NH subcommittee votes to recommend ITL on bill that would require insurers to pay ambulance bills in full

A New Hampshire House Commerce and Consumer Affairs subcommittee voted unanimously to recommend Inexpedient to Legislate (ITL) on House Bill 185 after more than two hours of debate about competing proposals to address ambulance reimbursement and balance billing.

HB185 would have required health insurers to reimburse ambulance providers the full amount billed when there is no agreed-upon contracted rate. Representative Gibbs moved to recommend ITL on HB185; the motion passed unanimously, with the clerk recording seven ayes during the roll call.

Committee members spent the session comparing three approaches: HB185 (insurers pay the billed amount when no contract exists), HB725 (a statutory reimbursement floor set at 325% of the Medicare rate and a prohibition on balance billing), and HB316 (a framework to hire an outside consultant to analyze provider costs and set a recommended default rate, with periodic updates). The Insurance Department and providers described the differences in how each bill would affect providers, insurers and municipal budgets.

Michelle Heaton, director of Life and Health at the New Hampshire Insurance Department, told the panel that emergency services are an essential benefit and included in the state benchmark plan. "Emergency services is an essential, considered an essential service," Heaton said, adding that she was not aware of any major medical plans that exclude ambulance coverage.

Providers and municipal representatives argued they need higher reimbursements to keep volunteer and municipal-run ambulance services financially viable. Michael Sitar, chief of the Tilton–Northfield Fire District, described his local method for estimating ambulance costs: separating fire costs from EMS costs, dividing operating budget by the number of EMS transports and deriving an average per-transport cost. "We take our operating budget, the total number of calls that we do in a year ... that's the basis of it," Sitar said, explaining why locally calculated charge rates can be higher than the consultant's estimate.

Supporters of a statutory percentage floor said balance billing and low Medicare/Medicaid rates shift costs to towns and property taxpayers. Several members noted testimony that roughly 80% of ambulance users are Medicare or Medicaid beneficiaries, and about 17% are commercially insured (the transcript records an exchange citing those payer-mix figures). Committee members debated conflicting estimates of how often balance bills are actually collected; one witness said 60–80% of bills are paid, while other testimony put unpaid balances higher.

Proponents of HB316 said setting a percentage without a supporting cost analysis is irresponsible. The bill directs the Insurance Department to use a consultant (the department earlier contracted Public Consulting Group, or PCG, to analyze provider data drawn from the GATS collection) to recommend rates that reflect urban, rural and "super-rural" cost differences and to update the number every two years.

Representative Gibbs, who moved ITL on HB185, argued the subcommittee should pass something substantive this session but supported using a data-driven approach rather than "pick[ing] a number out of the air." "We are breaking new ground here," Gibbs said while urging a rational, evidence-based system.

Representative Gitzke suggested recommending ITL on HB185 while advancing either HB316 or HB725; the motion to recommend ITL on HB185 carried. The committee did not take a final vote on HB316 or HB725 during the session.

The subcommittee record shows the action taken only on HB185. The Insurance Department and PCG indicated the consultant report leverages federal CMS GATS data supplied by New Hampshire providers; the report produced separate recommended rates for urban, rural and super-rural providers and adjusted for medical inflation.

Members signaled concern about spillover effects: some said mandating much higher insurer payments would raise premiums for policyholders, while others said shifting uncompensated costs onto municipal property taxpayers is unfair. Committee members also discussed that Medicaid and Medicare reimbursement levels are set at the federal level and generally cannot be changed by state law.

The subcommittee closed the meeting after the unanimous ITL recommendation for HB185. Committee staff and the Insurance Department offered to host a Q&A with the consultant (PCG) to explain the methodology and the report's different cost estimates for individual providers.

Votes at a glance: HB185 — Motion: Recommend Inexpedient to Legislate (ITL). Moved by Representative Gibbs. Vote: unanimous (7 ayes). No final votes were recorded for HB316 or HB725 during this session.