SLS 23RS-353 ENGROSSED
2023 Regular Session
SENATE BILL NO. 109
BY SENATOR TALBOT
Prefiled pursuant to Article III, Section 2(A)(4)(b)(i) of the Constitution of Louisiana.
INSURANCE POLICIES. Provides for balance billing by and reimbursement of covered
health services provided by out-of-network emergency ambulance services. (8/1/23)
1 AN ACT
2 To enact R.S. 22:1880.2, relative to out-of-network emergency ambulance services
3 providing covered healthcare services; to provide for definitions; to provide
4 reimbursement for emergency ambulance service providers by health insurance
5 issuers; to provide for balance billing requirements for an out-of-network emergency
6 ambulance service providers; to provide for effectiveness; and to provide for related
7 matters.
8 Be it enacted by the Legislature of Louisiana:
9 Section 1. R.S. 22:1880.2 is hereby enacted to read as follows:
10 ยง1880.2. Payment of claims for covered healthcare services provided by out-of-
11 network care insurer of the enrollee receiving the covered
12 healthcare services; definitions
13 A. As used in this Section, the following definitions apply unless the
14 context indicates otherwise:
15 (1) "Ambulance service provider" means a ground ambulance service
16 provider as defined in R.S. 40:1131. For purposes of this Section, "ambulance
17 service provider" shall not include an air ambulance service provider.
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Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions. SB NO. 109
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1 (2) "Covered services" means those emergency ground ambulance
2 services which an enrollee is entitled to receive under the terms of a healthcare
3 benefit plan.
4 (3) "Enrollee" means a person who is entitled to receive covered
5 healthcare services under the terms of a healthcare benefit plan.
6 (4) "Healthcare benefit plan" means a plan, policy, contract, certificate,
7 agreement, or other evidence of coverage for healthcare services offered, issued,
8 renewed, or extended in this state by a healthcare insurer.
9 (5) "Healthcare insurer" means an entity that is subject to state
10 insurance regulation and provides coverage for health benefits in this state and
11 includes the following:
12 (a) An insurance company.
13 (b) A health maintenance organization.
14 (c) A hospital and medical service corporation.
15 (d) A risk-based provider organization.
16 (e) A sponsor of self-funded governmental plan.
17 (f) "Out-of-network" means a provider that does not contract with the
18 healthcare insurer of the enrollee receiving the covered healthcare services.
19 (6) "Clean claim" means a claim that has no defect of impropriety,
20 including any lack of required substantiating documentation or particular
21 circumstances requiring special treatment that prevents timely payment from
22 being made on the claim.
23 B. The minimum allowable reimbursement rate under any healthcare
24 benefit plan issued by any healthcare insurer to an out-of-network ambulance
25 service provider for providing emergency services shall be one of the following
26 items:
27 (1) At the rates set or approved, whether in contract or ordinance, by a
28 local governmental entity in the jurisdiction in which the covered healthcare
29 services originate, or as provided for in R.S. 33:4791.
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Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions. SB NO. 109
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1 (2) In the absence of rates as provided in Paragraph (1) of Subsection B
2 of this Section, the minimum allowable rate of reimbursement under any health
3 benefit plan issued by any healthcare insurer shall be three hundred twenty-five
4 percent of the current published rate for ambulance services as established by
5 the Centers for Medicare and Medicaid Services under Title XVIII of the Social
6 Security Act for the same service provided in the same geographic area; or the
7 ambulance service provider's billed charges, whichever is less.
8 C. Payment made in compliance with this Section shall be considered
9 payment in full for the covered services provided, except for any copayment,
10 coinsurance, deductible and other cost-sharing feature amounts required to be
11 paid by the enrollee. An ambulance service provider is prohibited from billing
12 the enrollee for any additional amounts for paid covered services.
13 D. All copayment, coinsurance, deductible and other cost-sharing feature
14 amounts provided by Subsection B of this Section shall not exceed the in
15 network copayment, coinsurance, deductible and other cost-sharing features for
16 the covered healthcare services received by the enrollee.
17 E. A healthcare insurer shall, within thirty days after receipt of a clean
18 claim for covered services, promptly remit payment for ambulance services
19 directly to the ambulance service provider and shall not send payment to an
20 enrollee.
21 F. If the claim is not a clean claim, the healthcare insurer shall, within
22 thirty days after receipt of the claim, send a written notice acknowledging the
23 date of the receipt of the claim and shall provide one of the following items:
24 (1) That the insurer is declining to pay all or part of the claim and the
25 specific reason or reasons for the denial.
26 (2) That additional information is necessary to determine if all or part
27 of the claim is payable and the specific additional information that is required.
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Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions. SB NO. 109
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The original instrument and the following digest, which constitutes no part
of the legislative instrument, were prepared by Beth O'Quin.
DIGEST
SB 109 Engrossed 2023 Regular Session Talbot
Proposed law provides definitions for ambulance service provider, clean claim, covered
services, enrollee, healthcare benefit plan, healthcare insurer, and out-of-network.
Proposed law requires the minimum allowable reimbursement rate under any healthcare
benefit plan issued by a healthcare insurer to an out-of-network ambulance service provider
is one of the following:
(1)At the rates set or approved, whether in contract or ordinance, by a local
governmental entity in the jurisdiction in which the covered healthcare services
originate, or as provided by law.
(2)Requires if no rates have been set or approved, the minimum allowable rate of
reimbursement under any health benefit plan issued by any healthcare insurer is
325% of the current published rate for ambulance services as established by the
Centers for Medicare and Medicaid Services for the same service provided in the
same geographic area or the ambulance service provider's billed charges, whichever
is less.
Effective August 1, 2023.
(Adds R.S. 22:1880.2)
Summary of Amendments Adopted by Senate
Committee Amendments Proposed by Senate Committee on Insurance to the original
bill
1. Provides an air ambulance is not included as an ambulance service provider.
2. Provides definitions for a "clean claim" and "covered services".
3. Makes technical changes.
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Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.