DOA:......Lessner, BB0354 - Reimbursement for Emergency Ambulance Services
For 2025-2027 Budget -- Not Ready For Introduction
An Act ...; relating to: the budget.
Analysis by the Legislative Reference Bureau
INSURANCE
Reimbursement for emergency ambulance services under health insurance policies and plans
This bill makes several changes to the coverage and reimbursement of emergency ambulance services under health insurance policies and plans. First, the bill requires defined network plans, preferred provider plans, and self-insured governmental plans that provide coverage of emergency medical services to cover emergency ambulance services provided by an ambulance service provider that is not a participating provider at a rate that is the greatest of 1) a rate that is set or approved by a local governmental entity in the jurisdiction in which the emergency ambulance services originated; 2) a rate that is 400 percent of the current published rate for the provided emergency ambulance services established by the federal Centers for Medicare and Medicaid Services for the Medicare program in the same geographic area or a rate that is equivalent to the rate billed by the ambulance service provider for emergency ambulance services provided, whichever is less; or 3) the contracted rate at which the defined network plan, preferred provider plan, or self-insured governmental plan would reimburse a participating ambulance service provider for the same emergency ambulance services. The bill prohibits any defined network plan, preferred provider plan, or self-insured governmental plan from imposing a cost-sharing amount on an enrollee for emergency ambulance services provided by an ambulance service provider that is not a participating provider at a rate that is greater than the requirements that would apply if the emergency ambulance services were provided by a participating ambulance service provider. The bill provides that no ambulance service provider that receives reimbursement as provided in the bill may charge an enrollee for any additional amount for emergency ambulance services except for any copayment, coinsurance, deductible, or other cost-sharing responsibilities required to be paid by the enrollee. Finally, the bill provides that any health insurance policy or self-insured governmental health plan must respond to claims for covered emergency ambulance services within 30 days after receipt of the claim and, if the claim is without defect, promptly remit payment for the covered emergency ambulance services directly to the ambulance service provider. If the claim has a defect, the bill instead requires the health insurance policy or self-insured governmental health plan to provide a written notice to the ambulance service provider within 30 days after receipt of the claim.
This proposal may contain a health insurance mandate requiring a social and financial impact report under s. 601.423, stats.
For further information see the state fiscal estimate, which will be printed as an appendix to this bill.
The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:
Section 1. 609.825 of the statutes is created to read:
609.825 Coverage of emergency ambulance services. (1) In this section:
(a) “Ambulance service provider” has the meaning given in s. 256.01 (3).
(b) “Self-insured governmental plan” means a self-insured health plan of the state or a county, city, village, town, or school district that has a network of participating providers and imposes on enrollees in the self-insured health plan different requirements for using providers that are not participating providers.
(2) A defined network plan, preferred provider plan, or self-insured governmental plan that provides coverage of emergency medical services shall cover emergency ambulance services provided by an ambulance service provider that is not a participating provider at a rate that is not lower than the greatest rate that is any of the following:
(a) A rate that is set or approved by a local governmental entity in the jurisdiction in which the emergency ambulance services originated.
(b) A rate that is 400 percent of the current published rate for the provided emergency ambulance services established by the federal centers for medicare and medicaid services under title XVIII of the federal Social Security Act, 42 USC 1395 et seq., in the same geographic area or a rate that is equivalent to the rate billed by the ambulance service provider for emergency ambulance services provided, whichever is less. (c) The contracted rate at which the defined network plan, preferred provider plan, or self-insured governmental plan would reimburse a participating ambulance service provider for the same emergency ambulance services.
(3) No defined network plan, preferred provider plan, or self-insured governmental plan may impose a cost-sharing amount on an enrollee for emergency ambulance services provided by an ambulance service provider that is not a participating provider at a rate that is greater than the requirements that would apply if the emergency ambulance services were provided by a participating ambulance service provider.
(4) No ambulance service provider that receives reimbursement under this section may bill an enrollee for any additional amount for emergency ambulance services except for any copayment, coinsurance, deductible, or other cost-sharing responsibilities required to be paid by the enrollee.
(5) For purposes of this section, “emergency ambulance services” does not include air ambulance services.
Section 2. 632.851 of the statutes is created to read:
632.851 Reimbursement of emergency ambulance services. (1) In this section:
(a) “Ambulance service provider” has the meaning given in s. 256.01 (3).
(b) “Clean claim” means a claim that has no defect of impropriety, including a lack of required substantiating documentation or any particular circumstance that requires special treatment that prevents timely payment from being made on the claim.
(c) “Emergency medical responder” has the meaning given in s. 256.01 (4p).
(d) “Emergency medical services practitioner” has the meaning given in s. 256.01 (5).
(e) “Firefighter” has the meaning given in s. 36.27 (3m) (a) 1m.
(f) “Health care provider” has the meaning given in s. 146.81 (1) (a) to (hp).
(g) “Law enforcement officer” has the meaning given in s. 165.85 (2) (c).
(h) “Self-insured health plan” has the meaning given in s. 632.85 (1) (c).
(2) (a) A disability insurance policy or self-insured health plan shall, within 30 days after receipt of a clean claim for covered emergency ambulance services, promptly remit payment for the covered emergency ambulance services directly to the ambulance service provider. No disability insurance policy or self-insured health plan may send a payment for covered emergency ambulance services to an enrollee.
(b) A disability insurance policy or self-insured health plan shall respond to a claim for covered emergency ambulance services that is not a clean claim by sending a written notice, within 30 days after receipt of the claim, acknowledging the date of receipt of the claim and informing the ambulance service provider of one of the following:
1. That the disability insurance policy or self-insured health plan is declining to pay all or part of the claim, including the specific reason or reasons for the denial.
2. That additional information is necessary to determine if all or part of the claim is payable and the specific additional information that is required.
(3) A disability insurance policy or self-insured health plan shall remit payment for the transportation of any patient by ambulance as a medically necessary emergency ambulance service if the transportation was requested by an emergency medical services practitioner, an emergency medical responder, a firefighter, a law enforcement officer, or a health care provider.
Section 9323. Initial applicability; Insurance.
(1) Coverage of emergency ambulance services.
(a) For policies and plans containing provisions inconsistent with ss. 609.825 and 632.851, the treatment of ss. 609.825 and 632.851 first applies to policy or plan years beginning on the effective date of this paragraph, except as provided in par. (b).
(b) For policies and plans that are affected by a collective bargaining agreement containing provisions inconsistent with ss. 609.825 and 632.851, the treatment of ss. 609.825 and 632.851 first applies to policy or plan years beginning on the effective date of this paragraph or on the day on which the collective bargaining agreement is entered into, extended, modified, or renewed, whichever is later.
Section 9423. Effective dates; Insurance.
(1) Coverage of emergency ambulance services. The treatment of ss. 609.825 and 632.851 and Section 9323 (1) of this act take effect on the first day of the 4th month beginning after publication.
****Note: This is reconciled Section 9423 (1). This Section has been affected by drafts with the following LRB numbers: LRB-0863/P2.
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