WAILUKU, Maui — A change in state policies makes it so air ambulances no longer are required to transport uninsured patients in need of emergency medical care.

That raises the possibility of patients on the Neighbor Islands being denied transportation to hospitals in Honolulu if they can't afford it, said Dr. David Sakamoto, administrator for the state Health Planning and Development Agency.

"We're concerned about access," Sakamoto said. "We don't want ability to pay to be the determining factor if someone is transferred from a Neighbor Island to an O'ahu facility."

But one air ambulance company said uninsured patients won't lose service.

"It's a red herring," said Greg Kahlstorf, president of Pacific Wings.

He said air ambulance services don't need to worry about losing money from uninsured patients because the companies can recover some of their expenses through Medicaid claims.

The reason for the policy change is an opinion issued last week by Attorney General Mark Bennett, which says the state doesn't have the authority to regulate air travel, even when it involves specialized services.

That power rests solely with the Federal Aviation Administration, according to an advisory sent from the U.S. government to the state.

"As I understand it, where there is regulation of air traffic, the federal government pre-empts the state from asserting control over air traffic," said Dr. Linda Rosen, deputy director for health resources with the state. "Federal law trumps state law as far as air services are concerned."

Previously, air ambulances were allowed to operate only if they had received a certificate of need from the state. A certificate of need requires the business to provide access to everyone and demonstrate a need for the service.

"I'm told by legal counsel that they don't see a way where we could reinstate certificates of need for the air ambulance situation," Sakamoto said. "We're going to be watching."

Two companies, Hawaii Air Ambulance and AirMed Hawai'i, are providing medical airlift services under state-issued certificates. Five other providers, including Pacific Wings, have shown an interest in entering the air ambulance market.

"If we find a refusal to move a patient based on insurance, we would certainly take a hard look at it," Rosen said.