Indiana 2022 Regular Session

Indiana Senate Bill SB0135 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1
2	2	Introduced Version
3	3	SENATE BILL No. 135
4	4	_____
5	5	DIGEST OF INTRODUCED BILL
6	6	Citations Affected: IC 16-18-2-13; IC 16-31-14.
7	7	Synopsis: Ambulance fee dispute resolution. Provides that: (1) when
8	8	an individual covered by a health plan is provided emergency
9	9	ambulance service by a nonparticipating ambulance service provider,
10	10	the health plan operator shall pay toward the compensation of the
11	11	nonparticipating ambulance service provider the amount that the health
12	12	plan operator considers reasonable compensation for the emergency
13	13	ambulance service; and (2) after the health plan operator pays this
14	14	amount and after any deductible, copayment, and coinsurance amount
15	15	is paid, neither the nonparticipating ambulance service provider nor the
16	16	health plan operator may seek to obtain any further amount from the
17	17	covered individual. Provides that if the nonparticipating ambulance
18	18	service provider considers the amount paid to be insufficient, the
19	19	nonparticipating ambulance service provider: (1) may initiate
20	20	negotiations with the health plan operator; and (2) if negotiations do
21	21	not produce a result satisfactory to the nonparticipating ambulance
22	22	service provider, may initiate arbitration of the ambulance fee dispute.
23	23	Provides for the selection of an arbitrator and establishes a procedure
24	24	by which the arbitrator determines a figure representing fair
25	25	compensation for the emergency ambulance service. Provides that an
26	26	arbitrator's determination as to fair compensation is binding on the
27	27	parties and is admissible in any court proceeding. Empowers the
28	28	insurance commissioner to reprimand, impose a civil penalty on, or
29	29	suspend the certificate of authority of a health plan operator that fails
30	30	upon request to provide information on compensation paid to
31	31	participating ambulance service providers, refuses to negotiate in good
32	32	(Continued next page)
33	33	Effective: July 1, 2022.
34	34	Ford Jon
35	35	January 4, 2022, read first time and referred to Committee on Health and Provider
36	36	Services.
37	37	2022 IN 135—LS 6436/DI 55 Digest Continued
38	38	faith, or refuses to compensate a nonparticipating ambulance service
39	39	provider in accordance with an arbitrator's determination. Requires the
40	40	Indiana emergency medical services commission to adopt rules
41	41	concerning the certification of arbitrators and the administration of the
42	42	ambulance fee dispute resolution process.
43	43	2022 IN 135—LS 6436/DI 552022 IN 135—LS 6436/DI 55 Introduced
44	44	Second Regular Session of the 122nd General Assembly (2022)
45	45	PRINTING CODE. Amendments: Whenever an existing statute (or a section of the Indiana
46	46	Constitution) is being amended, the text of the existing provision will appear in this style type,
47	47	additions will appear in this style type, and deletions will appear in this style type.
48	48	Additions: Whenever a new statutory provision is being enacted (or a new constitutional
49	49	provision adopted), the text of the new provision will appear in this style type. Also, the
50	50	word NEW will appear in that style type in the introductory clause of each SECTION that adds
51	51	a new provision to the Indiana Code or the Indiana Constitution.
52	52	Conflict reconciliation: Text in a statute in this style type or this style type reconciles conflicts
53	53	between statutes enacted by the 2021 Regular Session of the General Assembly.
54	54	SENATE BILL No. 135
55	55	A BILL FOR AN ACT to amend the Indiana Code concerning
56	56	health.
57	57	Be it enacted by the General Assembly of the State of Indiana:
58	58	1 SECTION 1. IC 16-18-2-13 IS AMENDED TO READ AS
59	59	2 FOLLOWS [EFFECTIVE JULY 1, 2022]: Sec. 13. "Ambulance", for
60	60	3 purposes of IC 16-31, except IC 16-31-14, means a conveyance on:
61	61	4 (1) land;
62	62	5 (2) sea; or
63	63	6 (3) air;
64	64	7 that is used or is intended to be used for the purpose of responding to
65	65	8 emergency life-threatening situations and providing emergency
66	66	9 transportation service.
67	67	10 SECTION 2. IC 16-31-14 IS ADDED TO THE INDIANA CODE
68	68	11 AS A NEW CHAPTER TO READ AS FOLLOWS [EFFECTIVE
69	69	12 JULY 1, 2022]:
70	70	13 Chapter 14. Resolution of Ambulance Fee Disputes
71	71	14 Sec. 1. As used in this chapter, "ambulance" refers only to a
72	72	15 vehicle that is used to provide emergency ambulance service on
73	73	2022 IN 135—LS 6436/DI 55 2
74	74	1 land.
75	75	2 Sec. 2. As used in this chapter, "ambulance fee dispute" means
76	76	3 a dispute as to the compensation to be paid to an ambulance service
77	77	4 provider for emergency ambulance service.
78	78	5 Sec. 3. As used in this chapter, "ambulance service provider"
79	79	6 means a person that:
80	80	7 (1) provides emergency ambulance service; and
81	81	8 (2) holds a valid certificate issued by the commission under
82	82	9 IC 16-31-3 authorizing the person to provide emergency
83	83	10 ambulance service.
84	84	11 Sec. 4. As used in this chapter, "arbitrator" means a person that
85	85	12 holds a certificate issued by the commission under this chapter to
86	86	13 authorize the person to resolve ambulance fee disputes under this
87	87	14 chapter.
88	88	15 Sec. 5. As used in this chapter, "commission" refers to the
89	89	16 Indiana emergency medical services commission created by
90	90	17 IC 16-31-2-1.
91	91	18 Sec. 6. As used in this chapter, "cost sharing" means the total
92	92	19 amount paid:
93	93	20 (1) by a covered individual; or
94	94	21 (2) on behalf of a covered individual by any person other than
95	95	22 the health plan under which the individual is covered;
96	96	23 in the form of a deductible, copayment, or coinsurance, for
97	97	24 emergency ambulance service provided to the covered individual.
98	98	25 Sec. 7. As used in this chapter, "emergency ambulance service"
99	99	26 has the same meaning as "emergency ambulance services" set
100	100	27 forth in IC 16-18-2-107.
101	101	28 Sec. 8. As used in this chapter, "health plan" means any of the
102	102	29 following:
103	103	30 (1) A self-insurance program established under IC 5-10-8-7(b)
104	104	31 to provide group coverage.
105	105	32 (2) A prepaid health care delivery plan through which health
106	106	33 services are provided under IC 5-10-8-7(c).
107	107	34 (3) A policy of accident and sickness insurance as defined in
108	108	35 IC 27-8-5-1, but not including any insurance, plan, or policy
109	109	36 set forth in IC 27-8-5-2.5(a).
110	110	37 (4) An individual contract (as defined in IC 27-13-1-21) or a
111	111	38 group contract (as defined in IC 27-13-1-16) with a health
112	112	39 maintenance organization that provides coverage for basic
113	113	40 health care services (as defined in IC 27-13-1-4).
114	114	41 Sec. 9. As used in this chapter, "health plan operator" means
115	115	42 the following:
116	116	2022 IN 135—LS 6436/DI 55 3
117	117	1 (1) In the case of a health plan described in section 8(1) or 8(2)
118	118	2 of this chapter, the state of Indiana.
119	119	3 (2) In the case of a health plan described in section 8(3) of this
120	120	4 chapter, the insurer that issued the policy.
121	121	5 (3) In the case of a health plan described in section 8(4) of this
122	122	6 chapter, the health maintenance organization that entered
123	123	7 into the contract.
124	124	8 Sec. 10. For purposes of this chapter:
125	125	9 (1) an ambulance service provider that provides emergency
126	126	10 ambulance service to an individual covered by a health plan
127	127	11 is "nonparticipating" with respect to the health plan if the
128	128	12 ambulance service provider has not, by contract, affiliation,
129	129	13 agreement, or any other means, agreed to be compensated by
130	130	14 the health plan at no more than a certain amount or rate for
131	131	15 the emergency ambulance service; and
132	132	16 (2) an ambulance service provider that provides emergency
133	133	17 ambulance service to an individual covered by a health plan
134	134	18 is "participating" with respect to the health plan if the
135	135	19 ambulance service provider has agreed to be compensated by
136	136	20 the health plan at no more than a certain amount or rate for
137	137	21 the emergency ambulance service.
138	138	22 Sec. 11. As used in this chapter, "person" means an individual,
139	139	23 a corporation, a limited liability company, a partnership, or
140	140	24 another legal entity.
141	141	25 Sec. 12. As used in this chapter, the "usual and customary cost"
142	142	26 for emergency ambulance service provided in a particular case
143	143	27 means the eightieth percentile of charges recorded in the data base
144	144	28 maintained according to the rules adopted under section 13(6) of
145	145	29 this chapter for emergency ambulance services provided in the
146	146	30 same geographical area in which the particular emergency
147	147	31 ambulance service was provided.
148	148	32 Sec. 13. Before January 1, 2023, the commission shall adopt
149	149	33 rules under IC 4-22-2 to implement this chapter, including rules
150	150	34 concerning the following:
151	151	35 (1) The procedure for initiating and conducting negotiations
152	152	36 under section 16 of this chapter.
153	153	37 (2) The procedure for initiating arbitration, selecting an
154	154	38 arbitrator, and resolving an ambulance fee dispute through
155	155	39 arbitration under section 17 of this chapter, and for payment
156	156	40 of fair compensation to the arbitrator.
157	157	41 (3) The minimum qualifications that a person must meet to be
158	158	42 certified as an arbitrator under this chapter.
159	159	2022 IN 135—LS 6436/DI 55 4
160	160	1 (4) The certification of persons who apply for certification as
161	161	2 arbitrators and meet the qualifications established under
162	162	3 subdivision (3).
163	163	4 (5) The creation and publication on the Internet of a roster of
164	164	5 certified arbitrators.
165	165	6 (6) The establishment and maintenance of a data base of
166	166	7 information on compensation paid for emergency ambulance
167	167	8 service provided in particular geographical areas of Indiana.
168	168	9 (7) The use of the data base maintained under subdivision (6)
169	169	10 to determine the usual and customary cost of emergency
170	170	11 ambulance service in particular geographical areas of Indiana
171	171	12 for the purposes of section 17(c)(6) of this chapter.
172	172	13 Sec. 14. (a) If a health plan provides coverage for emergency
173	173	14 ambulance service, and if an individual covered by the health plan
174	174	15 is provided emergency ambulance service by a nonparticipating
175	175	16 ambulance service provider, the health plan operator shall pay
176	176	17 toward the compensation of the nonparticipating ambulance
177	177	18 service provider the amount that the health plan operator
178	178	19 considers:
179	179	20 (1) its legal obligation to pay; and
180	180	21 (2) reasonable compensation;
181	181	22 for the emergency ambulance service, minus the cost sharing paid
182	182	23 by or on behalf of the covered individual.
183	183	24 (b) The entire amount paid by a health plan to a
184	184	25 nonparticipating ambulance service provider:
185	185	26 (1) under subsection (a); and
186	186	27 (2) if applicable, at the conclusion of:
187	187	28 (A) negotiations under section 16 of this chapter; or
188	188	29 (B) arbitration under section 17 of this chapter;
189	189	30 shall be paid directly to the nonparticipating ambulance service
190	190	31 provider and shall not be remitted to the covered individual for
191	191	32 payment by the covered individual to the nonparticipating
192	192	33 ambulance service provider.
193	193	34 (c) After:
194	194	35 (1) the health plan operator pays toward the compensation of
195	195	36 the nonparticipating ambulance service provider the amount
196	196	37 required under subsection (a); and
197	197	38 (2) the full amount of cost sharing is paid to the
198	198	39 nonparticipating ambulance service provider by or on behalf
199	199	40 of the covered individual;
200	200	41 neither the nonparticipating ambulance service provider nor the
201	201	42 health plan operator may seek to obtain any further amount from
202	202	2022 IN 135—LS 6436/DI 55 5
203	203	1 the covered individual in compensation for the emergency
204	204	2 ambulance service provided to the covered individual by the
205	205	3 nonparticipating ambulance service provider.
206	206	4 Sec. 15. (a) For purposes of:
207	207	5 (1) evaluating the sufficiency of the amount paid by a health
208	208	6 plan operator under section 14(a) of this chapter; and
209	209	7 (2) preparing for and conducting:
210	210	8 (A) negotiations under section 16 of this chapter; or
211	211	9 (B) arbitration under section 17 of this chapter;
212	212	10 a nonparticipating ambulance service provider may obtain from
213	213	11 the health plan operator, and the health plan operator shall
214	214	12 provide to the nonparticipating ambulance service provider upon
215	215	13 request, information on compensation that the health plan
216	216	14 operator has paid to participating ambulance service providers for
217	217	15 emergency ambulance service.
218	218	16 (b) If a health plan operator fails or refuses to provide
219	219	17 information on compensation paid to participating ambulance
220	220	18 service providers for emergency ambulance service as required by
221	221	19 subsection (a), the insurance commissioner appointed under
222	222	20 IC 27-1-1-2 may:
223	223	21 (1) reprimand; or
224	224	22 (2) in the case of a health plan operator described in section
225	225	23 9(2) or 9(3) of this chapter, after notice and hearing under
226	226	24 IC 4-21.5:
227	227	25 (A) impose a civil penalty on; or
228	228	26 (B) suspend the certificate of authority of;
229	229	27 the health plan operator.
230	230	28 Sec. 16. (a) If a nonparticipating ambulance service provider
231	231	29 considers the amount paid by a health plan operator under section
232	232	30 14(a) of this chapter, in addition to any cost sharing paid by or on
233	233	31 behalf of the covered individual, to be insufficient compensation
234	234	32 for the emergency ambulance service provided to the covered
235	235	33 individual, the nonparticipating ambulance service provider may
236	236	34 initiate negotiations with the health plan operator according to the
237	237	35 rules adopted under section 13(1) of this chapter concerning the
238	238	36 adequacy of the amount paid by the health plan operator.
239	239	37 (b) In negotiations initiated under subsection (a), a health plan
240	240	38 operator shall negotiate in good faith and shall consider the facts
241	241	39 advanced by the nonparticipating ambulance service provider in
242	242	40 support of its position that the amount paid by a health plan
243	243	41 operator is insufficient compensation for the emergency ambulance
244	244	42 service provided to the covered individual.
245	245	2022 IN 135—LS 6436/DI 55 6
246	246	1 (c) If a health plan operator fails or refuses to negotiate in good
247	247	2 faith in negotiations initiated under subsection (a) or section
248	248	3 17(b)(3) of this chapter, the insurance commissioner appointed
249	249	4 under IC 27-1-1-2 may:
250	250	5 (1) reprimand; or
251	251	6 (2) in the case of a health plan operator described in section
252	252	7 9(2) or 9(3) of this chapter, after notice and hearing under
253	253	8 IC 4-21.5:
254	254	9 (A) impose a civil penalty on; or
255	255	10 (B) suspend the certificate of authority of;
256	256	11 the health plan operator.
257	257	12 (d) If, fifteen (15) days after negotiations are initiated under this
258	258	13 section, the negotiations do not result in an agreement to pay to the
259	259	14 nonparticipating ambulance service provider an amount that the
260	260	15 nonparticipating ambulance service provider considers sufficient,
261	261	16 the nonparticipating ambulance service provider may initiate
262	262	17 arbitration of the ambulance fee dispute under section 17 of this
263	263	18 chapter.
264	264	19 Sec. 17. (a) If a nonparticipating ambulance service provider, in
265	265	20 accordance with the rules adopted under section 13(2) of this
266	266	21 chapter, initiates arbitration of the ambulance fee dispute, the
267	267	22 commission shall select an arbitrator through a random drawing
268	268	23 of the name of one (1) certified arbitrator from the roster
269	269	24 maintained and published according to the rules adopted under
270	270	25 section 13(5) of this chapter.
271	271	26 (b) The arbitrator selected under subsection (a) shall determine
272	272	27 an amount that is fair compensation for the emergency ambulance
273	273	28 service provided to the covered individual according to the
274	274	29 following procedure:
275	275	30 (1) The nonparticipating ambulance service provider and the
276	276	31 health plan operator shall submit to the arbitrator the figure
277	277	32 each considers to be fair compensation for the emergency
278	278	33 ambulance service provided to the covered individual, along
279	279	34 with whatever additional information the nonparticipating
280	280	35 ambulance service provider and the health plan operator wish
281	281	36 to submit in support of the figure submitted.
282	282	37 (2) If the arbitrator, based on an analysis conducted under
283	283	38 subsection (c), determines that one (1) of the figures submitted
284	284	39 under subdivision (1) represents fair compensation for the
285	285	40 emergency ambulance service provided to the covered
286	286	41 individual, the arbitrator shall declare that figure to be fair
287	287	42 compensation.
288	288	2022 IN 135—LS 6436/DI 55 7
289	289	1 (3) If the arbitrator determines, based upon the figures and
290	290	2 information submitted under subdivision (1), that:
291	291	3 (A) a settlement between the health plan operator and the
292	292	4 nonparticipating ambulance service provider is reasonably
293	293	5 likely; or
294	294	6 (B) the figures submitted by the nonparticipating
295	295	7 ambulance service provider and the health plan operator
296	296	8 represent unreasonable extremes;
297	297	9 the arbitrator may direct both parties to resume negotiations
298	298	10 concerning the compensation for the emergency ambulance
299	299	11 service. The arbitrator may pause the dispute resolution
300	300	12 process under this section for not more than ten (10) business
301	301	13 days for negotiations under this subdivision. If the parties
302	302	14 reach a settlement through negotiations under this
303	303	15 subdivision, the dispute resolution process under this section
304	304	16 is concluded. If the parties do not reach a settlement through
305	305	17 negotiations under this subdivision, the dispute resolution
306	306	18 process shall continue under subdivision (4).
307	307	19 (4) If the arbitrator, based on an analysis conducted under
308	308	20 subsection (c), determines that neither of the figures
309	309	21 submitted under subdivision (1) represents fair compensation
310	310	22 for the emergency ambulance service provided to the covered
311	311	23 individual, and negotiations conducted under subdivision (3),
312	312	24 if any, do not result in a settlement of the ambulance fee
313	313	25 dispute, the arbitrator shall calculate an amount that
314	314	26 represents fair compensation for the emergency ambulance
315	315	27 service provided to the covered individual.
316	316	28 (c) In reaching a determination under subsection (b)(2) or
317	317	29 (b)(4), the arbitrator shall conduct an analysis according to the
318	318	30 following factors:
319	319	31 (1) Whether there is a gross disparity between:
320	320	32 (A) the figure submitted by the nonparticipating
321	321	33 ambulance service provider under subsection (b)(1); and
322	322	34 (B) fees paid by the health plan operator to participating
323	323	35 ambulance service providers for comparable emergency
324	324	36 ambulance service.
325	325	37 (2) The level of life support that the nonparticipating
326	326	38 ambulance service administered to the covered individual
327	327	39 before or during the transportation of the covered individual
328	328	40 in the ambulance.
329	329	41 (3) The distance that the nonparticipating ambulance service
330	330	42 transported the covered individual in the ambulance.
331	331	2022 IN 135—LS 6436/DI 55 8
332	332	1 (4) The usual charge of the nonparticipating ambulance
333	333	2 service for comparable emergency ambulance service.
334	334	3 (5) The circumstances and complexity of the emergency
335	335	4 ambulance service provided to the covered individual,
336	336	5 including the time and place of the service.
337	337	6 (6) The usual and customary cost of emergency ambulance
338	338	7 service in the particular geographical area in which the
339	339	8 nonparticipating ambulance service provided the emergency
340	340	9 ambulance service, as determined according to the rules
341	341	10 adopted under section 13(7) of this chapter.
342	342	11 (d) The arbitrator shall conclude an arbitration process under
343	343	12 this section not more than sixty (60) days after the selection of the
344	344	13 arbitrator under subsection (a).
345	345	14 (e) The determination of the arbitrator under subsection (b)(2)
346	346	15 or (b)(4):
347	347	16 (1) is binding on the health plan operator and the
348	348	17 nonparticipating ambulance service provider; and
349	349	18 (2) is admissible in any court proceeding between the health
350	350	19 plan operator and the nonparticipating ambulance service
351	351	20 provider.
352	352	21 (f) The health plan operator and the nonparticipating
353	353	22 ambulance service provider shall each pay fifty percent (50%) of
354	354	23 the compensation to be paid to the arbitrator according to the rules
355	355	24 adopted under section 13(2) of this chapter.
356	356	25 (g) The insurance commissioner appointed under IC 27-1-1-2
357	357	26 may:
358	358	27 (1) reprimand; or
359	359	28 (2) in the case of a health plan operator described in section
360	360	29 9(2) or 9(3) of this chapter, after notice and hearing under
361	361	30 IC 4-21.5:
362	362	31 (A) impose a civil penalty on; or
363	363	32 (B) suspend the certificate of authority of;
364	364	33 a health plan operator that refuses to compensate a
365	365	34 nonparticipating ambulance service provider in accordance with
366	366	35 the determination made by an arbitrator under subsection (b)(2)
367	367	36 or (b)(4), if the amount determined by the arbitrator under
368	368	37 subsection (b)(2) or (b)(4) to be fair compensation exceeds the
369	369	38 amount paid by the health plan operator under section 14(a) of this
370	370	39 chapter.
371	371	2022 IN 135—LS 6436/DI 55