Section 4303-F - Reimbursement for ambulance services and participation of ambulance service providers in carrier networks1. Reimbursement for ambulance services. With respect to a bill for covered services rendered by an ambulance service provider, a carrier shall reimburse the ambulance service provider or enrollee, as applicable, as follows. A. If the ambulance service provider participates in the carrier's network, the carrier shall reimburse at the ambulance service provider's rate or 200% of the Medicare rate for that service, whichever is less, plus any adjustment required by paragraph C. [2021, c. 241, §3(NEW).]B. If the ambulance service provider is an out-of-network provider, the carrier shall reimburse at the ambulance service provider's rate or 180% of the Medicare rate for that service, whichever is less, plus any adjustment required by paragraph C. [2021, c. 241, §3(NEW).]C. If the ambulance service provider is located in a rural or super rural area as designated by the federal Department of Health and Human Services, Centers for Medicare and Medicaid Services and eligible for additional Medicare reimbursement for services that were provided to a Medicare enrollee, the carrier shall increase the reimbursement to that ambulance service provider in the same amount as the additional Medicare reimbursement. [2021, c. 241, §3(NEW).]D. If, on the effective date of this subsection, an ambulance service provider's charge for ambulance services is below 200% of the Medicare rate for that service, the ambulance service provider may not increase the charge for that service by more than 5% annually. [2021, c. 241, §3(NEW).]E. A carrier may not require a ground ambulance service provider to obtain prior authorization before transporting an enrollee to a hospital, between hospitals or from a hospital to a nursing home, hospice care facility or other health care facility, as defined in Title 22, section328, subsection 8. A carrier may not require an air ambulance service provider to obtain prior authorization before transporting an enrollee to a hospital or between hospitals for urgent care. Notwithstanding this subsection, a carrier is not required to reimburse an ambulance service provider at the reimbursement rates required in this subsection for covered services delivered through community paramedicine in accordance with Title 32, section 84, subsection 4 and a carrier may require an ambulance service provider to obtain prior authorization before providing services through community paramedicine.
[2023, c. 468, §2(AMD).]
1-A.Reimbursement for nontransport services. With respect to a health plan with an effective date on or after January 1, 2024, when an ambulance service provider responds to a call for emergency services and an enrollee refuses transport to a hospital, a carrier shall reimburse that ambulance service provider for any services other than transport provided to the enrollee as follows. A. If the ambulance service provider participates in the carrier's network, the carrier shall reimburse the ambulance service provider at the ambulance service provider's rate or 200% of the average of the Medicare rate for basic life support services and the Medicare rate for advanced life support services, whichever is less, plus any adjustment required by paragraph C. [2023, c. 468, §2(NEW).]B. If the ambulance service provider is an out-of-network provider, the carrier shall reimburse the ambulance service provider at the ambulance service provider's rate or 180% of the average of the Medicare rate for basic life support services and the Medicare rate for advanced life support services, whichever is less, plus any adjustment required by paragraph C. [2023, c. 468, §2(NEW).]C. If the ambulance service provider is located in a rural or super rural area as designated by the federal Department of Health and Human Services, Centers for Medicare and Medicaid Services and eligible for additional Medicare reimbursement for services that were provided to a Medicare enrollee, the carrier shall increase the reimbursement to that ambulance service provider in the same amount as the additional Medicare reimbursement. [2023, c. 468, §2(NEW).]D. If, on the effective date of this subsection, an ambulance service provider's rate for ambulance services is below 200% of the average of the Medicare rate for basic life support and advanced life support services, the ambulance service provider may not increase the rate for that service by more than 5% annually. [2023, c. 468, §2(NEW).] [2023, c. 468, §2(NEW).]
2.Network participation; standard contract. A carrier shall offer a standard contract to all ambulance service providers willing to participate in the carrier's provider network with the following provisions:A. The reimbursement rate paid for ambulance services conforms to the requirements of subsection 1; [2023, c. 468, §2(AMD).]B. The contract term is for a minimum of 24 months; [2021, c. 241, §3(NEW).]C. The contract may be terminated as long as the party seeking to terminate the contract provides at least 180 days' prior notice; and [2021, c. 241, §3(NEW).]D. The contract provides that an ambulance service provider has a minimum of 120 days to submit a claim. [2021, c. 241, §3(NEW).] [2023, c. 468, §2(AMD).]
3.Exemption. Except as provided in subsection 1, paragraph E, this section does not apply to air ambulance services.4.Medical necessity. A carrier shall consider the requirements of the federal Department of Health and Human Services, Centers for Medicare and Medicaid Services related to medical necessity of ambulance services when establishing the carrier's own policies and guidelines related to the medical necessity and reasonableness of covered services provided by ambulance service providers. [2023, c. 468, §2(NEW).]
Amended by 2024, c. 591,§ 4, eff. 8/9/2024.Amended by 2024, c. 591,§ 3, eff. 8/9/2024.Amended by 2023SP1, c. 468,§ 2, eff. 10/25/2023.Added by 2021SP1, c. 241,§ 3, eff. 10/18/2021.