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IN THE UNITED STATES DISTRICT COURT FOR THE

NORTHERN DISTRICT OF FLORIDA

TALLAHASSEE DIVISION

AIR METHODS CORPORATION and 

ROCKY MOUNTAIN HOLDINGS LLC,

Plaintiffs,

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

DAVID ALTMAIER, in his official 

capacity as Commissioner of the Office of 

Insurance Regulation,

Defendant.

_______________________________/

FINAL ORDER OF DISMISSAL

A new Florida law requires that “[a] health insurance policy must require a 

health insurer to provide reasonable reimbursement to an air ambulance service.” 

Ch. 2020-177, Laws of Fla. §§ 1, 2.1 The law also forbids balance billing—that is, it

forbids air-ambulance services from seeking additional payment from one whose 

insurer made “reasonable reimbursement.” Fla. Stat. § 627.42397(2). Plaintiff Air 

Methods Corporation, an air-ambulance company, sued to enjoin the law’s 

enforcement.

2

It contends the Airline Deregulation Act of 1978 and the No Surprises 

1 Sections 1 and 2 are substantially identical, except that one deals with health 

insurance policies and the other with HMOs. They create Florida Statutes 

§ 627.42397 (for health insurers) and § 641.514 (for HMOs). For simplicity, this 

order will treat the two provisions as one but cite to § 627.42397.

2 Air Methods operates through its wholly owned subsidiary, Rocky Mountain 

Holdings LLC, which is also a plaintiff. FAC ¶ 16. This order refers to the two 

plaintiffs collectively as “Air Methods.” 

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Act conflict with and preempt Florida’s new law. ECF No. 33 (“FAC”). The sole 

defendant is David Altmaier, sued in his official capacity as the Commissioner of 

the Office of Insurance Regulation. FAC ¶ 19.

I granted the Commissioner’s earlier motion to dismiss, but I gave Air 

Methods leave to amend. See ECF No. 30. Air Methods responded with an amended 

complaint, ECF No. 33, and the Commissioner has again moved to dismiss, ECF 

No. 36. I have considered the motion, Air Methods’ response (ECF No. 39), and the 

parties’ notices of supplemental authority and responses. See ECF Nos. 40-43. 

As before, I must ensure that there is subject-matter jurisdiction before turning 

to the merits. See Jacobson v. Fla. Sec’y of State, 974 F.3d 1236, 1245 (11th Cir. 

2020). The court lacks subject-matter jurisdiction if Air Methods lacks standing. 

And to have standing, Air Methods must have “(1) an injury in fact that (2) is fairly 

traceable to the challenged action of the defendant and (3) is likely to be redressed 

by a favorable decision.” Id. (citing Lujan v. Defs. of Wildlife, 504 U.S. 555, 560-61 

(1992)). As the plaintiff, Air Methods has the burden to establish standing, and at 

this stage, it must have alleged facts to support standing. Lujan, 504 U.S. at 561. I 

concluded earlier that it had not done so, and having carefully reviewed the amended 

complaint, I conclude Air Methods still has not done so.

Air Methods alleges that “[s]ince enforcement of HB 747, [it] has sustained 

significant economic losses.” FAC ¶ 49. In support, Air Methods alleges that the 

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average amount received from first primary payments for CIGNA dropped in the six 

months after HB 747 took effect. Id. ¶ 50. For purposes of this motion, I will accept 

that Air Methods has alleged a financial loss constituting an injury-in-fact. But Air 

Methods still must show traceability and redressability. See Lewis v. Governor of 

Ala., 944 F.3d 1287, 1296 (11th Cir. 2019). “In plainer language, the plaintiff needs 

to show that the defendant harmed him, and that a court decision can either eliminate 

the harm or compensate for it.” Muransky v. Godiva Chocolatier, Inc., 979 F.3d 917, 

924 (11th Cir. 2020) (en banc). And it needs to do so with more than mere conclusory 

statements. Id. at 924-25.

Despite its new factual allegations, Air Methods still has not alleged 

traceability or redressability, elements that typically “overlap as two sides of a 

causation coin.” Dynalantic Corp. v. Dep’t of Def., 115 F.3d 1012, 1017 (D.C. Cir. 

1997).

In my earlier order, I noted that the alleged harm did not come from the 

requirement that insurance policies cover (at least in part) air-ambulance services. 

ECF No. 30 at 4. That is still the case. Even if I enjoined the Commissioner from 

requiring insurers to include this coverage, insurers could still do so.3 They could 

3 As the Supreme Court explained in Lujan, when “a plaintiff’s asserted injury 

arises from the government’s allegedly unlawful regulation (or lack of regulation) 

of someone else . . . causation and redressability ordinarily hinge on the response of 

the regulated (or regulable) third party to the government action or inaction.” Lujan, 

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also omit air-ambulance coverage altogether, which would surely not remedy Air 

Methods’ injury. All the law does in this respect is obligate insurers to include certain 

minimum coverage they would otherwise be free to omit. 

Moreover, any suggestion that insurers would offer more without the 

minimum-coverage requirement is purely speculative. Air Methods alleges that 

“[u]pon information and belief, this reduction [in insurer payments] was caused by 

HB 747 affording the insurer discretion to pay what the insurer alone considered a 

‘reasonable reimbursement.’” FAC ¶ 50. But it does not allege specific facts to 

support this. Although Air Methods relies on Bennett v. Spear to argue that the 

Commissioner’s regulation affects insurers’ offers, there are no allegations to show 

the Commissioner’s actions (or threatened actions) “in reality ha[d] a powerful 

coercive effect” on the third-party agency, as was the case in Bennett. 520 U.S. 154, 

169 (1997). 

Air Methods complains that the new law affords “insurer[s] carte blanche in 

setting the reimbursement rate” or “wholesale authority to decide the rate for 

ambulance services,” FAC ¶¶ 44-46, but the reality is that there are no set rates. With 

or without the challenged law, insurers had no obligation to meet Air Methods’ 

payment demands. As to the required-coverage or “reasonable reimbursement”

504 U.S. at 562 (internal quotations omitted). As a result, “standing is not precluded, 

but it is ordinarily substantially more difficult to establish.” Id.

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provision, Air Methods primarily takes issue with the law’s mere existence rather 

than any action (or threatened action) traceable to the Commissioner.4 Cf. Support 

Working Animals, Inc. v. Governor of Fla., 8 F.4th 1198, 1203 (11th Cir. 2021). 

Thus, it has not demonstrated standing to challenge that provision. 

As before, Air Methods’ real issue is with the no-balance-billing provision. 

The amended complaint includes a concrete example. It points to services it provided 

in October 2020, for which it billed some $46,000. FAC ¶ 52. The insurer paid less 

than $12,000, leaving a balance of approximately $34,000. Id. The no-balancebilling provision kept Air Methods from recovering that balance from the insured. 

This is, to be sure, an injury. But not one redressable here.

It remains the case that the Commissioner does not enforce this provision. So 

there is nothing to enjoin him from as to this part. And regardless of what happens 

in this case, the insured (in any subsequent suit) could assert the no-balance-billing

provision as a defense, and the preemption issue would have to be litigated all over 

again. No state-court judge would have to go along with what I decided here. See 

Lewis, 944 F.3d at 1303. Indeed, a suit between a provider and an insured is where 

the validity of the no-balance-billing provision ought to be decided. As I noted 

4

I agree with Air Methods that the Commissioner’s insistence that the law has 

yet to be enforced, see ECF No. 36 at 9, does not preclude relief. I have therefore 

not considered the declaration submitted by John Reilly. ECF No. 36-1. 

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earlier, in Bailey v. Rocky Mountain Holdings, LLC, 889 F.3d 1259 (11th Cir. 

2018)—a case Air Methods relies on—the underlying litigation was between 

balance-billed patients and air-ambulance providers. Id. at 1263; cf. also Lewis, 944 

F.3d at 1301 (“Plaintiffs could have sued their employers, who refused to pay the 

ordinance-prescribed $10.10 wage—and thereby (and perhaps most obviously) 

caused their injury.”).

The situation here is not among the limited circumstances in which “it is 

substantially likely as a practical matter that non-parties would abide by an 

authoritative interpretation of the law, even if such parties would not be directly 

bound by such a determination.” Reprod. Health Servs. v. Strange, 3 F.4th 1240, 

1252 (11th Cir. 2021) (cleaned up). There is no reason to think that an insured 

seeking the benefit of the no-balance-billing provision would abandon its defense 

based on an order from this case. In short, the injunction Air Methods seeks—

enjoining the Commissioner’s enforcement—would not redress their injury. Cf.

Jacobson, 974 F.3d at 1253; Support Working Animals, 8 F.4th at 1205 (“Even if we 

were to issue a decision in the plaintiffs’ favor, [the challenged law] would remain 

on the books, the plaintiffs’ businesses would remain illegal, and they would remain 

in the same position they were in when they filed the operative complaint.”).

Last, the statute’s nonseverability clause does not save Air Methods’ claim. 

In Air Methods’ view, if one part of the law falls, the other part falls too. This may 

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be so as a matter of state law, but it does not help Air Methods with traceability or 

redressability. Air Methods still has to show standing as to one provision or the other, 

and it has not. And even if it had shown standing as to one provision, the remedy 

would be to enjoin enforcement of that provision. Cf. Murphy v. Nat’l Collegiate 

Athletic Ass’n, 138 S. Ct. 1461, 1486 (2018) (Thomas, J., concurring) (“Invalidating 

a statute is not a ‘remedy,’ like an injunction, a declaration, or damages. Remedies 

operate with respect to specific parties, not on legal rules in the abstract.” (citation 

and marks omitted)); California v. Texas, 141 S. Ct. 2104, 2115 (2021); Jacobson, 

974 F.3d at 1255 (“[F]ederal courts have no authority to erase a duly enacted law 

from the statute books. Our power is more limited: we may enjoin executive officials 

from taking steps to enforce a statute.” (marks and citation omitted) (quoting 

Jonathan F. Mitchell, The Writ-of-Erasure Fallacy, 104 Va. L. Rev. 933, 936 

(2018)).

In sum, Air Methods has not alleged facts to show traceability or 

redressability. The Commissioner’s motion to dismiss (ECF No. 36) is therefore 

GRANTED. The clerk will enter judgment that says, “This case was resolved on a 

motion to dismiss. Plaintiffs’ claims are dismissed without prejudice based on lack 

of subject-matter jurisdiction.” The clerk will then close the file.

SO ORDERED on October 12, 2021. 

s/ Allen Winsor

United States District Judge

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