Surprise ambulance billing may soon become a thing of the past in New Hampshire.
Over the past few months, several lawmakers have proposed competing bills meant to address the struggles of patients who ride in an ambulance and end up surprised with massive bills after the fact. One such bill, Senate Bill 245, has now been approved by the House and Senate and is headed to Gov. Kelly Ayotte’s desk. Ayotte will have the options of signing it into law, vetoing it, or allowing it to enter into law without her signature.
Balance billing, also known as surprise billing, happens when the price of an ambulance ride exceeds what an insurance company is willing to pay, and so the ambulance provider charges the customer the difference. SB 245 bans that practice.
“That’s the one thing we could all agree,” Sen. Suzanne Prentiss, a West Lebanon Democrat and the sponsor of SB 245, said. “But how to get there is where we had disagreement.”
SB 245 also mandates the rate providers can charge for ambulance rides.
Starting in 2026, ambulance providers will be reimbursed by insurers at 325% of the federal Medicare rate. After two years, the state Insurance Department will complete an actuarial cost study to decide whether the rate should change, taking into account inflation and market factors.
SB 245 beat out several other bills targeting the same issue. House Bill 316, for example, also banned balanced billing and set a rate providers could charge. However, HB 316 incorporated an actuarial cost study previously commissioned by the Insurance Department to set a rate of 202% of the federal Medicare rate.
“The fundamental problem in this whole issue is that the Legislature’s mission is to get rid of balanced billing,” Rep. John Hunt, a Rindge Republican and the sponsor of HB 316, “That is maybe counterintuitive to what is the ambulances’ mission, which is to get private insurance to pay for the shortfall.”
Hunt said getting insurers to pay that shortfall “was a nonstarter; it was never going to happen.”
So instead he worked to come up with a rate he believed was fair for both the insurers and providers by basing it on the actuarial study.
Hunt believes municipalities should be supporting their public ambulance providers with more tax money. He also says ambulance providers should start charging patients who they treat but don’t transport.
When Hunt’s proposal, HB 316, passed the House in March, it was met with opposition from ambulance providers and some lawmakers who argued it wouldn’t pay enough to support the ambulance rides. They also argued the study used to derive that number was flawed because it didn’t properly take into account differences among communities.
“In 235 cities and towns, it’s done different ways,” Prentiss said. “Sometimes the government provides it. Sometimes a private sector provides it. Sometimes volunteers. Sometimes it’s paid career. All of these things make a big difference in what it costs you to do business.”
She said there’s “mismatch” in the field where insurers do not have such wide variety in their own work.
“So I can’t blame them 100%,” she said. “I just think there’s like these two worlds trying to come together.”
That’s why Prentiss feels action is needed to set the rates. She also hopes her bill can encourage more providers to become in-network with insurers.
Prentiss, who herself works for an ambulance provider outside of her duties as a state senator, also deemed HB 316’s rate too low and set the rate in her bill at 325% indefinitely.
Hunt thinks 325% was too much.
“As far as I’m concerned, they plucked the number out of thin air,” Hunt said.
Prentiss served on an advisory committee for the federal Centers for Medicare and Medicaid Services in 2023 and 2024. She said she came up with the rate based on her work there looking at what other states have done.
Backers of the two bills ultimately came to a compromise. They amended SB 245 to make 325% the rate for ambulance billing for two years instead of indefinitely — at which point the actuarial study determines a new rate — and they added a provision from HB 316 creating a commission to monitor the rates and the system as a whole.
“It sucks because we’re giving you guys (ambulance providers) this windfall for the next two years,” Hunt said. “At the end of the day, our mission was to get rid of balanced billing. That was the bogey that we were going after.”
He added that the rate in SB 245 is “125% more than (providers) deserve, but that was the compromise to get rid of balanced billing.”
Prentiss is happy with the compromise.
“I’m really proud of it,” she said. “I think the insurance industry came to the table. I think the Department of Insurance came to the table. I think that House Commerce, who initially had a completely different position, they came to the table. Everybody had to give something on this to get to go, and it’s going to be interesting to watch the next two years, but we’re all tied to this. And again, the common goal everyone could agree on was prohibiting balance billing and stabilizing the EMS system, but we had to do something. This has been going on for too long.”
Hunt, meanwhile, offered some advice to ambulance providers: “You guys have a huge windfall and all I can say is don’t blow it. Don’t start giving each other raises and doing all kinds of things because you’re getting this windfall, because clearly 325 (%) is way over the top.”