TJOFLAT, Circuit Judge

William John Cornwell, Seth Adam Kolton, David K. Friedman, Sylvia L. Wenger, Weiss Handler & Cornwell, PA, Boca Raton, FL, Bruce Franklin Silver, Silver & Silver, PA, Boca Raton, FL, for Plaintiff–Appellant.

Philip E. Rothschild, Holland & Knight, LLP, Fort Lauderdale, FL, Judith R. Nemsick, Holland & Knight, LLP, New York, NY, for Defendants–Appellees.

Before TJOFLAT, JULIE CARNES, and MELLOY, Circuit Judges.

TJOFLAT, Circuit Judge: The Airline Deregulation Act ("ADA") provides that "a State, political subdivision of a State, or political authority of at least 2 States may not enact or enforce a law, regulation, or other provision having the force and effect of law related to a price, route, or service of an air carrier." 49 U.S.C. § 41713(b)(1). This language expresses a broad preemptive intent that encompasses state enforcement actions "having a connection with or reference to airline ‘rates, routes, or services.’ " Morales v. Trans World Airlines, Inc. , 504 U.S. 374, 384, 112 S.Ct. 2031, 2037, 119 L.Ed.2d 157 (1992). Whenever a state law has "the forbidden significant effect" on the prices of an air carrier, the ADA preempts that law. Id. at 388, 112 S.Ct. at 2039 ; see also Branche v. Airtran Airways, Inc. , 342 F.3d 1248, 1255 (11th Cir. 2003).

This case concerns whether the ADA preempts a cause of action against an air ambulance provider based on a provision of the Florida Motor Vehicle No–Fault Law, Florida Statutes §§ 627.730 – 627.7405. The provision is part of the No–Fault Law's requirement that automobile insurance policies provide personal injury protection ("PIP") for persons injured in automobile accidents. This protection extends to "medically necessary" services, including emergency transport, "to a limit of $10,000." Fla. Stat. § 627.736(1)(a).

The PIP statute, Florida Statutes § 627.736, permits an insured to choose one of two methods for calculating the reimbursement of medical claims under his automobile insurance policy. See Allstate Ins. Co. v. Orthopedic Specialists , 212 So.3d 973, 976 (Fla. 2017). The first method requires the auto insurer to reimburse "[e]ighty percent of all reasonable expenses for medically necessary ... services." Fla. Stat. § 627.736(1)(a). To determine a reasonable amount, any "relevant" information may be considered. Id. § 627.736(5)(a). Under this first method, a medical provider can bill the insured for the reasonable fee that remains after his auto insurance has paid its portion.

The second method permits an insured and insurer to "limit reimbursement to 80 percent" of a schedule of charges that mostly tracks Medicare rates. Id. § 627.736(5)(a) 1. For example, an insurer may limit reimbursement for "emergency transport and treatment" to "200 percent of Medicare." Id. § 627.736(5)(a) 1.a. But once the parties have opted to limit payment under the schedule, a provision, which we shall call the "balance billing provision," prohibits the medical provider from billing or attempting to bill the insured for "any amount in excess of such limits, except for amounts that are not covered by the insured's personal injury protection coverage due to the coinsurance amount or maximum policy limits." Id. § 627.736(5)(a) 4. Under this second method, a medical provider may bill the insured only for the scheduled fee, regardless of the reasonableness of that fee.

In this case, an air ambulance provider, which was registered as an air carrier under federal law, transported a child injured in an automobile accident to a hospital by helicopter. The PIP coverage of the automobile owner's insurance policy covered the transportation. Seeking reimbursement for the transportation, the air ambulance provider submitted a reasonable bill for medical services to the owner's auto insurer. The owner's insurance policy limited reimbursement of the services under the fee schedule of the second method. The auto insurer therefore paid the bill pursuant to the fee schedule, which called for a payment that was less than the reasonable amount the provider charged for its services. The provider then charged the insured for the unpaid portion of its reasonable bill.

In an effort to avoid paying the balance of the bill, the insured brought a class action against the air ambulance provider seeking a declaration that the balance billing provision limited its reimbursement to the amount fixed in the fee schedule. In response, the provider moved to dismiss the action on the ground that the ADA preempted the enforcement of the balance billing provision. The insured contended in turn that the McCarran–Ferguson Act ("MFA")—which provides that federal laws cannot preempt "any law enacted by any State for the purpose of regulating the business of insurance"—precluded the ADA's preemption of his action. 15 U.S.C. § 1012(b).

The District Court agreed with the air ambulance provider and held that the ADA preempted the insured's action because it related to the prices of the air carrier. The MFA, it determined, prevents only inadvertent intrusion from federal legislation, not express preemption such as that of the ADA.

The insured appeals the District Court's decision. Because his action seeks to restrict the prices of an air carrier, we hold that the ADA preempts it. The MFA does not interfere with this preemption because the balance billing provision, on which the action rests, has nothing to do with the relationship between an insurer and an insured and therefore does not regulate the business of insurance. We therefore affirm the District Court's decision.

I.

On March 17, 2013, Lemar Bailey—the young son of the owner of the automobile insurance policy, Lenworth Bailey—suffered life-threatening injuries in an automobile accident that occurred while Deon Hyde, his stepmother, was driving. Because he required immediate medical attention, Air Methods Corporation ("AMC") was called upon to transport him thirty-seven miles by air ambulance from the scene of the accident to a hospital in West Palm Beach, Florida. In all, AMC operated the air ambulance between 2:30 PM and 4:04 PM, a total of one hour and thirty-four minutes. Lemar Bailey died at the hospital soon after arrival.

In exchange for its services, AMC presented a bill of $27,975.90. AMC first submitted this bill to State Farm Mutual Automobile Insurance Company, Bailey's automobile insurance provider. Pursuant to the fee schedule, State Farm paid $6,911.54 of the bill. AMC billed the balance of $21,064.36 to Bailey as Lemar's father. Bailey submitted this bill to Aetna Life Insurance Company, his health insurer. Aetna paid $3,681.60 of the claim. Thus, from State Farm and Aetna, AMC received $10,593.14. Bailey did not pay the remaining balance of $17,382.76.

Bailey brought this action in the Circuit Court of Broward County, Florida, on behalf of himself and a class of individuals who received air ambulance services from AMC, alleging that AMC was attempting "to collect amounts from persons transported by air ambulance that [it was] statutorily prohibited from collecting." In his complaint, Bailey alleges that the balance billing provision forbids a medical provider from charging a PIP insured in excess of the fee schedule, when the automobile insurance agreement limited coverage to the schedule.

Bailey used two Florida statutes as vehicles for asserting his argument that the balance billing provision limits the amount AMC could charge for its services. Counts II and III allege that AMC's attempt to collect the balance of the bill violated the Florida Deceptive and Unfair Trade Practices Act ("FDUTPA"), Florida Statutes § 501.204. Count IV alleges that AMC violated the Florida Consumer Collections Practices Act ("FCCPA"), Florida Statutes § 559.72(9), by seeking to collect an amount in excess of the fee schedule. The balance billing provision is the gravamen of each count. If the ADA preempts the balance billing provision, the counts fail.

AMC removed the case to the United States District Court for the Southern District of Florida under the Class Action Fairness Act, 28 U.S.C. § 1332(d)(2). Soon after removal, AMC moved to dismiss the complaint for failure to state a claim on two theories. First, AMC argued that the balance billing provision does not preclude medical providers from billing PIP-insured patients for medical expenditures that are reasonably necessary under the circumstances and from collecting from the patients the portion of the bill that remains unpaid. Second, AMC argued that the ADA preempts Bailey's action because it related to the prices of an air carrier. 49 U.S.C. § 41713(b)(1). Bailey, in response, contended that the MFA prevents preemption of his action because the PIP statute "regulate[s] the business of insurance." 15 U.S.C. § 1012(b).

The District Court denied AMC's motion to dismiss without explanation. AMC then answered Bailey's complaint, raising as an affirmative defense the same preemption theory it asserted in its motion to dismiss, and moved the District Court for summary judgment. Following limited discovery, Bailey moved the District Court for class certification. The District Court denied his motion. Shortly thereafter, the District Court granted summary judgment for AMC, holding that the ADA preempted Bailey's action, and entered judgment against Bailey.

Bailey appeals the dismissal of his action. He argues that the ADA does not preempt his action because the "PIP statute does not regulate the amount that Providers can charge for aeromedical transportation." In the alternative, Bailey contends that the MFA prevents the ADA from preempting his action because the PIP statute regulates the "business of insurance." 15 U.S.C. § 1012(b).

II.

We start with the question whether the ADA preempts Bailey's action because it challenges the rates of AMC, an air carrier. We review preemption determinations de novo . Ervast v. Flexible Prods. Co. , 346 F.3d 1007, 1012 (11th Cir. 2003). To begin our discussion, we trace the history of federal legislation relating to air carriers and then, drawing on Supreme Court precedent, show that Bailey's action falls squarely within the preemptive intent behind the ADA.

A.

In 1926, Congress enacted the Air Commerce Act ("ACA"), Pub. L. No. 69-254, 44 Stat. 568 (1926), as the first comprehensive legislation on aviation. The ACA tasked the Secretary of Commerce with developing, researching, and regulating the fledging industry of commercial aviation. See § 2, 44 Stat. at 569. Congress, through the ACA, directed the Secretary of Commerce to set the basic rules for commercial aviation. The Secretary did not, however, have the power to regulate the rates of air carriers. Thus, in the early days of aviation, the marketplace, not the federal government, determined air carrier prices.

Congress changed course in 1938. In that year, Congress enacted the Civil Aeronautics Act ("CAA"), Pub. L. No. 75-706, 52 Stat. 973, 980 (1938). Among other objectives, Congress intended the CAA to promote "adequate, economical, and efficient service by air carriers at reasonable charges." § 2(c), 52 Stat. at 980. To this end, the CAA required air carriers to "establish, observe, and enforce just and reasonable individual and joint rates, fares, and charges." § 404(a), 52 Stat. at 993. To enforce this and other provisions, the CAA created the Civil Aeronautics Authority, later reconstituted as the Civil Aeronautics Board ("CAB"). The CAB was authorized to investigate, upon complaint or its own initiative, whether "any individual or joint rate, fare, or charge ..., or any classification, rule, regulation, or practice affecting such rate, fare, or charge, ... is or will be unjust or unreasonable." § 1002(a)–(b), (d), (g), 52 Stat. at 1018–19; see also Lichten v. E. Airlines , 189 F.2d 939, 940–41 (2d Cir. 1951). After determining a rate or rule to be unjust or unreasonable, the CAB was required to "determine and prescribe the lawful rate, fare, or charge ..., or the lawful classification, rule, regulation, or practice." § 1002(d), 52 Stat. at 1018.

In 1958, after two decades, Congress replaced the CAA with the Federal Aviation Act ("FAA"), Pub. L. No. 85-726, 72 Stat. 731 (1958). In language identical to the CAA, the FAA required air carriers "to establish, observe, and enforce just and reasonable individual and joint rates, fares, and charges." § 404(a), 72 Stat. at 760. Like the CAA, the FAA also empowered the CAB to investigate whether a "rate, fare, or charge ..., or any classification, rule, regulation, or practice affecting such rate, fare, or charge, ... is or will be unjust or unreasonable." § 1002(a)–(d), (g), 72 Stat. at 788–89. Once more, if the CAB determined a rate or rule to be unjust or unreasonable, it was obligated to "determine and prescribe the lawful rate, fare, or charge ..., or the lawful classification, rule, regulation, or practice." § 1002(d), 72 Stat. at 789. The FAA also established factors for the CAB to consider "[i]n exercising and performing its powers and duties with respect to the determination of rates for the carriage of persons or property." § 1002(e), 72 Stat. at 789.

In 1978, Congress eliminated the regulation of air carrier prices through the Airline Deregulation Act, Pub. L. No. 95-504, 92 Stat. 1705 (1978). In doing so, Congress sought 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 to attract capital." 49 U.S.C. § 40101(a)(6) ; see Morales , 504 U.S. at 378–79, 112 S.Ct. at 2034. It set the rate-making provisions of the CAA to sunset on January 1, 1983, leaving air carriers to set prices for themselves after that date. § 1601(a)(2), 92 Stat. at 1744–45; see Am. Airlines, Inc. v. Wolens , 513 U.S. 219, 222–23, 115 S.Ct. 817, 821, 130 L.Ed.2d 715 (1995). Once more, air carriers were free to set prices independent of regulation, as in the days before the CAA.

"To ensure that the States would not undo federal deregulation with regulation of their own," Congress inserted a preemption provision into the ADA. Morales , 504 U.S. at 378, 112 S.Ct. at 2034. It reads as follows.

[A] State, political subdivision of a State, or political authority of at least 2 States may not enact or enforce 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). This language expresses "a broad pre-emptive purpose" and thus reaches any state statute or enforcement action that has "a connection with or reference to airline ‘rates, routes, or services.’ " Morales , 504 U.S. at 383–84, 112 S.Ct. at 2037. The ADA does not, however, preempt a "state-law-based court adjudication," Wolens , 513 U.S. at 232, 115 S.Ct. at 826, concerning a contractual obligation "voluntarily" undertaken by an air carrier, Nw., Inc. v. Ginsberg , 572 U.S. ––––, 134 S.Ct. 1422, 1432, 188 L.Ed.2d 538 (2014). Therefore, an air carrier may bring a state action to enforce the terms of a contract, whether express or implied, or the person with whom an air carrier has contracted may bring a breach-of-contract action against the air carrier—so long as the action concerns voluntary commitments and not state-imposed obligations. Wolens , 513 U.S. at 232–33, 237, 115 S.Ct. at 826, 828.

While the rates of air carriers are currently free from regulation, their practices are not. The Department of Transportation may "investigate and decide whether an air carrier ... has been or is engaged in an unfair or deceptive practice or an unfair method of competition." 49 U.S.C. § 41712(a). These words, "unfair" and "deceptive," were left for "case-by-case definition," Pan Am. World Airways, Inc. v. United States , 371 U.S. 296, 306, 83 S.Ct. 476, 483, 9 L.Ed.2d 325 (1963), but the Supreme Court has held them to encompass "broader concepts" than the common law, Am. Airlines v. North Am. Airlines , 351 U.S. 79, 85, 76 S.Ct. 600, 605, 100 L.Ed. 953 (1956). In enforcing this prohibition on unfair or deceptive practices and unfair competition, the Secretary must "ensur[e] that consumers in all regions of the United States ... have access to affordable, regularly scheduled air service." 49 U.S.C. § 40101(a)(16). After determining a practice to be "unfair or deceptive," the Secretary may order an air carrier to cease and desist from a practice following "notice and an opportunity for a hearing." Id. § 41712(a).

Therefore, while the ADA prevents the states from regulating the prices, routes, and services of air carriers, the Department of Transportation has the power to enjoin practices determined to be unfair or deceptive—words that could encompass a wide range of conduct such as the establishment of rates. Cf. Crawford v. Am. Title Ins. Co. , 518 F.2d 217, 219 (5th Cir. 1975) (stating that "unfair methods of competition" in 15 U.S.C. § 45"has been interpreted to cover a broad spectrum of unauthorized trade practices, including establishment of rates and charges").

B.

This case centers on the contract price for the services AMC rendered to Bailey. On March 17, 2013, AMC provided emergency medical services to Bailey "in the expectation" of a reasonable fee and thus received a contractual right to collect that fee. Yeats v. Moody , 128 Fla. 658, 175 So. 719, 720 (1937) ; see also Nursing Care Servs., Inc. v. Dobos , 380 So.2d 516, 517–18 (Fla. Dist. Ct. App. 1980) (holding that a contract is implied when a person supplies emergency aid to prevent serious bodily harm or pain). Bailey seeks to invoke Florida law, namely, the balance billing provision, to reduce the concededly reasonable fee of AMC.

In the present case, Bailey sued AMC in an effort to alter the contract price by invoking the balance billing provision. In effect, he brought suit to assert an affirmative defense against the action that he anticipated AMC would bring to collect the unpaid portion of its bill. For purposes of analysis and discussion, we take the liberty of reversing the position of the parties. AMC is the plaintiff. Bailey is the defendant. AMC's complaint contains a single count, a claim for the contract price, $27,975.90, less the sums it has received, $10,593.14. Bailey confesses that AMC has a contract right to the reasonable fee and pleads an avoidance defense that purportedly avoids that confession: the balance billing provision limits the amount of the fee. Cf. Haley v. Breeze , 144 U.S. 130, 131, 12 S.Ct. 836, 837, 36 L.Ed. 373 (1892) (describing a confession and avoidance defense). This is the case, Bailey argues, even though AMC did not have notice of the terms of his automobile insurance agreement—specifically the second method of payment—before providing services, and, in any event, could not have denied service because state law mandates that ambulance providers transport individuals in need of immediate medical attention. Examined through this lens, this case squeezes down into the question whether the balance billing provision, which reduces as a matter of law the contract price of medical services rendered to PIP-insured patients, relates to the prices an air carrier can charge for its services. We are without doubt on this front. The balance billing provision, a feature of the second method for calculating PIP reimbursement, has a significant effect on air carrier prices. This effect becomes clear when one examines the consequences of the first and second methods of calculating PIP reimbursement. We illustrate these consequences by walking through each method with an example.

The first method requires an auto insurer to reimburse "[e]ighty percent of all reasonable expenses for medically necessary ... services." Fla. Stat. § 627.736(1)(a). Once auto insurance has paid, a medical provider may bill the insured for the balance of the bill. The insured may submit the bill to a secondary health insurer. If the health insurer does not cover the bill, the medical provider may seek to collect the remainder from the insured. Therefore, when an insurer and insured elect to calculate the coverage of the insurance agreement using the reasonableness standard, a medical provider has a right to reasonable compensation and may charge an insured for the reasonable fee that remains after his automobile insurer has paid pursuant to the policy.

Suppose a medical provider charged an insured $30,000 for air ambulance transportation related to a car accident. Assume this fee was reasonable. The medical provider first submits the bill to the person's auto insurer. The auto insurer pays 80% of $30,000, up to the maximum policy limit of $10,000. Thus, the auto insurer pays $8,000, or 80% of $10,000. Since the auto insurer did not cover the entire balance, the medical provider could balance bill the remaining $22,000 to the insured. The insured could either pay the bill or send it to a health insurer. If not paid, the medical provider could sue the insured to collect its $22,000.

In contrast, the second method restricts the medical provider to the rate set in the fee schedule. Once an auto insurer has limited payment under the fee schedule, a medical provider is prohibited from charging the insured for any amount in excess of the fee schedule, "except for amounts that are not covered by the insured's personal injury protection coverage due to the coinsurance amount or maximum policy limits." Fla. Stat. § 627.736(5)(a) 4. Thus, when an insurer and insured limit the coverage of their insurance agreement under the fee schedule, a medical provider may recover only the fee schedule amount. It does not matter whether the reimbursement prescribed by the fee schedule would be considered reasonable under the circumstances.

To illustrate, suppose once more that a medical provider billed a person $30,000 for air ambulance transportation following an automobile accident—a reasonable fee. The medical provider submitted the bill to the person's auto insurer. The auto insurer limited payment under the fee schedule, which prescribed a price of $20,000, and paid 80% of the $10,000 policy maximum limit: $8,000. The balance billing provision prohibits the medical provider from billing the insured for anything other than the $2,000 coinsurance and the $10,000 of the fee schedule amount that exceeds the maximum policy limit. Therefore, because the insurer and the insured opted to calculate the reimbursement of medical claims with the fee schedule, the medical provider is limited to $20,000 for its services. The insured receives a benefit of $10,000 at the expense of the medical provider.

In conclusion, the first method permits the medical provider to recover a reasonable fee, while the second method restricts the medical provider to the fee schedule amount. Because the fee schedule tracks Medicare, which in most cases stipulates less-than-generous rates for medical services, the second method reduces the compensation of a medical provider. The Florida Legislature has thus authorized an insured to limit the rates of a medical provider—even though the medical provider has neither received notice of nor agreed to the limitation. The insured thus has reduced exposure. He is liable for the scheduled rate instead of the reasonable fee. The medical provider takes the haircut, or, in other words, bears the loss. Given this scheme, a rational insured would always elect the second method over the first.

These examples make clear that the balance billing provision has "the forbidden significant effect" on the prices of an air carrier, here AMC. Morales , 504 U.S. at 384, 112 S.Ct. at 2037. AMC rendered emergency services in the expectation of a reasonable fee in return. Yeats , 175 So. at 720 ; Dobos , 380 So.2d at 517–18. After the rendition of those services, Bailey sought to limit AMC's reimbursement to $8,639.41 for operating an air ambulance for an hour and thirty-four minutes with a trained pilot and medical personnel, an amount $19,336.49 less than the presumably reasonable fee. Bailey thus seeks to reduce the contract price for the services rendered using the balance billing provision of the second method—a provision that the Florida Supreme Court has not yet interpreted.

He attempts to impose a price restriction upon an air carrier to which the air carrier neither agreed nor could "free [itself]." Ginsberg , 572 U.S. at —, 134 S.Ct. at 1432. An emergency provider, such as AMC, oftentimes has no notice of insurance arrangements before rendering service. Even if it did, Florida law prohibits an emergency medical provider from denying service due to a patient's ability to pay. Therefore, the balance billing provision, which prohibits medical providers from charging in excess of the fee schedule amount, operates as a "state-imposed regulation" on air carrier rates. Wolens , 513 U.S. at 222, 115 S.Ct. at 820. The ADA preempts the application of the balance billing provision to air carriers. Because Bailey's claims invoke the balance billing provision as "a means to guide and police" AMC's rates, the ADA preempts his action. Id. at 228, 115 S.Ct. at 823.

* * *

Florida law requires an emergency ambulance provider to transport individuals in need of immediate medical attention. In return for this service, Florida law gives such providers a legal entitlement to a reasonable fee. Through the balance billing provision, Bailey has attempted to reduce the contract price from a reasonable fee to an amount specified in a fee schedule, all because of his privately negotiated arrangements with an automobile insurance company. The ambulance provider has no notice of such arrangements prior to rendering service. It could not deny service even if it did.

In this case, however, the ambulance provider happens to be an air carrier under federal law. The state-imposed restriction on price thus cannot be enforced. Congress left decisions related to prices to air carriers themselves, "and not at all to States." Id. Therefore, Bailey "crash[es] headlong into the shoals of preemption." Turbeville v. Fin. Indus. Reg. Auth. , 874 F.3d 1268, 1276 (11th Cir. 2017).

III.

In an attempt to avoid this result, Bailey argues that the MFA reverses the ADA's preemption because the PIP statute regulates the business of insurance. We disagree. In pertinent part, the MFA provides:

No act of Congress shall be construed to invalidate, impair, or supersede any law enacted by any State for the purpose of regulating the business of insurance ..., unless such Act specifically relates to the business of insurance.

15 U.S.C. § 1012(b). Congress enacted the MFA after the Supreme Court ruled that insurance transactions were subject to federal regulation. SEC v. Nat'l Sec., Inc. , 393 U.S. 453, 458, 89 S.Ct. 564, 567, 21 L.Ed.2d 668 (1969). Through the MFA, Congress intended "to turn back the clock, to assure that the activities of insurance companies in dealing with their policyholders would remain subject to state regulation." Nat'l Sec., Inc. , 393 U.S. at 459, 89 S.Ct. at 568. To achieve this goal, the MFA "reverses the doctrine of preemption in cases involving state insurance laws, such that a state law regulating the business of insurance shall preempt a conflicting federal law unless that federal law specifically relates to the business of insurance." Blackfeet Nat'l Bank v. Nelson , 171 F.3d 1237, 1244 (11th Cir. 1999). The MFA, however, "is to be narrowly construed in the face of valid federal regulatory interests." Cochran v. Paco, Inc. , 606 F.2d 460, 467 (5th Cir. 1979) (quotation omitted).

The MFA prevents a federal statute from preempting state law if "(1) the federal statute at issue does not ‘specifically relate to the business of insurance’; (2) the state statute at issue was ‘enacted for the purpose of regulating the business of insurance’; and (3) application of the federal statute would ‘invalidate, impair, or supersede’ the state statute." Moore v. Liberty Nat'l Life Ins. Co. , 267 F.3d 1209, 1220 (11th Cir. 2001) (alterations omitted) (quoting Humana Inc. v. Forsyth , 525 U.S. 299, 307, 119 S.Ct. 710, 716, 142 L.Ed.2d 753 (1999) ). In this case, our first and only question is whether the balance billing provision regulates a practice within the "business of insurance."

The Supreme Court first addressed the phrase "business of insurance" in SEC v. National Securities, Inc . 393 U.S. at 460, 89 S.Ct. at 568. In that case, the Supreme Court announced that the "core" of the phrase centers on "[t]he relationship between insurer and insured, the type of policy which could be issued, and [that policy's] reliability, interpretation, and enforcement." Id. Relying on such principles, the Supreme Court later devised a three-part test to determine whether a state law regulates a practice that comes within the business of insurance: "first, whether the practice has the effect of transferring or spreading a policyholder's risk; second, whether the practice is an integral part of the policy relationship between the insurer and the insured; and third, whether the practice is limited to entities within the insurance industry." Union Labor Life Ins. Co. v. Pireno , 458 U.S. 119, 129, 102 S.Ct. 3002, 3009, 73 L.Ed.2d 647 (1982) (emphasis omitted). "Each of these criteria works in tandem with the others," and no single criterion "is necessarily determinative in itself." Blackfeet , 171 F.3d at 1246–47 (quotation omitted). Bailey argues that the PIP statute as a whole relates to the business of insurance. But we need not decide that issue. We need only decide whether the balance billing provision relates to the business of insurance. The balance billing provision prevents a medical provider from charging a PIP insured for the balance of a medical bill that exceeds the amount prescribed in the fee schedule. The question is thus whether the billing and pricing practices of a medical provider constitute the business of insurance. They do not.

The balance billing provision restricts how much a medical provider may charge an insured after his auto insurer has paid and left the picture. It affects the billing and pricing practices of medical providers only with respect to insureds. Therefore, the practices affected by the balance billing provision have nothing to do with the "policy relationship between the insurer and insured." Pireno , 458 U.S. at 129, 102 S.Ct. at 3009. In addition, while the balance billing provision may spread the risk of a policyholder, that risk is spread not to insurers but to medical providers. Given these considerations, the balance billing provision cannot be said to regulate the "business of insurance."

Because the balance billing provision concerns the relationship between the insured and medical providers—not the relationship between the insurer and insured—the MFA does not reverse the ADA's preemptive effect in this case. See Pireno , 458 U.S. at 131–32, 102 S.Ct. at 3010 (holding that the use of a peer review committee to help set reasonable fees for chiropractic treatments did not constitute the business of insurance partly because the review committee was "not an integral part of the policy relationship between insurer and insured" and "involve[d] third parties wholly outside the insurance industry–namely, practicing chiropractors"); Grp. Life & Health Ins. Co. v. Royal Drug. Co. , 440 U.S. 205, 216–17, 99 S.Ct. 1067, 1075–76, 59 L.Ed.2d 261 (1979) (holding that "contractual arrangements" between an insurance company and pharmacies did not constitute the business of insurance because they concerned a relationship with third parties and not the relationship "between insurer and insured").

IV.

We accordingly conclude that the ADA preempts Bailey's action and therefore that the District Court did not err in granting summary judgment.

AFFIRMED.