Concerning the Payment Methodology for Non-Contracted Service Agencies that Provide Emergency Ambulance Services
Section 1 Authority
This regulation is promulgated and adopted by the Commissioner of Insurance under the authority of §§ 10-1-109(1), 10-16-109, 10-16-704(5.5)(d)(II)(A), and 10-16-708, C.R.S.
Section 2 Scope and Purpose
The purpose of this regulation is to establish a payment methodology to be utilized by carriers to pay noncontracted service agencies that provide emergency ambulance services pursuant to HB 19-1174. This payment methodology does not apply to a publicly-funded fire agency.
Section 3 Applicability
This regulation applies to carriers offering individual, small group and large group health benefit plans that will receive claims incurred on or after January 1, 2020 from non-contracted services agencies which provide emergency ambulance services and who are subject to the requirements of § 10-16-704(5.5), C.R.S.
Section 4 Definitions
A. “Ambulance service” shall have the same meaning as found at § 25-3.5-103(3), C.R.S.
B. “Carrier” shall have the same meaning as found at § 10-16-102(8), C.R.S.
C. “Covered person” shall have the same meaning as found at § 10-16-102(15), C.R.S.
D. “Geographic area” means, for the purposes of this regulation, the geographic area established by the Division for out-of-network reimbursements pursuant to § 10-16-704(3)(d)(VI)(A), C.R.S., and contained in Appendix A of this regulation.
Note, Appendix A may be accessed at https://www.sos.state.co.us/CCR/GenerateRulePdf.do?ruleVersionId=8922&fileName=3%20CCR%20702-4%20Series%204-2
E. “Medicare reimbursement rate” shall have the same meaning as found at § 10-16-
F. “Non-contracted service agency” means, for the purposes of this regulation, a service agency that does not have a contract with a carrier to provide emergency ambulance services.
G. “Publicly-funded fire agency” means, for the purposes of this regulation, an ambulance service provider that has been established as part of a fire protection district, health services district, municipality, special tax district, or other government entity.
H. “Service agency” shall have the same meaning as found at § 25-3.5-103(11.5), C.R.S.
Section 5 Payment Methodology Rules
A. Carriers shall reimburse a non-contracted service agency that provides emergency ambulance services to a covered person at three hundred twenty-five percent (325%) of the Medicare reimbursement rate for the same service provided in the same geographic area, including mileage.
B. A non-contracted service agency that does not meet the definition of a publicly-funded fire
agency, but does contract with a fire department, fire protection district, health services district, municipality, special tax district, or other government entity to provide emergency ambulance services on their behalf shall be reimbursed in accordance with the terms of that contract.
C. A non-contracted service agency shall remain subject to Section 5.D. of this regulation if it
contracts with a fire department, fire protection district, health services district, municipality,
special tax district, or other government entity to provide emergency ambulance services and is prohibited from billing the covered person, except as permitted in Section 5.D. of this regulation.
D. Covered persons shall only be responsible for the applicable in-network deductible, coinsurance, and/or copayment they would be required to pay for in-network emergency ambulance services.
E. Payment made in compliance with Section 5.A. of this regulation shall be considered payment in full for the covered services provided, except for any in-network deductible, coinsurance and/or copayment amount required to be paid by the covered person.
F. An ambulance service provider must demonstrate to a carrier that it meets the definition of a publicly-funded fire agency found at Section 4.G. of this regulation in order to be exempt from the requirements found in this regulation.
Section 6 Severability
If any provision of this regulation or the application of it to any person or circumstances is for any reason held to be invalid, the remainder of this regulation shall not be affected.
Section 7 Enforcement
Noncompliance with this regulation may result in the imposition of any of the sanctions made available in the Colorado statutes pertaining to the business of insurance, or other laws, which include the imposition of civil penalties, issuance of cease and desist orders, and/or suspensions or revocation of license, subject to the requirements of due process.
Section 8 Effective Date
This regulation shall become effective April 15, 2020.
Section 9 History
Emergency regulation effective December 20, 2019.
Regulation effective April 15, 2020.