The issue of balance billing among air ambulance providers took center stage last Friday as Maryland’s Insurance Administration (MIA) held an open hearing to get public input on this issue. Although Maryland is among the handful of states that regulate balance billing for out-of-network situations, as we discuss in our report, the state’s law does not address air ambulance charges. Air ambulances are used rarely, but when they are, it’s generally a life-threatening and emergency situation in which the patient has no control over how they are transported to treatment.

Stakeholders that were interviewed for our report acknowledged that Maryland’s balance billing policy leaves air ambulance patients unprotected. Consumer complaints, with some alleging balance bills of up to $40,000, prompted the MIA to get involved. During Friday’s hearing, residents who were balance billed described aggressive strategies by air ambulance companies to recoup payment, from weekly calls to threats of liens on their home.

This was not the first time that Maryland has attempted to tackle costly balance billing by air ambulance services; in 2006, the Maryland Health Care Commission issued a report after the legislature directed it to study the issue because of consumer complaints. The 2006 report provided five options for Maryland to consider, but almost ten years later, air ambulance bills continue to plague consumers. One key challenge to enacting balance billing protections in this area is that federal law likely preempts states from regulating rates for air transport.

In fact, there is currently a case in the U.S. District Court for North Dakota alleging that its recently enacted state law prescribing air transport rates for its worker’s compensation cases and prohibiting balance billing for those cases violate federal law. The North Dakota law also requires those requesting air ambulance services to use a list of primary air ambulance providers that are in-network with insurers that provide coverage for 75 percent of the market. In practice, this requires air ambulance providers to participate with the one major insurance carrier in North Dakota, Blue Cross Blue Shield.

Out-of-network air ambulance bills appear to be an issue nationwide. CHIR’s own recent survey of state consumer assistance programs identified air ambulance services as a source of consumer balance billing complaints. The National Association of Insurance Commissioners has issued a model consumer alert that insurance departments can use to inform consumers about the potential for large bills. At least two states, Kentucky and South Carolina, recently introduced legislation addressing either the transparency of air ambulance costs or a requirement that insurers cover air ambulance costs in emergencies. While Maryland has been wrestling with this issue for the last ten years, we’re hoping that this hearing marks the beginning of a more concerted effort to protect residents from extremely high, unexpected bills.