HB961: HB961 Surprise Billing Consumer Protection Act; insurance coverage for certain out-of-network ambulance transportation service; provide

26 LC 46 1466S House Bill 961 (COMMITTEE SUBSTITUTE) By: Representatives Powell of the 33rd, Au of the 50th, Jasperse of the 11th, Oliver of the 84th, Cooper of the 45th, and others A BILL TO BE ENTITLED AN ACT To amend Chapter 20E of Title 33 of the Official Code of Georgia Annotated, the "Surprise1 Billing Consumer Protection Act," so as to provide for insuranc e coverage for certain2 out-of-network ambulance transportation service; to provide for the minimum allowable3 reimbursement rate for such service; to provide for maximum amo unts on copayments,4 coinsurance, or deductibles for such service; to provide for definitions; to provide for related5 matters; to repeal conflicting laws; and for other purposes.6 BE IT ENACTED BY THE GENERAL ASSEMBLY OF GEORGIA:7 SECTION 1.8 Chapter 20E of Title 33 of the Official Code of Georgia Annotat ed, the "Surprise Billing9 Consumer Protection Act," is amended by revising Code Section 3 3-20E-23, relating to10 financial responsibilities for ground ambulance transportation, as follows:11 "33-20E-23.12 Nothing in this chapter shall reduce a covered person's financial responsibilities with regard13 to ground ambulance transportation.14 (a) As used in this Code section, the term:15 (1) 'Ambulance provider' means an agency, including an agency of any political16 subdivision of this state, or a company which is operating under a valid license from the17 H. B. 961 (SUB) - 1 - 26 LC 46 1466S Emergency Health Section of the Department of Public Health and which provides18 emergency transport service; provided, however, that such term shall not include an air19 ambulance service as such term is defined in Code Section 31-11-2.20 (2) 'Clean claim' means a claim for reimbursement of service rendered by an ambulance21 provider that has no defect or impropriety, including any lack of required substantiating22 documentation, which would reasonably prevent timely payment for a claim.23 (3) 'Covered service' means emergency transport service which a covered person is24 entitled to receive under the terms of a healthcare plan.25 (4) 'Emergency transport service' means the provision of emerg ency transportation on26 the public streets and highways of this state by an ambulance p rovider for a wounded,27 injured, sick, invalid, or incapacitated human being to or from a place where medical or28 hospital care is furnished.29 (5) 'First responder' means any firefighter of a municipal, co unty, or volunteer fire30 department; paramedic as defined in Code Section 31-11-2; emerg ency medical31 technician as defined in Code Section 31-11-2; peace officer as defined in Code32 Section 35-8-2; or communications officer as defined in Code Section 37-12-1.33 (6) 'Medical necessity' means the need to use emergency ambula nce transport when a34 wounded, injured, sick, invalid, or incapacitated human being's condition would appear35 to a ordinarily prudent person to make other forms of transport dangerous to the health36 or condition of such human being to or from a place where medic al or hospital care is37 furnished.38 (b) A healthcare plan shall consider emergency transport servi ce as a covered service39 when:40 (1) Such emergency transport service is requested by a first r esponder or healthcare41 practitioner responsible for the care of the individual receiving the emergency transport42 service; or43 H. B. 961 (SUB) - 2 - 26 LC 46 1466S (2) Such emergency transport service is requested by an indivi dual not included in44 paragraph (1) of this subsection but the use of such service was a medical necessity.45 (c)(1) The minimum allowable reimbursement rate under any healthcare plan other than46 a state healthcare plan for covered service to an out-of-network ambulance provider shall47 be the rate agreed to by contract with or through passage of an ordinance, resolution, rule,48 or regulation by a county, municipality, special district, or a uthority for such service49 within the respective jurisdiction.50 (2) When no agreement on a minimum reimbursement rate exists a s set forth in51 paragraph (1) of this subsection, the minimum allowable reimbur sement amount shall52 be 300 percent of the reimbursement rate under the Medicare pro gram, Part A or B of53 Title XVIII of the federal Social Security Act, 42 U.S.C. Secti on 1395, et seq., as54 amended, for ambulance services.55 (d) Any payment made to an ambulance provider pursuant to this Code section shall56 release a covered person from any further payment responsibilit y other than any57 copayment, coinsurance, or deductible owed by the covered person.58 (e) Any copayment, coinsurance, or deductible paid for covered service provided by an59 out-of-network ambulance provider shall not exceed the amount o f a copayment,60 coinsurance, or deductible amount owed for similar service prov ided by an ambulance61 provider that belongs to the provider network in a healthcare plan.62 (f) No later than 30 days after the receipt of a clean claim for covered service, an insurer63 shall remit payment for such service directly to the ambulance provider and shall not remit64 any payment to a covered person. When an insurer receives a cl aim that is not a clean65 claim, such insurer shall, within 30 days after receipt of such claim, send written notice to66 the ambulance provider making such claim that acknowledges the receipt of such claim and67 informs the ambulance provider that:68 (1) The insurer has declined to pay all or part of the claim, including the reasons for such69 denial; or70 H. B. 961 (SUB) - 3 - 26 LC 46 1466S (2) Additional information is necessary to make a determination regarding payment of71 all or part of the claim submitted, including the specific information required."72 SECTION 2.73 All laws and parts of laws in conflict with this Act are repealed.74 H. B. 961 (SUB) - 4 -