Creates provisions relating to payments to ambulance providers

SECOND REGULAR SESSION
HOUSE BILL NO. 2597
103RD GENERAL ASSEMBL Y
INTRODUCED BY REPRESENT A TIVE HINMAN.
6386H.01I JOSEPH ENGLER, Chief Clerk
AN ACT
T o amend chapter 376, RSMo, by adding thereto one new section relating to payments to
ambulance providers.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Chapter 376, RSMo, is amended by adding thereto one new section, to be
2 known as section 376.684, to read as follows:
376.684. 1. As used in this section, unless the context indicates otherwise, the
2 following terms mean:
3 (1) "Ambulance pro vider", any ambulance service, as defined in section 190.100.
4 The term "ambulance pr ovider" shall not include an air ambulance pro vider;
5 (2) "Clean claim", a claim that has no defect or impropr iety , including any lack
6 of requ ired substantiating documentation or particular cir cumstance req uiring special
7 tr eatment that pre vents timely payment fr om being made on the claim;
8 (3) "Covered services", those emergency ambulance services that an enr ollee is
9 entitled to rec eive under the terms of a health benefit plan;
10 (4) "Enro llee", the same meaning given to the term in section 376.1350;
11 (5) "Health benefit plan", the same meaning given to the term in section
12 376.1350;
13 (6) "Health carrier", the same meaning given to the term in section 376.1350;
14 (7) "Out-of-network ambulance pr ovider", an ambulance pro vider that does not
15 contract with the health carrier of the enr ollee recei ving the cover ed services.
EXPLANA TION — Matter enclosed in bold-faced brackets [thus] in the above bill is not enacted and is
intended to be omitted from the law . Matter in bold-face type in the above bill is proposed language.
16 2. The minimum allowable re imbursement rate under any health benefit plan
17 issued by any health carrier to an out-of-network ambulance prov ider for pr oviding
18 emergency services shall be:
19 (1) At the rates set or appr oved, whether in contract or ordinance, by a local
20 governmental entity in the jurisdiction in which the cover ed services originate, or as
21 pr ovided for in section 190.105; or
22 (2) In the absence of rates as provi ded in subdivision (1) of this subsection, thr ee
23 hundr ed twenty-five percen t of the curren t published rate for ambulance services, as
24 established by the Centers for Medicare and Medicaid Services under T itle XVIII of the
25 Social Security Act for the same service prov ided in the same geographic ar ea, or the
26 ambulance pr ovider's billed charges, whichever is less.
27 3. Payment made in compliance with this section shall be consider ed payment in
28 full for the cover ed services pr ovided, except for any co-payment, coinsurance,
29 deductible, and other cost-sharing amounts req uire d to be paid by the enr ollee. An
30 ambulance pr ovider is pr ohibited fro m billing the enr ollee for any additional amounts
31 for paid cover ed services.
32 4. All co-payment, coinsurance, deductible, and other cost-sharing amounts
33 pr ovided by subsection 3 of this section shall not exceed the in-network co-payment,
34 coinsurance, deductible, and other cost-sharing amounts for the cover ed services
35 r eceived by the enr ollee.
36 5. A health carrier shall, within thirty days after receip t of a clean claim for
37 cover ed services, pr omptly rem it payment for ambulance services dire ctly to the
38 ambulance pr ovider and shall not send payment to an enro llee.
39 6. If the claim is not a clean claim, the health carrier shall, within thirty days
40 after recei pt of the claim, send a written notice acknowledging the date of the receip t of
41 the claim and shall specify:
42 (1) That the health carrier is declining to pay all or part of the claim and the
43 specific reas on or reas ons for the denial; or
44 (2) That additional information is necessary to determine if all or part of the
45 claim is payable and the specific additional information that is req uired .
46 7. T o the extent that this section conflicts with section 376.690 or any other
47 pr ovision of law , this section shall prev ail.
✔
HB 2597 2