§ 26.1-47-12 — Ambulance insurance coverage - Direct payment required - Determination of reimbursement rate for out-of-network ambulance service providers

North Dakota § 26.1-47-12

• Jurisdiction: North Dakota
• Title 26.1: Insurance
• Ch. 26.1-47: Preferred Provider Organizations

Text

of reimbursement rate for out-of-network ambulance service providers.
1. As used in this section:
a. "Ambulance service provider" means a service entity licensed under chapter
23-27 as a basic life support or advanced life support ambulance service. The
term does not include an air ambulance provider.
b. "Covered person" means an individual eligible to receive coverage of covered
services by a health care insurer under a health benefit plan.
c. "Covered services" means medically necessary patient care or transportation
provided by ambulance service providers.
d. "Health care insurer" means an entity subject to state insurance regulation that
provides health benefit coverage in this state. The term includes:
(1) An insurance company;

(2) A health maintenance organization;
(3) A hospital or medical service corporation; and
(4) A risk-based provider organization.
e. "Medicare reimbursement rate" means the reimbursement rate for a particular
health care service provided under the Health Insurance for the Aged and
Disabled Act, title XVIII of the federal Social Security Act of 1965 [42 U.S.C.
1395 et seq.], as amended.
2. All reimbursements made by a health care insurer for the provision of ambulance
services to a covered person must be paid directly to the ambulance service provider
or the provider's designee.
3. If a covered person receives ambulance services from an out-of-network ambulance
service provider, the health care insurer shall pay the ambulance service provider the
lesser of:
a. Two hundred fifty percent of the Medicare reimbursement rate for the same
service in the same geographic area; or
b. The ambulance provider's billed charges.
4. Any rate the health care insurer pays under this section may not be required to include
the coinsurance, copayment, and deductible owed or already paid by the covered
person.
5. The insurance commissioner may adopt rules to implement and enforce this section.