Select a state or province from the map above to get primary contact and web information for any
member fund.

By Mary Nichols, SVP & General Counsel, Texas Mutual, and Jo Betsy Norton, VP Public Affairs, Texas Mutual

Although air ambulances sometimes provide needed transports for critically injured individuals, the growing use of air ambulances in non-life-threatening situations, coupled with their sky-high charges and predatory collection practices, has prompted state legislators and members of Congress to seek various legislative solutions. In addition, aggressive private air ambulance companies have filed numerous lawsuits challenging caps on reimbursement and prohibitions against balance billing, the practice of a healthcare provider billing a patient for any outstanding balance beyond what the insurance company has paid.

Background
Over the last 15 years, market shifts in the air ambulance industry¹ and substantial regulatory gaps have fueled the rapid and unfettered growth of for-profit air ambulance operators, which has led to exorbitant charges, and aggressive billing and collection practices.

As the number of air ambulance for-profit providers has increased, so too has the financial pressure to maximize profits and satisfy investors.² This creates an incentive for air ambulance providers to remain out of networks, inflate billed charges, and pursue balance billing.³

The recent expansion of the industry has brought air ambulance services into rural areas affected by hospital closures (82 since 2010).⁴ But an oversupply of providers in many urban areas has created an ultra-competitive environment that has led to overuse and transports that are not medically necessary. Patients are at a disadvantage in these situations because they do not know whether air transport is medically necessary, they are unable to select which air ambulance company provides the service, and they are often required to sign forms agreeing to pay unspecified and unlimited “billed charges.”

To provide a stable revenue base, some air ambulance companies offer memberships charging a monthly or annual fee to help cover costs above and beyond what insurance plans will pay. However, these memberships are only an effective consumer protection tool if the company issuing the membership is the one responding to the emergency situation, something on which a consumer has no say. These memberships often target rural consumers without close access to major emergency medical services.⁵

A 2015 study from researchers affiliated with the University of Arizona found that, in a six-year period at one trauma center, nearly one-third of patients transported by air ambulance were minimally injured and would have had similar health outcomes with traditional ground ambulance transportation.⁶

Air ambulance companies’ charges are generally unregulated, and in the words of The New York Times, “sky-high.”⁷ Their bills often exceed $50,000 for routine flights, with actual costs averaging less than $10,000.⁸ Their aggressive billing and collection tactics have driven many unsuspecting patients into bankruptcy and have increased costs for workers’ compensation and health insurance.

Regulated payment systems like Medicare, Medicaid, and state workers’ compensation systems achieve medical cost control through fee schedules, and large health care insurers are able to negotiate reasonable reimbursement rates. But air ambulance companies, as “emergency medical providers,” refuse to enter into managed care contracts and aggressively seek payment of their billed charges from every payor except Medicare and Medicaid.

A number of states have attempted to regulate various aspects of the air ambulance industry over the past several years, but until recently their attempts to rein in runaway charges and halt abusive practices have been thwarted by a few court decisions finding that the federal Airline Deregulation Act of 1978⁹ (ADA) preempts states from regulating the rates, routes, or services of any air carrier, including an air ambulance company.

However, a Texas court has ruled that the McCarran-Ferguson Act,¹⁰ a federal law that explicitly reserves to the states the regulation of the business of insurance, preempts the application of the ADA (reverse preemption). That same court also ruled that 125 percent of Medicare was a sufficient payment for air ambulance services.

Medicare Fee Schedule
In 1997, Congress directed the Centers for Medicare and Medicaid Services (CMS) to develop a single national fee schedule for Medicare ambulance services to be established through a negotiated rulemaking process.¹¹ Implementation of the fee schedule began in 2002 and was completed in 2010.¹²

Before 2002, Medicare reimbursement differed depending on the air ambulance provider’s business model: hospital-based providers were reimbursed based on reasonable costs,¹³ while independent providers were reimbursed based on reasonable charges.¹⁴ This policy contributed to wide variation in the reimbursement rate for the same service, with hospital-based providers generally receiving higher reimbursement than independent providers for similar services. The new national fee schedule established separate payment rates for fixed-wing and helicopter transports and provided higher reimbursement rates for flights in rural areas.¹⁵

The new Medicare fee schedule prompted multiple and almost immediate changes to the air ambulance industry. From 1999 through 2008, the number of patients transported by helicopter air ambulance increased from just over 200,000 to over 270,000, or about 35 percent. The number of air ambulance helicopters increased from 360 to 677, or by about 88 percent. The structure of the industry also changed from a preponderance of hospital-based providers to a fairly even split between hospital-based and independent providers. The new fee schedule gave air ambulance providers a degree of predictability and increased stability in funding, which made the market much more attractive.¹⁶

Medicare’s air ambulance fee schedule has two primary components: a base payment and a mileage payment, which make up the total Medicare payment for each transport. Since 2006, CMS has adjusted rates annually, primarily based on inflation.¹⁷

The Medicare ambulance fee schedule is important in the debate about the appropriate reimbursement rate for air ambulance providers because it was adopted after a thorough investigation of the “reasonable cost”  for emergency medical services, and many state workers’ compensation laws tie reimbursement to a percentage of the Medicare fee schedule.

Federal Legislative Activity

• U.S. Government Accountability Office Report
  In July 2017, in response to a request from leadership of the House Committee on Transportation and Infrastructure, the Government Accountability Office (GAO) issued a report on its review of issues related to air ambulance operations and pricing.¹⁸
  
  The GAO concluded that between 2010 and 2014, the median prices charged for helicopter air ambulance services approximately doubled.
  • Median charges to Medicare increased from $14,000 in 2010 to $29,859 in 2014 (113 percent).
  • Median charges to private health insurers increased from $17,010 in 2010 to $29,859 in 2014 (76 percent).
  The GAO also noted that the industry trend from hospital-affiliated air ambulance providers to independent providers is continuing. For example, in 2015, three for-profit independent providers together reported operating 692 helicopters, or about 66 percent of the total 1,045 helicopters in the industry that year.
  
  The GAO recommended that the Secretary of Transportation take several executive actions to increase transparency and obtain information to better inform decisions on whether to investigate potentially unfair or deceptive practices in the air ambulance industry.

• Federal Legislation
  Several bills relating to air ambulance operations have been filed in Congress. Some propose consumer protections, such as requiring price transparency or prohibiting balance billing, while others would increase the Medicare reimbursement rate.
  • H.R. 2997 – “21st Century Aviation Innovation, Reform, and Reauthorization Act”
    On September 6, 2017, the House Committee on Transportation and Infrastructure approved H.R. 2997, the Federal Aviation Administration (FAA) reauthorization bill,¹⁹ which included an amendment by Rep. Rob Woodall (R-GA) that requires the Secretary of Transportation to take several actions relating to air ambulance operations:
    • Adopt rules, based on the recommendations of an advisory committee, that require air ambulance operators to clearly disclose charges for air transportation services separately from charges for non-air transportation services within any invoice or bill; and establish and provide other consumer protections for customers of air ambulance operators.
    • Require air ambulance operators to include a hotline telephone number for consumer complaints on any invoice, bill or other communication provided to a passenger or customer.
    • Investigate complaints of unfair or deceptive practices by an air ambulance operator.
    
    
    The House and Senate could not reach agreement on H.R. 2997 (on unrelated issues), and on September 28, 2017, Congress passed H.R. 3823, by Rep. Kevin Brady (R-TX), which extends funding for several expiring FAA programs and authorities through March 31, 2018.
  • S. 471 – “Isla Rose Life Flight Act”
    On February 28, 2017, Senator Tester (D-MT) introduced S.471,²⁰ which would allow state governments to regulate air ambulance billing and pricing practices to ensure policies are transparent for patients. The bill is pending in the Senate Committee on Commerce, Science, and Transportation.
  • H.R. 3378 – “Ensuring Access to Air Ambulance Services Act of 2017”
    On July 25, 2017, Rep. Jackie Walorski (R-IN) introduced H.R. 3378,²¹ which is bipartisan legislation that is being pursued by the air ambulance industry to raise Medicare reimbursement rates.
    
    • H.R. 3378 requires air ambulance providers/suppliers to submit cost data and quality data to the Secretary of Transportation on an annual basis, and requires the Secretary and the Comptroller General to submit reports on the data to Congress not later than July 1, 2021.
    • The Comptroller General’s report must include an analysis of cost variation of air ambulance providers by geography and status and a recommendation on the adequate amount of reimbursement that reflects operational costs and preserves access to critical air medical services.
    • H.R. 3378 provides for a temporary increase in the base rate of the Medicare air ambulance fee schedule: 12 percent in 2018 and 20 percent in 2019–2020.
  H.R. 3378 is pending in the House Committee on Ways and Means and the House Committee on Energy and Commerce, Subcommittee on Health.
  • H.R. 3780 – “Air Ambulance Quality and Accountability Act”
    On September 14, 2017, Rep. Richard Hudson (R-NC) introduced H.R. 3780,²² which requires the Secretary of Health and Human Services to establish minimum standards and cost and quality reporting programs for air ambulance providers/suppliers. The bill requires the Medicare Payment Advisory Commission to submit a report to Congress on access, quality, costs, and reimbursement.
    
    H.R. 3780 is pending in the House Committee on Ways and Means and the House Committee on Energy and Commerce, Subcommittee on Health.

State Legislative Activity
Several state legislatures have considered or enacted legislation to address air ambulance billing practices and collection tactics.

• Montana
  In 2015, the Montana Legislature passed H.J.R. 29, which required an interim committee to study a variety of issues, including air ambulance costs and charges, balance billing, and air ambulance membership services. The Economic Affairs Interim Committee issued a report²³ and adopted two bill drafts as committee bills. Both bills passed during the 2017 Regular Session.
  • H.B. 73²⁴ brings air ambulance membership programs under the regulatory authority of the commissioner of insurance.
  • S.B. 44²⁵ outlines a process to hold patients harmless for balance billing of air ambulance services.
  In 2017, the Montana Legislature also passed S.J.R. 13,²⁶ which urges the federal government to take several actions.
  • Revise the ADA to clarify that states may set rates for air ambulances, prevent balance billing on truly emergency transports, and regulate air ambulance memberships.
  • Require more timely changes to Medicare reimbursement rates for air ambulances to keep up with medical inflation so that air ambulances are not cost-shifting to non-Medicare patients the cost of patients covered.

• New Mexico
  • In 2016, New Mexico’s Legislature, under House Memorial 78 and Senate Memorial 62, directed the New Mexico Office of Superintendent of Insurance (OSI) to study the impact and cost of air ambulance transports and related insurance policies and payments on consumers, beneficiaries, and payers in New Mexico. The OSI issued its final report in January 2017.²⁷
  • In 2017, Rep. Thomson filed H.B. 402,²⁸ which would cap reimbursement for air ambulance services paid under a health benefits policy at 250 percent of the Medicare fee guideline and would hold consumers harmless for balance billing. The legislature adjourned without taking action on the bill.
• North Dakota
  
  • In 2017, the North Dakota Legislative Assembly passed S.B. 2231,²⁹ which addresses how health insurance companies pay for certain out-of-network air ambulance services and requires a hospital, before referring a non-emergency patient to an air ambulance provider for transport, to notify the patient of the air ambulance provider’s network status.
  • The North Dakota Insurance Department website includes a participation guide showing which air ambulance companies have contracts with health insurance providers in North Dakota.³⁰
• Utah
  In 2017, the Utah Legislature passed two bills relating to air ambulance services.
  • S.B. 95³¹ establishes an Air Ambulance Committee that is tasked with making recommendations regarding state standards and requirements for air medical transport providers, and compiling and publishing data on air ambulance charges and patient personal responsibility.
  • S.C.R. 2³² urges Congress to amend the ADA to clarify that states may regulate air ambulance billing and collections of patient care costs in order to protect patients from overwhelming financial burdens for emergency medical services.
• West Virginia
  • In 2016, the West Virginia Legislature passed H.B. 4315, which protects consumers covered by the “Public Employees Insurance Act” from balance billing by air ambulance companies.³³
  • In 2017, Senator Miller filed S.B. 276,³⁴ which would require an air ambulance provider that does not have a contract with an insurer to bill the insurer before submitting any bill to the insured, and would prohibit an air ambulance provider from collecting from an insured an amount that exceeds the Medicare fee guideline. The bill was left pending in the Senate Banking and Insurance Committee.

Legislative and Regulatory Associations
Several national legislative and regulatory associations have committees or task forces examining air ambulance issues.

• National Conference of State Legislatures
  At the August 2017 National Conference of State Legislatures (NCSL) Legislative Summit, there were multiple discussions on air ambulance issues.
  • The Standing Committee on Natural Resources and Infrastructure adopted a resolution urging Congress to amend the ADA in order to clarify that states may enforce insurance regulation on air ambulance providers to protect consumers.³⁵
  • The new Task Force on Insurance, co-chaired by Rep. George Keiser (ND) and Rep. Brian Kennedy (RI), heard several presentations on air ambulance issues:
    • Christopher Eastlee, VP of Governmental Relations for the Association of Air Medical Services³⁶
    • Betsy Imhjolz, Special Projects Director for Consumers Union³⁷
    • Commissioner Ted Nickel, Wisconsin, NAIC President
• National Conference of Insurance Legislators
  In March 2017, the National Conference of Insurance Legislators (NCOIL) formed an Air Ambulance Task Force to examine how best to protect consumers from excessive and often out-of-network billing, as well as how air ambulance providers can be regulated on a state level.
  
  Task force members include: Chairman Rep. Jeff Greer (KY), Rep. Bill Botzow (VT), Assem. Kevin Cahill (NY), Rep. Greg Cromer (LA), Sen. Bob Hackett (OH), and Rep. George Keiser (ND).
  • On June 8, 2017, the Air Ambulance Task Force held its first meeting via conference call.³⁸
  • On July 15, 2017, the Air Ambulance Task Force met at the NCOIL Summer Meeting in Chicago.³⁹
    • Eleanor Kitzman, a former insurance commissioner, representing Air Evac Life team, a subsidiary of Air Medical Group Holdings (AMGH), outlined an industry proposal that includes a voluntary dispute resolution process, pricing transparency, and data reporting.
    • Tim Pickering, director of government affairs for AMGH, appearing on behalf of Save Our Air Medical Resources (SOAR), discussed the high costs associated with having to be prepared to respond 24/7/365 and providing medical services on helicopters.
    • Dianne Bricker, America’s Health Plans, and David Korsh, Blue Cross Blue Shield Association, urged the task force to encourage Congress to amend the ADA to clarify that states may regulate air ambulance charges.
    • Ron Jackson, American Insurance Association, informed the task force that air ambulance issues also affect workers’ compensation.
  • On October 13, 2017, the Air Ambulance Task Force held a joint conference call with the NCOIL Health, Long Term Care and Health Retirement Issues Committee. Both groups adopted the Model Act Regarding Air Ambulance Insurance Claims sponsored by Assem. Will Barclay (NY).⁴⁰
    
    Although the air ambulance industry contends it has made tremendous concessions through negotiations with NCOIL staff, the Model Act is the air ambulance industry’s dream bill.
    
    The Model Act:
    • Requires a health plan deemed to have an inadequate network to reimburse an air ambulance provider no less than the average rates published by the air ambulance provider and determined by the department of insurance on an annual basis.
    • Deems an air ambulance transport to be medically necessary if requested by a neutral third party medical professional or first responder who requests the air ambulance transport without regard to the patient’s ability to pay.
    • Requires a health plan to assume a covered person’s responsibility for out-of-network air ambulance charges other than any applicable copayment, coinsurance, and deductibles.
    • Requires a health plan to pay an out-of-network air ambulance provider based on billed charges, a negotiated amount, or the maximum amount the health plan would pay to an in-network provider (average rates if the health plan has an inadequate network).
    • Requires the department of insurance to establish and administer an independent dispute resolution process to determine the reasonable charge for the air ambulance service provided, which shall include, but not be limited to, costs of maintaining aircraft, hangar, and crew facilities; pilot and flight crew compensation; overhead; insurance; fuel; in-flight medical service; costs associated with 24/7/365 readiness; uncompensated/undercompensated care; and a reasonable profit.
    • Requires each party participating in the dispute resolution process to submit a “binding award amount” for consideration by an independent reviewer that is either agreed upon by the parties or selected by the commissioner.
    • Requires the independent reviewer to make a final and binding decision by choosing the “binding award amount” that is closest to the reasonable charges for the air ambulance services in question.
    • Requires an air ambulance provider who opts to participate in the dispute resolution process to register with the department of insurance, agree to publish transport rates charged in the state, and provide de-identified, itemized billing for each transport.
  • On November 18, the Health, Long Term Care and Health Retirement Issues Committee⁴¹ will meet at the NCOIL Annual Meeting in Phoenix, and will consider a technical amendment to the Model Act.
  • National Association of Insurance Commissioners
    At the April 2017 Spring National Meeting of the National Association of Insurance Commissioners (NAIC), Susan Donegan, Chief Regulatory Officer for the National Council on Compensation Insurance (NCCI), briefed the Workers’ Compensation Task Force on air ambulance issues and provided countrywide air ambulance data for service years 2011 to 2015.⁴²
    
    The NAIC has made it a top legislative priority to amend the ADA to explicitly allow states to regulate air ambulance network and pricing issues, and supports the Woodall amendment to H.R. 2997 and S. 471 by Sen. Tester.⁴³

Legal Challenges
Air ambulance companies, citing the ADA preemption language, have mounted a recent assault on workers’ compensation, insisting that their unregulated “billed charges” be used in lieu of state-mandated reimbursement amounts, and attempting to strike down statutes that prohibit balance billing an injured employee, which is a key element of the “Grand Bargain.”

However, another federal law—the McCarran-Ferguson Act—holds that no federal law may preempt the state regulation of the business of insurance. This legal issue is being played out in state and federal courts across the country. In fact, Texas Mutual Insurance Company and the Wyoming Department of Workforce Services, Workers Compensation Division, are involved in lawsuits on this issue.

• Texas
  Texas Mutual (along with the Texas Department of Insurance) is involved in litigation with two air ambulance providers: one case is in state court and the other is in federal court.
  • PHI Air Medical, LLC
    In December 2016, a Texas state district judge concluded that, because the preemption in the McCarran-Ferguson Act trumps the ADA, the ADA cannot preempt the Texas workers’ compensation fee guideline for air ambulance providers (125 percent of the Medicare ambulance fee schedule) or the statutory prohibition on billing injured employees for health care fees. That decision is on appeal to the Texas Third Court of Appeals.⁴⁴ Oral argument is scheduled for November 15, 2017.
  • Air Evac EMS
    Air Evac sought an injunction in federal district court to prohibit the Texas Department of Insurance–Division of Workers’ Compensation from enforcing the air ambulance fee guideline and require reimbursement for billed charges. Texas Mutual and other workers’ compensation insurers intervened. The parties will file motions for summary judgment in January 2018.

• Wyoming
  In May 2016, a Wyoming federal trial judge held that the ADA preempts the Wyoming fee schedule for air ambulance services, ordered the Workers’ Compensation Division to pay the air ambulance providers’ full billed charges, and ruled that the McCarran-Ferguson Act does not override the ADA preemption because Wyoming’s state-run workers’ compensation system does not regulate the business of insurance.
  
  In August 2017, the U.S. Court of Appeals for the Tenth Circuit affirmed the district court’s holding that the ADA preempts the Wyoming fee schedule and an injunction permanently enjoining the state from enforcing the rate schedule against air ambulance companies. But the court reversed the district court’s order that the state pay full billed charges, holding that the order was an overreach by federal courts, and leaving it to the state to determine how it should administer its workers’ compensation system.⁴⁵

Conclusion
Although air ambulance companies can provide lifesaving transports in some emergency situations, the shift in the air ambulance industry from hospitals and governmental entities to independent for-profit companies has put quarterly earnings ahead of medical necessity and has left consumers holding the bag.
While most of the media attention and proposed legislation relating to air ambulance companies’ billing and collection abuses are focused on health insurance and balance billing issues, aggressive private air ambulance companies have now set their sights on workers’ compensation. We must work alongside our health insurer brethren to clarify that states may enforce insurance regulation on air ambulance providers, including improved data collection, transparency, and consumer protections, because what starts in the health insurance arena has a tendency to spill over into workers’ compensation.

References

1. Atlas & Database of Air Medical Services (ADAMS) (Sept. 2017), available at http://www.adamsairmed.org/pubs/atlas_2017.pdf. ADAMS is a national web-based, interactive map database that contains information on air medical services by state, and trends since 2004.
2. For example, American Medical Group Holdings (AMGH), one of the largest air ambulance conglomerates, was acquired by global private equity firm Kohlberg Kravis Roberts & Co. (KKR & Co) in 2015 for $2 billion. In August, KKR & Co. announced that AMGH is acquiring Envision Health Corp.’s medical transportation unit, American Response, in a $2.4 billion transaction. In April, private equity firm American Securities acquired Air Methods, a rival air ambulance provider, for $2.5 billion. http://markets.businessinsider.com/news/stocks/r-lpc-air-medical-lands-us22bn-of-debt-for-amr-purchase-2017-8-1002252524
3. Consumers Union, Up in the Air: Inadequate Regulation for Emergency Air Ambulance Transportation (March 2017), available at http://consumersunion.org/wp-content/uploads/2017/04/Up-In-The-Air-Inadequate-Regulation-for-Emergency-Air-Ambulance-Transportation.pdf.
4. NC Rural Health Research Program, University of North Carolina Center for Health Services Research, Hospital Closure: January 2010- Present (October 2017), available at http://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/.
5. National Association of Insurance Commissioners [hereinafter NAIC], New Heights in Air Ambulance Costs (August 2017), available at http://www.naic.org/cipr_newsletter_archive/vol22.pdf.
6. Vercruysse et al., Overuse of helicopter transport in the minimally injured: A health care system problem that should be corrected, Journal of Trauma and Acute Care Surgery (March 2015), available at https://www.ncbi.nlm.nih.gov/pubmed/25710420
7. Peter Eavis, Air Ambulances Offer a Lifeline, and Then a Sky-High Bill, The New York Times (May 5, 2015), available at https://www.nytimes.com/2015/05/06/business/rescued-by-an-air-ambulance-but-stunned-at-the-sky-high-bill.html?_r=0.
8. Delgado et al., Cost-Effectiveness of Helicopter Versus Ground Emergency Medical Services for Trauma Scene Transport in the United States, Ann. Emerg. Med. (Oct. 2013), at tbl. 1, available at http://www.annemergmed.com/article/S0196-0644(13)00203-5/fulltext.
9. 49 U.S.C. §41713(b)(1), available at http://uscode.house.gov/view.xhtml?req=granuleid:USC-prelim-title49-section41713&num=0&edition=prelim.
10. 15 U.S.C. §§1011-1015, available at http://uscode.house.gov/view.xhtml?path=/prelim@title15/chapter20&edition=prelim.
11. Balanced Budget Act of 1997, Public L. No. 105-33, §4531(b)(2), 111 Stat. 251, 450, available at https://www.congress.gov/105/plaws/publ33/PLAW-105publ33.pdf
12. Medicare Payment Advisory Commission, Report to the Congress: Medicare and the Health Care Delivery System (June 2013), Online Appendix 7-A, History of Medicare’s Ambulance Payment System, available at http://www.medpac.gov/docs/default-source/reports/jun13_ch07_appendix.pdf?sfvrsn=0.
13. Reasonable-cost payments were based upon the provider’s cost of providing ambulance services as reported on costs reports.
14. Reasonable-charge payments were based on the bill from the ambulance service provider, but were subject to an upper limit.
15. U.S. Gov't Accountability Office, GAO-10-907, Air Ambulance: Effects of Industry Changes on Services Are Unclear (2010) [hereinafter 2010 GAO Report], p.6, available at http://www.gao.gov/new.items/d10907.pdf.
16. 2010 GAO Report, pp. 6-9, available at http://www.gao.gov/new.items/d10907.pdf.
17. Medicare Payment Advisory Commission, Ambulance Services Payment System, Revised October 2017, available at http://www.medpac.gov/docs/default-source/payment-basics/medpac_payment_basics_17_ambulance_final.pdf?sfvrsn=0.
18. U.S. Gov't Accountability Office, GAO-17-637, AIR AMBULANCE: Data Collection and Transparency Needed to Enhance DOT Oversight (2017), available at https://www.gao.gov/products/GAO-17-637.
19. 21^st Century Aviation Innovation, Reform, and Reauthorization Act, H.R. 2997, 115^th Cong. (2017), pp. 293-299, available at https://www.congress.gov/115/bills/hr2997/BILLS-115hr2997rh.pdf.
20. Isla Rose Life Flight Act, S.471,115^th Cong. (2017), available at: https://www.congress.gov/bill/115th-congress/senate-bill/471/text.
21. Ensuring Access to Air Ambulance Services Act of 2017, H.R. 3378, 115^th Cong. (2017), available at https://www.congress.gov/bill/115th-congress/house-bill/3378/text
22. Air Ambulance Quality and Accountability Act, H.R. 3780, 115^th Cong. (2017), available at https://www.congress.gov/bill/115th-congress/house-bill/3780/text?q=%7B%22search%22%3A%5B%22hr+3780%22%5D%7D&r=1.
23. Montana Economic Affairs Interim Committee, Touching All Corners of Montana: From Air Ambulances to Broadband and From Licensed Professionals to Livestock and Economic Development, Appendix C, Study of Air Ambulance Costs” (May 2017) pp. 62-82, available at http://leg.mt.gov/content/Publications/Committees/interim/2015-2016/eaic-final-report.pdf.
24. H.B. 73, 65^th Leg., Reg. Sess. (Mont. 2017) (enacted), available at https://legiscan.com/MT/text/HB73/id/1589208/Montana-2017-HB73-Enrolled.pdf.
25. S.B. 44, 65^th Leg., Reg. Sess. (Mont. 2017) (enacted), available at https://legiscan.com/MT/text/SB44/id/1589738/Montana-2017-SB44-Enrolled.pdf.
26. S.J.R., 65^th Leg., Reg. Sess. (Mont. 2017) (enacted), available at http://leg.mt.gov/bills/2017/BillPdf/SJ0013.pdf.
27. New Mexico Office of Superintendent of Insurance, 2017 Air Ambulance Memorial Study Report, available at: http://www.osi.state.nm.us/MiscPages/docs/newsroom/Air%20Ambulance%20Memorial%20-%201.19.17.pdf
28. H.B. 402, 53^rd Leg., 1^st Sess. (N.M. 2017), available at https://legiscan.com/NM/text/HB402/id/1512894/New_Mexico-2017-HB402-Introduced.pdf
29. H.B. 2231, 65^th Leg. Ass., Reg. Sess. (N.D. 2017) (enacted), available at http://www.legis.nd.gov/assembly/65-2017/documents/17-0231-04000.pdf.
30. North Dakota Insurance Department, Air Ambulance Participation Guide (2017), available at https://www.google.com/url?q=https://www.nd.gov/ndins/uploads/57/20170728AirAmbulanceParticipationGuide.pdf&sa=U&ved=0ahUKEwizh77Il4fXAhVGb1AKHRZVC9oQFggLMAI&client=internal-uds-cse&cx=012062294093941210829:v9ne-cbfu5i&usg=AOvVaw38U_1MDo5RWnn_XgVaiYCi.
31. S.B. 95, 62^nd Leg., Gen. Sess. (Utah 2017) (enacted), available at http://le.utah.gov/~2017/bills/static/SB0095.html.
32. S.C.R. 2, 62^nd Leg., Gen. Sess. (Utah 2017) (enacted), available at http://le.utah.gov/~2017/bills/static/SCR002.html.
33. H.B. 4315, Reg. Sess. (W.V. 2016) (enacted), available at http://www.legis.state.wv.us/Bill_Status/Bills_history.cfm?input=4315&year=2016&sessiontype=RS&btype=bill
34. S.B. 276, Reg. Sess. (W.V. 2017), available at http://www.legis.state.wv.us/Bill_Text_HTML/2017_SESSIONS/RS/bills/sb276%20intr.pdf.
35. National Conference of State Legislatures, Adopted Policy Directives and Resolutions (August 2017), pp. 55-56, available at: http://www.ncsl.org/Portals/1/Documents/statefed/2017_Consent_Calendar_Final.pdf.
36. Association of Air Medical Services (AAMS) , Emergency Air Medical Services (August 10, 2017), available at https://comm.ncsl.org/productfiles/95646393/Eastlee-AirAmbulanceTransport-PPT.pdf
37. Betsy Imholz, Consumer Union, Air Ambulances: Consumer Protections Needed (August 10, 2017) available at https://comm.ncsl.org/productfiles/95646393/Imholz-AirAmbulance-PPT.pdf.
38. National Conference of Insurance Legislators [hereinafter NCOIL], Air Ambulance Task Force, Interim Conference Call Draft Minutes (June 8, 2017), available at http://ncoil.org/wp-content/uploads/2017/07/Air-Ambulance-TF-interim-minutes.pdf
39. NCOIL Air Ambulance Task Force, Draft Minutes (July 15, 2017), available at http://ncoil.org/wp-content/uploads/2017/08/air-ambulance-minutes-chicago-final-7-25-17.pdf.
40. NCOIL, Tentative General Schedule, NCOIL Annual Meeting, Nov. 16-19, 2017 (2017), pp. 68-73, available at http://ncoil.org/wp-content/uploads/2017/10/phoenix-30-day-final.pdf
41. NCOIL Health, Long-Term Care & Health Retirement Issues Committee: Assem. Kevin Cahill (NY), Chair;
    Rep. Glen Mulready (OK), Vice Chair;  Rep. Sam Kito (AK); Rep. Deborah Ferguson (AR); Sen. Jason Rapert (AR);
    Assem. Kenneth Cooley (CA); Rep. Martin Carbaugh (IN); Rep. Joseph Fischer (KY); Rep. Jim Gooch (KY); Rep. Jeff Greer (KY); Sen. J. Dorsey Ridley (KY); Rep. Mark Abraham (LA); Rep. Greg Cromer (LA); Sen. Dan "Blade" Morrish (LA);
    Rep. Major Thibaut (LA); Rep. Justin Hill (MO); Rep. John Wiemann (MO); Rep. George Keiser (ND); Sen. Jerry Klein (ND),
    Assem. Maggie Carlton (NV); Assem. William Barclay (NY); Sen. James Seward (NY); Sen. Robert Hackett (OH);
    Rep. Marguerite Quinn (PA); Rep. Brian Kennedy (RI); Rep. Bill Botzow (VT); Rep. Sarah Copeland Hanzas (VT); and
    Rep. Kathie Keenan (VT).
42. NAIC, Workers’ Compensation Task Force Handout (April 10, 2017), available at: http://naic.org/meetings1704/cmte_c_wctf_2017_spring_nm_materials.pdf?1491525920000.
43. NAIC, Letter to the U.S. Senate Committee on Commerce, Science and Transportation (July 12, 2017), available at: http://www.naic.org/documents/government_relations_171217_letter_to_congress_21st_century_airr_act_air_ambulance_provision.pdf
44. PHI Air Medical, LLC v. Texas Mutual Ins. Co., No. 03-17-00081-CV (2017), available at http://www.search.txcourts.gov/Case.aspx?cn=03-17-00081-CV&coa=coa03.
45. EagleMed LLC. v. Cox, No.16-8064, 868 F.3d 893 (10^th Cir. Aug 22, 2017), available at https://www.ca10.uscourts.gov/opinions/16/16-8064.pdf