What's happening
This bill requires insurers to pay ambulance services directly at customary rates, even if the provider is out-of-network, when benefits are assigned.
Why it matters
Direct insurer payments to ambulance providers may reduce patient financial stress. by ensuring that insurance payments go straight to ambulance services (even if out-of-network) when a patient assigns benefits, potentially decreasing surprise bills and collection efforts against patients.
Ambulance providers are guaranteed payment at “usual and customary” rates if no negotiated rate exists. , which may stabilize revenue for emergency medical services, particularly for those not in insurer networks, and could incentivize more ambulance services to remain operational in underserved areas.
The bill preserves insurers’ ability to set different cost-sharing levels for in-network versus out-of-network providers. , meaning patients may still pay more out-of-pocket for using non-network ambulance services, but the provider’s payment process is streamlined and less likely to involve the patient as a middleman.
These provisions will only apply to insurance policies that cover ambulance services. , so the impact will be greatest for insured patients in plans with such coverage, and will not affect those whose policies exclude ambulance benefits.
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Who cares
Headline styles
Insurers Must Pay All Ambulance Providers
Plain English, a few words. Used as the page title.
Sponsors
History
- Committed to rules
- Advanced to third reading
- 2nd report cal.
- 1st report cal.521
- Referred to insurance
- Committed to rules
- Advanced to third reading
- 2nd report cal.
- 1st report cal.664
- Referred to insurance
Full text
3 pagesUnderlined is new[Struck] is removedOfficial text on nysenate.gov ↗
STATE OF NEW YORK
3526
2019-2020 Regular Sessions
IN SENATE
February 8, 2019
Introduced by Sens. BRESLIN, SEWARD, ADDABBO, AKSHAR, BOYLE, FUNKE, GALLIVAN, HELMING, SEPULVEDA -- read twice and ordered printed, and when printed to be committed to the Committee on Insurance
AN ACT to amend the insurance law, in relation to payments to prehospital emergency medical services providers
The People of the State of New York, represented in Senate and Assembly, do enact as follows:
Section 1. Section 3224-a of the insurance law is amended by adding a new subsection (k) to read as follows:
(k) Payments to nonparticipating or nonpreferred providers of ambulance services licensed under article thirty of the public health law. (1) Whenever an insurer or an organization, or corporation licensed or certified pursuant to article forty-three or forty-seven of this chapter or article forty-four of the public health law provides that any health care claims submitted under contracts or agreements issued or entered into pursuant to this article or article forty-two, forty-three or forty-seven of this chapter and article forty-four of the public health law are payable to a participating or preferred provider of ambulance services for services rendered, the insurer, organization, or corporation licensed or certified pursuant to article forty-three or fortyseven of this chapter or article forty-four of the public health law shall be required to pay such benefits either directly to any similarly licensed nonparticipating or nonpreferred provider at the usual and customary charge, which shall not be excessive or unreasonable, when the provider has rendered such services, has on file a duly executed assignment of benefits, and has caused notice of such assignment to be given to the insurer, organization, or corporation licensed or certified pursuant to article forty-three or forty-seven of this chapter or article forty-four of the public health law or jointly to such nonparticipating or nonpreferred provider and to the insured, subscriber, or other covered person; provided, however, that in either case the insur-
EXPLANATION--Matter in italics (underscored) is new; matter in brackets
[ ] is old law to be omitted.
LBD00646-01-9
S. 3526 2
er, organization, or corporation licensed or certified pursuant to article forty-three or forty-seven of this chapter or article forty-four of the public health law shall be required to send such benefit payments directly to the provider who has the assignment on file. When payment is made directly to a provider of ambulance services as authorized by this section, the insurer, organization, or corporation licensed or certified pursuant to article forty-three or forty-seven of this chapter or article forty-four of the public health law shall give written notice of such payment to the insured, subscriber, or other covered person.
(2) An insurer shall provide reimbursement for those services prescribed by this section at rates negotiated between the insurer and the provider of such services. In the absence of agreed upon rates, an insurer shall pay for such services at the usual and customary charge, which shall not be excessive or unreasonable.
(3) Nothing contained in this section shall be deemed to prohibit the payment of different levels of benefits or from having differences in coinsurance percentages applicable to benefit levels for services provided by participating or preferred providers and nonparticipating or nonpreferred providers.
The provisions of this section shall not apply to policies that do not include coverage for ambulance services.
§ 2. Subparagraphs (C) and (D) of paragraph 24 of subsection (i) of section 3216 of the insurance law, as added by chapter 506 of the laws of 2001, are amended to read as follows:
(C) An insurer shall provide reimbursement for those services prescribed by this section at rates negotiated between the insurer and the provider of such services. In the absence of agreed upon rates, an insurer shall pay for such services at the usual and customary charge, which shall not be excessive or unreasonable. The insurer shall send such payments directly to the provider of such ambulance services, if the ambulance service has on file an executed assignment of benefits form with the claim.
(D) The provisions of this paragraph shall have no application to transfers of patients between hospitals or health care facilities by an ambulance service as described in subparagraph (A) of this paragraph unless such services are covered under the policy.
§ 3. Subparagraphs (C) and (D) of paragraph 15 of subsection (l) of section 3221 of the insurance law, as added by chapter 506 of the laws of 2001, are amended to read as follows:
(C) An insurer shall provide reimbursement for those services prescribed by this section at rates negotiated between the insurer and the provider of such services. In the absence of agreed upon rates, an insurer shall pay for such services at the usual and customary charge, which shall not be excessive or unreasonable. The insurer shall send such payments directly to the provider of such ambulance services, if the ambulance service has on file an executed assignment of benefits form with the claim.
(D) The provisions of this paragraph shall have no application to transfers of patients between hospitals or health care facilities by an ambulance service as described in subparagraph (A) of this paragraph unless such services are covered under the policy.
§ 4. Paragraphs 3 and 4 of subsection (aa) of section 4303 of the insurance law, as added by chapter 506 of the laws of 2001, are amended to read as follows:
(3) An insurer shall provide reimbursement for those services prescribed by this section at rates negotiated between the insurer and
S. 3526 3
the provider of such services. In the absence of agreed upon rates, an insurer shall pay for such services at the usual and customary charge, which shall not be excessive or unreasonable. The insurer shall send such payments directly to the provider of such ambulance services, if the ambulance service has on file an executed assignment of benefits form with the claim.
(4) The provisions of this subsection shall have no application to transfers of patients between hospitals or health care facilities by an ambulance service as described in paragraph one of this subsection unless such services are covered under the policy.
§ 5. This act shall take effect January 1, 2021 and shall apply to health care claims submitted for payment after such date.
Reflowed for reading: line numbers and page breaks removed. Cite the official text.
Sponsor's memo
Title of bill
An act to amend the insurance law, in relation to payments to prehospital emergency medical services providers
Purpose
To ensure that responding ambulance service companies receive direct payment for all ambulance service transports upon submission of an invoice to the insurance company without the need for the responding ambulance company to be a preferred provider.
Summary of provisions
Section 1 amends section 3224-a of the insurance law to provide that payments made to nonparticipating or non-preferred providers of ambu- lance services made by health insurers shall be done so directly to the provider or jointly to both the provider and the insured.
Read the full memo (660 words)
Section 2 amends subparagraphs (c) and (d) of paragraph 24 of subsection (i) of section 3216 of the insurance law stating that the insurers shall send such payments directly to the provider of such ambulance services if the ambulance service includes an executed assignment of benefits form with the claim and the provisions of this paragraph shall apply to transfers of patients between hospitals or health care facilities.
Section 3 amends subparagraphs (c) and (d) of paragraph 15 of subsection (1) of section 3221 of the insurance law stating that the insurers shall send such payments directly to the provider of such ambulance services if the ambulance service includes an executed assignment of benefits form with the claim and the provisions of this paragraph shall apply to transfers of patients between hospitals or health care facilities.
Section 4 amends paragraphs 3 and 4 of subsection (aa) of section 4303 of the insurance law stating that the insurers shall send such payments directly to the provider of such ambulance services if the ambulance service includes an executed assignment of benefits form with the claim and the provisions of this paragraph shall apply to transfers of patients between hospitals or health care facilities.
Section 5. Effective Date.
Justification
The constant and quick availability of ambulance response is something that all of our citizens have grown accustomed to and it is essential to the survivability of all New Yorkers- when there is a medical crisis.
Fair and direct reimbursement for those services is paramount to the financial stability and continued availability of ambulances to respond.
Current law permits insurance companies to pay for ambulance service charges direct to the patient until and unless the ambulance company becomes a preferred provider of that specific insurance company. It is not practical to expect a preferred provider relationship with every insurance company. But then it is the responsibility of the ambulance company to try to recoup payment for service from that patient.
All types of EMS providers routinely are not paid by the patient for ambulance services even though the patient receives payment from the insurance company. Especially as the financial crisis we are currently facing deepens, more and more patients are pocketing these funds. Further, the insurance company is not obligated to advise the ambulance company that they in fact paid the ambulance transport bill direct to the patient. This disconnect of information leads to confusion and furthers the lack of proper payment issue.
In New York State, ambulance companies are mandated responders. As such, most ambulance providers have no knowledge of the patient's ability to pay or if or by whom they are insured by when a medical emergency or accidental event occurs. Ambulance service is one of the few medical services where payment is not expected at the time of service.
This legislation will assure that responding ambulance service will receive direct payment for all ambulance service transports upon submission of an invoice to the insurance company without the need for the responding ambulance company to be a preferred provider.
Legislative history
S.2527a of 2017-18; S.1764 of 2015-16; S.3542 of 2013-14; S.2714-8 of 2011-12; S.4462 of 2010.
Fiscal implications
None.
Effective date
This act shall take effect January 1, 2020 and shall apply to health care claims submitted for payment after such date.
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