9-1-1 ambulance: your plan pays the provider directly

It is a 2019 law that closed two gaps at once. The first: many basic coverages simply did not include ground ambulance, so emergency transport came out of the patient’s pocket. The second, which the statement of motives itself describes: private ambulances that help decongest the system sometimes refused service because the patient had no coverage or because the rates offered by the responsible entities were unreasonable. The law mandates the coverage, orders direct payment to the ambulance provider and fines both refusals. It also repealed Act 383-2000 for conflicting with what it provides.

Every person insured under a health plan authorized to operate in Puerto Rico, for ground ambulance transport in a medical emergency. The law defines medical emergency: a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a reasonably prudent person with average knowledge of health and medicine could expect that, absent immediate medical attention, the person’s health would be placed in serious jeopardy or would result in serious dysfunction of any bodily member or organ; or, with respect to a pregnant woman having contractions, that there is not enough time to transfer her to another facility before delivery, or that transferring her would threaten her health or that of the unborn child.

• That the transport be by ground ambulance and on account of a medical emergency, per the law’s definition.Verified against the official source
• For direct payment to the ambulance provider, that the service was used through the 9-1-1 System.Verified against the official source

• The transport record the ambulance provider generates and, if there was one, the 9-1-1 call. The law ties direct payment to the service having been used through the 9-1-1 System.
• The bill they sent you, if the provider billed you for the transport cost instead of charging the plan.

1. 1

   Step 1: Confirm it was a medical emergency and came in through 9-1-1

   The two elements that trigger direct payment are the medical emergency — as the law defines it — and use of the service through the 9-1-1 System. A scheduled transfer between facilities is not what this article describes. If your case came in through 9-1-1, that fact is half the claim.

2. 2

   Step 2: Verify your basic plan includes the coverage

   Article 1 does not leave it optional: every insurer, health service organization or other health plan provider authorized to operate in Puerto Rico must include ground ambulance transport coverage for medical emergencies in its basic plan or insurance. If your basic policy does not list it, that is what to take to the Office of the Insurance Commissioner.

3. 3

   Step 3: If they billed you, cite the direct payment

   The law says the insurer or health service organization shall pay the ambulance provider directly for the cost of the transport, except for deductibles and copay percentages, and subject to the health plan’s coverage limits. That is: your deductible and copay are yours, and the rest goes from the plan to the provider without passing through your hands. If the full bill reached you, that is the provision to cite in writing.

4. 4

   Step 4: If a private ambulance refused for lack of coverage

   Article 4 is direct: every private ambulance that refuses to serve a patient on account of the emergency because of lack of medical coverage shall incur a fine of one thousand dollars ($1,000) for each infraction of this law. And in case of more than three consecutive violations, the license holder faces automatic suspension of that license.

5. 5

   Step 5: Know who the "responsible entity" that must pay is

   The law defines entity responsible for a patient’s health as hospitals, diagnostic and treatment centers, health providers, employers and insurers that, within the circumstances of each emergency case, have legal responsibility over the health of each patient using ambulance services. All of them must honor at minimum the rates set by regulation by the Bureau of Transportation and other Public Services. It is not just the health plan: if the transport happened at your workplace, the employer also falls within that definition.

6. 6

   Step 6: Take the payment failure to the Bureau of Transportation

   Failure to meet the payment obligation by an entity responsible for a patient’s health carries an administrative sanction or fine of five hundred dollars ($500) per occurrence, and that sanction is imposed by the Bureau of Transportation and other Public Services, attached to the Public Service Regulatory Board. In case of more than three consecutive violations, the Bureau may go to all pertinent forums to collect its claim, including seeking suspension of any license, permit or operating authorization before any Government of Puerto Rico agency.

The coverage claim goes first to your health plan. If the basic plan does not include emergency ground ambulance, or if you were billed what should have been paid directly to the provider, the Office of the Insurance Commissioner is the one that regulates insurers; the law expressly authorizes it, along with the Bureau of Transportation and other Public Services, to issue the necessary regulation. The fine for payment failure is imposed by the Bureau of Transportation and other Public Services, attached to the Public Service Regulatory Board. The Office of the Patient Advocate receives patient claims.

• Paying the full ambulance bill: the law orders direct payment to the provider, minus deductibles and copay percentages.
• Accepting that the basic plan excludes emergency ground ambulance, when the law makes it mandatory.
• Not reporting the private ambulance that refused to take you for lack of coverage: that carries a $1,000 fine per infraction.
• Believing the only obligated entity is the health plan: the definition includes hospitals, diagnostic and treatment centers, health providers and employers.
• Assuming the rate regulation says a figure nobody has shown you.
• Forgetting that direct payment is subject to the plan’s coverage limits.
• Looking for the law under Act 383-2000, which this law expressly repealed.

These are the government pages this guide is based on.

• Oficina del Comisionado de Seguros (OCS)

  OCS

  bvirtualogp.pr.gov

• Office of the Insurance Commissioner

  OCS

  ocs.pr.gov

• Public Service Regulatory Board (Bureau of Transportation)

  JRSP

  jrsp.pr.gov

• File your claim — Patient Advocate

  OPP

  www.opp.pr.gov