North Carolina 2025-2026 Regular Session

North Carolina House Bill H489 Compare Versions

Version 1 (Old)

Version 2 (New)

Old	New		Differences
1	1		GENERAL ASSEMBLY OF NORTH CAROLINA
2	2		SESSION 2025
3		-	H 1
4		-	HOUSE BILL 489
	3	+	H D
	4	+	HOUSE BILL DRH10236-MR-97
	5	+
5	6
6	7
7	8		Short Title: Insurance Coverage Emergency Ambulance Trans. (Public)
8		-	Sponsors: Representatives Loftis, Potts, Huneycutt, and Lambeth (Primary Sponsors).
9		-	For a complete list of sponsors, refer to the North Carolina General Assembly web site.
10		-	Referred to: Health, if favorable, Insurance, if favorable, Finance, if favorable, Rules,
11		-	Calendar, and Operations of the House
12		-	March 25, 2025
13		-	H489 -v-1
	9	+	Sponsors: Representative Loftis.
	10	+	Referred to:
	11	+
	12	+	DRH10236 -MR-97
14	13		A BILL TO BE ENTITLED 1
15	14		AN ACT TO PROVIDE FOR A MINIMUM ALLOWABLE REIMBURSEMENT RATE 2
16	15		UNDER HEALTH BENEFIT PLANS FOR EMERGENCY AMBULANCE SERVICES 3
17	16		PROVIDED BY AN OUT-OF-NETWORK AMBULANCE SERVICE PROVIDER. 4
18	17		The General Assembly of North Carolina enacts: 5
19	18		SECTION 1.(a) G.S. 58-3-190 reads as rewritten: 6
20	19		"§ 58-3-190. Coverage required for emergency care. 7
21	20		(a) Every insurer shall provide coverage for emergency services to the extent necessary 8
22	21		to screen and to stabilize the person covered under the plan or to transport the covered person to 9
23	22		a medically appropriate location for screening and stabilization and shall not require prior 10
24	23		authorization of the services if a prudent layperson acting reasonably would have believed that 11
25	24		an emergency medical condition existed. Payment of claims for emergency services shall be 12
26	25		based on the retrospective review of the presenting history and symptoms of the covered person. 13
27	26		(b) With respect to emergency services provided by a health care provider who is not 14
28	27		under contract with the insurer, the services shall be covered if:if any of the following criteria are 15
29	28		met: 16
30	29		(1) A prudent layperson acting reasonably would have believed that a delay would 17
31	30		worsen the emergency, oremergency. 18
32	31		(2) The covered person did not seek services from a provider under contract with 19
33	32		the insurer because of circumstances beyond the control of the covered person. 20
34	33		(3) The covered person did not have a choice in the ground ambulance 21
35	34		transportation service provider due to the emergency. 22
36	35		… 23
37	36		(d) Coverage of emergency services shall may be subject to coinsurance, co-payments, 24
38	37		and deductibles applicable under the health benefit plan. An insurer shall not impose cost-sharing 25
39	38		for emergency services provided under this section section, including emergency ambulance 26
40	39		transportation services, that differs from the cost-sharing that would have been imposed if the 27
41	40		physician or provider furnishing the services were a provider contracting with the insurer. 28
42	41		… 29
43	42		(g) As used in this section, the term:The following definitions apply in this section: 30
44	43		(1) Covered person. – An individual who is enrolled in a health benefit plan and 31
45	44		entitled to receive the benefits and services covered by that particular health 32
46		-	benefit plan. 33 General Assembly Of North Carolina Session 2025
47		-	Page 2 House Bill 489-First Edition
48		-	(1a) "Emergency Emergency medical condition" means a condition. – A medical 1
49		-	condition manifesting itself by acute symptoms of sufficient severity, 2
50		-	including, but not limited to, severe pain, or by acute symptoms developing 3
51		-	from a chronic medical condition that would lead a prudent layperson, 4
52		-	possessing an average knowledge of health and medicine, to reasonably 5
53		-	expect the absence of immediate medical attention to result in any of the 6
54		-	following: 7
55		-	a. Placing the health of an individual, or with respect to a pregnant 8
56		-	woman, the health of the woman or her unborn child, in serious 9
57		-	jeopardy. 10
58		-	b. Serious impairment to bodily functions. 11
59		-	c. Serious dysfunction of any bodily organ or part. 12
60		-	(1b) Emergency medical transportation. – An emergency response, as defined 13
61		-	under 42 C.F.R. § 414.605, and includes all of the following: 14
62		-	a. Transportation to a healthcare facility. 15
63		-	b. Ground ambulance transportation between two healthcare facilities 16
64		-	"interfacility" transportation, when the transportation is being 17
65		-	provided to the covered person because the needed medical care to 18
66		-	treat the covered person's medical condition is not available at the 19
67		-	current healthcare facility. 20
68		-	c. Emergency medical services that resulted with a medical evaluation 21
69		-	being provided to the covered person without the covered person being 22
70		-	transported to an emergency department. 23
71		-	(2) "Emergency services" means health care Emergency services. – Healthcare 24
72		-	items and services furnished or required to screen for or treat an emergency 25
73		-	medical condition until the condition is stabilized, including prehospital care 26
74		-	care, ambulance transportation services, and ancillary services routinely 27
75		-	available to the emergency department. 28
76		-	… 29
77		-	(4b) Out-of-network provider. – A provider that does not contract with the insurer 30
78		-	of the health benefit plan under which a covered person is receiving services 31
79		-	from that provider is enrolled. 32
80		-	(5) "To stabilize" means to Stabilize. – To provide medical care that is appropriate 33
81		-	to prevent a material deterioration of the person's condition, within reasonable 34
82		-	medical probability, in accordance with the HCFA (Health Care Financing 35
83		-	Administration) Centers for Medicare and Medicaid Services interpretative 36
84		-	guidelines, policies and regulations pertaining to responsibilities of hospitals 37
85		-	in emergency cases (as cases, as provided under the Emergency Medical 38
86		-	Treatment and Labor Act, section 1867 of the Social Security Act, 42 U.S.C.S. 39
87		-	1395dd), including medically necessary services and supplies to maintain 40
88		-	stabilization until the person is transferred.42 U.S.C.S. 1395dd. 41
89		-	(h) The minimum allowable reimbursement rate under any health benefit plan for 42
90		-	emergency medical transportation services provided by an ambulance service provider that shall 43
91		-	be paid to an out-of-network ambulance service provider is one hundred percent (100%) of the 44
92		-	rate set or approved, either by contract or in ordinance, by a local governmental entity established 45
93		-	pursuant to G.S. 153A-250 in the jurisdiction in which the ambulance services originated. In the 46
94		-	absence of a rate set or approved by a local governmental entity, the minimum allowable 47
95		-	reimbursement rate under this subsection is the lesser of the following amounts: 48
96		-	(1) Four hundred percent (400%) of the most recent published Medicare rate for 49
97		-	the ambulance service or services by the Centers for Medicare and Medicaid 50 General Assembly Of North Carolina Session 2025
98		-	House Bill 489-First Edition Page 3
99		-	Services under Title XVIII of the Social Security Act for the same services 1
100		-	provided in the same geographic area. 2
101		-	(2) The out-of-network ambulance service provider's billed charges. 3
102		-	(i) All of the following apply to emergency medical transportation services provided by 4
103		-	an ambulance service provider: 5
104		-	(1) Payment by an insurer that is in compliance with subsection (h) of this section 6
105		-	is considered payment in full by that insurer for the covered services. This 7
106		-	subdivision does not preclude the billing for, or collection of, any copayment, 8
107		-	coinsurance, deductible, and other cost-sharing feature amounts required to be 9
108		-	paid by the covered person. 10
109		-	(2) An insurer shall promptly remit payment for emergency medical 11
110		-	transportation services directly to the ambulance services provider, regardless 12
111		-	of the network status of that provider. An insurer shall not send any payments 13
112		-	for the reimbursement of these services to a covered person. 14
113		-	(3) An insurer shall not impose upon a covered person any cost-sharing 15
114		-	requirement for emergency transportation services that exceeds the lesser of 16
115		-	the following amounts: 17
116		-	a. One hundred dollars ($100.00). 18
117		-	b. Ten percent (10%) of the minimum allowable reimbursement rate 19
118		-	amount required to be paid by the insurer established under subsection 20
119		-	(h) of this section. 21
120		-	(j) Nothing in this section shall be construed to prevent a self-funded group plan 22
121		-	regulated under the Employee Retirement Income Security Act (ERISA) from opting into the 23
122		-	provisions of this section." 24
123		-	SECTION 1.(b) Subdivisions (3) and (4) of G.S. 58-3-190 are repealed. 25
124		-	SECTION 2. Section 1(a) of this act is effective October 1, 2025, applies to 26
125		-	insurance contracts issued, renewed, or amended on or after that date and ambulance services 27
126		-	provided on or after that date. The remainder of this act is effective when it becomes law. 28
	45	+	benefit plan. 33
	46	+	(1a) "Emergency Emergency medical condition" means a condition. – A medical 34
	47	+	condition manifesting itself by acute symptoms of sufficient severity, 35
	48	+	including, but not limited to, severe pain, or by acute symptoms developing 36
	49	+	H.B. 489
	50	+	Mar 24, 2025
	51	+	HOUSE PRINCIPAL CLERK General Assembly Of North Carolina Session 2025
	52	+	Page 2 DRH10236-MR-97
	53	+	from a chronic medical condition that would lead a prudent layperson, 1
	54	+	possessing an average knowledge of health and medicine, to reasonably 2
	55	+	expect the absence of immediate medical attention to result in any of the 3
	56	+	following: 4
	57	+	a. Placing the health of an individual, or with respect to a pregnant 5
	58	+	woman, the health of the woman or her unborn child, in serious 6
	59	+	jeopardy. 7
	60	+	b. Serious impairment to bodily functions. 8
	61	+	c. Serious dysfunction of any bodily organ or part. 9
	62	+	(1b) Emergency medical transportation. – An emergency response, as defined 10
	63	+	under 42 C.F.R. § 414.605, and includes all of the following: 11
	64	+	a. Transportation to a healthcare facility. 12
	65	+	b. Ground ambulance transportation between two healthcare facilities 13
	66	+	"interfacility" transportation, when the transportation is being 14
	67	+	provided to the covered person because the needed medical care to 15
	68	+	treat the covered person's medical condition is not available at the 16
	69	+	current healthcare facility. 17
	70	+	c. Emergency medical services that resulted with a medical evaluation 18
	71	+	being provided to the covered person without the covered person being 19
	72	+	transported to an emergency department. 20
	73	+	(2) "Emergency services" means health care Emergency services. – Healthcare 21
	74	+	items and services furnished or required to screen for or treat an emergency 22
	75	+	medical condition until the condition is stabilized, including prehospital care 23
	76	+	care, ambulance transportation services, and ancillary services routinely 24
	77	+	available to the emergency department. 25
	78	+	… 26
	79	+	(4b) Out-of-network provider. – A provider that does not contract with the insurer 27
	80	+	of the health benefit plan under which a covered person is receiving services 28
	81	+	from that provider is enrolled. 29
	82	+	(5) "To stabilize" means to Stabilize. – To provide medical care that is appropriate 30
	83	+	to prevent a material deterioration of the person's condition, within reasonable 31
	84	+	medical probability, in accordance with the HCFA (Health Care Financing 32
	85	+	Administration) Centers for Medicare and Medicaid Services interpretative 33
	86	+	guidelines, policies and regulations pertaining to responsibilities of hospitals 34
	87	+	in emergency cases (as cases, as provided under the Emergency Medical 35
	88	+	Treatment and Labor Act, section 1867 of the Social Security Act, 42 U.S.C.S. 36
	89	+	1395dd), including medically necessary services and supplies to maintain 37
	90	+	stabilization until the person is transferred.42 U.S.C.S. 1395dd. 38
	91	+	(h) The minimum allowable reimbursement rate under any health benefit plan for 39
	92	+	emergency medical transportation services provided by an ambulance service provider that shall 40
	93	+	be paid to an out-of-network ambulance service provider is one hundred percent (100%) of the 41
	94	+	rate set or approved, either by contract or in ordinance, by a local governmental entity established 42
	95	+	pursuant to G.S. 153A-250 in the jurisdiction in which the ambulance services originated. In the 43
	96	+	absence of a rate set or approved by a local governmental entity, the minimum allowable 44
	97	+	reimbursement rate under this subsection is the lesser of the following amounts: 45
	98	+	(1) Four hundred percent (400%) of the most recent published Medicare rate for 46
	99	+	the ambulance service or services by the Centers for Medicare and Medicaid 47
	100	+	Services under Title XVIII of the Social Security Act for the same services 48
	101	+	provided in the same geographic area. 49
	102	+	(2) The out-of-network ambulance service provider's billed charges. 50 General Assembly Of North Carolina Session 2025
	103	+	DRH10236-MR-97 Page 3
	104	+	(i) All of the following apply to emergency medical transportation services provided by 1
	105	+	an ambulance service provider: 2
	106	+	(1) Payment by an insurer that is in compliance with subsection (h) of this section 3
	107	+	is considered payment in full by that insurer for the covered services. This 4
	108	+	subdivision does not preclude the billing for, or collection of, any copayment, 5
	109	+	coinsurance, deductible, and other cost-sharing feature amounts required to be 6
	110	+	paid by the covered person. 7
	111	+	(2) An insurer shall promptly remit payment for emergency medical 8
	112	+	transportation services directly to the ambulance services provider, regardless 9
	113	+	of the network status of that provider. An insurer shall not send any payments 10
	114	+	for the reimbursement of these services to a covered person. 11
	115	+	(3) An insurer shall not impose upon a covered person any cost-sharing 12
	116	+	requirement for emergency transportation services that exceeds the lesser of 13
	117	+	the following amounts: 14
	118	+	a. One hundred dollars ($100.00). 15
	119	+	b. Ten percent (10%) of the minimum allowable reimbursement rate 16
	120	+	amount required to be paid by the insurer established under subsection 17
	121	+	(h) of this section. 18
	122	+	(j) Nothing in this section shall be construed to prevent a self-funded group plan 19
	123	+	regulated under the Employee Retirement Income Security Act (ERISA) from opting into the 20
	124	+	provisions of this section." 21
	125	+	SECTION 1.(b) Subdivisions (3) and (4) of G.S. 58-3-190 are repealed. 22
	126	+	SECTION 2. Section 1(a) of this act is effective October 1, 2025, applies to 23
	127	+	insurance contracts issued, renewed, or amended on or after that date and ambulance services 24
	128	+	provided on or after that date. The remainder of this act is effective when it becomes law. 25