
20 accordance with the rules adopted under section 13(2) of this
21 chapter, initiates arbitration of the ambulance fee dispute, the
22 commission shall select an arbitrator through a random drawing
23 of the name of one (1) certified arbitrator from the roster
24 maintained and published according to the rules adopted under
25 section 13(5) of this chapter.
26 (b) The arbitrator selected under subsection (a) shall determine
27 an amount that is fair compensation for the emergency ambulance
28 service provided to the covered individual according to the
29 following procedure:
30 (1) The nonparticipating ambulance service provider and the
31 health plan operator shall submit to the arbitrator the figure
32 each considers to be fair compensation for the emergency
33 ambulance service provided to the covered individual, along
34 with whatever additional information the nonparticipating
35 ambulance service provider and the health plan operator wish
36 to submit in support of the figure submitted.
37 (2) If the arbitrator, based on an analysis conducted under
38 subsection (c), determines that one (1) of the figures submitted
39 under subdivision (1) represents fair compensation for the
40 emergency ambulance service provided to the covered
41 individual, the arbitrator shall declare that figure to be fair
42 compensation.
2022 IN 135—LS 6436/DI 55 7
1 (3) If the arbitrator determines, based upon the figures and
2 information submitted under subdivision (1), that:
3 (A) a settlement between the health plan operator and the
4 nonparticipating ambulance service provider is reasonably
5 likely; or
6 (B) the figures submitted by the nonparticipating
7 ambulance service provider and the health plan operator
8 represent unreasonable extremes;
9 the arbitrator may direct both parties to resume negotiations
10 concerning the compensation for the emergency ambulance
11 service. The arbitrator may pause the dispute resolution
12 process under this section for not more than ten (10) business
13 days for negotiations under this subdivision. If the parties
14 reach a settlement through negotiations under this
15 subdivision, the dispute resolution process under this section
16 is concluded. If the parties do not reach a settlement through
17 negotiations under this subdivision, the dispute resolution
18 process shall continue under subdivision (4).
19 (4) If the arbitrator, based on an analysis conducted under
20 subsection (c), determines that neither of the figures
21 submitted under subdivision (1) represents fair compensation
22 for the emergency ambulance service provided to the covered
23 individual, and negotiations conducted under subdivision (3),
24 if any, do not result in a settlement of the ambulance fee
25 dispute, the arbitrator shall calculate an amount that
26 represents fair compensation for the emergency ambulance
27 service provided to the covered individual.
28 (c) In reaching a determination under subsection (b)(2) or
29 (b)(4), the arbitrator shall conduct an analysis according to the
30 following factors:
31 (1) Whether there is a gross disparity between:
32 (A) the figure submitted by the nonparticipating
33 ambulance service provider under subsection (b)(1); and
34 (B) fees paid by the health plan operator to participating
35 ambulance service providers for comparable emergency
36 ambulance service.
37 (2) The level of life support that the nonparticipating
38 ambulance service administered to the covered individual
39 before or during the transportation of the covered individual
40 in the ambulance.
41 (3) The distance that the nonparticipating ambulance service
42 transported the covered individual in the ambulance.
2022 IN 135—LS 6436/DI 55 8
1 (4) The usual charge of the nonparticipating ambulance
2 service for comparable emergency ambulance service.
3 (5) The circumstances and complexity of the emergency
4 ambulance service provided to the covered individual,
5 including the time and place of the service.
6 (6) The usual and customary cost of emergency ambulance
7 service in the particular geographical area in which the
8 nonparticipating ambulance service provided the emergency
9 ambulance service, as determined according to the rules
10 adopted under section 13(7) of this chapter.
11 (d) The arbitrator shall conclude an arbitration process under
12 this section not more than sixty (60) days after the selection of the
13 arbitrator under subsection (a).
14 (e) The determination of the arbitrator under subsection (b)(2)
15 or (b)(4):
16 (1) is binding on the health plan operator and the
17 nonparticipating ambulance service provider; and
18 (2) is admissible in any court proceeding between the health
19 plan operator and the nonparticipating ambulance service
20 provider.
21 (f) The health plan operator and the nonparticipating
22 ambulance service provider shall each pay fifty percent (50%) of
23 the compensation to be paid to the arbitrator according to the rules
24 adopted under section 13(2) of this chapter.
25 (g) The insurance commissioner appointed under IC 27-1-1-2
26 may:
27 (1) reprimand; or
28 (2) in the case of a health plan operator described in section
29 9(2) or 9(3) of this chapter, after notice and hearing under
30 IC 4-21.5:
31 (A) impose a civil penalty on; or
32 (B) suspend the certificate of authority of;
33 a health plan operator that refuses to compensate a
34 nonparticipating ambulance service provider in accordance with
35 the determination made by an arbitrator under subsection (b)(2)
36 or (b)(4), if the amount determined by the arbitrator under
37 subsection (b)(2) or (b)(4) to be fair compensation exceeds the
38 amount paid by the health plan operator under section 14(a) of this
39 chapter.
2022 IN 135—LS 6436/DI 55