2023 Regular Session ENROLLED
SENATE BILL NO. 109
BY SENATOR TALBOT
Prefiled pursuant to Article III, Section 2(A)(4)(b)(i) of the Constitution of Louisiana.
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 providers by health insurance issuers; to
5 provide for balance billing requirements for out-of-network emergency ambulance
6 providers; to provide for effectiveness; and to provide for related matters.
7 Be it enacted by the Legislature of Louisiana:
8 Section 1. R.S. 22:1880.2 is hereby enacted to read as follows:
9 ยง1880.2. Payment of claims for covered healthcare services provided by out-of-
10 network care insurer of the enrollee receiving the covered
11 healthcare services; definitions
12 A. As used in this Section, the following definitions apply unless the
13 context indicates otherwise:
14 (1) "Ambulance provider" means an ambulance provider as defined in
15 R.S. 40:1131. For purposes of this Section, "ambulance provider" does not
16 include an air ambulance provider.
17 (2) "Clean claim" means a claim that has no defect of impropriety,
18 including any lack of required substantiating documentation or particular
19 circumstances requiring special treatment that prevents timely payment from
20 being made on the claim.
21 (3) "Covered services" means those emergency ambulance services
22 which an enrollee is entitled to receive under the terms of a healthcare benefit
23 plan.
24 (4) "Enrollee" means a person who is entitled to receive covered
25 healthcare services under the terms of a healthcare benefit plan.
ACT No. 453
Page 1 of 3
Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions. SB NO. 109 ENROLLED
1 (5) "Healthcare benefit plan" means a plan, policy, contract, certificate,
2 agreement, or other evidence of coverage for healthcare services offered, issued,
3 renewed, or extended in this state by a healthcare insurer.
4 (6) "Healthcare insurer" means an entity that is subject to state
5 insurance regulation and provides coverage for health benefits in this state and
6 includes the following:
7 (a) An insurance company.
8 (b) A health maintenance organization.
9 (c) A hospital and medical service corporation.
10 (d) A risk-based provider organization.
11 (e) A sponsor of self-funded governmental plan.
12 (7) "Out-of-network" means a provider that does not contract with the
13 healthcare insurer of the enrollee receiving the covered healthcare services.
14 B. The minimum allowable reimbursement rate under any healthcare
15 benefit plan issued by any healthcare insurer to an out-of-network ambulance
16 provider for providing emergency services shall be one of the following items:
17 (1) At the rates set or approved, whether in contract or ordinance, by a
18 local governmental entity in the jurisdiction in which the covered healthcare
19 services originate, or as provided for in R.S. 33:4791.
20 (2) In the absence of rates as provided in Paragraph (1) of this
21 Subsection, the minimum allowable rate of reimbursement under any health
22 benefit plan issued by any healthcare insurer shall be three hundred twenty-five
23 percent of the current published rate for ambulance services as established by
24 the Centers for Medicare and Medicaid Services under Title XVIII of the Social
25 Security Act for the same service provided in the same geographic area; or the
26 ambulance provider's billed charges, whichever is less.
27 C. Payment made in compliance with this Section shall be considered
28 payment in full for the covered services provided, except for any copayment,
29 coinsurance, deductible, and other cost-sharing amounts required to be paid by
30 the enrollee. An ambulance provider is prohibited from billing the enrollee for
Page 2 of 3
Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions. SB NO. 109 ENROLLED
1 any additional amounts for paid covered services.
2 D. All copayment, coinsurance, deductible, and other cost-sharing
3 amounts provided by Subsection C of this Section shall not exceed the in-
4 network copayment, coinsurance, deductible, and other cost-sharing amounts
5 for the covered healthcare services received by the enrollee.
6 E. A healthcare insurer shall, within thirty days after receipt of a clean
7 claim for covered services, promptly remit payment for ambulance services
8 directly to the ambulance provider and shall not send payment to an enrollee.
9 F. If the claim is not a clean claim, the healthcare insurer shall, within
10 thirty days after receipt of the claim, send a written notice acknowledging the
11 date of the receipt of the claim and shall provide one of the following items:
12 (1) That the insurer is declining to pay all or part of the claim and the
13 specific reason or reasons for the denial.
14 (2) That additional information is necessary to determine if all or part
15 of the claim is payable and the specific additional information that is required.
PRESIDENT OF THE SENATE
SPEAKER OF THE HOUSE OF REPRESENTATIVES
GOVERNOR OF THE STATE OF LOUISIANA
APPROVED:
Page 3 of 3
Coding: Words which are struck through are deletions from existing law;
words in boldface type and underscored are additions.