Subcommittee narrows House Bill 13-22 to out-of-network ambulance payments, approves insurance-tax fund pilot

BISMARCK, N.D. — The North Dakota House Human Services Subcommittee on Wednesday moved to narrow House Bill 13-22 so its mandated ambulance reimbursement rules apply only to out-of-network providers, discussed replacing a fixed 400%-of-Medicare ceiling with an “in-network median,” and approved an amendment to create a pilot reimbursement program funded from the insurance tax distribution fund.

The bill, introduced as an act relating to ambulance service provider reimbursement and to the insurance tax distribution fund, had prompted sustained testimony from health plans, ambulance associations and lawmakers about unintended consequences if the measure applied to in-network providers.

Blue Cross Blue Shield of North Dakota senior policy adviser Megan Ruby told the subcommittee the amendments would “restrict this to out of network ambulance services so that you’re not touching the in-network ambulance services that have the contracts already in place.” Ruby said existing in-network contracts include consumer protections such as prohibitions on balance billing and that applying a statutory rate across the board could remove incentives for providers to contract with insurers.

Dylan Wheeler of Sanford Health Plan explained one alternative discussed in the hearing: replacing the draft bill’s 400%‑of‑Medicare reimbursement figure with an in‑network median drawn from carriers’ contractual rates. “The 400% is just about double of what the reimbursement rate for the health plan is today,” Wheeler said. He described the in‑network median as “a combination of the existing contracts in the state of North Dakota” and said carriers would be the practical source for the data if the subcommittee chose that approach.

Speakers also reviewed the bill’s ERISA exposure and the difficulty states have had regulating air ambulance rates because of federal preemption. Ruby and other witnesses urged removing language that would sweep ERISA self‑funded government plans into the bill; the subcommittee agreed and approved that amendment by voice vote. Witnesses referenced prior litigation and the Airline Deregulation Act as complicating factors in state regulation of air ambulance billing.

Members also discussed a separate amendment to create a pilot reimbursement program for unpaid ambulance runs, funded from the state’s insurance tax distribution fund. Chair Fegley and lawmakers described a proposed mechanism in which the insurance commissioner would administer a roughly $5,000,000 pilot appropriation, prorated monthly across claims that have exhausted collection options; the subcommittee passed a motion to add that language to HB 13-22.

Bill Kalanick of the North Dakota EMS Association told the panel he was generally supportive of the ERISA and air-ambulance clarifications and reserved judgment on other changes until his organization could review a formal amended bill. Kalanick also said the EMS Association could provide statewide estimates of unpaid ambulance receivables to the committee.

The subcommittee’s votes were voice votes; no roll-call tallies were recorded in the transcript. Members asked staff to coordinate with the insurance commissioner’s office to define how an in‑network median would be calculated and to work through the rules and appropriation details for the proposed reimbursement pilot.

The subcommittee adjourned after approving the package of amendments and directing staff to return an amended bill for full-committee consideration.