a) It is the goal of STATE to protect patients from “surprise ambulance bills” in which they are charged for unknowing receipt of out-of-network services for emergency ambulance services without the patient affirmatively choosing to receive out-of-network care.

b) No health carrier shall require prior authorization for rendering emergency services, including ambulance services, to an insured.

c) No health carrier shall impose, for ambulance services rendered to an insured by an out-of-network healthcare provider, a coinsurance, copayment, deductible or other out-of-pocket expense that is greater than the coinsurance, copayment, deductible or other out-of-pocket expense that would be imposed if such ambulance services were rendered by an in-network healthcare provider.

d) If ambulance services were rendered to an insured by an out-of-network healthcare provider, such health care provider may bill the health carrier directly and the health carrier shall reimburse such health care provider the greatest of the following amounts: 

i) The amount the insured’s health care plan would pay for such services if rendered by an in-network provider; 

ii) The usual, customary and reasonable rate for such services, or 

iii) The amount Medicare would reimburse for such services. 

iv) As used in this subparagraph, (A)“usual, customary and reasonable rate” means the eightieth percentile of all charges for the particular health care service performed by a health care provider in the same or similar specialty and provided in the same geographical area, as reported in a benchmarking database maintained by a nonprofit organization specified by the Insurance Commissioner. Such organizations shall not be affiliated with any health carrier. (B) Nothing in this subdivision shall be construed to prohibit such health carriers and out-of-network health care providers from agreeing to a greater reimbursement amount.

e) “Ambulance service” means the furnishing, operating, conducting, maintaining, advertising, or otherwise engaging in (or professing to be engaged in) the transportation of patients by ambulance.Taken in context, it also means the person so engaged or professing to be so engaged.

f) With respect to a surprise ambulance bill: 

i) An insured shall only be required to pay the applicable coinsurance, copayment, deductible or other out-of-pocket expense that would be imposed for such healthcare services if such services were rendered by an in-network healthcare provider; and

ii) A health carrier shall reimburse the out-of-network health care provider or insured, as applicable, for healthcare services rendered at the in-network rate under the insured’s health care plan as payment in full, unless such health carrier and health care provider agree otherwise.

g) It shall be an unfair trade practice in violation of the [general business laws of STATE] for any health care provider, including laboratory, to request payment by an insured other than the applicable coinsurance, copayment, deductible or other out-of-pocket expense that would be imposed for such healthcare services if such services were rendered by an in-network healthcare provider for emergency services covered under a health care plan and rendered by an out-of-network healthcare provider.

h) In providing for emergency services, including ambulance services and laboratory tests and services, and care as a covered service, a health maintenance organization may not:

i) Require prior authorization for the receipt of prehospital transport or treatment or for emergency services and care.

ii) Indicate that emergencies are covered only if care is secured within a certain period of time.

iii) Use terms such as “life threatening” or “bona fide” to qualify the kind of emergency that is covered.

iv) Deny payment based on the subscriber’s failure to notify the health maintenance organization in advance of seeking treatment or within a certain period of time after the care is given.

i) Within 1 year of the effective date of this law, the STATE [Department of Health/Insurance] shall report to the Governor, Legislature, and on its website on the efficacy of dispute resolution practices between providers, including physicians, laboratories, and hospitals, and insurance companies, and make recommendations as to any changes that should be made based on best practices from surprise ambulance billing laws in other states.