HLS 18RS-618 ORIGINAL
2018 Regular Session
HOUSE BILL NO. 439
BY REPRESENTATIVE TALBOT
INSURANCE/HEALTH: Provides relative to insurance claims for air ambulance services
1 AN ACT
2To enact Subpart E of Part II of Chapter 6 of Title 22 of the Revised Statutes of 1950, to be
3 comprised of R.S. 22:1885.1 through 1885.6, relative to insurance coverage for air
4 ambulance services; to provide for legislative findings; to provide for purpose and
5 scope; to provide for definitions; to provide for payment of air ambulance claims; to
6 prohibit balance billing for out-of-network air ambulance services; to establish a
7 process for independent dispute resolution; and to provide for related matters.
8Be it enacted by the Legislature of Louisiana:
9 Section 1. Subpart E of Part II of Chapter 6 of Title 22 of the Revised Statutes of
101950, comprised of R.S. 22:1885.1 through 1885.6, is hereby enacted to read as follows:
11 SUBPART E. AIR AMBULANCE INSURANCE CLAIMS
12 §1885.1. Legislative findings; purpose; scope
13 A. The legislature finds all of the following:
14 (1) Air ambulance services provide a necessary, and sometimes lifesaving,
15 means of transporting medical patients in both emergency and nonemergency
16 situations.
17 (2) Adequate access to air ambulance services is essential.
18 (3) In some cases, the difference between charges assessed by
19 out-of-network air ambulance service providers and reimbursements by consumers'
20 health benefit plans have resulted in high balance bills to consumers.
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1 (4) The federal Airline Deregulation Act preempts states from enacting any
2 law related to a price, route, or service of an air carrier, which has been interpreted
3 by some courts as applying to air ambulance service provider charges.
4 B. The purpose of this Subpart is to protect consumers who are covered by
5 commercial insurance from overall disproportionate financial responsibility and
6 liability for using out-of-network air ambulance services instead of in-network air
7 ambulance services in an emergency situation, including balance bills from
8 out-of-network air ambulance service providers in a manner that is not preempted
9 by the federal Employee Retirement Income Security Act of 1974 or the Airline
10 Deregulation Act.
11 C. This Subpart applies to all health insurance issuers licensed, operating,
12 or otherwise doing business in this state and licensed air ambulance service
13 providers.
14 §1885.2. Definitions
15 As used in this Subpart, the following meanings apply:
16 (1) "Balance bill" and "balance billing" means the difference between the
17 amount charged by an air ambulance service provider and any amount paid by a
18 health benefit plan plus the covered person’s copayment, deductible, or coinsurance
19 amount applicable to a specific air ambulance transport.
20 (2) "Commissioner" means the commissioner of insurance.
21 (3) "Covered person" means an individual covered by a health benefit plan
22 issued by a health insurance issuer licensed, operating, or otherwise authorized to do
23 business in this state.
24 (4) "Department" means the Department of Insurance.
25 (5) "Disputed air ambulance service provider charge" means the amount
26 remaining after payment by a health benefit plan of the amount provided for in R.S.
27 22:1885.4.
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1 (6)(a) "Health benefit plan" means a policy, contract, certificate, or
2 agreement entered into, offered, or issued to provide, deliver, arrange for, pay for,
3 or reimburse any of the costs of healthcare services.
4 (b) "Health benefit plan" shall include health benefit plans issued by health
5 insurance issuers as well as self-funded health benefit plans.
6 (c) "Health benefit plan" shall not include any of the following:
7 (i) Managed care programs operating as part of the Louisiana medical
8 assistance program.
9 (ii) Medicaid.
10 (iii) LaCHIP.
11 (iv) Medicare.
12 (v) Excepted benefit products as defined in 42 U.S.C. 300gg-91(c).
13 (7) "Health insurance issuer" means an entity subject to the insurance laws
14 and regulations of this state, or subject to the jurisdiction of the commissioner, that
15 contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse
16 any of the costs of healthcare services, including through a health benefit plan as
17 defined in this Section. "Health insurance issuer" shall include a sickness and
18 accident insurance company, a health maintenance organization, a preferred provider
19 organization or any similar entity, or any other entity providing a plan of health
20 insurance or health benefits.
21 (8) "LaCHIP" means the state child health plan administered by the
22 Louisiana Department of Health pursuant to R.S. 46:976.
23 (9) "Medicaid" and "medical assistance program" mean the medical
24 assistance program provided for in Title XIX of the federal Social Security Act as
25 administered by the Louisiana Department of Health.
26 (10) "Medicare" means coverage under Title XVIII of the federal Social
27 Security Act, 42 U.S.C. 1395 et seq., as amended.
28 (11) "Program" means the program of independent dispute resolution for
29 disputed air ambulance service charges established pursuant to this Subpart.
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1 (12) "Registered air ambulance service provider" means an air ambulance
2 service provider licensed by the Louisiana Department of Health that has registered
3 with the Department of Insurance to participate in the voluntary dispute resolution
4 process established pursuant to this Subpart.
5 §1885.3. Reimbursement; network adequacy; medical necessity
6 A. A health benefit plan that does not have an adequate network of air
7 ambulance service providers in this state shall not use an allowed amount for air
8 ambulance reimbursement that is less than the applicable average rates published by
9 registered air ambulance service providers. The department shall determine the
10 average rates on an annual basis.
11 B. For purposes of this Subpart, a patient transport shall be deemed to be
12 medically necessary by health benefit plans if requested by a neutral third party
13 licensed or certified medical professional or first responder and determined by that
14 neutral third party licensed or certified medical professional or first responder to be
15 conducted by an air ambulance service provider without regard to the patient's ability
16 to pay.
17 §1885.4. Hold harmless
18 A. If a covered person, after being picked up in this state, receives services
19 from a registered air ambulance service provider that is not part of the covered
20 person's health benefit plan's network, the health benefit plan shall assume the
21 covered person's responsibility for amounts charged by the registered air ambulance
22 service provider other than any applicable copayments, coinsurance, and deductibles.
23 B. A health benefit plan that has assumed a covered person's responsibility
24 as required pursuant to Subsection A of this Section shall notify the air ambulance
25 service of that assumption no later than the date the health benefit plan issues
26 payment pursuant to Subsection D of this Section.
27 C. If a registered air ambulance service provider receives notice pursuant to
28 Subsection B of this Section, with the exception of amounts owed for applicable
29 copayments, coinsurance, and deductibles, the registered air ambulance service shall
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1 not do any of the following in connection with the amount assumed by the health
2 benefit plan pursuant to Subsection A of this Section:
3 (1) Bill, collect, or attempt to collect from the covered person.
4 (2) Report to a consumer reporting agency that the covered person is
5 delinquent.
6 (3) Obtain a lien on the covered person's property.
7 (4) Take any other action adverse to the covered person.
8 D.(1) Subject to the provisions of the covered person's health benefit plan
9 contract, a health benefit plan is responsible for payment directly to the air
10 ambulance service provider or denial of a claim for air ambulance services within
11 thirty days after receipt of a proof of loss. Within this time frame, the health benefit
12 plan shall notify the covered person and the registered air ambulance service
13 provider of the amount of deductible, coinsurance, or copayment that is the covered
14 person's responsibility to pay.
15 (2) The health benefit plan responsible pursuant to Subsection A of this
16 Section shall make payment based on any of the following:
17 (a) The billed charges of the registered air ambulance service.
18 (b) Another amount negotiated with the registered air ambulance service.
19 (c) The maximum amount the health benefit plan would pay to an in-network
20 air ambulance service provider for the services performed, unless R.S. 22:1885.3(A)
21 is applicable, in which case the average amount as determined by the department.
22 E. If, after payment is made pursuant to Paragraph (D)(2) of this Section, the
23 health benefit plan or registered air ambulance service provider disputes the
24 reasonableness of that payment, the health benefit plan or registered air ambulance
25 service provider shall invoke the independent dispute resolution process established
26 pursuant to this Subpart, if good-faith settlement negotiations fail to resolve the
27 dispute.
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1 §1885.5. Independent dispute resolution program; registration; reporting
2 A.(1) The department shall establish and administer a program of
3 independent dispute resolution for disputed air ambulance service charges.
4 (2) The department shall promulgate rules, forms, and procedures for the
5 implementation and administration of the program.
6 (3) The department may charge any fees necessary to cover the costs of
7 implementation and administration.
8 (4) The department shall maintain a list of qualified reviewers.
9 B.(1)(a) By January 1 of each year, air ambulance service providers wishing
10 to participate in the independent dispute resolution program established pursuant to
11 this Section shall register with the department in a manner and providing all
12 information as required by the department.
13 (b) Registration shall automatically renew quarterly unless the registered air
14 ambulance service provider gives notice to the department of the intent to not renew
15 the registration not less than thirty days prior to the end of the quarter.
16 (c) All disputed charges incurred during the quarter of a registered air
17 ambulance service provider's registration shall be subject to independent dispute
18 resolution.
19 (2) An air ambulance service provider who registers with the department
20 pursuant to this Section shall acknowledge that, notwithstanding the federal Airline
21 Deregulation Act, the air ambulance service provider voluntarily agrees to participate
22 in the independent dispute resolution program established pursuant to this Section.
23 The voluntary agreement shall constitute a waiver of the air ambulance service
24 provider's ability to challenge the program based on the federal Airline Deregulation
25 Act with respect to disputed charges subject to independent dispute resolution
26 pursuant to Subsection B of this Section.
27 (3) As a further condition of participation in the program, the registered air
28 ambulance provider shall do both of the following:
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1 (a) Publish the air ambulance transport rates charged by the air ambulance
2 provider in this state.
3 (b) Provide de-identified, itemized billings for each of the air ambulance
4 provider's transports in this state.
5 (4) The department shall keep and maintain records of each independent
6 dispute resolution proceeding.
7 (5)(a) The department shall analyze the results of the independent dispute
8 resolution proceedings, as well as the information submitted pursuant to Paragraph
9 (3) of this Subsection each year.
10 (b) The department shall issue a report annually, the contents of which shall
11 include but not be limited to all of the following:
12 (i) The overall aggregate statistics of the program for the year.
13 (ii) The de-identified results of all disputes decided by each independent
14 reviewer through the program.
15 (iii) The number of disputes settled between the parties.
16 (iv) An analysis of financial and market trends of the air ambulance service
17 provider claims.
18 (v) Recommended changes to improve the program.
19 (6) The report shall be made public through, at minimum, posting on the
20 website of the department.
21 C.(1) The sole issue to be considered and determined in an independent
22 dispute resolution proceeding is the reasonable charge for the air ambulance service
23 provided.
24 (2) The basis for this determination shall include but not be limited to the
25 overall fixed and variable cost for providing the air ambulance services including all
26 of the following:
27 (a) Costs of maintaining aircraft, hangar, and crew facilities.
28 (b) Compensation for pilots and flight crew, taking into consideration
29 training and qualifications.
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1 (c) Overhead.
2 (d) Insurance.
3 (e) Fuel.
4 (f) Costs attributable to any medical services provided in-flight.
5 (g) Costs associated with maintaining continuous readiness.
6 (h) The cost of uncompensated care and undercompensated care.
7 (i) A reasonable profit.
8 §1885.6. Independent dispute resolution; procedures
9 A. Either the registered air ambulance service provider or the health benefit
10 plan may request adjudication of a disputed charge by submitting a request for
11 independent dispute resolution on forms or in any manner as prescribed by the
12 department. The request shall include the amount in dispute and a brief description
13 of the service provided. The requesting party shall copy the other party on the
14 submission to the department.
15 B. The commissioner shall establish an application process and fee schedule
16 for independent reviewers.
17 C. If the parties have not designated an independent reviewer by mutual
18 agreement within thirty days of the request for independent dispute resolution, the
19 commissioner shall select an independent reviewer from the department's list of
20 qualified reviewers.
21 D.(1) To be eligible to serve as an independent reviewer, an individual shall
22 be knowledgeable and experienced in applicable principles of contract and insurance
23 law and the healthcare industry generally.
24 (2)(a) In approving an individual as an independent reviewer, the
25 commissioner shall ensure that the individual does not have a conflict of interest that
26 would adversely impact the individual's independence and impartiality in rendering
27 a decision in an independent dispute resolution procedure.
28 (b) A conflict of interest shall include but is not limited to current or recent
29 ownership or employment of either the individual or a close family member in a
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1 health benefit plan, a healthcare provider, or an air ambulance service provider that
2 may be involved in an independent dispute resolution procedure.
3 (3) The commissioner shall immediately terminate the approval of an
4 independent reviewer who no longer meets the requirements to serve as an
5 independent reviewer.
6 E.(1) Either party to an independent dispute resolution proceeding may
7 request an oral hearing.
8 (2) If no oral hearing is requested, the independent reviewer shall set a date
9 for the submission of all information to be considered by the independent reviewer.
10 (3) Each party to the independent dispute resolution shall submit a binding
11 award amount. The independent reviewer shall choose one party's or the other's
12 binding award amount based on which amount the independent reviewer determines
13 to be closest to the reasonable charge for air ambulance services provided in
14 accordance with R.S. 22:1885.5(C), with no deviation.
15 (4) If an oral hearing is requested, the independent reviewer may make
16 procedural rulings.
17 (5) There shall be no discovery in independent dispute resolution
18 proceedings conducted pursuant to this Subpart.
19 (6) The independent reviewer shall issue a written decision within ten days
20 of submission or hearing.
21 F. Unless otherwise agreed by the parties, each party shall do all of the
22 following:
23 (1) Bear the party's own attorney fees and costs.
24 (2) Equally bear all fees and costs of the independent reviewer.
25 G. The decision of the independent reviewer shall be final and binding on
26 the parties. The prevailing party may seek enforcement of the independent
27 reviewer's decision in any court of competent jurisdiction.
28 Section 2. The provisions of this Act shall apply to all new policies, plans,
29certificates, and contracts issued on or after January 1, 2019. Existing policies, plans,
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1certificates, and contracts shall include the coverage required by this Act on renewal thereof,
2but in no case later than January 1, 2019.
DIGEST
The digest printed below was prepared by House Legislative Services. It constitutes no part
of the legislative instrument. The keyword, one-liner, abstract, and digest do not constitute
part of the law or proof or indicia of legislative intent. [R.S. 1:13(B) and 24:177(E)]
HB 439 Original 2018 Regular Session Talbot
Abstract: Prohibits balance billing for out-of-network air ambulance services and
establishes an independent dispute resolution process for reimbursement claims.
Proposed law establishes legislative findings and the purpose and scope of proposed law.
Proposed law defines "balance billing", "covered person", "disputed air ambulance service
provider charge", "health benefit plan", and "registered air ambulance service provider".
Proposed law prohibits a health benefit plan that does not have an adequate network of air
ambulance service providers in this state from using an allowed amount for air ambulance
reimbursement that is less than the applicable average rates published by registered air
ambulance service providers.
Proposed law requires a health benefit plan, if a covered person receives services from a
registered air ambulance service provider that is not part of the health benefit plan's network,
to assume the covered person's responsibility for amounts charged by the registered air
ambulance service provider other than any applicable copayments, coinsurance, and
deductibles.
Proposed law prohibits, with the exception of amounts owed for applicable copayments,
coinsurance, and deductibles, the registered air ambulance service from doing any of the
following in connection with the amount assumed by the health benefit plan:
(1)Bill, collect, or attempt to collect from the covered person..
(2)Report to a consumer reporting agency that the covered person is delinquent.
(3)Obtain a lien on the covered person's property..
(4)Take any other action adverse to the covered person.
Proposed law requires the health benefit plan to make payment based on any of the
following:
(1)The billed charges of the registered air ambulance service.
(2)Another amount negotiated with the registered air ambulance service.
(3)The maximum amount the health benefit plan would pay to an in-network air
ambulance service provider for the services performed, unless the plan fails to have
an adequate network of air ambulance providers, in which case the average amount
as determined by the Dept. of Insurance (DOI).
Proposed law authorizes a health benefit plan or registered air ambulance service provider
who disputes the reasonableness of a payment to invoke the independent dispute resolution
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process established pursuant to proposed law, if good-faith settlement negotiations fail to
resolve the dispute.
Proposed law requires DOI to establish and administer a program of independent dispute
resolution for disputed air ambulance service charges. Proposed law authorizes DOI to
charge any fees necessary to cover the costs of implementation and administration.
Proposed law requires DOI to maintain a list of qualified reviewers.
Proposed law requires an air ambulance service provider wishing to participate in the
independent dispute resolution program to register with DOI. Proposed law provides that
registration shall automatically renew quarterly unless the registered air ambulance service
provider gives notice of the intent to not renew the registration not less than 30 days prior
to the end of the quarter.
Proposed law provides that all disputed charges incurred during the quarter of a registered
air ambulance service provider's registration shall be subject to independent dispute
resolution.
Proposed law requires a registered air ambulance provider to publish the air ambulance
transport rates charged by the air ambulance provider in this state and to provide
de-identified, itemized billings for each of the air ambulance provider's transports in this
state.
Proposed law requires DOI to keep and maintain records of each independent dispute
resolution proceeding and to analyze the results of the independent dispute resolution
proceedings. Proposed law further requires DOI to publish on its website an annual report
concerning statistics of the program.
Proposed law limits the sole issue to be considered and determined in an independent dispute
resolution proceeding to the reasonable charge for the air ambulance service provided based
upon the overall fixed and variable cost for providing the air ambulance services.
Proposed law permits either the registered air ambulance service provider or the health
benefit plan to request adjudication of a disputed charge by submitting a request for
independent dispute resolution to DOI.
Proposed law requires DOI, if the parties have not designated an independent reviewer by
mutual agreement within 30 days of the request for independent dispute resolution, to select
an independent reviewer from the department's list of qualified reviewers.
Proposed law requires an individual acting as an independent reviewer to be knowledgeable
and experienced in applicable principles of contract and insurance law and the healthcare
industry generally and prohibits an individual with a conflict of interest that would adversely
impact the individual's independence and impartiality.
Proposed law establishes the procedures for an independent dispute resolution proceeding.
Proposed law provides that the decision of the independent reviewer shall be final and
binding on the parties and the prevailing party may seek enforcement of the independent
reviewer's decision in any court of competent jurisdiction.
Proposed law applies to all new policies, plans, certificates, and contracts issued on or after
Jan. 1, 2019. Existing policies, plans, certificates, and contracts shall include the coverage
required by proposed law on renewal, but in no case later than Jan. 1, 2019.
(Adds R.S. 22:1885.1-1885.6)
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