SB 1376

For health benefit plans issued or renewed on or after July 1, 2025, this bill prohibits an out-of-network ambulance service provider from balance billing an enrollee in a health benefit plan of a health insurer for the use of a privately or publicly own ed land or air ambulance for transportation of injured or infirm persons with an emergency medical condition ("ambulance services"") covered under the enrollee's health benefit plan. Further, an enrollee satisfies their obligation to pay for out-of-networ k ambulance services if the enrollee pays the lesser of the following:  The in-network cost-sharing amount specified in the enrollee's health benefit plan for ambulance services.  The ambulance service provider's billed charges.  325% of the current published rate for ambulance services as established by the federal centers for medicare and medicaid services for the same service provided in the same geographic area. This bill requires a health insurer to treat a cost sharing amount determined under the formula above, paid by the enrollee for out-of-network ambulance services, in the same manner as cost sharing for in-network ambulance services, and to apply the cost -sharing amount paid by the enrollee for such services toward the enrollee's deductible and maximum out-of-pocket payment obligation under the enrollee's health benefit plan, as applicable. This bill prohibits an ambulance service organization from requesting or requiring an enrollee to sign or otherwise execute by oral, written, or electronic means, a document that would attempt to void, waive, or alter this bill. ON APRIL 2, 2026, THE HOUSE ADOPTED AMENDMENT #1 AND PASSED HOUSE BILL 1061, AS AMENDED. AMENDMENT #1 rewrites the bill to, instead, prohibit an ambulance provider from balance billing an enrollee of a health benefit plan for ambulance services that are covered services under the enrollee's health benefit plan on or after July 1, 2026. As u sed in this amendment, ""balance billing"" means the practice of charging an enrollee in a health benefit plan to recover from the enrollee the balance of an ambulance service provider's fee for transportation received by the enrollee for ambulance service th at exceeds the reimbursable amount for such service under the enrollee's health benefit plan. Any payment made to an ambulance provider under this amendment must release a covered person from any further payment responsibility other that any copayment, c oinsurance, or deductible owed under the health benefit plan. An ambulance provider is prohibited from requesting or requiring an enrollee to execute a document that would void, waive, or alter the requirements of this amendment. HEALTH INSURER OBLIGATIONS This amendment provides that a health insurer satisfies the health insurer's obligation to pay for out-of-network ambulance services if the health insurer pays the minimum allowable reimbursement rate under the health benefit plan for covered service, wh ich must be the rate agreed to by contract or through passage of an ordinance, resolution, rule, or regulation by a political subdivision. If there is no such contract or applicable ordinance, rule, or regulation, the minimum allowable reimbursement amou nt is the lesser of (i) the ambulance provider's billed charges; or (ii) 425% of the current published medicare rate for ambulance services for comparable services in the same geographic area. A health insurer must treat any cost-sharing amount paid by the enrollee for out-of-network ambulance services the same as cost-sharing paid by the enrollee for in-network ambulance services. Further, such cost-sharing amount must be applied to the enrollee's deductible and out of pocket maximums under the plan. This amendment requires an insurer to remit payment for ambulance services within 30 days of receiving a clean claim for a covered service. Such payment must be made directly to the ambulance service and not to the covered person. If a health insurer has received a claim that is not a clean claim, then the health insurer must inform the ambulance provider, within 30 days, ( ii) that the health insurer has declined to pay all or part of the claim, including the reasons for such denial; or (ii) what additional information is necessary to make a determination on the claim. As used in this amendment, a ""clean claim"" means a cla im for reimbursement of service rendered by an ambulance provider that has no defect of impropriety, including any lack of required substantiating documentation, which would reasonably prevent timely payment for a claim. Remedies and Enforcement If an ambulance provider believes that a health insurer has not complied with this amendment, then such provider may send a written notice advising the health insurer of the suspected violation. A health insurer must comply with this amendment with 15 d ays of receipt of a notice from an ambulance provider, or notify the provider of the basis upon which the health insurer relies in denying a violation of this amendment. If the ambulance provider and the health insurer disagree about a violation once the se requirements are met, then the ambulance provider may file an action against the health insurer within one year of the date of service. If the court finds the health insurer has violated this amendment, then the court must award treble damages and reaso nable court costs and fees to the ambulance service. The commissioner of commerce and insurance is also authorized to enforce this amendment. EXEMPTIONS This amendment exempts TennCare, CoverKids, group insurance plans offered to state employees, and air ambulance services from its provisions."