Budget Amendment ID: FY2016-S3-775-R1

Redraft EHS 775

Payment for Ambulance Services

Mr. Donnelly, Ms. Flanagan, Ms. Donoghue, Ms. O'Connor Ives, Mrs. L'Italien, Messrs. Hedlund, Ross and Kennedy moved that the proposed new text be amended by inserting after section 53 the following section:-

"SECTION 53A. Chapter 176D of the General Laws is hereby amended by inserting after section 3B the following section:-

Section 3C. (a) As used in this section, the following words shall have the following meanings unless the context clearly requires otherwise:-

“Ambulance service provider”, a person or entity licensed by the department of public health pursuant to section 6 of chapter 111C to establish or maintain an ambulance service.

“Emergency ambulance services”, emergency services that an ambulance service provider may render under its ambulance service license when a condition or situation in which an individual has a need for immediate medical attention or if the individual, bystander or emergency medical services provider perceives the potential for the need for immediate medical attention.

“Insurance policy” or “insurance contract”, a contract of insurance, motor vehicle insurance, indemnity, medical or hospital service, dental or optometric services, suretyship or annuity issued, proposed for issuance or intended for issuance by any insurer.

“Insured”, an individual entitled to ambulance services benefits pursuant to an insurance policy or insurance contract.

“Insurer”, a person as defined in section 1; a health maintenance organization as defined in section 1 of chapter 176G; a non-profit hospital service corporation organized pursuant to chapter 176A; an organization as defined in section 1 of chapter 176I that participates in a preferred provider arrangement as defined in said section 1 of said chapter 176I; a carrier offering a small group health insurance plan pursuant to chapter 176J; a company as defined in section 1 chapter 175; an employee benefit trust; a self-insurance plan; or a company certified pursuant to section 34A of chapter 90 and which may issue a policy of motor vehicle liability insurance pursuant to section 113A of said chapter 175 that provides insurance for the expense of medical coverage.

(b) Notwithstanding any general or special law to the contrary, if an ambulance service provider provides an emergency ambulance service to an insured but is not an ambulance service provider under contract to the insurer maintaining or providing the insured’s insurance policy or insurance contract, the insurer maintaining or providing the insurance policy or insurance contract shall pay the ambulance service provider directly and promptly for the emergency ambulance service rendered to the insured. The payment shall be made to the ambulance service provider notwithstanding that the insured’s insurance policy or insurance contract contains a prohibition against the insured assigning benefits under the insurance policy or insurance contract so long as the insured executes an assignment of benefits to the ambulance service provider and the payment shall be made to the ambulance service provider if an insured is either incapable or unable as a practical matter to execute an assignment of benefits under an insurance policy or insurance contract which does not prohibit an assignment of benefits or in connection with an insurance policy or insurance contract that contains a prohibition against an assignment of benefits. An ambulance service provider shall not be considered to have been paid for an emergency ambulance service rendered to an insured if the insurer makes payment for the emergency ambulance service to the insured. An ambulance service provider shall have a right of action against an insurer that fails to make a payment to it under this subsection.

(c) Payment to an ambulance service provider shall be pursuant to pricing schedules established by regulation by the secretary of health and human services. The pricing schedules shall ensure that the payments reflect the actual cost of providing the services within a municipality. The schedules shall reflect geographic differences and population density that disproportionately affect access in a municipality when compared to similarly positioned municipalities. The secretary shall review the pricing schedules every 3 years.

(d) An ambulance service provider receiving payment for emergency ambulance services pursuant to subsections (b) and (c) shall be considered to have been paid in full for the emergency ambulance services provided to the insured and shall have no further right or recourse to bill the insured for emergency ambulance services, with the exceptions of coinsurance, co-payments or deductibles for which the insured is responsible pursuant to the insured’s insurance policy or insurance contract.

(e) Nothing in this section shall be construed to limit or adversely affect an insured’s right to receive benefits under an insurance policy or insurance contract providing insurance coverage for emergency ambulance services. Nothing in this section shall create an entitlement on behalf of an insured to coverage for emergency ambulance services if the insured’s insurance policy or insurance contract provides no coverage for emergency ambulance services.

(f) The secretary shall enforce this section.” ; and

by inserting after section 105 the following section:-

“SECTION 105A. (a) The secretary of health and human services shall implement regulations to establish the pricing schedules set forth in subsection (c) of section 3C of chapter 176D of the General Laws. When developing the rate, the division shall seek comments from the ambulance service advisory council established in subsection (b).

(b) There shall be an ambulance service advisory council to advise the secretary on the pricing schedules set forth in subsection (c) of section 3C of chapter 176D. The council shall be appointed by the secretary and consist of the following members or a designee: (i) the secretary of public safety and security; (ii) the commissioner of the group insurance commission; (iii) a representative of the Fire Chiefs Association of Massachusetts; (iv) the president of the Massachusetts Municipal Association; (v) the president of the Massachusetts Association of Health Plans, Inc.; (vi) the president of the Professional Fire Fighters of Massachusetts; (vii) a representative of the Massachusetts Ambulance Association, Incorporated; and (viii) the president of a commercial insurer. The council shall make recommendations for pricing schedules that consider (A) cost differences associated with differences in geography and population density that impact services; (B) differences in distances travelled for services; and(C) the actual cost of providing services.”.