Assembly Bill 720 aims to enhance the coverage and reimbursement processes for emergency ambulance services under health insurance policies and plans in Wisconsin. The bill mandates that defined network plans, preferred provider plans, and self-insured governmental plans must cover emergency ambulance services provided by non-participating ambulance service providers at specified rates. These rates are prioritized in the following order: a mutually agreed rate between the plan and the provider, a rate set or approved by a local governmental entity, or a rate that is 350 percent of the Medicare published rate for the services, whichever is lower. Additionally, the bill prohibits ambulance service providers from charging enrollees any amount beyond their cost-sharing responsibilities, such as copayments or deductibles, and limits the cost-sharing amounts to those applicable if the services were provided by a participating provider.

The bill also introduces new requirements for health insurance policies and self-insured plans regarding the timely processing of claims for emergency ambulance services. Specifically, these plans must respond to claims within 30 days, either by remitting payment directly to the ambulance service provider or notifying them of any claim defects. Furthermore, the bill establishes that payment for medically necessary emergency ambulance services must be made at the rates outlined in the new provisions, provided that the ambulance service provider submits a medical necessity certification statement. The bill includes amendments to existing statutes and creates new sections to ensure compliance with these requirements, thereby improving access to emergency medical services for enrollees.

Statutes affected:
Bill Text: 40.51(8), 40.51, 40.51(8m), 66.0137(4), 66.0137, 120.13(2)(g), 120.13, 185.983(1)(intro.), 185.983