States Forge Ahead to Protect Consumers, as Advisory Committee Recommends Federal Action on Surprise Ambulance Bills

The Advisory Committee on Ground Ambulance and Patient Billing (GAPB committee) was created as part of the No Surprises Act (NSA), a federal law that prevents surprise billing for most out-of-network emergency medical bills but does not protect against surprise bills from ground ambulance providers. The GAPB committee was established to develop guidance on federal consumer protections in this area. To date, 18 states have passed laws shielding residents enrolled in state-regulated health plans from large out-of-pocket ground ambulance surprise bills, but these laws don’t apply to federally regulated self-funded employer-sponsored coverage, which is where most working Americans get their health benefits. In September, the GAPB committee published its recommendations to Congress. They represent an important blueprint for controlling out-of-pocket costs for consumers, although Congress will need to fill in key details.

GAPB Committee Recommendations to Protect Consumers

As described in a previous post, the GAPB committee proposals aim to protect consumers from out-of-network bills for emergency ground ambulance services and attempt to contain costs. They recommend an out-of-pocket payment cap for consumers when using either emergency or interfacility transports.

The GAPB committee agreed on recommending specific reimbursement standards to inform payment amounts and would require insurers to make payments under these standards in a timely manner. The recommended approach is significantly different from the NSA’s independent dispute resolution process, but is similar to standards set in recent state laws. However, the recommendations do not offer guidance on what the payment rates should be (for example, setting payment at a specific percentage of Medicare rates) or whether it would be beneficial to establish minimum or maximum amounts on locally set rates. Decisions that affect rate-setting rules can lead to increases in prices for carriers in the future, which could have cascading effects on consumers.

More States Are Enacting Protections

In the absence of federal action, states are passing laws to protect consumers with state-regulated health plans. Four states have done so this year, joining 14 other states. Washington’s new law, enacted following a report by a state advisory group that studied the issue, is comprehensive in covering public and private providers, and emergency and nonemergency transports, such as interfacility ambulances. It pegs reimbursement to the rate set by local government; if no such rate exists, then reimbursement is set at 325 percent of the Medicare rate or the amount billed, whichever is lower. This reimbursement guidance is similar to those enacted by several other states, but it expires in two years to mitigate concerns about inflationary rates. This sunset clause is a unique strategy to prevent a significant increase in insurers’ spending on ambulances, which could eventually affect consumer premiums. State regulators will review the formula and recommend updated reimbursement rates to minimize any significant increases. Indiana, Mississippi, and Oklahoma have similar payment standards, with a relatively higher reimbursement rate in Indiana.

Looking Forward

Congress must decide whether and how to use the GAPB committee’s recommendations to extend federal ground ambulance billing protections to all private coverage enrollees nationwide. They will also have to add information where the recommendations are silent, such as choosing a percentage of the Medicare rate for the payment standard, and guidance on preventing the potential inflationary impact of reimbursement rates. Members can look to the states for suggestions, as they did when developing the NSA. But Congress has limited opportunities to act this year. The impetus will remain on states to act on behalf of consumers where they have the power to do so.