Ambulance providers press for state rule to ban balance billing and set reimbursement floor; insurers warn of cost shifts

Representative Jerry Stringham introduced House Bill 725 to the House Commerce and Consumer Affairs Committee as legislation to address a national and local squeeze on ground ambulance finances. “This bill does 2 things,” Stringham told the committee: it would extend the prohibition on balance billing to ground ambulance services and establish a non‑contract rate of 325% of the Medicare rate for nonparticipating providers.

Advocates: stabilize EMS, protect taxpayers and patients

A string of witnesses — including chiefs from local departments and leaders of the New Hampshire Ambulance Association — told the committee operators are struggling with low reimbursement, rising costs, and the revenue uncertainty that balance billing historically covered. Mike Sitar, chief of the Tilton‑Northville Fire District and representative of the New Hampshire Association of Fire Chiefs, said the 325% figure aligns with other states and provides “a fairly established rate” linked to Medicaid/Medicare baselines. Justin Van Etten of Stewart’s Ambulance, a large rural provider, warned that out‑of‑state insureds and multistate carriers could shift costs to New Hampshire property taxpayers if reimbursements are set unevenly; he called HB 725 “a compromise” that respects local elected officials’ ability to set municipal support levels.

Providers and ambulance associations argued balance billing is an unreliable revenue stream and that a statutory floor would allow stable planning. Chris Daywas and Derek Auman of the New Hampshire Ambulance Association said their members view a 325% Medicare floor as necessary to bridge the gap if balance billing is prohibited. Cheshire County officials described newly formed county EMS operations with sizable startup deficits and warned that some agencies statewide face closure without revenue changes.

Insurers and trade groups urge caution on a statewide floor

Health carriers and their trade groups said they support ending surprise balance bills but warned that a 325% floor for noncontract providers raises cost‑shifting concerns and could have unintended effects on premiums and networks. Sabrina Dunlap, senior director of government relations for Anthem, said a statutorily fixed floor could “disincentivize” providers from joining carrier networks and could disproportionately shift costs to some insureds; she also noted many employer plans are governed by ERISA and lie outside some state regulations. Chris Kennedy of Centene said the proposal could raise premiums in the individual market and that carriers need clarity on the contracting/credentialing interplay before agreeing to a mandate.

Open questions: how much balance billing currently offsets shortfalls and who pays

Committee members repeatedly asked witnesses how much of ambulance providers’ budgets balance billing currently covers. Providers said collection rates vary by agency and that the state’s commissioned cost study (the New Hampshire ground ambulance cost study) quantifies costs but did not precisely track balance‑billing recovery percentages; ambulance witnesses said this uncertainty is part of the fiscal pain. Representative Stringham and witnesses cited estimates for the insurer impact of roughly $0.36 per member per month under one model, rising to about $0.60 in other projections — small per member but meaningful in aggregate. Witnesses also noted Medicaid, Medicare and municipal funding sources complicate the statewide fiscal picture.

Process and next steps

Committee members and witnesses agreed more work is needed. Several speakers urged detailed subcommittee work to compare three competing legislative proposals and the department’s recently produced cost study. The committee closed the public hearing and will take the matter up in subcommittee and work sessions. No formal action or vote was taken at the hearing.

Why this matters locally

Committee testimony repeatedly emphasized that unstable ambulance finances threaten rural coverage and that each local closure or cutback changes response times and can raise property taxes for towns that must subsidize service. HB 725 frames the question as a tradeoff between predictable provider revenue and the potential for higher insurer costs and premium consequences. The committee will consider technical fixes and funding consequences as the bill moves to subcommittee.