AN ACT relating to coverage for emergency ground ambulance services.

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AN ACT relating to coverage for emergency ground ambulance services. 1
Be it enacted by the General Assembly of the Commonwealth of Kentucky: 2
SECTION 1. A NEW SECTION OF SUBTITLE 17A OF KRS CHAPTER 304 3
IS CREATED TO READ AS FOLLOWS: 4
(1) As used in this section: 5
(a) "Adverse determination" has the same meaning as in KRS 304.17A -600, 6
except for purposes of this section t he term includes determinations 7
regarding emergency ground ambulance services furnished or proposed to 8
be furnished to a covered person; 9
(b) "Clean claim" has the same meaning as in KRS 304.17A-700; 10
(c) "Cost sharing" means any copayments, coinsurance, deductibles, and other 11
out-of-pocket expense requirements imposed upon a covered person by a 12
health benefit plan; 13
(d) "Emergency ground ambulance services" means emergency ambulance 14
services provided by a g round ambulance provider that are not air 15
ambulance services; 16
(e) "Ground ambulance provider" means a ground ambulance provider 17
licensed in accordance with administrative regulations promulgated by the 18
Kentucky Board of Emergency Medical Services; 19
(f) "Local governing authority" means: 20
1. Any city, county, charter county government, urban -county 21
government, consolidated local government, unified local government, 22
special district, or municipal corporation of this state; and 23
2. Any agency, authority, board, bureau, department, commission, 24
council, committee, instrumentality, joint venture, or other entity of an 25
entity referenced in subparagraph 1. of this paragraph; 26
(g) "Local emergency ground ambulance service rate" means either: 27
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1. The rate contracted betwe en an out -of-network ground ambulance 1
provider and a local governing authority for emergency ground 2
ambulance services; or 3
2. The rate for emergency ground ambulance services approved or 4
established by a local governing authority, including by ordinance, 5
regulation, or resolution; and 6
(h) "Out-of-network ground ambulance provider" means a ground ambulance 7
provider that has not entered into a contract to provide emergency ground 8
ambulance services under the health benefit plan. 9
(2) A health benefit plan shall: 10
(a) Provide coverage for emergency ground ambulance services, which shall 11
include coverage for emergency ground ambulance services provided by an 12
out-of-network ground ambulance provider; 13
(b) Consider emergency ground ambulance services requested by a f irst 14
responder, any other health care practitioner, or through a 911 answering 15
point to be: 16
1. Medically necessary; and 17
2. Not subject to an adverse determination; and 18
(c) Not impose cost sharing for emergency ground ambulance services provided 19
by an out -of-network ground ambulance provider that exceeds the cost 20
sharing imposed by the plan for emergency ground ambulance services that 21
are not provided by an out-of-network ground ambulance provider. 22
(3) The minimum allowable reimbursement under any health ben efit plan to an out -23
of-network ground ambulance provider for emergency ground ambulance 24
services shall be: 25
(a) The local emergency ground ambulance service rate of the local governing 26
authority in whose jurisdiction the emergency ground ambulance services 27
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originated; or 1
(b) In the absence of an applicable local emergency ground ambulance service 2
rate under paragraph (a) of this subsection, the lesser of the following: 3
1. Four hundred percent (400%) of the reimbursement allowed to a 4
ground ambulance provider providing the same services to a Medicare 5
beneficiary; or 6
2. The out-of-network ground ambulance provider's billed charges. 7
(4) (a) Except as provided in paragraph (c) of this subsection, an insurer shall 8
make a reimbursement to an out-of-network ground ambulance provider for 9
a claim made for emergency ground ambulance services under a health 10
benefit plan in accordance with subsection (3) of this section, less any cost 11
sharing required to be paid for the services under the health benefit plan, 12
within thirty (30) days of receipt of the claim from the provider. 13
(b) The reimbursement required under this subsection shall: 14
1. Be made directly to the out -of-network ground ambulance provider; 15
and 16
2. Not be made or sent to the covered person. 17
(c) If the insurer det ermines that a claim made by an out -of-network ground 18
ambulance provider for emergency ground ambulance services is not a 19
clean claim, lacks required substantiating documentation, is not covered 20
under the health benefit plan, or is subject in whole or in p art to cost 21
sharing, the insurer shall, within thirty (30) days of receipt of the claim, 22
send a written notification to the out -of-network ground ambulance 23
provider that: 24
1. Acknowledges the date of receipt of the claim; and 25
2. Provides one (1) of the following notifications: 26
a. A notification that states: 27
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i. The insurer is declining to pay all or part of the claim; and 1
ii. The specific reason or reasons for the declination; or 2
b. A notification that states: 3
i. Additional information is necessary to determine if all or 4
part of the claim is payable; and 5
ii. The specific additional information that is required to 6
make the determination. 7
(5) An out-of-network ground ambulance prov ider shall not seek reimbursement for 8
emergency ground ambulance services from a covered person that is in excess of 9
any cost sharing required to be paid for the services under the health benefit plan 10
if the provider receives any of the following from the insurer: 11
(a) Reimbursement in compliance with subsection (3) of this section; 12
(b) A partial reimbursement and a notification that the remaining 13
reimbursement, which together with the partial reimbursement is in 14
compliance with subsection (3) of this section, is subject to cost sharing; or 15
(c) A notification that reimbursement in compliance with subsection (3) of this 16
section is subject in whole to cost sharing. 17
(6) In the event of a conflict between this section and any other law, other than KRS 18
304.17A-099, this section shall control. 19
Section 2. KRS 18A.225 is amended to read as follows: 20
(1) (a) The term "employee" for purposes of this section means: 21
1. Any person, including an elected public official, who is regularly 22
employed by any department, office, board, agency, or branch of state 23
government; or by a public postsecondary educational institution; or by 24
any city, urban -county, charter county, county, or consolidated local 25
government, whose legislative body has opted t o participate in the state-26
sponsored health insurance program pursuant to KRS 79.080; and who 27
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is either a contributing member to any one (1) of the retirement systems 1
administered by the state, including but not limited to the Kentucky 2
Retirement Systems, County Employees Retirement System, Kentucky 3
Teachers' Retirement System, the Legislators' Retirement Plan, or the 4
Judicial Retirement Plan; or is receiving a contractual contribution from 5
the state toward a retirement plan; or, in the case of a public 6
postsecondary education institution, is an individual participating in an 7
optional retirement plan authorized by KRS 161.567; or is eligible to 8
participate in a retirement plan established by an employer who ceases 9
participating in the Kentucky Employees Retirement System pursuant to 10
KRS 61.522 whose employees participated in the health insurance plans 11
administered by the Personnel Cabinet prior to the employer's effective 12
cessation date in the Kentucky Employees Retirement System; 13
2. Any certified or classifi ed employee of a local board of education or a 14
public charter school as defined in KRS 160.1590; 15
3. Any elected member of a local board of education; 16
4. Any person who is a present or future recipient of a retirement 17
allowance from the Kentucky Retirement Systems, County Employees 18
Retirement System, Kentucky Teachers' Retirement System, the 19
Legislators' Retirement Plan, the Judicial Retirement Plan, or the 20
Kentucky Community and Technical College System's optional 21
retirement plan authorized by KRS 161.567, except that a person who is 22
receiving a retirement allowance and who is age sixty -five (65) or older 23
shall not be included, with the exception of persons covered under KRS 24
61.702(2)(b)3. and 78.5536(2)(b)3., unless he or she is actively 25
employed pursuant to subparagraph 1. of this paragraph; and 26
5. Any eligible dependents and beneficiaries of participating employees 27
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and retirees who are entitled to participate in the state -sponsored health 1
insurance program; 2
(b) The term "health benefit plan" for the purpos es of this section means a health 3
benefit plan as defined in KRS 304.17A-005; 4
(c) The term "insurer" for the purposes of this section means an insurer as defined 5
in KRS 304.17A-005; and 6
(d) The term "managed care plan" for the purposes of this section mean s a 7
managed care plan as defined in KRS 304.17A-500. 8
(2) (a) The secretary of the Finance and Administration Cabinet, upon the 9
recommendation of the secretary of the Personnel Cabinet, shall procure, in 10
compliance with the provisions of KRS 45A.080, 45A.08 5, and 45A.090, 11
from one (1) or more insurers authorized to do business in this state, a group 12
health benefit plan that may include but not be limited to health maintenance 13
organization (HMO), preferred provider organization (PPO), point of service 14
(POS), and exclusive provider organization (EPO) benefit plans 15
encompassing all or any class or classes of employees. With the exception of 16
employers governed by the provisions of KRS Chapters 16, 18A, and 151B, 17
all employers of any class of employees or former e mployees shall enter into 18
a contract with the Personnel Cabinet prior to including that group in the state 19
health insurance group. The contracts shall include but not be limited to 20
designating the entity responsible for filing any federal forms, adoption o f 21
policies required for proper plan administration, acceptance of the contractual 22
provisions with health insurance carriers or third -party administrators, and 23
adoption of the payment and reimbursement methods necessary for efficient 24
administration of the h ealth insurance program. Health insurance coverage 25
provided to state employees under this section shall, at a minimum, contain 26
the same benefits as provided under Kentucky Kare Standard as of January 1, 27
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1994, and shall include a mail -order drug option as p rovided in subsection 1
(13) of this section. All employees and other persons for whom the health care 2
coverage is provided or made available shall annually be given an option to 3
elect health care coverage through a self -funded plan offered by the 4
Commonwealth or, if a self -funded plan is not available, from a list of 5
coverage options determined by the competitive bid process under the 6
provisions of KRS 45A.080, 45A.085, and 45A.090 and made available 7
during annual open enrollment. 8
(b) The policy or policies shall be approved by the commissioner of insurance 9
and may contain the provisions the commissioner of insurance approves, 10
whether or not otherwise permitted by the insurance laws. 11
(c) Any carrier bidding to offer health care coverage to employees shall agree to 12
provide coverage to all members of the state group, including active 13
employees and retirees and their eligible covered dependents and 14
beneficiaries, within the county or counties specified in its bid. Except as 15
provided in subsection (20) of this section, any carrier bidding to offer health 16
care coverage to employees shall also agree to rate all employees as a single 17
entity, except for those retirees whose former employers insure their active 18
employees outside the state -sponsored health insurance program and as 19
otherwise provided in KRS 61.702(2)(b)3.b. and 78.5536(2)(b)3.b. 20
(d) Any carrier bidding to offer health care coverage to employees shall agree to 21
provide enrollment, claims, and utilization data to the Commonwealth in a 22
format specified by the Personnel Cabinet with the understanding that the data 23
shall be owned by the Commonwealth; to provide data in an electronic form 24
and within a time frame specified by the Personnel Cabinet; and to be subject 25
to penalties for noncompli ance with data reporting requirements as specified 26
by the Personnel Cabinet. The Personnel Cabinet shall take strict precautions 27
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to protect the confidentiality of each individual employee; however, 1
confidentiality assertions shall not relieve a carrier fro m the requirement of 2
providing stipulated data to the Commonwealth. 3
(e) The Personnel Cabinet shall develop the necessary techniques and capabilities 4
for timely analysis of data received from carriers and, to the extent possible, 5
provide in the request -for-proposal specifics relating to data requirements, 6
electronic reporting, and penalties for noncompliance. The Commonwealth 7
shall own the enrollment, claims, and utilization data provided by each carrier 8
and shall develop methods to protect the confidential ity of the individual. The 9
Personnel Cabinet shall include in the October annual report submitted 10
pursuant to the provisions of KRS 18A.226 to the Governor, the General 11
Assembly, and the Chief Justice of the Supreme Court, an analysis of the 12
financial stab ility of the program, which shall include but not be limited to 13
loss ratios, methods of risk adjustment, measurements of carrier quality of 14
service, prescription coverage and cost management, and statutorily required 15
mandates. If state self -insurance was a vailable as a carrier option, the report 16
also shall provide a detailed financial analysis of the self -insurance fund 17
including but not limited to loss ratios, reserves, and reinsurance agreements. 18
(f) If any agency participating in the state -sponsored employee health insurance 19
program for its active employees terminates participation and there is a state 20
appropriation for the employer's contribution for active employees' health 21
insurance coverage, then neither the agency nor the employees shall receive 22
the state-funded contribution after termination from the state -sponsored 23
employee health insurance program. 24
(g) Any funds in flexible spending accounts that remain after all reimbursements 25
have been processed shall be transferred to the credit of the state -sponsored 26
health insurance plan's appropriation account. 27
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(h) Each entity participating in the state-sponsored health insurance program shall 1
provide an amount at least equal to the state contribution rate for the employer 2
portion of the health insurance premium. For any participating entity that used 3
the state payroll system, the employer contribution amount shall be equal to 4
but not greater than the state contribution rate. 5
(3) The premiums may be paid by the policyholder: 6
(a) Wholly from funds contributed by the employee, by payroll deduction or 7
otherwise; 8
(b) Wholly from funds contributed by any department, board, agency, public 9
postsecondary education institution, or branch of state, city, urban -county, 10
charter county, county, or consolidated local government; or 11
(c) Partly from each, except that any premium due for health care coverage or 12
dental coverage, if any, in excess of the premium amount contributed by any 13
department, board, agency, postsecondary education institution, or branch of 14
state, city, urban -county, charter county, county, or consolidated local 15
government for any other health care coverage shall be paid by the employee. 16
(4) If an employee moves his or her place of residence or employment out of the 17
service area of an insurer offering a manage d health care plan, under which he or 18
she has elected coverage, into either the service area of another managed health care 19
plan or into an area of the Commonwealth not within a managed health care plan 20
service area, the employee shall be given an option, at the time of the move or 21
transfer, to change his or her coverage to another health benefit plan. 22
(5) No payment of premium by any department, board, agency, public postsecondary 23
educational institution, or branch of state, city, urban -county, charter cou nty, 24
county, or consolidated local government shall constitute compensation to an 25
insured employee for the purposes of any statute fixing or limiting the 26
compensation of such an employee. Any premium or other expense incurred by any 27
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department, board, agen cy, public postsecondary educational institution, or branch 1
of state, city, urban -county, charter county, county, or consolidated local 2
government shall be considered a proper cost of administration. 3
(6) The policy or policies may contain the provisions with respect to the class or classes 4
of employees covered, amounts of insurance or coverage for designated classes or 5
groups of employees, policy options, terms of eligibility, and continuation of 6
insurance or coverage after retirement. 7
(7) Group rates under this section shall be made available to the disabled child of an 8
employee regardless of the child's age if the entire premium for the disabled child's 9
coverage is paid by the state employee. A child shall be considered disabled if he or 10
she has been determined to be eligible for federal Social Security disability benefits. 11
(8) The health care contract or contracts for employees shall be entered into for a 12
period of not less than one (1) year. 13
(9) The secretary shall appoint thirty -two (32) persons to an Ad visory Committee of 14
State Health Insurance Subscribers to advise the secretary or the secretary's 15
designee regarding the state -sponsored health insurance program for employees. 16
The secretary shall appoint, from a list of names submitted by appointing 17
authorities, members representing school districts from each of the seven (7) 18
Supreme Court districts, members representing state government from each of the 19
seven (7) Supreme Court districts, two (2) members representing retirees under age 20
sixty-five (65), one (1) member representing local health departments, two (2) 21
members representing the Kentucky Teachers' Retirement System, and three (3) 22
members at large. The secretary shall also appoint two (2) members from a list of 23
five (5) names submitted by the Kentuc ky Education Association, two (2) members 24
from a list of five (5) names submitted by the largest state employee organization of 25
nonschool state employees, two (2) members from a list of five (5) names submitted 26
by the Kentucky Association of Counties, two (2) members from a list of five (5) 27
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names submitted by the Kentucky League of Cities, and two (2) members from a 1
list of names consisting of five (5) names submitted by each state employee 2
organization that has two thousand (2,000) or more members on state payroll 3
deduction. The advisory committee shall be appointed in January of each year and 4
shall meet quarterly. 5
(10) Notwithstanding any other provision of law to the contrary, the policy or policies 6
provided to employees pursuant to this section shall not provide coverage for 7
obtaining or performing an abortion, nor shall any state funds be used for the 8
purpose of obtaining or performing an abortion on behalf of employees or their 9
dependents. 10
(11) Interruption of an established treatment regime with mainte nance drugs shall be 11
grounds for an insured to appeal a formulary change through the established appeal 12
procedures approved by the Department of Insurance, if the physician supervising 13
the treatment certifies that the change is not in the best interests of the patient. 14
(12) Any employee who is eligible for and elects to participate in the state health 15
insurance program as a retiree, or the spouse or beneficiary of a retiree, under any 16
one (1) of the state-sponsored retirement systems shall not be eligible t o receive the 17
state health insurance contribution toward health care coverage as a result of any 18
other employment for which there is a public employer contribution. This does not 19
preclude a retiree and an active employee spouse from using both contribution s to 20
the extent needed for purchase of one (1) state sponsored health insurance policy 21
for that plan year. 22
(13) (a) The policies of health insurance coverage procured under subsection (2) of 23
this section shall include a mail -order drug option for maintenan ce drugs for 24
state employees. Maintenance drugs may be dispensed by mail order in 25
accordance with Kentucky law. 26
(b) A health insurer shall not discriminate against any retail pharmacy located 27
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within the geographic coverage area of the health benefit plan a nd that meets 1
the terms and conditions for participation established by the insurer, including 2
price, dispensing fee, and copay requirements of a mail -order option. The 3
retail pharmacy shall not be required to dispense by mail. 4
(c) The mail -order option sh all not permit the dispensing of a controlled 5
substance classified in Schedule II. 6
(14) The policy or policies provided to state employees or their dependents pursuant to 7
this section shall provide coverage for obtaining a hearing aid and acquiring hearing 8
aid-related services for insured individuals under eighteen (18) years of age, subject 9
to a cap of one thousand four hundred dollars ($1,400) every thirty -six (36) months 10
pursuant to KRS 304.17A-132. 11
(15) Any policy provided to state employees or their de pendents pursuant to this section 12
shall provide coverage for the diagnosis and treatment of autism spectrum disorders 13
consistent with KRS 304.17A-142. 14
(16) Any policy provided to state employees or their dependents pursuant to this section 15
shall provide co verage for obtaining amino acid -based elemental formula pursuant 16
to KRS 304.17A-258. 17
(17) If a state employee's residence and place of employment are in the same county, 18
and if the hospital located within that county does not offer surgical services, 19
intensive care services, obstetrical services, level II neonatal services, diagnostic 20
cardiac catheterization services, and magnetic resonance imaging services, the 21
employee may select a plan available in a contiguous county that does provide 22
those services, and the state contribution for the plan shall be the amount available 23
in the county where the plan selected is located. 24
(18) If a state employee's residence and place of employment are each located in 25
counties in which the hospitals do not offer surgical services, intensive care 26
services, obstetrical services, level II neonatal services, diagnostic cardiac 27
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catheterization servic es, and magnetic resonance imaging services, the employee 1
may select a plan available in a county contiguous to the county of residence that 2
does provide those services, and the state contribution for the plan shall be the 3
amount available in the county where the plan selected is located. 4
(19) The Personnel Cabinet is encouraged to study whether it is fair and reasonable and 5
in the best interests of the state group to allow any carrier bidding to offer health 6
care coverage under this section to submit bids that may vary county by county or 7
by larger geographic areas. 8
(20) Notwithstanding any other provision of this section, the bid for proposals for health 9
insurance coverage for calendar year 2004 shall include a bid scenario that reflects 10
the statewide rating structure provided in calendar year 2003 and a bid scenario that 11
allows for a regional rating structure that allows carriers to submit bids that may 12
vary by region for a given product offering as described in this subsection: 13
(a) The regional rating bid scenario shall not include a request for bid on a 14
statewide option; 15
(b) The Personnel Cabinet shall divide the state into geographical regions which 16
shall be the same as the partnership regions designated by the Department for 17
Medicaid Services for purpos es of the Kentucky Health Care Partnership 18
Program established pursuant to 907 KAR 1:705; 19
(c) The request for proposal shall require a carrier's bid to include every county 20
within the region or regions for which the bid is submitted and include but not 21
be restricted to a preferred provider organization (PPO) option; 22
(d) If the Personnel Cabinet accepts a carrier's bid, the cabinet shall award the 23
carrier all of the counties included in its bid within the region. If the Personnel 24
Cabinet deems the bids submi tted in accordance with this subsection to be in 25
the best interests of state employees in a region, the cabinet may award the 26
contract for that region to no more than two (2) carriers; and 27
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(e) Nothing in this subsection shall prohibit the Personnel Cabinet from including 1
other requirements or criteria in the request for proposal. 2
(21) Any fully insured health benefit plan or self -insured plan issued or renewed on or 3
after July 12, 2006, to public employees pursuant to this section which provides 4
coverage for services rendered by a physician or osteopath duly licensed under KRS 5
Chapter 311 that are within the scope of practice of an optometrist duly licensed 6
under the provisions of KRS Chapter 320 shall provide the same payment of 7
coverage to optometrists as allowed for those services rendered by physicians or 8
osteopaths. 9
(22) Any fully insured health benefit plan or self -insured plan issued or renewed to 10
public employees pursuant to this section shall comply with: 11
(a) KRS 304.12-237; 12
(b) KRS 304.17A-270 and 304.17A-525; 13
(c) KRS 304.17A-600 to 304.17A-633; 14
(d) KRS 205.593; 15
(e) KRS 304.17A-700 to 304.17A-730; 16
(f) KRS 304.14-135; 17
(g) KRS 304.17A-580 and 304.17A-641; 18
(h) KRS 304.99-123; 19
(i) KRS 304.17A-138; 20
(j) KRS 304.17A-148; 21
(k) KRS 304.17A-163 and 304.17A-1631; 22
(l) KRS 304.17A-265; 23
(m) KRS 304.17A-261; 24
(n) KRS 304.17A-262; 25
(o) KRS 304.17A-145; 26
(p) KRS 304.17A-129; 27
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(q) KRS 304.17A-133; 1
(r) KRS 304.17A-264;[ and] 2
(s) Section 1 of this Act; and 3
(t) Administrative regulations promulgated pursuant to statutes listed in this 4
subsection. 5
(23) (a) Any fully insured health benefit plan or self-insured plan issued or renewed to 6
public employees pursuant to this section shall provide a special enrollment 7
period to pregnant women who are eligible for coverage in accordance with 8
the requirements set forth in KRS 304.17-182. 9
(b) The Department of Employee Insurance shall, at or before the time a public 10
employee is initially offered the opportunity to enroll in t he plan or coverage, 11
provide the employee a notice of the special enrollment rights under this 12
subsection. 13
Section 3. This Act applies to health benefit plans issued or renewed on or after 14
January 1, 2027. 15
Section 4. This Act takes effect on January 1, 2027. 16