UNITED STATES DISTRICT COURT 

NORTHERN DISTRICT OF FLORIDA 

TALLAHASSEE DIVISION 

AIR METHODS CORPORATION and 

ROCKY MOUNTAIN HOLDINGS LLC, 

Plaintiffs, 

vs. Case No. 4:20-cv-462-AW-MAF 

DAVID ALTMAIER, in his official 

capacity as Commissioner of the Office 

of Insurance Regulation, 

 

Defendant. 

______________________________________/ 

AMENDED COMPLAINT FOR DECLARATORY 

AND INJUNCTIVE RELIEF 

Plaintiffs, Air Methods Corporation (“Air Methods”) and its wholly-owned 

subsidiary Rocky Mountain Holdings, LLC (“Rocky Mountain”) (collectively, “Air 

Methods”), by and through their undersigned attorneys, bring this civil action for 

declaratory and injunctive relief and allege as follows: 

1. This is an action to declare invalid and to permanently enjoin the 

enforcement of Florida House Bill 747, enacted on September 18, 2020, codified at 

new Florida Statutes sections 627.42397 and 641.514 (“HB 747”). The new law is 

unconstitutional and expressly preempted by federal law, namely the Airline 

Deregulation Act of 1978 (“ADA”), 49 U.S.C. § 41713(b). Additionally, recentlyenacted federal statutes preempt HB 747 on conflict and field preemption grounds. 

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2. Congress included an express preemption clause in the ADA that 

prohibits states from “enact[ing] or enforc[ing] a law, regulation, or other provision 

having the force and effect of law related to a price, route, or service of an air carrier 

that may provide air transportation under this subpart.” 49 U.S.C. § 41713(b). 

3. Air Methods is an “air carrier” for purposes of the ADA because it is 

certified to provide interstate air transportation. See 49 U.S.C. § 40102(a)(2); see 

also Stout v. Med-Trans Corp., 313 F. Supp. 3d 1289, 1294-95 (N.D. Fla. 2018). 

4. The ADA prohibits state laws that regulate an air carrier’s pricing, even 

when the state law purports to apply only to transports within the state. See Scarlett 

v. Air Methods Corp., 922 F.3d 1053, 1060-61 (10th Cir. 2019). 

5. Despite the ADA’s well-established prohibition, HB 747 empowers 

insurers to expressly regulate the prices set by air ambulance service operators in the 

State of Florida (“State”). 

6. Specifically, the law grants insurers the absolute right to determine the 

amount that will be paid to the air ambulance operator as reasonable payment for 

out-of-network air ambulance services. It disregards completely the amount that 

was billed by the air ambulance operator for its services and the usual and customary 

amount that insurers have previously paid for out-of-network air ambulance 

services. 

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7. The insurer’s payment, in fact, is the only payment that the air 

ambulance operator, like Air Methods, receives because the law also prohibits any 

“balance billing” to patients for any amount in excess of the reimbursement rate set 

by the insurer other than payment of his or her applicable copayment, coinsurance, 

or deductible. 

8. The Office of Insurance Regulation (“OIR”), which has broad authority 

to enforce all provisions in the Insurance Code, is the entity charged with ensuring 

that all insurance and HMO policies allow for insurers to have this rate-setting 

power. 

9. Because HB 747 blatantly regulates pricing for air ambulance services, 

there is no question that HB 747 is expressly preempted by the ADA, and therefore 

violates the United States Constitution’s Supremacy clause. This is so even if the 

new law is described and rationalized as an effort to regulate the business of 

insurance. 

10. Additionally, HB 747 is subject to conflict and field preemption under 

two federal laws that address pricing and balance billing issues in the air ambulance 

industry on a nationwide basis. 

11. First, The FAA Reauthorization Act of 2018 established an Air 

Ambulance and Patient Billing (“AAPB”) Advisory Committee that has issued 

several reports to the U.S. Department of Transportation (“DOT”) for purposes of 

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issuing national guidance and rules in order to prevent the application of inconsistent 

state laws like HB 747. 

12. Second, on December 27, 2020, Congress passed the No Surprises Act

(the “Act”), as part of the Consolidated Appropriations Act (HR 133). Under the 

Act, Congress has mandated a procedure for payment disputes between air 

ambulance providers and insurance carriers for out-of-network patients, which 

requires binding arbitration between an insurer and operator and also prohibits 

balance billing of the insured. The law takes effect in January of 2022. 

13. In sum, HB 747 is expressly preempted by the ADA, and also conflict 

and field preempted by federal laws addressing these issues, and thus violates the 

Supremacy Clause, and must be declared unconstitutional and invalid. 

JURISDICTION AND VENUE 

14. The Court has subject matter jurisdiction over this action pursuant to 

28 U.S.C. § 1331 because the action arises under (i) the Supremacy Clause of the 

Constitution of the United States, Article VI, clause 2 (“the Supremacy Clause”); 

and (ii) the laws of the United States, specifically the Airline Deregulation Act of 

1978, 49 U.S.C. § 41713(b)(1). Additionally, subject matter jurisdiction arises under 

28 U.S.C. § 1337, because the matter in controversy arises under an Act of Congress 

regulating commerce, i.e., the ADA, and the Federal Declaratory Judgment Act, 28 

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U.S.C. §§ 2201-2202, because this is an actual controversy in which Plaintiffs seek 

declaratory relief. 

15. Venue is proper in the Northern District of Florida pursuant to 28 

U.S.C. § 1391(b) because Defendant performs his official duties and transacts his 

affairs in this District, and a substantial part of the events giving rise to the claims 

occurred in this District. 

PARTIES 

16. Air Methods, operating through its subsidiary Rocky Mountain, 

provides life-saving, emergency transport to critically injured patients in many states 

throughout the country, including the State of Florida. 

17. Air Methods is certified by the Federal Aviation Administration 

(“FAA”) as an on-demand air carrier that is subject to pervasive federal regulation. 

18. Air Methods employs medical professionals and flight crews, owns and 

operates air medical service helicopters, and maintains all required state and local 

licensure and insurance that enables it to provide life-saving transportation services 

to those in need. 

19. Defendant David Altmaier, the Commissioner of the Florida OIR, is 

sued in his official capacity. The Commissioner’s office is charged with enforcing 

the law at issue and ensuring that all policies abide by the law’s requirements. See 

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Fla. Stat. § 20.121(3)(a)1. His office is located at 200 East Gaines Street, 

Tallahassee, Florida 32399. 

20. OIR has a statutory duty to enforce the provisions of the Florida 

Insurance Code and investigate violations of the Code, including the provisions 

enacted under HB 747. See Fla. Stat. § 624.307. As stated on its welcome page, 

OIR is responsible “for regulation, compliance, and enforcement of statutes related 

to the business of insurance.” See https://www.floir.com/

21. OIR’s Life and Health Product Review unit “reviews all life and health 

policy forms and rates for compliance with Florida Statutes, regulations and actuarial 

standards.” See https://www.floir.com/Office/AgencyOrganizationOperation.aspx

Accordingly, OIR ensures that insurance policies comply with HB 747’s terms. 

22. The OIR also has a “Life and Health Market Regulation” unit that 

conducts examinations and investigations of life and health insurers and related 

parties regarding business practices and alleged violations of the Florida Insurance 

Code. Id. This unit is authorized to “work with the Legal Services office to take 

administrative action, impose administrative penalties and require corrective action 

in order to protect insurance consumers from unlawful or harmful business 

practices.” Id. 

 

 

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FACTUAL BACKGROUND

A. Air Methods’ Life-Saving Operations in Florida 

23. Air Methods is a federally regulated air carrier that provides life-saving 

emergency air transportation services to critically ill and injured patients. 

24. Air Methods provides these emergency air ambulance services 

throughout the State of Florida to destinations in Florida and across state lines into 

neighboring states. 

25. Air Methods has 14 different bases located across Florida: from 

Escambia County in the Panhandle to Jacksonville in Northeast Florida to St. Lucie 

in Southeast Florida to Lee County in Southwest Florida. 

26. Air Methods operates on average one or two emergency air transports 

on a daily basis from each one of these 14 locations. 

27. Air Methods also serves several under-served rural communities, and 

transports patients from these rural communities to higher care facilities located in 

metro areas of Florida. 

28. Air Methods is authorized by the FAA to operate as a Part 135 air 

carrier providing on-demand air ambulance services. 

29. Air Methods also is registered with the DOT to operate as a Part 298 

air taxi operator providing on-demand services. 

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30. Pursuant to its Part 135 certificate and Part 298 registration, Air 

Methods is authorized to operate interstate flights and, as a common carrier for 

compensation, qualifies as an “air carrier” as that term is defined in the ADA. 

31. Air Methods maintains a fleet of air ambulances, fixed wing aircraft 

and helicopters, that are prepared to respond at a moment’s notice to medical 

emergencies. It provides life-saving emergency air ambulance transportation to 

critically ill or injured patients, while medical professionals provide in-flight care. 

32. Air Methods is dispatched by first responders at the scene of an accident 

or by a physician or medical facility that determines a patient requires emergency 

transport to a hospital that can offer a higher level of care. 

33. In accordance with federal and state law, Air Methods serves patients 

in its aircraft regardless of their insurance status or their ability to pay for the 

services. 

34. For uninsured patients, Air Methods often does not recover any portion 

of its fees. For patients covered by Medicaid, Air Methods is reimbursed at the 

federal Medicaid rates. 14 C.F.R. § 447.15. For Medicare patients, air ambulance 

providers cannot bill patients for services beyond deductibles and coinsurance 

requirements. 14 C.F.R. § 414.610. 

35. To continue to provide air ambulance service to every patient regardless 

of their ability to pay, Air Methods must receive its billed charges for a sufficient 

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proportion of its flights to offset the losses it suffers when it transports patients who 

are uninsured, underinsured or are covered by Medicare or Medicaid. 

36. For several insurers, Air Methods has negotiated rates for its air 

ambulance services and is considered an “in-network” provider for transports under 

these circumstances. This arrangement allows for payment according to terms 

negotiated in advance and as agreed to by the insurer and Air Methods. 

37. When Air Methods does not have a contract with an insurer, however, 

they are performing those services “out-of-network.” Under these circumstances, 

Air Methods will bill insurers for its services at its full rates. 

38. For “out-of-network” transports, the insurance company reimburses 

providers at a rate based on usual and customary charges and then, as per the 

insurance contract with its insured, the insurer leaves the remainder to be paid by the 

insured. Under these circumstances, a provider like Air Methods may then send a 

bill to the insured for the remaining balance. This is known as “balance billing.” 

39. Air Methods makes every attempt to work with the insurer (and the 

insured) to negotiate an appropriate reimbursement from the insurance company to 

reduce or eliminate any remaining balance for the patient. In many cases, Air 

Methods must go through provider appeals or assist in facilitating member appeals 

for an insurer’s initial determination of payment. For certain insurers, such as 

CIGNA, Air Methods must balance bill the patient before the insurance company 

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will review an appeal by Air Methods on behalf of the insured of the initial payment 

for its services. CIGNA does not allow providers an appeal path for disputes over 

the maximum reimbursable amount, thus requiring Air Methods to involve the 

insured in all payment disputes. See https://www.cigna.com/health-careproviders/coverage-and-claims/appeals-disputes/ Air Methods works with the 

insured patient and the insurance company who has insured the patient to negotiate 

further payment from the insurance company. 

B. Florida House Bill 747 

40. On November 22, 2019, HB 747 was introduced as a bill in the Florida 

House of Representatives. The purpose of HB 747 is to regulate the prices air 

ambulance service providers can receive in the State of Florida from its patients and 

their health insurers. 

41. On March 12, 2020, the Florida Legislature passed HB 747. 

42. On September 18, 2020, the Governor of Florida signed HB 747 and 

the law took effect immediately. 

43. Under HB 747, Florida Statutes are amended to limit the prices that air 

ambulance operators can receive for their transportation services from their patients’ 

health insurers. By definition, the reimbursement required under the statute must be 

something less than the air ambulance service provider’s billed charges. 

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44. HB 747 accomplishes this impact by allowing health insurers to pay 

“reasonable reimbursement” to an air ambulance service for out-of-network 

services. 

45. Air ambulance operators are forced to accept this vague and lower 

reimbursement rate, which is expressly not based upon air ambulance operators’ 

billed charges and is not tied to the usual and customary reimbursement rate. 

Essentially, the new law gives the insurer carte blanche in setting the reimbursement 

rate. 

46. Air ambulance service providers like Air Methods are harmed by the 

express terms of this reimbursement provision because the rate being paid is (1) now 

set by the insurer without regard to the billed charges or usual and customary 

reimbursement rate, (2) will always be lower than Air Methods’ billed charges, and 

(3) upon information and belief, has resulted in a significant drop in the average 

payment for out-of-network services. By the State of Florida giving insurers this 

sanctioned legal discretion to decide payment for out-of-network services without 

regard for billed charges, the insurer has wholesale authority to decide the rate for 

the air ambulance services -- a rate that has shown to be demonstrably lower than 

not only the billed charges, but past reimbursements for out-of-network services. 

47. The OIR is charged with enforcing implementation of the new law. 

Specifically, OIR is responsible for approving and enforcing the implementation of 

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the statute’s “reasonable reimbursement” language into the policy. By ensuring that 

these rate-setting terms are incorporated in every insurance policy, OIR is causing 

harm to Air Methods through implementation of those terms, and therefore Air 

Methods (i) will never receive a reimbursement that is equal to its billed charges and 

(ii) since the law took effect, has consistently received reimbursements below the 

average payments received prior to the law’s enactment. 

48. As explained above, the new law gives health insurers the ability to set 

air ambulance rates as the statute authorizes the insurers to pay whatever they 

determine to be a “reasonable reimbursement” rate. 

49. Since enforcement of HB 747, Air Methods has sustained significant 

economic losses. Because reimbursements from insurers are not equal to Air 

Methods’ billed charges and, in fact, have been less than “out-of-network” payments 

preceding enactment of the law, Air Methods has been harmed and sustained 

significant losses. 

50. For example, comparing the 9-month period before HB 747 took effect 

(January 2020 through September 2020) to the 6-month period after HB 747 took 

effect (October 2020 through March 2021), the average first primary payment for 

CIGNA dropped from $34,360 to $8,342 (excluding $0 first payments, the average 

post HB 747 payment is $18,096.77), showing a significant reduction in 

payments. Upon information and belief, this reduction was caused by HB 747 

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affording the insurer discretion to pay what the insurer alone considered a 

“reasonable reimbursement.” 

51. Additionally, the new law prohibits any “balance billing” of the patient 

and states that any “payment by the insured of his or her applicable copayment, 

coinsurance, or deductible constitutes an accord and satisfaction of, and constitutes 

a release of, any claim for additional moneys owed by the insured to the health 

insurer or to any person or entity in connection with the air ambulance service.” Fla. 

Stat. § 627.42397(1)(c)(2). Accordingly, the “reasonable reimbursement” provision 

results in lower payments to Air Methods, and the prohibition on “balance billing” 

acts as a final cap on such payments. 

52. For example, on October 23, 2020, a patient insured by CIGNA 

(referred to herein by the pseudonym “Jane Doe” to protect patient privacy) was 

transported by Air Methods. On October 29, 2020, Air Methods electronically billed 

$46,666.81 to CIGNA for its air ambulance services. On November 20, 2020, 

CIGNA made a payment of $11,723.54. The remaining balance of $34,943.27 for 

services provided by Air Methods to Jane Doe may not be recovered by Air Methods 

as a result of HB 747. This unrecoverable loss of a substantial portion of an account 

receivable is an injury in fact suffered by Air Methods and would be redressed by a 

judgment declaring that HB 747 is unconstitutional. 

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53. Because insurers require their insureds to remain liable for the account 

balances before the insurers will negotiate further payment, Air Methods, in fact, 

cannot challenge and further negotiate the insurer’s payment in many cases unless 

and until Air Methods has issued a balance bill to the patient. Because the new act 

prohibits any balance billing to the patient, HB 747 has caused hardship and financial 

loss to Air Methods because there is no longer a negotiation process with insurers 

like CIGNA. Air Methods is left to accept the lower payment -- which is determined 

solely by the insurers. 

54. The Florida House of Representatives, in fact, fully recognized and 

foresaw that HB 747 would have this “negative, indeterminate fiscal impact” on air 

ambulance service providers.1

 

55. Not only does the “reasonable reimbursement” provision result in lower 

out-of-network reimbursements from the insurers, the linked prohibition on balance 

billing the patient under the new law serves to cap the insurer’s payment of 

“reasonable reimbursement” at an amount well below the prices set by Air Methods. 

56. Indeed, the Florida Legislature expressly stated in HB 747 that the 

“reasonable reimbursement” and “balance billing” provisions in the new law are not 

 

1 See House of Representatives Staff Final Bill Analysis for HB 747 (“House 

Report”) (2020), at 6, available at 

https://www.flsenate.gov/Session/Bill/2020/747/Analyses/h0747z.HMR.PDF.   

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enacted “individually” and “expressly finds them not to be severable.” This means 

that a finding of unconstitutionality of one provision (i.e., the “reasonable 

reimbursement” provision) means the invalidity of the remainder of the law (i.e., the 

“balance billing” provision). When such clauses are included, as here with HB 747, 

courts “should adhere to the text of the nonseverability clause” and “hew closely to 

[it].” See Barr v. Am. Ass’n of Political Consultants, Inc., 140 S. Ct. 2335, 2349 

(2020). 

57. Even more concerning is that Air Methods will be forced to evaluate 

the ongoing financial viability of operations in the State as a result of the significant 

loss of revenue it has experienced under HB 747. Indeed, the new law leaves little, 

or no, incentive for insurers to negotiate in good faith with Air Methods regarding 

in-network rates. 

C. The Airline Deregulation Act 

58. In 1978, Congress amended the Federal Aviation Act of 1958, 49 

U.S.C. § 40101 et. seq., and enacted the ADA with the intention of deregulating the 

aviation industry. 

59. Congress included an express preemption clause in the ADA that 

prohibits states from “enact[ing] or enforc[ing] a law, regulation, or other provision 

having the force and effect of law related to a price, route, or service of an air carrier 

that may provide air transportation under this subpart.” 49 U.S.C. § 41713(b)(1). 

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60. This express preemption clause was included “to ensure that States 

would not undo federal deregulation with regulation of their own,” Morales v. Trans 

World Airlines, Inc., 504 U.S. 374, 378 (1992), and to “prevent conflicts and 

inconsistent regulations” of air carriers by the federal government and the 50 states. 

H.R. Rep. No. 95-1211, at 16 (1978).

61. In passing the ADA, Congress determined that “an air transportation 

system relying on actual and potential competition” would best further “efficiency, 

innovation, and low prices” as well as “variety [and] quality . . . of air transportation 

services.” 49 U.S.C. § 40101(a)(12).

62. Congress also recognized that it is in the public interest to place 

“maximum reliance on competitive market forces and on actual and potential 

competition − (A) to provide the needed air transportation system; and (B) to 

encourage efficient and well-managed carriers to earn adequate profits and attract 

capital.” 49 U.S.C. § 40101(a)(6).

63. The ADA’s preemption clause is interpreted broadly, and preemption 

is found where claims, directly or indirectly, have “a connection with, or reference 

to” an air carrier’s prices, routes or services. See Nw., Inc. v. Ginsberg, 572 U.S. 

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273, 280-81 (2014); see also Am. Airlines, Inc. v. Wolens, 513 U.S. 219 (1995); 

Morales v. Trans World Airlines, Inc., 504 U.S. 374 (1992).2

64. HB 747’s ill-conceived pricing scheme is federally preempted by the 

ADA because it allows the State to regulate and set rates for air ambulance services 

in contravention of the ADA’s express prohibition of such state conduct. 

65. State statutes like HB 747 that regulate air ambulance pricing have been 

stricken in declaratory judgment actions like this, where the defendant was the 

relevant state’s insurance commissioner charged with enforcing the law. In 

Guardian Flight, LLC v. Godfread, the U.S. Court of Appeals for the Eighth Circuit 

affirmed ADA preemption of a newly-enacted North Dakota statute that had insurers 

reimburse air ambulance operators an amount based on the average of the insurer’s 

in-network rates. 991 F.3d 916, 9021 (8th Cir. 2021). Because the North Dakota 

law made the operator accept a state-mandated rate and prohibited balance billing 

(the same as HB 747 does), the district court had found “it caps air ambulance prices” 

and is “precisely the type of state regulation Congress sought to prevent when it 

included an express preemption clause in the ADA.” Guardian Flight, LLC v. 

Godfread, 359 F. Supp. 3d 744, 755 (D.N.D. 2019); see also Valley Med Flight, Inc. 

 

2

 To the extent the Commissioner asserts reverse preemption under the McCarranFerguson Act, it is clear that HB 747 regulates the activities of an air ambulance 

operator by setting the price for the services, and is therefore not limited to the 

relationship between the insured and the insurer. 

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v. Dwelle, 171 F. Supp. 3d 930, 943-45 (D.N.D. 2016) (in suit against state officials 

charged with overseeing health insurance and workers’ compensation policies, 

granting declaratory judgment and striking state law that created priority call lists 

for only those air ambulance operators that had in-network contracts with insurers).

66. Significantly, the U.S. Court of Appeals for the Eleventh Circuit in 

Bailey v. Rocky Mountain Holdings, LLC, 889 F.3d 1259, 1271 (11th Cir. 2018) 

likewise found ADA preemption of a Florida statute with a balance billing provision 

as the law imposed a “price restriction” and, thus, had “‘[a] forbidden significant 

effect’ on the prices of an air carrier.” 889 F.3d at 1271. See also EagleMed LLC 

v. Cox, 868 F.3d 893, 905 (10th Cir. 2017) (holding fee schedules in workers 

compensation act were preempted because they regulated air ambulances’ prices); 

Air Evac EMS, Inc. v. Cheatham, 260 F. Supp. 3d 628, 633 (S.D. W. Va. 2017) 

(holding ADA preempted West Virginia law prohibiting air ambulance companies 

from balance billing patients insured by West Virginia’s Public Employees 

Insurance Agency), aff’d, 910 F.3d 751 (4th Cir. 2018).

67. The House Report for HB 747 and the Senate Report regarding the 

sister Senate Bill (SB 736) expressly recognize the foregoing cases, including the 

Eleventh Circuit Bailey decision, and the various states’ repeated failed efforts to 

enact new laws or enforce state fee schedules in an attempt to cap or restrict air 

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ambulance prices.3

 Additionally, the Senate Report predicted that the new law 

would be struck down given the breadth of the ADA’s prohibition of state regulation 

of air carrier prices.4

68. The DOT’s Office of the General Counsel also has reinforced an 

expansive view of preemption and reliance on market forces, specifically in the air 

ambulance context. In its Guidelines for the Use and Availability of Helicopter 

Emergency Medical Transport (HEMS),

5

 the Office of the General Counsel 

summarizes its various opinions on FAA and ADA preemption in air ambulance 

cases. In discussing federal preemption of state laws that require certificates of 

authority to operate in the state, the Office notably confirmed that: 

[o]nce the Secretary [of Transportation] certificates an air ambulance 

operator, the competitive marketplace, rather than state regulations, 

controls the operator’s prices, routes, and services, and only the 

Secretary may revoke an air ambulance operator’s certificate.

Id. at 11 (emphasis added). 

 

3 See House Report, at 3-4; Senate Bill Analysis and Fiscal Impact Statement for SB 

736 (the sister bill to HB 747) (“Senate Report”), at 7-8 (2020), available at 

https://www.flsenate.gov/Session/Bill/2020/736/Analyses/2020s00736.rc.PDF 

4

 See Senate Report, at 11 (recognizing ADA preemption as one of the “Technical 

Deficiencies” with the new law). 

5 Available at

https://www.transportation.gov/sites/dot.gov/files/docs/Guidelines%20for%

20the%20Use%20and%20Availability%20of%20Helicopter%20Emergency

%20Medical%20Transport%20%28HEMS%29%20OCR.pdf.

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D. The FAA Reauthorization Act of 2018 

69. The FAA Reauthorization Act established an Air Ambulance and 

Patient Billing (“AAPB”) Advisory Committee, comprised of health insurers and air 

ambulance operators, to review ways to improve the disclosure of air ambulance 

charges, better inform consumers of insurance options, and protect them from 

balance billing. Pub. L. No. 115-254, § 418, 132 Stat. 3186, 3334-3336 (2018). 

70. The AAPB has issued several reports, which the DOT is presently using 

to conduct oversight of air ambulance service providers and to issue forthcoming 

guidance concerning provider pricing and billing practices. This will include 

guidance for States to refer such matters to the Secretary of Transportation. Pub. L. 

No. 115-254, § 420, 132 Stat. 3336. 

71. DOT has plenary authority to investigate allegedly unfair business 

practices of air ambulance operators, including complaints concerning prices and 

balance billing, and bring enforcement actions. See 49 U.S.C. § 41712(a). DOT 

reviews consumer complaints to determine compliance with federal law and identify 

areas of concern that serve as the basis for federal rulemaking and legislation.

E. Federal No Surprises Act 

72. On December 27, 2020, Congress passed the No Surprises Act (the 

“Act”), as part of the Consolidated Appropriations Act (HR 133). 

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73. The new legislation, effective in January 2022, is intended to protect 

consumers from surprise bills for: (1) emergency services delivered by out-ofnetwork providers, including emergency air ambulance operators, or by out-ofnetwork facilities; and (2) nonemergency services provided by out-of-network 

providers in network facilities and for which patients do not consent. Consumers’ 

costs will be limited to cost-sharing amounts that apply to in-network services. 

Service providers are banned from billing patients for any higher amounts.

74. Section 105 of the Act, titled “Ending surprise air ambulance bills,” 

specifically covers and preempts the reimbursement and billing rules enacted by the 

Florida Legislature in HB 747. Section 105 holds patients harmless from surprise 

air ambulance medical bills and only requires them to pay the in-network costsharing amount for out-of-network air ambulances. That cost-sharing amount is 

applied to their in-network deductible. Air ambulances are barred from sending 

patients surprise bills for more than the in-network cost-sharing amount. 

75. The new federal law also provides for a 30-day open negotiation period 

for air ambulance providers and payers to settle out-of-network claims. If the parties 

are unable to reach a negotiated agreement, they may access binding arbitration 

through an Independent Dispute Resolution (“IDR”) process. By January 21, 2022, 

the Secretary of Labor and Secretary of Transportation are to jointly establish by 

regulation the specific IDR process under which, in the case of air ambulance 

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services, a certified IDR entity will determine the amount of payment under the plan 

or coverage for such services. 

76. The Act further confirms federal preemption of HB 747 on conflict and 

field preemption grounds. Congress specifically enacted a federal statute to address 

the very issues that are at the heart of HB 747. 

77. Unlike HB 747, the Act does not address nor dictate the amount that an 

insurer pays an air ambulance provider for out-of-network services. Rather, the 

parties will have a 30-day open negotiation period for air ambulance providers and 

payers to settle out-of-network claims. If no agreement is reached, the Act provides 

for binding arbitration.

Count I: Declaratory Judgment that HB 747 Is Preempted By the ADA 

and Injunctive Relief to Enjoin Its Enforcement 

78. Plaintiffs repeat and reallege paragraphs 1 through 77 of this Amended 

Complaint as though fully set forth herein.

79. HB 747 is preempted by the ADA because it “relates to” the prices and 

services provided by air ambulance service providers in Florida, including Air 

Methods. 

80. Specifically, HB 747 directly affects the prices that air ambulance 

operators may charge because the operator will be required to accept the prices 

mandated by the statute, which by definition will be less than the billed charges of 

the operator. 

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81. Air Methods, if unable to set its air carrier rates to sustain its operations 

in the State, will likely be forced to cease its critical life-saving operations in many 

counties, including the rural communities in Florida, with such cessation at the 

expense of the life and health of Florida’s citizens. 

82. Because HB 747 (i) authorizes health insurers to ignore billed charges 

and set reimbursement rates, (ii) prohibits balance billing, and (iii) threatens Air 

Methods’ ability to continue to provide services to the Florida emergency air 

transport market, the statute is preempted by the ADA and this Court should declare 

HB 747 invalid and unenforceable.

Count II: Declaratory Judgment that HB 747 Violates the Supremacy Clause 

of the U.S. Constitution and Injunctive Relief to Enjoin Its Enforcement 

83. Plaintiffs repeat and reallege paragraphs 1 through 82 of this Amended 

Complaint as though fully set forth herein.

84. Pursuant to Article VI, Section 2 of the U.S. Constitution (the 

Supremacy Clause), any state statute, rule or regulation that conflicts with federal 

law is preempted. 

85. Specifically, HB 747 is unconstitutional and conflicts with the ADA, 

which prohibits states from enacting or enforcing laws that relate to prices, routes or 

services of air carriers such as Air Methods. 

86. Additionally, HB 747 conflicts with (i) the FAA Reauthorization Act, 

which specifically designates the DOT to oversee and issue guidance and rules on 

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pricing and balance billing practices in the air ambulance industry, and (ii) the No 

Surprises Act, which provides for negotiation of reimbursement rates for out-ofnetwork transports, and if necessary arbitration, rather than forcing air ambulance 

operators to accept whatever the insurer considers a “reasonable reimbursement.” 

87. Accordingly, this Court should declare that the provisions of HB 747 

are invalid and unenforceable because they violate the Supremacy Clause of the U.S. 

Constitution, Article VI. 

PRAYER FOR RELIEF 

Wherefore, Plaintiffs request that the Court:

(1) Issue a declaratory judgment that declares HB 747 invalid and 

unenforceable as preempted by the Constitution and laws of the United 

States; 

 

(2) Issue a preliminary injunction, the same to be made permanent on final 

 judgment: 

(a) Restraining and enjoining defendant, his employees, or agents from 

enforcing or seeking to enforce the provisions of HB 747 determined 

by this Court to be invalid and preempted by federal law; and 

 

(b) Requiring defendant to issue such notices, and take such steps as 

shall be necessary and appropriate to carry into effect the substance and 

intent of paragraph (a) above, including but not limited to the 

requirement that defendant publicly withdraw, and rescind any orders 

that seek to enforce, the provisions of HB 747 herein determined by this 

Court to be preempted by federal law; and 

(3) Grant such other further or different relief as to which the Plaintiffs may 

be entitled. 

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Dated: April 28, 2021 HOLLAND & KNIGHT LLP 

Attorneys for Plaintiffs 

/s/ Tiffany A. Roddenberry 

Tiffany A. Roddenberry 

Florida Bar No. 92524 

Email: tiffany.roddenberry@hklaw.com 

315 South Calhoun Street, Suite 600 

Tallahassee, FL 32301 

Tel: (850) 425-5658 

/s/ Judith R. Nemsick 

Judith R. Nemsick 

(admitted pro hac vice) 

Email: judy.nemsick@hklaw.com 

31 West 52nd Street 

New York, NY 10019 

Tel: (212) 513-3200 

/s/ Philip E. Rothschild 

Philip E. Rothschild 

Florida Bar No. 88536 

Email: phil.rothschild@hklaw.com 

515 East Las Olas Boulevard, 12th Floor 

Fort Lauderdale, FL 33302-4070 

Tel: (954) 525-1000

CERTIFICATE OF SERVICE

I HEREBY CERTIFY that a true and correct copy of the foregoing was served 

to all counsel of record through the Court’s CM/ECF system on April 28, 2021. 

s/ Tiffany A. Roddenberry 

Tiffany A. Roddenberry 

Florida Bar No. 92524 

Case 4:20-cv-00462-AW-MAF Document 33 Filed 04/28/21 Page 25 of 25