The Florida Senate
BILL ANALYSIS AND FISCAL IMPACT STATEMENT
(This document is based on the provisions contained in the legislation as of the latest date listed below.)
Prepared By: The Professional Staff of the Committee on Banking and Insurance
BILL: CS/SB 568
INTRODUCER: Senator Hooper
SUBJECT: Coverage for Out-of-network Ground Ambulance Emergency Services
DATE: January 10, 2024 REVISED:
ANALYST STAFF DIRECTOR REFERENCE ACTION
1. Johnson Knudson BI Fav/CS
2. HP
3. RC
Please see Section IX. for Additional Information:
COMMITTEE SUBSTITUTE - Substantial Changes
I. Summary:
CS/SB 568 requires all health insurers and health maintenance organizations (HMOs) to
reimburse nonparticipating or out-of-network ground ambulance service providers for
emergency ambulance services at the lowest of the following rates:
 The rate set or approved by a local government entity in the jurisdiction in which the covered
services originated;
 Three hundred and twenty five percent of the current rates for ambulance services established
by Medicare for the same service provided in the same geographic area; or
 The provider’s billed charges.
Payment made pursuant to this fee schedule is deemed to be payment in full for the emergency
ground ambulance services provides except for any cost sharing required to be paid by the
insured or subscriber. Accordingly, an insured or subscriber may not be balanced billed for the
difference between the payment prescribed in the bill and the amount billed by the ground
ambulance service provider.
Possible fiscal impacts from this bill are addressed in Section V of this analysis.
BILL: CS/SB 568 Page 2
II. Present Situation:
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 departments2, 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 ground ambulance service. Balance
billing occurs when 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 $450.4 In some states, the
average is more than $1,000.5
Federal and State Laws Relating to Emergency Medical Treatment
Emergency Medical Treatment and Active Labor Act (EMTALA)
In 1986, Congress enacted EMTALA 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 to determine if the 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. If a hospital is unable to
stabilize a patient or, if the patient requests, the hospital must transfer the patient to another
appropriate facility.6 A hospital that violates EMTALA is subject to civil monetary penalty7 or
civil suit by a patient who suffers personal harm.8
Florida law imposes a similar duty.9 The law requires the Agency for Health Care
Administration (agency) to maintain an inventory of the service capability of all licensed
1
Ground ambulance rides and potential for surprise billing - Peterson-KFF Health System Tracker (June 24, 2021) (last
visited Jan. 4, 2024).
2
What are the differences between public and private ambulance services? (ems1.com) (Oct. 23, 2017) (last visited Jan. 3,
2024).
3
Protecting Consumers from Surprise Ambulance Bills | Commonwealth Fund (Nov. 15, 2021) (last visited Jan. 6, 2024).
4
https://www.medicalbillersandcoders.com/blog/role-of-states-in-exclusion-of-ground-ambulances-from-nsa/ (last visited
Jan. 5, 2024).
5
EMERGENCY: The high cost of ambulance surprise bills (pirg.org) (Oct. 26, 2023) (last visited Jan. 6, 2024).
6
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),
http://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/index.html?redirect=/emtala/ (last visited Jan. 4,
2024).
7
42 U.S.C. s. 1395dd(d)(1).
8
42 U.S.C. s. 1395dd(d)(2).
9
See s. 395.1041, F.S. A hospital that violates Florida’s access to care statute is subject to administrative penalties; denial,
revocation, or suspension of its license; or civil action by another hospital or physician suffering 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
BILL: CS/SB 568 Page 3
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.
Federal Patient Protection and Affordable Care Act (PPACA)10
The PPACA imposes many insurance requirements, such as mandated benefits, rating and
underwriting standards, review of rate increases, reporting of medical loss ratios and payment of
rebates, coverage of adult dependents, internal and external appeals of adverse benefit
determinations, and other requirements. The PPACA also requires that major medical coverage
provide ten essential health benefits in the individual and small group markets, which includes
emergency services.11
The Federal No Surprise Act12
The No Surprises Act13 protects people covered under group and individual health plans from
receiving surprise medical bills when they receive most emergency services, non-emergency
services from non-participating providers at in-network facilities, and services from non-
participating air ambulance service providers. It does not regulate the payment of
nonparticipating ground ambulance services or prohibit balance billing by such providers. It also
establishes an independent dispute resolution process for payment disputes between plans and
providers, and provides new dispute resolution opportunities for uninsured and self-pay
individuals when they receive a medical bill that is substantially greater than the good faith
estimate they get from the provider.
The No Surprises Act requires the establishment of an Advisory Committee on Air Ambulance
Quality and Patient Safety Advisory Committee. The committee’s final report is expected to be
issued in early 2024,14 and the recommendations must address, at a minimum:
 Options, best practices, and identified standards to prevent instances of balance billing;
 Steps that can be taken by state legislatures, state insurance regulators, state attorneys
general, and other state officials as appropriate, consistent with current legal authorities
regarding consumer protection; and
guilty of a second-degree misdemeanor for a knowing or intentional violation. Physicians who violate the statute are also
subject to disciplinary action against their license or civil action by another hospital or physician suffering financial loss.
10
P.L. 111-148. On March 30, 2010, PPACA was amended by P.L. 111-152, the Health Care and Education Reconciliation
Act of 2010.
11
42 U.S.C. 300gg-6.
12
No Surprises: Understand your rights against surprise medical bills | CMS (last visited Jan. 6, 2024).
13
Pub. L. No. 116-260, 134 Stat. 1182, Division BB, s. 109.
14
Ground Ambulance and Patient Billing- Third Meeting Summary _Final (cms.gov) (last visited Jan. 6, 2024).
BILL: CS/SB 568 Page 4
 Legislative options for Congress to prevent balance billing.15
In late 2023, the committee presented the following key findings:16
 Congress should work with stakeholders once the data from the Ground Ambulance Data
Collection System and Medicare Payment Advisory Commission reports are available to
modernize the Medicare ground ambulance benefit.
 Congress should establish a standing advisory committee to evaluate expanding coverage and
reimbursement of ground ambulance services beyond transports under the Social Security
Act to include community paramedicine, advanced life support and first response, high-cost
drugs and medical equipment, and oxygen and other ancillary supplies.
 Congress and the Secretary of Health and Human Services should evaluate and limit the
Medicare beneficiary out-of-pocket obligations for ground ambulance emergency and
nonemergency.
 Congress and the Secretary of Health and Human Services should consider evaluating the
cost and reimbursement of services under the Social Security Act for those ground
ambulance service providers and suppliers in rural, super-rural, and medically-underserved
areas.17
State Regulation of Emergency Medical Transportation
Part III of ch. 401, F.S., governs the provision of emergency medical transportation services in
Florida and establishes the licensure and operational requirements for emergency medical
services, including air ambulances18 and ground ambulances.19
State Regulation of Insurance
In Florida, the Office of Insurance Regulation (OIR) licenses and regulates insurers, HMOs, and
other risk-bearing entities.20 To operate in Florida, an insurer or HMO must obtain a certificate
of authority from the OIR.21 The agency regulates the quality of care provided by HMOs under
part III of ch. 641, F.S. Prior to receiving a certificate of authority22 from the OIR, an HMO must
receive a Health Care Provider Certificate from the agency. As part of the certification process
used by the agency, an HMO must provide information to demonstrate that the HMO has the
ability to provide quality of care consistent with the prevailing standards of care.23
Balance Billing
15
See s. 117 of the No Surprises Act.
16
Supra at 14.
17
Federal Ground Ambulance and Patient Billing Advisory Committee, Key Findings. On file with the Senate Committee on
Banking and Insurance staff.
18
Sections 401.23 and 401.251, F.S. An air ambulance service refers to a licensed publicly or privately owned service that
operates air ambulances to transport persons requiring or likely to require medical attention during transport. An air
ambulance is intended to be used for, the air transportation of sick or injured persons that require or are likely to require
medical attention during transport.
19
Section 401.25, F.S.
20
Section 20.121(3)(a)1., F.S.
21
Section 641.21(1), F.S.
22
Sections 624.401 and 641.49, F.S.
23
Section 641.495, F.S.
BILL: CS/SB 568 Page 5
A provider, regardless of whether it is under contract with an HMO, may not collect or attempt
to collect money from a subscriber.24 The subscriber is not liable for payment of fees to the
provider.25 Balance billing is also prohibited in cases when emergency services are provided by a
nonparticipating provider, and when nonemergency services are provided by a nonparticipating
provider and the insured or subscriber does not have the ability and opportunity to choose a
participating provider at the facility who is available to treat that patient.26 However, this
provision does not prohibit balance billing of services related to ground ambulance providers.
Insurance Coverage for Air Ambulance Services
In 2020, the Florida Legislature enacted legislation to address coverage for air ambulance
services.27 The law requires a health insurer28 or HMO29 to provide reasonable reimbursement to
an air ambulance service for emergency and nonemergency transport services provided to a
covered individual in accordance with the terms of the insurance policy or HMO contract. The
bill defines “reasonable reimbursement” as payment that considers the direct cost of services
provided, costs incurred by the operation of an air ambulance service by a county which operates
entirely within a designated area of critical state concern30 as determined by the Department of
Economic Opportunity, and in-network reimbursement for comparable services.
In cases where an air ambulance provider and an insurer have not contractually agreed to
reimbursement rates, the air ambulance provider would be required to accept “reasonable
reimbursement” from the insurer. The term, “reasonable reimbursement” does not include the
amount of billed charges for the costs of services rendered.31 The bill specifies that payment in
full of applicable copayments, coinsurance, and deductibles by an insured patient who receives
air ambulance services shall constitute the full financial obligation of the patient for those
services. Accordingly, an air ambulance service provider may not balance bill insureds or
subscribers.
Prompt Payment of Health Insurance Claims
The Insurance Code prescribes rights and responsibilities of health care providers, health
insurers, and health maintenance organization for the payment of claims. Florida’s prompt
payment laws govern payment of provider claims submitted to insurers and HMOs, including
Medicaid managed care plans, in accordance with ss. 627.6131 and 641.3155, F.S.,
respectively.32 The law prescribes a protocol for specified providers to use for the submission of
their claims to an insurer or HMO, as well as a statutory process for insurers or HMOs use for
the payment or denial of the claims.
24
Sections 641.315(1) and 641.3154(1) and (4), F.S.
25
Id.
26
Section 627.64194, F.S.
27
Ch. 2020-177, Laws of Fla.
28
Section 627.42397, F.S. Ch. 2016-222, Laws of Fla.
29
Section 641.514, F.S.
30
The Areas of Critical State Concern Program was created by the Florida Environmental Land and Water Management Act
of 1972. The program is intended to protect resources and public facilities of major statewide significance, within designated
geographic areas, from uncontrolled development that would cause substantial deterioration of such resources.
31
Section 627.42397(1)(c), F.S.
32
The prompt pay provisions apply to HMO contracts and major medical policies offered by individual and group insurers
licensed under ch. 624, F.S., including preferred provider policies and an exclusive provider organizations, and specified
contracts.
BILL: CS/SB 568 Page 6
Division of State Group Insurance
Under the authority of s. 110.123, F.S., the Department of Management Services, through the
Division of State Group Insurance, administers the state group health insurance program under a
cafeteria plan consistent with s. 125, Internal Revenue Code. To administer the state group health
insurance program, DMS contracts with third party administrators for self-insured health plans
and insured (HMOs), as well as a pharmacy benefits manager for the state employees’ self-
insured prescription drug program pursuant to s. 110.12315, F.S.
Florida’s Medicaid Coverage of Emergency Transportation Services33
The Agency for Health Care Administration (agency) administers Florida’s Medicaid Program,
which is a partnership of the federal and state governments, and provides coverage for health
services for eligible persons. 34 Medicaid reimburses for medically necessary emergency ground