PROPOSED FEDERAL REGS ISSUED FOR PLAN AND INSURER REPORTING REQUIREMENTS ON AIR AMBULANCE CLAIMS

Proposed Federal Regs Issued for Plan and Insurer Reporting Requirements on Air Ambulance Claims

Federal regulators issued proposed regulations on September 16, 2021 pursuant to the Consolidated Appropriations Act, 2021’s air ambulance reporting requirements. Below please find a summary of the proposed regulations. Final regulations have yet to be issued as of 1/12/2023.

Introduction

Group health plans and health insurance insurers offering group or individual health insurance coverage must file with federal regulators a report that includes the following information described below for calendar years 2022 and 2023. This mandate applies to both grandfathered and non-grandfathered plans.

Timing. The proposed regulations require the reports for the 2022 and 2023 calendar year reporting periods to be submitted by March 31, 2023, and by March 30, 2024, respectively, in the form and manner prescribed by regulators in forthcoming guidance. As of 1/12/23, the guidance has not been issued. The report must include data relevant to services furnished or paid within the reporting period.

Required data elements. The report must include the following data elements for air ambulance services during the relevant reporting period, for each claim for air ambulance services that was received or paid for during the reporting period:

1. Identifying information for any group health plan, plan sponsor, or insurer, and any entity reporting on behalf of the plan or insurer, as applicable.
2. Market type for the plan or coverage (individual, large group, small group, self-insured plans offered by small employers, self-insured plans offered by large employers, and Federal Employees Health Benefits).
3. Date of service.
4. Billing NPI information.
5. Current Procedural Terminology (CPT) code or Healthcare Common Procedure Coding System (HCPCS) code information.
6. Transport information (including aircraft type, loaded miles, pick-up (origin zip code) and drop-off (destination zip code) locations, whether the transport was emergent or non-emergent, whether the transport was an inter-facility transport, and, to the extent this information is available to the plan or insurer, the service delivery model of the provider (such as governmentsponsored (Federal, State, county, city/township, other municipal), public-private partnership, tribally-operated program in Alaska, hospital-owned or sponsored program, hospital independent partnership (hybrid) program, independent).
7. Whether the provider had a contract with the group health plan or insurer of group or individual health insurance coverage, as applicable, to furnish air ambulance services under the plan or coverage, respectively.
8. Claim adjudication information, including whether the claim was paid, denied, appealed; denial reason; and appeal outcome.
9. Claim payment information, including submitted charges, amounts paid by each payor, and cost sharing amount, if applicable.

Other contractual arrangements. A group health plan, or group or individual health insurer may satisfy the requirements by entering into a written agreement under which another party (such as a third-party administrator or health care claims clearinghouse) reports the required information. Notwithstanding the preceding sentence, if a group health plan or health insurer chooses to enter into such an agreement and the party with which it contracts fails to provide the information in accordance with this section, the plan or insurer violates the reporting requirements.

Special rules to prevent unnecessary duplication for insured group health plans.

To the extent coverage under a group health plan consists of group health insurance coverage, the plan satisfies the requirements if the plan requires the health insurer offering the coverage to report the information required by this section pursuant to a written agreement. Accordingly, if a health insurer and a group health plan sponsor enter into a written agreement under which the insurer agrees to report the information required in compliance with this section, and the insurer fails to do so, then the insurer, but not the plan, violates the reporting requirements.

Transfer of business. A health insurance insurer offering group or individual health insurance coverage that acquires a line or block of business from another insurer offering group or individual health insurance coverage must submit the information required on behalf of the acquired business, for the entire calendar year during which the acquisition took place. The reporting requirement in this paragraph also applies to the selling and acquiring insurers if a sale or transfer occurs because of insurers being merged, combined, spun off, affected by, or engaging in any similar transaction during a calendar year.