HOUSE OF REPRESENTATIVES STAFF ANALYSIS
BILL #: CS/HB 639 Coverage of Out-of-network Ground Ambulance Emergency Services
SPONSOR(S): Select Committee on Health Innovation, Yeager
TIED BILLS: IDEN./SIM. BILLS: CS/SB 568
REFERENCE ACTION ANALYST STAFF DIRECTOR or
BUDGET/POLICY CHIEF
1) Select Committee on Health Innovation 11 Y, 0 N, As CS Lloyd Calamas
2) Appropriations Committee 27 Y, 0 N Helpling Pridgeon
3) Health & Human Services Committee
SUMMARY ANALYSIS
Congress adopted the federal No Surprises Act in 2021 to address balance billing in health care, except in the
area of ground transportation, emergency and non-emergency. Emergency transportation companies do not
get a choice in their patients and must answer every 911 call received for a medical emergency. Whether or
not a patient has insurance, what insurance, or ability to pay is not a consideration at the time a ground
ambulance responds to the emergency call. In the same manner, patients in need of an emergency transport
are not able to shop around for services or to research which ambulance to call.
The vast majority of ground ambulance emergency services are owned or operated by a county or local
municipality such as fire departments (37 percent) or other government entities (25 percent) with the remainder
being held by private businesses (30 percent) and hospital owned ambulances. When there is a choice of
ambulance providers in an area, the 911 operator typically picks the provider based on its proximity to the
scene and the patient’s injury severity.
Florida established its own balance billing law in 2016. The law prohibits nonparticipating providers, including
hospitals, ambulatory surgical centers, and urgent care centers, from balance billing members of a preferred
provider organization (PPO) or exclusive provider organization (EPO) for emergency services or for
nonemergency services when the nonemergency services are provided in a network hospital and the patient
had no ability and opportunity to choose a network provider.
The bill addresses the gap left by the two laws through the establishment of a set of options for payment of out-
of-network claims by group health plans and individual health plan policies to be the lesser of:
 The rate set or approved, whether it is established in a contract or local government ordinance, in the
jurisdiction in which the covered services occurred.
 350 percent of the current published rate by federal CMS for ambulance services under Title XVIII of
the Social Security Act for the same geographic area; or the ambulance’s billed charges, whichever is
less.
 The contracted rate at which the health care provider would reimburse an in-network ambulance
provider for providing the covered service.
The bill also establishes that payment from the insurer is considered payment in full. Cost sharing from the
patient may not exceed the in-network amounts that would have been charged for the same service.
The bill may have an insignificant, negative fiscal impact on state government. See Fiscal Analysis and
Economic Impact Statement.
The bill has an effective date of July 1, 2024.
This docum ent does not reflect the intent or official position of the bill sponsor or House of Representatives .
STORAGE NAME: h0639c.APC
DATE: 2/14/2024
 FULL ANALYSIS
I. SUBSTANTIVE ANALYSIS
A. EFFECT OF PROPOSED CHANGES:
Background
Emergency Ground Transportation
Ground emergency medical transportation is a life-saving service that may affect anyone, including the
uninsured, privately insured, and those covered by governmental health care programs. In 2020, 37
percent1 of emergency ground ambulance rides were provided through local fire departments,2 25
percent through other government agencies, 30 percent through private companies, and 8 percent
through hospitals.3 Federal laws and current Florida laws do not provide balance billing protections for
insured consumers that use a non-participating or out-of-network emergency ground ambulance
service.
About 51 percent of all ground ambulance calls require Advanced Life Support (ALS) 4 services
compared to Basic Life Support (BLS) services.5,6 Emergency ambulance fees usually include two
components: a base fee and a mileage fee. According to FAIR Health report, the average charge for
ALS emergency ground ambulance services has increased from $1,042 in 2017 to $1,277 in 2020,
which represents a 22.6 percent increase. In Medicare, the average increase for these same services
was $441 to $463, a five percent increase.7 The average charge for BLS emergency ground
ambulance services increased 17.5 percent from $800 in 2017 to $940 in 2020. The average Medicare
amount for these services increased 4.8 percent from $372 to $390.8 The second component of the
billing rate, mileage fees can vary greatly as well from $20 per mile to $90 per mile. 9 And, depending on
where a patient lives in relation to the closest emergency facility, the cost per mile can quic kly add up.
In urban Florida, the hospital ride may be less than 10 miles, but in more rural areas of Florida, it could
be 50 or more miles to the closest or most appropriate hospital for the patient. In 2019, Florida has one
of the lowest averages for mileage for ground ambulance emergency transportation at 7.2 miles
compared to the highest state of Wyoming at 29.2 miles. 10
One study found that 71 percent of all ambulance rides had the potential to incur surprise medical
bills.11 While this study occurred in 2000, prior to the implementation of the federal legislation
addressing most types of balance billing, it still speaks to the percentage of ambulance rides that end
up as balance billing cases, whether ground or air, and the costs involved for such transportation. The
1 Ground amb ulance rides and potential for surprise b illing - Peterson-KFF Health System Tracker (June 24, 2021), available at Ground
ambulance rides and potential for surprise billing - Peterson-KFF Health System Tracker (last visited January 31, 2024).
2 What are the differences b etween pub lic and private amb ulance services? (ems1.com) (Oct. 23, 2017), available at What are the
differences between public and private ambulance services? (ems1.com) (last visited January 31, 2024).
3 Protecting Consumers from Surprise Amb ulance Bills | Commonwealth Fund (Nov. 15, 2021), available at
https://www.commonwealthfund.org/blog/2021/protecting-consumers-surprise-ambulance-bills (last visited January 31, 2024).
4
Advanced Life Support Services (ALS) includes basic life support but must have a paramedic on board. The technicians on an AL S
ambulance have a higher level of training. Typically, to treat a patient during an ALS ambulance service, an invasive procedu re is done,
for example, with needles or other devices that make cuts in the skin. An ALS provider can give injections, do very limited s urgical
procedures (e.g., a tracheotomy) and administer medicine. ALS ambulances are typically outfitted with airway equip ment, cardiac life
support, cardiac monitors and glucose testing devices.
5
Also called “first step treatment,” these services can be provided by either a paramedic or an emergency medical technician ( EMT).
They typically include fractures or injuries, psychiatric patients or medical and surgical patients who do not need cardiac monitoring or
respiratory interventions.
6
Ground Ambulance Services in the United States (2022), FAIR HEALTH , available at: Ground Ambulance Services in the United States -
A FAIR Health White Paper.pdf (last visited January 30, 2024).
7 Id.
8 Id.
9 PBS News Hour, The No Surprises Act left out ground amb ulances. Here is what is happening now, (August 17, 2023), availab le at
The No Surprises Act left out ground ambulances. Here’s what’s happening now | PBS NewsHour (last visited January 29, 2024).
10 Supra, note 6.
11 Karan R. Chhabra, Keegan McGuire, et al., “Most Patients Undergoing Ground and Air Ambulance Transportation Receive Si zeable
Out-Of-Network Bills, HEALTH AFFAI rs (April 15, 2020), available at :Most Patients Undergoing Ground And Air Ambulance
Transportation Receive Sizable Out-Of-Network Bills | Health Affairs
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 study found the median range in 2020 for surprise ground emergency transportation bill to be $450. 12 In
balance billing for emergency ground transportation, which was not included in either the state or
national balance billing laws, the Florida ambulance providers are reimbursed, on average, for 56
percent of their billed charges.
An ambulance may also arrive to a call, treat the patient, and not transport the patient to a facility.
Nationally, from 2017 to 2019, the percentage has dropped for the number of cases from one percent
of all calls to 0.7 percent, and then bounced back to one percent of all calls for emergency ground
transportation.13 For the four-year period of 2017-2020, the top five reasons for emergency ground
transportation calls, but no transport to a facility have remained the same, if out of order. For 2020, the
number one reason for a call was for general, non-specific reasons, followed by circulatory and
respiratory issues, injury to the body, endocrine and metabolic issues, and signs and symptoms related
to cognition.14
Balance Billing
Balance billing occurs when an insured patient accesses out of network services at an emergency
facility or while receiving non-emergency services at in-network hospital or facility for covered
services.15 With balance billing, a provider bills a patient for the difference between the amounts the
provider charges and the amount that the patient’s insurance company pays. This does not include
cost-sharing requirements such as copayments that are typically paid by a patient. As a result, a
consumer may incur an average balance billing or out of pocket cost of $450. 16 In some states, the
average is more than $1,000.17
Statewide Provider and Health Plan Claim Dispute Resolution Program
The Statewide Provider and Health Plan Claim Dispute Resolution Program was established by the
2000 Florida Legislature to assist contracted and non-contracted providers and managed care
organizations reach a resolution of claim disputes that were not resolved by the provider and the
managed care organization without litigation. Statute requires the Agency for Health Care
Administration (AHCA) to contract with a resolution organization to timely review and consider claim
disputes and submit recommendations to AHCA.
As of June 30, 2023, no provider and health plan claim disputes are being reviewed as the contract
with the resolution organization ended at the end of the fiscal year. The AHCA is soliciting a new third-
party vendor, but until then, claims are not being resolved. According to figures from AHCA, 563 claims
were received last year and 443 claims were reviewed. The difference between the claims accepted
and those reviewed may be attributed to several factors, including lack of follow up for additional
information, or failure to submit a complete application.
Emergency Medical Treatment and Active Labor Act (EMTALA)
In 1986, Congress enacted EMTALA18 to ensure public access to emergency services regardless of
ability to pay. The EMTALA imposes specific obligations on hospitals participating in the Medicare
program, which offer emergency services. Any patient who comes to the emergency department must
be provided with a medical screening examination within the hospital’s capabilities to determine if the
12
Id.
13 Id.
14 Id.
15 Supra, note 1.
16
Role of States in Exclusion of Ground Amb ulances from NSA, Medicalbillersandcoders.com, available at: Role of States in Exclusion
of Ground Ambulances from NSA (medicalbillersandcoders.com) (July 22, 2022) (last visited January 29, 2024).
17 EMERGENCY: The high cost of amb ulance surprise b ills (pirg.org) (Oct. 26, 2023), available at EMERGENCY: The high cost of
ambulance surprise bills (pirg.org) (last visited January 29, 2024).
18 42 U.S.C. 1395dd; Section 1867 of the Social Security Act.
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 patient has an emergency medical condition. If an emergency medical condition exists, the hospital
must provide treatment within its service capability to stabilize the patient. 19
If a hospital is unable to stabilize a patient or, if the patient requests, the hospital must transfer the
patient to another appropriate facility.20 A hospital that violates EMTALA is subject to civil monetary
penalty21 or civil suit by a patient who suffers personal harm.22
Florida law imposes a similar duty.23 The law requires AHCA to maintain an inventory of the service
capability of all licensed hospitals that provide emergency care in order to assist emergency medical
services (EMS or ambulance) providers and the public in locating appropriate medical care. Hospitals
must provide all listed services when requested, whether by a patient, an emergency medical services
provider, or another hospital, regardless of the patient’s ability to pay. If the hospital is at capacity or
does not provide the requested emergency service, the hospital may transfer the patient to the nearest
facility with appropriate available services. Each hospital must ensure the services listed can be
provided at all times either directly or through another hospital. A hospital is prohibited from basing
emergency treatment and care on a patient’s insurance status, economic status, or ability to pay.
Florida No Surprises Act
In 2016, the Florida Legislature passed and Governor Scott signed CS\CS\CS\HB 22124 which, among
other provisions, prohibited out of network providers for preferred provider organizations (PPOs) 25 and
exclusive provider organizations (EPOs) 26 from balance billing its enrollees for emergency services or
for nonemergency services when the nonemergency services are provided in a network hospital and
the patient had no ability and opportunity to choose a network provider. Effective July 1, 2016, the
legislation sets standards for determining reimbursement to the providers and authorized providers and
insurers to settle disputed claims under the statewide provider and health plan claim dispute resolution
program.27
A health maintenance organization (HMO) is an organization that provides a wide range of health care
services, including emergency care, inpatient hospital care, physician care, ambulatory diagnostic
treatment and preventive health care pursuant to contractual arrangements with preferred providers in
a designated service area. The network is made up of providers who have agreed to supply services to
members at pre-negotiated rates. Traditionally, an HMO member must use the HMO’s network of
health care providers in order for the HMO to make payment of benefits. The use of a health care
provider outside the HMO’s network generally results in the HMO limiting or denying the payment of
benefits for out-of-network services rendered to the member. Current statutes governing HMOs already
prohibit balance billing for covered emergency services at an out of network provider.
CS\CS\CS\HB 221 also required PPOs to publish a list of their network providers on their websites, and
to update the list monthly. All PPOs must give their subscribers notice regarding the potential for
19 Emergency Medical Treatment and Active Labor Act (EMTALA), 42 U.S.C. §1395dd; see also CENTERS FOR MEDICARE &
MEDICAID SERVICES, Emergency Medical Treatment & Labor Act (EMTALA), (last visited January 29, 2024).
20
42 U.S.C. 1395dd(b)(2).
21 42 U.S.C. 1395dd(d)(1).
22 42 U.S.C. 1395dd(d)(2).
23 See s. 395.1041, F.S. A hospital that violates Florida’s access to care statute is subject to administrative penalties; denial, r evocation,
or suspension of its license; or civil action by another hospital or physician su ffering financial loss. In addition, hospital administrative or
medical staff are subject to civil suit by a patient who suffers personal harm and may be found guilty of a second -degree misdemeanor
for a knowing or intentional violation. Physicians who vio late the statute are also subject to disciplinary action against their license or
civil action by another hospital or physician suffering financial loss.
24 ch. 2016-222, L.O.F.
25 A PPO is a health plan that contracts with providers, such as hospitals and d octors, to create a network of providers who participate
for an alternative or reduced rate of payment. A PPO is an insurance product. PPO plan members generally see specialists with out
prior referral or authorization from the insurer. Generally, the membe r is only responsible for the policy co-payment, deductible, or
coinsurance amounts if covered services are obtained from network providers. However, if a member chooses to obtain services from
an out-of-network provider, those out-of-pocket costs likely will be higher. See generally s. 627.6471, F.S.
26 In an EPO arrangement, an insurance company contracts with hospitals, physicians, and other medical facilities. Insured membe rs
must use the participating hospitals or providers to receive covered benefits, subject