Revision: May 28, 2025, 2:21 p.m.
Rep. Hunt, Ches. 14
May 27, 2025
2025-2458h
05/11
Amendment to SB 245-FN
Amend the bill by replacing all after the enacting clause with the following:
1 New Subdivision; Managed Care Law; Reimbursement for Ground Ambulance Services. Amend RSA 420-J by inserting after section 19 the following new subdivision:
Reimbursement for Ground Ambulance Services
420-J:20 Definitions. In this subdivision:
I. “Enrolling ground ambulance provider” means a ground ambulance provider who is pursuing in good faith the contracting process for becoming a participating ground ambulance provider with specified health carriers during the period between January 1, 2026, and December 30, 2027, and who has filed with the commissioner a written declaration to that effect on a form provided by the commissioner.
II. “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.
III. “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.
IV. "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, that does not have a contractual relationship directly or indirectly with a health carrier, and that is not an enrolling ground ambulance provider.
V. "Participating ground ambulance provider" means a ground ambulance provider that is a “participating provider” as defined in RSA 420-J:3.
420-J:21 Rate Schedule Established for Certain Ground Ambulance Providers.
I. There is hereby established a rate schedule applicable to all health carriers doing business in the state to reimburse participating and enrolling ground ambulance providers.
(a) Beginning January 1, 2026, through December 31, 2027, participating and enrolling ground ambulance providers shall be reimbursed for ambulance services at a temporary rate schedule of 3.25 times the Medicare rate that is current as of the date of service.
(b) Beginning January 1, 2028, participating ground ambulance providers shall be reimbursed for ambulance services at a rate established by the commissioner. The commissioner shall adopt rules under RSA 541-A with an effective date of January 1, 2028, that establish a statewide, cost-based rate schedule for health carriers to use in reimbursing participating ground ambulance providers that implements the rate schedule recommended by the independent accounting and actuarial expert retained pursuant to RSA 420-J:26.
(c) Beginning January 1, 2029, and annually thereafter, the commissioner shall adjust the participating ground ambulance provider rate for inflation using the general consumer price index as reported by the United States Bureau of Labor Statistics. The commissioner shall publish the updated rate by bulletin before January 1 each year.
II. Nothing shall prevent health carriers and ground ambulance providers from voluntarily negotiating an alternative agreed upon rate schedule.
III. Health carriers may apply cost sharing for ambulance services.
IV. For the purpose of determining cost sharing amounts, the rates established in this section shall be considered the allowed amount.
V. Ambulance providers shall be responsible for collecting any cost sharing associated with the ground ambulance services.
420-J:22 Rate Schedule Established for Nonparticipating Ground Ambulance Providers. Beginning on January 1, 2026, nonparticipating ground ambulance providers shall be reimbursed by health carriers at the carrier’s nonparticipating rate or at the Medicare rate that is current as of the date of service, whichever is higher.
420-J:23 Standardized Ground Ambulance Provider Contract.
I. The commissioner shall issue a bulletin no later than December 31, 2025, establishing a standardized ground ambulance provider contract template that includes a standardized format and language for contracts between health carriers and ground ambulance providers.
II. Once published by bulletin, all health carriers shall offer ground ambulance providers a standardized ground ambulance contract that incorporates the template established by the commissioner. The health carrier’s standardized contract shall be offered to any ground ambulance provider that is qualified and willing to meet the terms and conditions of the standardized ground ambulance provider contract.
III. Nothing shall prevent health carriers and ground ambulance providers from voluntarily negotiating a contract that varies in any respect from the standardized contract.
420-J:24 Contract Negations between Ambulance Providers and Health Carriers.
I. Beginning January 1, 2026, and continuing through December 31, 2027, enrolling ground ambulance providers shall be entitled to the provider rate specified in RSA 420-J:21, I(a) as long as they continue to work in good faith towards executing a contract.
II. If a ground ambulance provider fails to actively engage in the contracting process for a period of 60 days, the ambulance provider shall no longer be considered an enrolling ground ambulance provider. Failure to actively engage in the contracting process shall include, but is not limited to, failure to respond to requests by the health carrier for information and failure to sign necessary documents.
III. Health carriers shall act upon and finalize the contracting process within 45 calendar days of receipt of all necessary documents and information required to execute the contract.
420-J:25 Temporary Maintenance of a Registry of Providers Who Qualify as an Enrolling Ground Ambulance Provider.
I. No later than December 31, 2025, the commissioner shall publish through bulletin a written contract negotiation initiation form that shall be used by ground ambulance providers to initiate contract negotiations with specified health carriers and to initially qualify as an enrolling ground ambulance provider with respect to the specified health carriers.
II. A ground ambulance provider must submit the form to the department and to the specified health carriers in order to be eligible for the status of an enrolling ground ambulance provider with respect to those carriers.
III. During the period between January 1, 2026, and December 31, 2027, the insurance department shall maintain a list on its website of ambulance providers who qualify as an enrolling ground ambulance provider with respect to a particular carrier.
IV. If the commissioner finds that a ground ambulance provider has failed to engage in the contracting process with respect to a health carrier, the commissioner shall update the list to reflect that the ambulance provider no longer qualifies as an enrolling ground ambulance provider with respect to that carrier.
420-J:26 Requiring an Independent Study by an Accounting and Actuarial Expert of Ground Ambulance Costs in the State and the Establishment of a Cost-Based Reimbursement Schedule for Participating Ground Ambulance Service Providers.
I. Beginning on the effective date of this section, the commissioner shall oversee the process provided for in this section of contracting with an independent accounting and actuarial expert to conduct a study of the costs incurred by ground ambulance providers related to the provision of ground ambulance services in the state. Costs shall include the cost of pre-hospital care and the cost of sustaining a reasonable operating margin in support of the expectation that ground ambulance providers in the state maintain readiness to meet demand for services. Cost estimates shall be based on the assumption that services shall be provided in a reasonably cost-effective manner.
II. The commissioner of the department of safety shall collaborate with the commissioner in collecting cost surveys from ground ambulance providers in the state. These surveys may either be designed by the accounting and actuarial expert or may be adopted by the expert from the medicare ground ambulance data collection system cost reports. The commissioner of the department of safety shall have authority to enforce this reporting requirement upon ground ambulance providers under the general supervision and specific enforcement authority conferred by RSA 153-A and shall work with the commissioner to set a deadline for ground ambulance providers to submit their cost reports that is sufficient to facilitate the completion of the study and report provided for in this section in a timely manner.
III. The independent accounting and actuarial expert shall submit all cost data submitted by ground ambulance providers to rigorous data validation and auditing procedures and shall verify that the ground ambulance provider has used proper cost allocation methods, including when fire and ambulance services are provided by the same entity. The commissioner of the department of safety shall have authority under the general supervision and specific enforcement authority conferred by RSA 153-A to enforce compliance by ground ambulance providers with data validation and auditing of cost reports. The commissioner of the department of safety shall work with the commissioner to set a deadline for ground ambulance providers to comply with data validation and auditing requirements that is sufficient to facilitate the completion of the study and report provided for in this section in a timely manner.
IV. If a ground ambulance provider fails to cooperate with cost data submission requirements or with requirements to facilitate data validation or cost report auditing requirements, then that provider shall lose access to the temporary rate schedule established for enrolling and participating ground ambulance providers in RSA 420-J:21, and health carriers shall be required to reimburse such providers at their nonparticipating rate or at the Medicare rate that is current as of the date of service, whichever is higher. During the period of the cost study, the commissioner shall maintain a list that shall be made available to health carriers doing business in the state that includes all ground ambulance providers who have been determined by the commissioner to have failed to cooperate with cost data submission requirements or with requirements to facilitate data validation or cost report auditing requirements.
V. If an analytical sample of audited cost reports is utilized by the independent expert that is obtained from a subset of ground ambulance providers in the state, then the most appropriate statistical methods shall be used to ensure that the analytical sample is appropriately normalized and adequately representative of the general population of ground ambulance providers doing business in the state.
VI. Based on the information provided through the cost reports, the independent accounting and actuarial expert shall be directed to summarize the cost information collected and to derive a statewide cost-based rate schedule appropriate for health carriers to use in reimbursing participating ground ambulance providers. The schedule may vary based on geographic region. Reimbursement under the schedule shall be designed to cover the costs attributable to the provision of covered services assuming that all public and commercial ground ambulance payers in the state are paying at the same rate. The independent accounting and actuarial expert shall produce a final report by June 30, 2027, which shall include the expert’s recommended cost-based reimbursement schedule for participating ground ambulance providers and which shall detail the methodology used to calculate ground ambulance costs in the state and such other supplemental information as shall be directed by the commissioner. The commissioner shall assist the independent expert as necessary to complete the study, the rate schedule, and the report in a timely manner.
VII. Prior to the completion of its work on June 30, 2027, the independent accounting and actuarial expert shall also advise the commission on improving the ground ambulance services financing and delivery system established in RSA 153-A:38 on 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 implement a uniform, cost-based reimbursement schedule for ground ambulance services that includes Medicare, Medicaid, and all commercial payers and that builds upon the mandatory participating rate schedule and the cost study conducted under this section.
VIII. The cost study required under this section shall be funded in an amount up to $400,000 out of funds as provided in RSA 400-A:15, IV.
2 Repeal. The following are repealed:
I. RSA 420-J:20, I, relative to the definition of enrolling ground ambulance provider.
II. RSA 420-J:21 I(a), relative to the temporary reimbursement rate for ambulance services in 2026 and 2027.
III. RSA 420-J:24, relative to contract negotiations between ambulance providers and health carriers.
IV. RSA 420-J:25, relative to temporary maintenance of a registry of providers who qualify as an enrolling ground ambulance provider.
3 New Paragraphs; Prohibition on Balance Billing Covered Persons for Health Care Services; Definition of Ground Ambulance Provider and Ground Ambulance Services Added. Amend RSA 358-T:1 by inserting after paragraph V the following new paragraphs:
V-a. “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-b. “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.
4 New Paragraph; Definition of Nonparticipating Ground Ambulance Provider Added. Amend RSA 358-T:1 by inserting after paragraph IX the following new paragraph:
IX-a. "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.
5 New Section; Prohibition on Balance Billing Covered Persons for Health Care Services; Balance Billing for Ground Ambulance Services Prohibited. Amend RSA 358-T by inserting after section 4 the following new section:
358-T:5 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).
6 New Section; Commission on Improving the Ground Ambulance Services Financing and Delivery System. Amend RSA 153-A by inserting after section 37 the following new section:
153-A:38 Commission on Improving the Ground Ambulance Services Financing and Delivery System. There is established a commission on improving the ground ambulance financing and delivery system.
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:
(a) Review the history and operation of ground ambulance services delivery in New Hampshire and the current financing and delivery models adopted by municipal, hospital-based, and commercial ground ambulance providers in the state.
(b) Identify areas in which the ground ambulance financing and delivery system in the state is not meeting the needs of citizens of this state or is in jeopardy of failing to meet the needs of citizens of this state and requires reform.
(c) Make recommendations for systemic reforms to support a viable ground ambulance financing and delivery system that will improve sustainability, efficiency, and quality of care while controlling costs.
IV. 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 implement a uniform, cost-based reimbursement schedule for ground ambulance services that includes Medicare, Medicaid, and all commercial payers and that builds upon the mandatory in-network rate schedule and the cost study conducted under RSA 420-J:26. 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.
V. 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) Developing an improved education program for ambulance providers relating to billing and reimbursement of ambulance services by third party payers.
(f) Evaluating options for improving recruitment and retention of emergency medical services staff.
VI. 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 section. Eight members of the commission shall constitute a quorum.
VII. The commission shall produce a report on November 1 of each year that the commission is in operation detailing the progress made to date carrying out its mandates and including such recommendations for legislative or administrative reforms or initiatives as are timely and appropriate. The commission shall submit its assessment of 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 no later than its November 1, 2027 report. If this report finds the waiver application not feasible or advisable, then the commission shall continue to report on 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, III and V and any other policy options the commission deems would serve the needs of New Hampshire citizens. The commission shall issue its report and any recommendations for proposed legislation or administrative actions 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.
7 Repeal. RSA 153-A:38 and the section heading preceding RSA 153-A:38, relative to the commission on improving the ground ambulance services financing and delivery system, are repealed.
8 New Paragraph; Insurance Department; Statutes, Rules, and Regulations; Violation. Amend RSA 400-A:15 by inserting after paragraph III the following new paragraph:
IV. For state fiscal years ending June 30, 2026 and June 30, 2027, fines collected against an insurer or any other regulated entity or person for violation of any of the provisions of Title XXXVII or rules adopted thereunder or for any violation of a duly authorized order of the commissioner over this period shall be deposited by the commissioner in the insurance department administration fund established under RSA 400-A:39 in an amount not to exceed $400,000 and shall be utilized for the purpose of contracting for the independent accounting and actuarial study required under RSA 420-J:26. Any fines collected during this period in excess of this $400,000 amount shall be deposited by the commissioner in the general fund. If there is any portion of the $400,000 amount that remains unused after the purposes of RSA 420-J:26 are accomplished, then the commissioner shall notify the state treasurer that such amount is to be transferred to the general fund under this paragraph.
9 Repeal. RSA 400-A:15, IV, relative to the deposit of fines in the insurance department administration fund for the purpose of an independent accounting and actuarial study of ground ambulance services financing and delivery system, is repealed.
I. Section 2 of this act shall take effect January 1, 2028.
II. Section 3, 4, and 5 of this act shall take effect January 1, 2026.
III. Section 7 of this act shall take effect June 30, 2030.
IV. Section 9 of this act shall take effect July 1, 2027.
V. The remainder of this act shall take effect upon passage.
2025-2458h
AMENDED ANALYSIS
This bill:
I. Regulates reimbursement for ground ambulance services under the managed care law and prohibits balance billing for ground ambulance services.
II. Establishes a commission on improving the ground ambulance services financing and delivery system and provides for use of funds from the insurance department administration fund to be used for an accounting and actuarial study of ground ambulance costs in the state of New Hampshire.