Revision: Jan. 7, 2025, 11:39 a.m.
HB 316-FN - AS INTRODUCED
2025 SESSION
25-0498
05/08
HOUSE BILL 316-FN
AN ACT relative to reimbursement for ground ambulance services.
SPONSORS: Rep. Hunt, Ches. 14
COMMITTEE: Commerce and Consumer Affairs
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ANALYSIS
This bill makes changes to the regulatory environment for ground ambulance services and commercial health insurance reimbursement for these services by establishing a uniform, default rate schedule, prohibiting ground ambulance providers from balance billing, providing for continued updating of the rate schedule, and establishing a commission on an all-payer model program for ground ambulance services.
The bill is a request of the insurance department.
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Explanation: Matter added to current law appears in bold italics.
Matter removed from current law appears [in brackets and struckthrough.]
Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.
25-0498
05/08
STATE OF NEW HAMPSHIRE
In the Year of Our Lord Two Thousand Twenty Five
AN ACT relative to reimbursement for ground ambulance services.
Be it Enacted by the Senate and House of Representatives in General Court convened:
1 New Subdivision; Managed Care Law; Reimbursement for Ground Ambulance Services. Amend RSA 420-J by adding a new subdivision and new sections as follows:
Reimbursement for Ground Ambulance Services
420-J:27 Definitions. In this subdivision:
I. “Ground ambulance provider” means a public or private organization licensed by the department of safety under RSA 153-A:10 to provide ground ambulance emergency medical services or the transportation of patients upon any public way of the state.
II. “Ground ambulance services" means:
(a) The rendering of medical treatment and care at the scene of a medical emergency or while transporting a patient from the scene to an appropriate health care facility or behavioral health emergency services provider when the services are provided by one or more ground ambulance vehicles designed for this purpose and licensed by the department of safety under RSA 153-A:10; and
(b) Ground ambulance transport between hospitals or behavioral health emergency services providers, hospitals or behavioral health emergency services providers and other health care facilities or locations, and between health care facilities when the services are medically necessary and are provided by one or more ground ambulance vehicles designed for this purpose and licensed by the department of safety under RSA 153-A:10.
III. "Nonparticipating ground ambulance provider" means a ground ambulance provider that is acting within the scope of practice for ground ambulance providers as set out in RSA 153-A and that does not have a contractual relationship directly or indirectly with a health carrier.
IV. "Participating ground ambulance provider" means a ground ambulance provider that is a “participating provider” as defined in RSA 420-J:3.
420-J:28 Rate Schedule Established.
I. This section is intended to establish a cost-based rate schedule applicable to all fully insured, commercial payers in the state for use in reimbursing nonparticipating ground ambulance providers. Reimbursement under the schedule is intended to cover to the costs attributable to the provision of covered services under the assumption that all public and commercial ground ambulance payers in the state are paying at the same rate and assuming that the rate of subsidization of ground ambulance services in the state through public funds remains constant. Costs include the cost of pre-hospital care and the cost of sustaining a reasonable operating margin as necessary to fulfill the expectation that ground ambulance providers in the state maintain readiness to meet future demand for services under normal demand growth rates and under moderately adverse scenarios. Cost estimates shall be based on the assumption that services will be provided in a reasonably cost-effective manner. Consideration shall be given to the impact on the affordability of fully-insured health insurance, and, if practicable, incentives shall be included for promoting cost-effectiveness, efficiency and value.
II. Based on the work of the independent actuarial and accounting expert retained pursuant to 2024, 256, and with consideration of the purposes and intent articulated in paragraph I, the commissioner shall adopt a rule under RSA 541-A, effective no later than January 1, 2026, that establishes a statewide default cost-based rate schedule for health carriers offering fully-insured coverage to use in reimbursing nonparticipating ground ambulance providers. This schedule shall not be materially different from the default cost-based rate schedule developed by the independent actuarial and accounting expert retained pursuant to 2024, 256. Health carriers offering fully-insured coverage shall be required to utilize this schedule in reimbursing nonparticipating ground ambulance providers for ground ambulance services provided. Health carriers shall remain free under the rule to contract with participating ground ambulance providers for rates that differ from the default rate. Payment to a nonparticipating ground ambulance provider pursuant to the default rate schedule, plus cost sharing required to be paid by the covered person, shall be considered payment in full. The rule shall provide for reimbursement paid directly to the participating or nonparticipating ground ambulance provider by the health carrier.
III. The commissioner shall biennially review the default rate schedule for the purpose of developing and implementing an annual adjustment factor for the succeeding 2 years to account for inflation and other trends affecting costs. The cost of the rate schedule biennial review, which shall be conducted by an independent actuarial and accounting expert, shall be borne by the department. The commissioner shall select a qualified actuarial and accounting vendor to carry out the biennial review. The commissioner shall implement the annual rate schedule adjustment factor through the publication of a bulletin.
420-J:29 Cost Sharing Requirements for Services Provided by Nonparticipating Ground Ambulance Providers.
I. Each health carrier that issues or renews any health benefit plan providing benefits for ground ambulance services shall cover these services provided by a nonparticipating ground ambulance provider in the same manner and without imposing any additional requirements as if the services were provided by a participating ground ambulance provider.
II. The covered person's cost-sharing for items or services provided by a nonparticipating ground ambulance provider shall be calculated by the health carrier based on the default rate schedule for nonparticipating ground ambulance providers that is currently in effect under the provisions of this subdivision.
2 New Chapter; Prohibition on Balance Billing Covered Persons for Ground Ambulance Services. Amend RSA by inserting after chapter 358-T the following new chapter:
CHAPTER 358-U
PROHIBITION ON BALANCE BILLING COVERED PERSONS
FOR GROUND AMBULANCE SERVICES
358-U:1 Definitions. In this chapter:
I. “Covered benefits” means “covered benefits” as defined in RSA 420-J:3.
II. “Covered person” means “covered person” as defined in RSA 420-J:3.
III. “Facility” means “facility” as defined in RSA 420-J:3.
IV. “Ground ambulance provider” means a public or private organization licensed by the department of safety under RSA 153-A:10 to provide ground ambulance emergency medical services or the transportation of patients upon any public way of the state.
V. “Ground ambulance services" means:
(a) The rendering of medical treatment and care at the scene of a medical emergency or while transporting a patient from the scene to an appropriate health care facility or behavioral health emergency services provider when the services are provided by one or more ground ambulance vehicles designed for this purpose and licensed by the department of safety under RSA 153-A:10; and
(b) Ground ambulance transport between hospitals or behavioral health emergency services providers, hospitals or behavioral health emergency services providers and other health care facilities or locations, and between health care facilities when the services are medically necessary and are provided by one or more ground ambulance vehicles designed for this purpose and licensed by the department of safety under RSA 153-A:10.
VI. “Heath benefit plan” means “health benefit plan" as defined in RSA 420-J:3.
VII. "Health carrier" means “health carrier” as defined in RSA 420-J:3.
VIII. "Nonparticipating ground ambulance provider" means a ground ambulance provider that is acting within the scope of practice for ground ambulance providers as set out in RSA 153-A and that does not have a contractual relationship directly or indirectly with a health carrier.
IX. "Participating ground ambulance provider" means a ground ambulance provider that is a “participating provider” as defined in RSA 420-J:3.
358-U:2 Balance Billing for Ground Ambulance Services Prohibited.
I. If a covered person with covered benefits that include ground ambulance services under a health benefit plan is furnished ground ambulance services, then, whether the ground ambulance provider is a participating provider or a nonparticipating provider, the ground ambulance provider shall not bill, and shall not hold liable, the covered person for a payment amount for such services that is more than the cost-sharing requirement for such services under the covered person’s health benefit plan.
II. Paragraph I shall not apply with respect to ground ambulance services that consist of scheduled inter-facility transfers of the covered person furnished by a nonparticipating ground ambulance provider if the provider satisfies the notice and consent criteria under 42 U.S.C. section 300gg-132 (c) and (d).
3 New Paragraph; Consumer Protection Act; Acts Unlawful; Balance Billing. Amend RSA 358-A:2 by inserting after paragraph XIX the following new paragraph:
XX. Balance billing a covered person in violation of RSA 358-U.
4 New Section; Commission on an All-Payer Model Program for ground ambulance services. Amend RSA 153-A by inserting after section 37 the following new section:
153-A:38 Commission on an All-Payer Model Program for Ground Ambulance Services. There is established a commission on an all-payer model program for ground ambulance services.
I. The members of the commission shall be as follows:
(a) Six members of the house of representatives, appointed by the speaker of the house of representatives, 3 of whom shall be nominated by the leader of the minority party. Two members shall be from the commerce committee, 2 members from the health and human services committee, 1 member from the municipal and county government committee, and 1 member from the criminal justice and public safety committee.
(b) Two members of the senate, appointed by the president of the senate, 1 of whom shall be nominated by the leader of the minority party. One member shall be from the health and human services committee, and 1 member shall be from the commerce committee.
(c) The commissioner of the department of safety, or designee.
(d) The commissioner of the department of insurance, or designee.
(e) The commissioner of the department of health and human services, or designee.
(f) A representative from the New Hampshire Ambulance Association, nominated by the association and appointed by the governor.
(g) A representative from the New Hampshire Association of Fire Chiefs, nominated by the association and appointed by the governor.
(h) A representative from the New Hampshire Hospital Association, nominated by the association and appointed by the governor.
(i) A representative from America’s Health Insurance Plans (AHIP), nominated by the association and appointed by the governor.
II. Legislative members of the commission shall receive mileage at the legislative rate when attending to the duties of the commission.
III. The commission shall determine the feasibility and advisability of applying for a waiver under Section 1115A of the Social Security Act to enter into an all-payer model agreement for ground ambulance services in the state to create a uniform, cost-based reimbursement schedule for ground ambulance services that includes Medicare, Medicaid and all commercial payers and that builds upon the default cost-based rate schedule established for commercial payers in RSA 420-J:28 and the cost information collected under Chapter 256 of the laws of 2024. To determine the feasibility and advisability of applying for the federal waiver, the commission shall determine the most appropriate design of an all-payer model program that could form the basis of an application for a federal waiver.
IV. The proposed all-payer program design shall include measures to align payment policies across public and commercial payers to promote ground ambulance financing and delivery system reforms to improve sustainability, efficiency, and quality of care while controlling costs. The commission shall study the feasibility and advisability of at least the following public policy options for improving the ground ambulance financing and delivery system and such other options as would help meet the requirements for federal approval of the Section 1115A waiver application:
(a) Expanding mobile integrated health services in the state as appropriate to improve health system efficiency and quality of care and promote efficiently delivered "treatment in place" where appropriate.
(b) Further strengthening regional services coordination systems or regional EMS networks for the rural areas of the state to share the cost of readiness and disperse workloads.
(c) Implementing an improved system for delivering and compensating facility-to-facility or scheduled transfers of patients with consideration of supply shortages that have occurred and of the differing nature of emergency and scheduled transports.
(d) Implementing a system for compensating care provided in the treat-no-transport context.
(e) Requiring standard provider contracts for ambulance providers and standard utilization review criteria and procedures across payers.
(f) Developing an improved education program for ambulance providers relating to billing and reimbursement of ambulance services by health carriers.
(g) Evaluating options for improving recruitment and retention of emergency medical services staff.
V. The members of the commission shall elect a chairperson from among the members. The first meeting of the commission shall be called by the first named house member. The first meeting of the commission shall be held within 45 days of the effective date of this act. Eight members of the commission shall constitute a quorum.
VI. The commission shall produce a report assessing the feasibility and advisability of applying for a waiver under Section 1115A of the Social Security Act to enter into an all-payer model agreement for ground ambulance services in the state to create a uniform, cost-based reimbursement schedule for ground ambulance services that includes Medicare, Medicaid and all commercial payers and that builds upon the default cost-based rate schedule established for commercial payers in RSA 420-J:28 and the cost information collected under Chapter 256 of the laws of 2024. If the report finds the waiver application not feasible or advisable, then the report shall address the feasibility and advisability of at least the public policy options for improving the ground ambulance financing and delivery system listed in RSA 153-A:38 IV and any other policy options the commission deems would better serve the needs of New Hampshire citizens. The commission shall issue its report and any recommendations for proposed legislation to the president of the senate, the speaker of the house of representatives, the chairs of commerce, municipal and county government, health and human services, and criminal justice and public safety in the house of representatives, the chairs of commerce and health and human services in the senate, the president of the senate, the speaker of the house of representatives, the house clerk, the senate clerk, the governor, and the state library. The commission’s report shall be submitted on or before November 1, 2026.
5 Repeal. RSA 153-A:38 and the section heading preceding RSA 153-A:38, relative to the commission to study reforms to the New Hampshire ground ambulance and delivery system, are repealed.
I. Section 5 of this act shall take effect January 1, 2027.
II. The remainder of this act shall take effect upon passage.
25-0498
12/29/24
HB 316-FN- FISCAL NOTE
AS INTRODUCED
AN ACT relative to reimbursement for ground ambulance services.
FISCAL IMPACT: This bill does not provide funding.
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Estimated State Impact | ||||||
| FY 2025 | FY 2026 | FY 2027 | FY 2028 | ||
Revenue | Indeterminable | Indeterminable | Indeterminable | Indeterminable | ||
Revenue Fund(s) | General Fund | |||||
Expenditures* | $0 | $0 | $0 | $0 | ||
Funding Source(s) | None | |||||
Appropriations* | $0 | $0 | $0 | $0 | ||
Funding Source(s) | None | |||||
*Expenditure = Cost of bill *Appropriation = Authorized funding to cover cost of bill | ||||||
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Estimated Political Subdivision Impact | ||||||
| FY 2025 | FY 2026 | FY 2027 | FY 2028 | ||
County Revenue | Indeterminable | Indeterminable | Indeterminable | Indeterminable | ||
County Expenditures | Indeterminable | Indeterminable | Indeterminable | Indeterminable | ||
Local Revenue | Indeterminable | Indeterminable | Indeterminable | Indeterminable | ||
Local Expenditures | Indeterminable | Indeterminable | Indeterminable | Indeterminable | ||
METHODOLOGY:
This bill makes changes to the regulatory environment for ground ambulance services and commercial health insurance reimbursement for these services by establishing a uniform, default
rate schedule, prohibiting ground ambulance providers from balance billing, providing for continued updating of the rate schedule, and establishing a commission on an all-payer model program for ground ambulance services.
The Insurance Department states this bill's prohibition on balance billing may increase the use of ground ambulance services, potentially raising health insurance premiums and, consequently, Insurance Premium Tax revenue for the State. Local and county governments purchasing health insurance could face higher premium costs, while those operating ambulance services may see financial impacts based on a standardized reimbursement rate schedule, with varying effects by locality.
AGENCIES CONTACTED:
Insurance Department