GENERAL ASSEMBLY OF NORTH CAROLINA
SESSION 2025
H 1
HOUSE BILL 489
Short Title: Insurance Coverage Emergency Ambulance Trans. (Public)
Sponsors: Representatives Loftis, Potts, Huneycutt, and Lambeth (Primary Sponsors).
For a complete list of sponsors, refer to the North Carolina General Assembly web site.
Referred to: Health, if favorable, Insurance, if favorable, Finance, if favorable, Rules,
Calendar, and Operations of the House
March 25, 2025
*H489 -v-1*
A BILL TO BE ENTITLED 1
AN ACT TO PROVIDE FO R A MINIMUM ALLOWABL E REIMBURSEMENT RATE 2
UNDER HEALTH BENEFIT PLANS FOR EMERGENCY AMBULANCE SERVICES 3
PROVIDED BY AN OUT-OF-NETWORK AMBULANCE SERVICE PROVIDER. 4
The General Assembly of North Carolina enacts: 5
SECTION 1.(a) G.S. 58-3-190 reads as rewritten: 6
"§ 58-3-190. Coverage required for emergency care. 7
(a) Every insurer shall provide coverage for emergency services to the extent necessary 8
to screen and to stabilize the person covered under the plan or to transport the covered person to 9
a medically appropriate location for screening and stabilization and shall not require prior 10
authorization of the services if a prudent layperson acting reasonably would have believed that 11
an emergency medical condition existed. Payment of claims for emergency services shall be 12
based on the retrospective review of the presenting history and symptoms of the covered person. 13
(b) With respect to emergency services provided by a health care provider who is not 14
under contract with the insurer, the services shall be covered if:if any of the following criteria are 15
met: 16
(1) A prudent layperson acting reasonably would have believed that a delay would 17
worsen the emergency, oremergency. 18
(2) The covered person did not seek services from a provider under contract with 19
the insurer because of circumstances beyond the control of the covered person. 20
(3) The covered person did not have a choice in the ground ambulance 21
transportation service provider due to the emergency. 22
… 23
(d) Coverage of emergency services shall may be subject to coinsurance, co-payments, 24
and deductibles applicable under the health benefit plan. An insurer shall not impose cost-sharing 25
for emergency services provided under this section section, including emergency ambulance 26
transportation services, that differs from the cost-sharing that would have been imposed if the 27
physician or provider furnishing the services were a provider contracting with the insurer. 28
… 29
(g) As used in this section, the term:The following definitions apply in this section: 30
(1) Covered person. – An individual who is enrolled in a health benefit plan and 31
entitled to receive the benefits and services covered by that particular health 32
benefit plan. 33 General Assembly Of North Carolina Session 2025
Page 2 House Bill 489-First Edition
(1a) "Emergency Emergency medical condition" means a condition. – A medical 1
condition manifesting itself by acute symptoms of sufficient severity, 2
including, but not limited to, severe pain, or by acute symptoms developing 3
from a chronic medical condition that would lead a prudent layperson, 4
possessing an average knowledge of health and medicine, to reasonably 5
expect the absence of immediate medical attention to result in any of the 6
following: 7
a. Placing the health of an individual, or with respect to a pregnant 8
woman, the health of the woman or her unborn child, in serious 9
jeopardy. 10
b. Serious impairment to bodily functions. 11
c. Serious dysfunction of any bodily organ or part. 12
(1b) Emergency medical transportation. – An emergency response, as defined 13
under 42 C.F.R. § 414.605, and includes all of the following: 14
a. Transportation to a healthcare facility. 15
b. Ground ambulance transportation between two healthcare facilities 16
"interfacility" transportation, when the transportation is being 17
provided to the covered person because the needed medical care to 18
treat the covered person's medical condition is not available at the 19
current healthcare facility. 20
c. Emergency medical services that resulted with a medical evaluation 21
being provided to the covered person without the covered person being 22
transported to an emergency department. 23
(2) "Emergency services" means health care Emergency services. – Healthcare 24
items and services furnished or required to screen for or treat an emergency 25
medical condition until the condition is stabilized, including prehospital care 26
care, ambulance transportation services, and ancillary services routinely 27
available to the emergency department. 28
… 29
(4b) Out-of-network provider. – A provider that does not contract with the insurer 30
of the health benefit plan under which a covered person is receiving services 31
from that provider is enrolled. 32
(5) "To stabilize" means to Stabilize. – To provide medical care that is appropriate 33
to prevent a material deterioration of the person's condition, within reasonable 34
medical probability, in accordance with the HCFA (Health Care Financing 35
Administration) Centers for Medicare and Medicaid Services interpretative 36
guidelines, policies and regulations pertaining to responsibilities of hospitals 37
in emergency cases (as cases, as provided under the Emergency Medical 38
Treatment and Labor Act, section 1867 of the Social Security Act, 42 U.S.C.S. 39
1395dd), including medically necessary services and supplies to maintain 40
stabilization until the person is transferred.42 U.S.C.S. 1395dd. 41
(h) The minimum allowable reimbursement rate under any health benefit plan for 42
emergency medical transportation services provided by an ambulance service provider that shall 43
be paid to an out-of-network ambulance service provider is one hundred percent (100%) of the 44
rate set or approved, either by contract or in ordinance, by a local governmental entity established 45
pursuant to G.S. 153A-250 in the jurisdiction in which the ambulance services originated. In the 46
absence of a rate set or approved by a local governmental entity, the minimum allowable 47
reimbursement rate under this subsection is the lesser of the following amounts: 48
(1) Four hundred percent (400%) of the most recent published Medicare rate for 49
the ambulance service or services by the Centers for Medicare and Medicaid 50 General Assembly Of North Carolina Session 2025
House Bill 489-First Edition Page 3
Services under Title XVIII of the Social Security Act for the same services 1
provided in the same geographic area. 2
(2) The out-of-network ambulance service provider's billed charges. 3
(i) All of the following apply to emergency medical transportation services provided by 4
an ambulance service provider: 5
(1) Payment by an insurer that is in compliance with subsection (h) of this section 6
is considered payment in full by that insurer for the covered services. This 7
subdivision does not preclude the billing for, or collection of, any copayment, 8
coinsurance, deductible, and other cost-sharing feature amounts required to be 9
paid by the covered person. 10
(2) An insurer shall promptly remit payment for emergency medical 11
transportation services directly to the ambulance services provider, regardless 12
of the network status of that provider. An insurer shall not send any payments 13
for the reimbursement of these services to a covered person. 14
(3) An insurer shall not impose upon a covered person any cost-sharing 15
requirement for emergency transportation services that exceeds the lesser of 16
the following amounts: 17
a. One hundred dollars ($100.00). 18
b. Ten percent (10%) of the minimum allowable reimbursement rate 19
amount required to be paid by the insurer established under subsection 20
(h) of this section. 21
(j) Nothing in this section shall be construed to prevent a self-funded group plan 22
regulated under the Employee Retirement Income Security Act (ERISA) from opting into the 23
provisions of this section." 24
SECTION 1.(b) Subdivisions (3) and (4) of G.S. 58-3-190 are repealed. 25
SECTION 2. Section 1(a) of this act is effective October 1, 2025, applies to 26
insurance contracts issued, renewed, or amended on or after that date and ambulance services 27
provided on or after that date. The remainder of this act is effective when it becomes law. 28