FARGO — North Dakota insurance regulators, responding to consumers who have complained about receiving bills averaging $55,341 for air ambulance flights not covered by their health insurance, are announcing steps to protect patients.

As of Aug. 1, a new law requires health providers to give consumers a guide showing which air ambulance companies operating in North Dakota have contracts with the state's three major health insurers.

The guide, which must be given to patients who are facing non-emergency transfers, is intended to avoid placing consumers in a position where they could be saddled with huge bills for out-of-network air ambulance services.

From 2013 through July 2017, the North Dakota Insurance Department has received 32 complaints totaling $1.77 million, or an average of $55,341, for air ambulance rides that were not covered by insurance.

"That's a lot of complaints for North Dakota in a single issue," and also the complaints involve unusually large sums of money, Jeff Ubben, deputy insurance commissioner, said Wednesday, Aug. 9. "It's been a leading complaint."

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The bills to consumers ranged from $18,000 to $83,613.

The air ambulance participation guide is North Dakota's latest effort to protect consumers from enormous out-of-pocket costs for air ambulance services.

In 2015, the North Dakota Legislature passed a law creating a primary call list of air ambulance services that included only operators that qualified as "participating providers" with major health insurers.

The law was an effort to avoid dispatching air ambulances that were not in the patient's health insurance network. Out-of-network air ambulance services were "balance billing" consumers for the large amounts not paid by their insurance, prompting the complaints of price gouging.

A federal judge struck down the North Dakota law, concluding that the state lacked authority to regulate air ambulance services, which fall under federal jurisdiction.

North Dakota officials are confident the new law - and a stronger provision that will take effect Jan. 1 - are within the state's authority. States have the authority to regulate insurance.

Starting Jan. 1, health plans in North Dakota can't be issued unless their reimbursement rate for out-of-network air ambulance service equals the average of the insurance company's in-network rates for air ambulances licensed in the state.

The insurance payments will constitute "full and final payment" for the air ambulance bills, protecting consumers from paying large out-of-pocket sums, Ubben said.

"It's regulating how insurance companies pay," not the actual delivery of air ambulance services, he said.

North Dakota's new regulatory approach appears novel. "As far as I know, this is a new avenue that North Dakota has taken," Ubben said.

In Congress, U.S. Sen. Jon Tester, D-Mont., is working on legislation that would allow states to regulate air ambulance services.

Sanford AirMed welcomes the new law, said Tim Meyer, the air ambulance service's director. He said Sanford was not the subject of any of the billing complaints, because the service has agreements with the state's three major health insurers.

"I don't know that it would really affect our operation much," he said. "We want to be good stewards of the resources in the state."

The state's air ambulance participation guide indicates that Sanford AirMed has agreements with Blue Cross Blue Shield of North Dakota, the Sanford Health Plan and six Medica health plans.

Valley Med Flight, based in Grand Forks, has agreements with Blue Cross Blue Shield and seven Medica plans, but not the Sanford Health Plan, according to the state guide.

Bismarck Air Medical has agreements with Blue Cross Blue Shield and the Sanford Health Plan, but not Medica.

Trinity NorthStar Criticair, based in Minot, has agreements with Blue Cross Blue Shield, Sanford Health Plan and six Medica plans.