HHS Provider Relief Tranche 2 Calculator

Use the American Ambulance Association’s simple form to estimate relief you may receive from the second tranche of HHS COVID-19 funding. Please note that not all providers will receive funds.

More information about this program as well as access to the form you must complete in the General Allocation Portal can be found on the HHS website.

For-profit and non-profit non-governmental providers,  to determine your Net Patient Revenue for the portal, use the following information from your most recently filed tax return. (2019 if filed, otherwise use 2018 numbers).

Governmental providers,  enter your revenue generated for the last audited financial year. When completing the form in the portal,  select Tax Exempt Organization. When asked to upload a return at the end, upload your most recent audited financials.

Please do not enter commas or dollar signs. A negative number or zero in the Tranche 2 box indicates that you WILL NOT receive funding in tranche  2.

CMS Reevaluates Accelerated Payments, Suspends Advances

From the CMS Newsroom

April 26, 2020

 CMS Reevaluates Accelerated Payment Program and Suspends Advance Payment Program

Today, the Centers for Medicare & Medicaid Services (CMS) announced that it is reevaluating the amounts that will be paid under its Accelerated Payment Program and suspending its Advance Payment Program to Part B suppliers effective immediately. The agency made this announcement following the successful payment of over $100 billion to healthcare providers and suppliers through these programs and in light of the $175 billion recently appropriated for healthcare provider relief payments.

CMS had expanded these temporary loan programs to ensure providers and suppliers had the resources needed to combat the beginning stages of the 2019 Novel Coronavirus (COVID-19). Funding will continue to be available to hospitals and other healthcare providers on the front lines of the coronavirus response primarily from the  Provider Relief Fund. The Accelerated and Advance Payment (AAP) Programs are typically used to give providers emergency funding and address cash flow issues for providers and suppliers when there is disruption in claims submission or claims processing, including during a public health emergency or Presidentially-declared disaster.

Since expanding the AAP programs on March 28, 2020, CMS approved over 21,000 applications totaling $59.6 billion in payments to Part A providers, which includes hospitals. For Part B suppliers, including doctors, non-physician practitioners and durable medical equipment suppliers, CMS approved almost 24,000 applications advancing $40.4 billion in payments. The AAP programs are not a grant, and providers and suppliers are typically required to pay back the funding within one year, or less, depending on provider or supplier type. Beginning today, CMS will not be accepting any new applications for the Advance Payment Program, and CMS will be reevaluating all pending and new applications for Accelerated Payments in light of historical direct payments made available through the Department of Health & Human Services’ (HHS) Provider Relief Fund.

Significant additional funding will continue to be available to hospitals and other healthcare providers through other programs. Congress appropriated $100 billion in the Coronavirus Aid, Relief, and Economic Security (CARES) Act (PL 116-136) and $75 billion through the Paycheck Protection Program and Health Care Enhancement Act (PL 116-139) for healthcare providers. HHS is distributing this money through the Provider Relief Fund, and these payments do not need to be repaid.

The CARES Act Provider Relief Fund is being administered through HHS and has already released $30 billion to providers, and is in the process of releasing an additional $20 billion, with more funding anticipated to be released soon. This funding will be used to support healthcare-related expenses or lost revenue attributable to the COVID-19 pandemic and to ensure uninsured Americans can get treatment for COVID-19.

For more information on the CARES Act Provider Relief Fund and how to apply, visit hhs.gov/providerrelief

For an updated fact sheet on the Accelerated and Advance Payment Programs, visit: https://www.cms.gov/files/document/Accelerated-and-Advanced-Payments-Fact-Sheet.pdf


Get CMS news at cms.gov/newsroom, sign up for CMS news via email and follow CMS on Twitter CMS Administrator @SeemaCMS@CMSgov, and @CMSgovPress.

HHS Announces Plans for Distribution of Remaining CARES Act Provider Relief Funding

HHS Announces Plans for Distribution of Remaining CARES Act Provider Relief Funding
By Brian S. Werfel, Esq.

March 27, 2020, President Trump signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act).  As part of that Act, Congress allocated $100 billion to the creation of a “CARES Act Provider Relief Fund,” which will be used to support hospitals and other healthcare providers on the front lines of the nation’s coronavirus response.  These funds will be used to fund healthcare-related expenses or to offset lost revenue attributable to COVID-10.  These funds will also be used to ensure that uninsured Americans have access to testing a treatment for COVID-19.  Collectively, this funding is referred to as the “CARES Act Provider Relief Fund.”

The Department of Health and Human Services (HHS) began the disbursement of the first $30 billion tranche of the CARES Act Provider Relief Funding on April 10, 2020, with full disbursement of this tranche being completed by April 17, 2020.  The American Ambulance Association has issued a Frequently Asked Question that provides additional details on how the payments under this first tranche were calculated, as well as the terms and conditions that are applicable to this disbursement.

On April 22, 2020, HHS announced its plans for the disbursement of the remaining $70 billion in CARES Act Provider Relief Funding.  These monies will be distributed using four broad categories:

  1. General Allocation. HHS indicated that it will be supplementing the initial $30 billion tranche with an additional $20 billion.  Ultimately, HHS’ intent is to distribute this $50 billion to all eligible healthcare providers and suppliers (including ambulance providers and suppliers) based on the provider’s or supplier’s 2018 net patient revenue.  “Net patient revenue” is a term of art in the Medicare world, and is used to describe all patient revenues (from whatever source) minus: (i) provision for bad debts, (ii) contractual adjustments, (iii) charity discounts, (iv) teaching allowances, (v) policy discounts, (vi) administrative adjustments, and (vii) other deductions from revenue.  HHS indicated that it would calculate every provider’s and supplier’s proportionate share of the entire $50 billion would be using their 2018 net patient revenue.  HHS would then subtract the amounts that the provider or supplier received during the first tranche, and pay the unpaid balance over the next few weeks.  For institutional providers that have already submitted 2018 cost reports, these payments will go out on April 24, 2020.  Providers or suppliers that do not have adequate cost report data on file will need to submit their revenue information using an online portal that will become available this week, with payments to follow on a rolling basis once a provider’s or supplier’s information has been validated.  As with the first tranche, recipients of relief funding will be required to sign an attestation confirming receipt of the funds, and agreeing to the terms and conditions, including the restrictions on surprise medical billing.
  2. Targeted Allocations. HHS indicated that it would be setting aside an additional $20.4 billion for certain targeted segments of the health care industry.  This includes: (i) $10 billion being allocated to hospitals in areas that have been particularly hard-hit by the COVID-19 outbreak, (ii) $10 billion for rural health clinics and hospitals, and (iii) $400 for the Indian Health Service.
  3. Reimbursement for Uninsured Patients. HHS indicated that it will allocate an undisclosed portion of the remaining $29.6 billion to reimburse healthcare providers and suppliers for COVID-related treatment of the uninsured.  This allocation is available for the reimbursement of emergency and non-emergency ground ambulance transportation furnished to uninsured COVID-19 patients; however, air and water ambulance providers are not eligible to participate.  Reimbursement will be available for COVID-related care furnished with dates of service on or after February 4, 2020.  Payments will be made at the Medicare rates, subject to available funding.  To be eligible for reimbursement for care furnished to uninsured COVID-19 patients, ambulance providers and suppliers will need to enroll as a provider participant, which can be done starting on April 27, 2020.  Claims will be accepted starting in early May 2020.  As a condition to receiving reimbursement for the care of uninsured COVID-19 patients, you will be required to accept HHS’ payment as payment-in-full, i.e., you will not be permitted to balance bill the patient.  Additional information on HHS’ reimbursement for uninsured COVID-19 patients can be found at: http://www.coviduninsuredclaim.hrsa.gov.
  4. Reimbursement for Certain Medicaid-Only Providers. HHS indicated that it will allocate an undisclosed portion of the remaining $29.6 billion to reimburse skilled nursing facilities, dentist, and provides that only participate in State Medicaid Programs.

Upcoming Important Dates

 To participate in these future funding tranches, AAA Members will need to keep the following dates in mind:

  1. On or after April 23/24 – You will need to access the online portal to submit your revenue information in order to receive the second tranche of the $50 billion general allocation of provider relief funds.
  2. April 27, 2020 – You will need to register for the COVID-19 Uninsured Reimbursement Allocation. Once open, the online portal can be accessed from the following webpage: http://www.coviduninsuredclaim.hrsa.gov.
  3. Early May 2020 – You will be able to start submitting claims to the COVID-19 Uninsured Reimbursement Allocation.


NREMT Statement to National Governors Association

COVID-19 Impact on Essential Critical Infrastructure Workers and Requested URGENT Action of Governors to Ensure Continuity of the Supply of Certified Emergency Medical Services Professionals (EMTs & Paramedics) and other Essential Critical Infrastructure Workers.

Statement by the National Registry of Emergency Medical Technicians. Download PDF

Problem: The national COVID-19 pandemic containment efforts inadvertently impact a vital component of the licensure pathway for Essential Critical Infrastructure Workers like emergency medical services (EMS) responders (EMTs and paramedics) and many other health professions. Without immediate intervention, thousands of professionals – prepared and scheduled to take their final certification exams – could be prohibited from responding to the national public health crisis.

Facts bearing on the problem:
• Essential Critical Infrastructure Workers like EMTs, Paramedics, and other health professionals – in the interest of public safety – are required to take certification or licensure examinations prior to state licensure. For over 70 health professions, these examinations are administered by Pearson VUE in either a Pearson VUE owned facility (PPC) or its network of independent third-party test centers (PVTCs).
• During the week of March 9th, most colleges and universities in the United States closed; consequently, this closed many PVTCs co-located on these campuses where many EMT and Paramedic candidates take their national certification examinations.
• On Tuesday, March 17, 2020, in response to the national guidance calling for social distancing, Pearson VUE closed their facilities in the United States, including its PPCs, thus significantly diminishing the licensing pathway for Essential Critical Infrastructure Workers.
• Based on the nation-wide closure of Pearson VUE and college and university test centers,
12,000+ EMT and Paramedic candidates are currently unable to test or have a significantly diminished ability to test, plus an additional 60,000+ EMTs and Paramedic candidates will be unable to test between now and June 30.
• Essential Critical Infrastructure Workers like healthcare professionals, including EMTs and Paramedics, are required to obtain necessary education, clinical experience, and successfully complete certification examinations prior to being eligible for state licensure. State licensing and regulatory agencies for EMS professionals, represented by NASEMSO, are dependent on the national boards/certifications to assess competence (protection of the public) for licensure. Similar licensing and regulatory agencies exist for various others Essential Critical Infrastructure Workers.
• EMTs and Paramedics, as well as other public safety and healthcare personnel (i.e., Nurses) are defined as “Essential Critical Infrastructure Workers” in the “Guidance on the Essential Critical Infrastructure Workforce: Ensuring Community and National Resilience in COVID-19 Response” (03/19/2020; under theauthority of Presidential Directive 7)
• The COVID-19 pandemic is already straining the nation’s healthcare system. Over 1,400 EMS professionals are currently quarantined, and we anticipate these numbers to quickly rise.
• Pearson VUE and college and universities can implement measures and recommended guidelines at PPCs and PVTCs during the COVID -19 emergency including appropriate social distancing, hygiene, and disinfection. However, the closing of many colleges and universities, as well as closing of commercial businesses resulted in reduction of Essential Critical Infrastructure Workers. The services provided by Pearson VUE are essential in allowing Essential Critical Infrastructure Workers to enter the workforce and provide the necessary services which are vital during the pandemic.

• We ask that the Governors promptly designate the services provided by Pearson VUE in conjunction with the licensing and certification of Essential Critical Infrastructure Workers as “Essential Services” and/or “Life-Sustaining Services” according to the applicable state definitions and to open colleges and universities that operate test centers which have historically administered EMT and Paramedic certification examinations. Once the Governors designate Pearson VUE’s services as Essential and/or Life-Sustaining Services, and authorize the opening of the colleges and universities that operate test centers that deliver exams on behalf of Pearson VUE, EMT and Paramedic certification examinations, other certification and licensing examinations for “Essential Critical Infrastructure Workers”, as well as those services provided in conjunction with such certification and licensing may be offered by Pearson VUE and its test centers.
• Pearson VUE and its PPCs, owned and operated through Pearson VUE, and its PVTCs need to be viewed as a critical infrastructure as they allow the continuity of certifying and licensing of critical infrastructure workers (EMTs, Paramedics, Nurses, and more). Further, the employees working for Pearson VUE who provide these services in conjunction with certifying and licensing Essential Critical Infrastructure Workers need to be identified as“Essential Critical Infrastructure Workers.”
o “Functioning critical infrastructure is imperative during the response to the COVID-19 emergency for both public health and safety as well as community well-being. Certain critical infrastructure industries have a special responsibility in these times to continue operations.” “Guidance on the Essential Critical Infrastructure Workforce: Ensuring Community and National Resilience in COVID-19 Response” (03/19/2020; under the authority of Presidential Directive 7)

Taking these actions to recognize Pearson VUE and its test centers as critical infrastructures, as well as authorizing the re-opening of Pearson VUE and its test centers so that essential critical infrastructure workers can re-start taking certification examinations will help to preserve the fragile, but critical pipeline of new EMS and other healthcare professionals during this national emergency.

CMS NEWS: Trump Administration Launches New Healthcare Toolkit

Trump Administration Launches New Toolkit to Help States Navigate COVID-19 Pre-Hospital/Emergency Medical Services (EMS) Resources

At President Trump’s direction, the Centers for Medicare & Medicaid Services (CMS) and the Assistant Secretary of Preparedness and Response (ASPR) released a new toolkit to help state and local healthcare decision-makers maximize workforce flexibilities when confronting 2019 Novel Coronavirus (COVID-19) in their communities. This toolkit includes a full suite of available resources to maximize responsiveness based on state and local needs, building on President Trump’s commitment to a COVID-19 response that is locally executed, state-managed, and federally supported. This work was developed by the Healthcare Resilience Task Force as part of the unified government’s response to COVID-19.

This Topic Collection focuses on plans, tools, templates, and other immediately implementable resources to help with COVID-19 preparedness, response, recovery, and mitigation efforts, focusing on pre-hospital and emergency medical services (EMS) settings, including public safety answering points (PSAPs).

Please refer to CDC’s Coronavirus Disease 2019 webpage for the most up-to-date clinical guidance on COVID19 outbreak management.

If you have COVID-19 promising practices, plans, tools, or templates to share with your peers, please visit the ASPR TRACIE Information Exchange COVID-19 Information Sharing Page (registration required) and place your resources under the relevant topic area. Resources specific to pre-hospital and EMS can be placed under the COVID-19 Pre-Hospital/EMS Resources Topic.

View EMS Resources

PEW Stateline | Many Health Providers on Brink of Insolvency

Thank you to PEW Stateline journalist Michael Ollove for taking the time to learn about EMS economics from AAA Payment Reform Chair Asbel Montes and Professional Ambulance Association of Wisconsin President Chris Anderson.

Stay-at-home orders have paused many activities that resulted in emergency calls, such as traffic accidents and shootings, said Chris Anderson, director of operations for Bell Ambulance in Wisconsin. As for non-emergency transportation, many people want to avoid health facilities now if they can, he said.

Asbel Montes, a senior vice president with Acadian Companies, a Louisiana-based firm operating 500 ambulances in Louisiana, Mississippi, Tennessee and Texas, said emergency calls have dropped by 30% and non-emergency calls by 70%.

Read the full article►

FAQs – HHS CARES Act Provider Relief Funding

Frequently Asked Questions (FAQs) related to HHS CARES Act Provider Relief Funding

By Brian S. Werfel, Esq.

In March 27, 2020, President Trump signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act).  As part of that Act, Congress allocated $100 billion to the creation of a “CARES Act Provider Relief Fund,” which will be used to support hospitals and other healthcare providers on the front lines of the nation’s coronavirus response.  These funds will be used to fund healthcare-related expenses or to offset lost revenue attributable to COVID-10.  These funds will also be used to ensure that uninsured Americans have access to testing a treatment for COVID-19.  Collectively, this funding is referred to as the “CARES Act Provider Relief Fund.”

On April 9, 2020, the Department of Health and Human Services (HHS) began the disbursement of the first $30 billion of this provider relief funding.  This disbursement was made to all healthcare providers and suppliers that were enrolled in the Medicare Program, and who received Medicare Fee-for-Service reimbursements during Calendar Year 2019.  For most ambulance providers and suppliers, these relief funds were automatically deposited into their bank accounts.

In this Frequently Asked Question (FAQ), the AAA will address some of the more common questions that have arisen with respect to the Cares Act Provider Relief Funds.

Question #1: My organization received relief funds through an ACH Transfer.  Is there anything our organization needs to do?

Answer #1: Yes.  Within thirty (30) days of receiving the payment, you must sign an attestation confirming your receipt of the provider relief funds.  As part of that attestation, you must also agree to accept certain Terms and Conditions.  The attestation can be signed electronically by clicking here.

Question #2: Am I required to accept these funds?  What happens if I am not willing to accept the Terms and Conditions imposed on the receipt of these funds?

 Answer #2: You are not obligated to accept the provider relief funds.  The purpose of these funds was to provide healthcare providers and suppliers with an immediate cash infusion in order to assist them in paying for COVID-related expenses and/or to offset lost revenues attributable to the COVID-19 pandemic.

If you are not willing to abide by the Terms and Conditions associated with these funds, you must contact HHS within thirty (30) days of receipt of payment, and then return the full amount of the funds to HHS as instructed.  The CARES Act Provider Relief Fund Payment Attestation Portal provides instructions on the steps involved in rejecting the funds.  Please note that your failure to contact HHS within 30 days to arrange for the return of these funds will be deemed to be an acceptance of the Terms and Conditions. 

 Question #3: Our organization has elected to retain the provider relief funds.  Are there any major restrictions on how we can use these funds?

 Answer #3: Yes.  In the Terms and Conditions, HHS has indicated that you must certify that the funds will only be used to prevent, prepare for, and respond to coronavirus.  You are also required to certify that the funding will only be used for health-care related expenses and/or to offset lost revenues that are attributable to coronavirus.

You are specifically required to certify that you will not use the relief funding to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse.

While the language in the Terms and Conditions are somewhat ambiguous, the AAA interprets this to mean that you must certify that your organization’s operations have been impacted, in some way, by the national response to the coronavirus.  The AAA further interprets this language as requiring that, on net, the coronavirus pandemic has had an adverse impact on either your operations (in terms of added costs) or your revenues (in terms of decreased revenues).  At the present time, the AAA believes that most, if not all, of our members that are currently providing services in response to the coronavirus pandemic will meet this standard.

Note: one situation where a provider may not be eligible for provider relief funding would be a situation where the provider ceased operations prior to January 31, 2020.  For example, a provider that ceased operations on December 31, 2019.  Because the ambulance provider was paid for Medicare FFS services furnished in 2019, it may receive provider relief funding.  However, if the organization’s operations ceased prior to the onset of the current state of emergency, it would not be able to meet the requirement that it provided diagnoses, testing, or care for individuals with possible or actual cases of COVID-19.  In this situation, the ambulance provider would likely be obligated to reject the provider relief funding.

 Question #4: Are there any other restrictions on our use of provider relief funding?

 Answer #4: Yes.  In addition to the restrictions discussed in Answer #3 above, you are also restricted from using the provider relief funding for any of the following purposes:

  1. The provider relief funds may not be used to pay the salary of an individual at a rate in excess of Executive Level II (approximately $189,600);
  2. The provider relief funds may not be used, in whole or in part, to advocate or promote gun control;
  3. The provider relief funds may not be used, in whole or in part, for lobbying activities;
  4. The provider relief funds may not be used to fund abortions (subject to certain exceptions);
  5. The provider relief funds may not be used for embryo research;
  6. The provider relief funds may not be used for the promotion of the legalization of controlled substances;
  7. The provider relief funds may not be used to maintain or establish a computer network, unless such network blocks the viewing, downloading, and exchanging of pornography;
  8. The provider relief funds may not be provided to the Association of Community Organizations for Reform Now (ACORN), or any of its affiliates, subsidiaries, allied organizations, or successors;
  9. The provider relief funds may not be used to purchase sterile needles or syringes for hypodermic injections of illegal drugs.

Question #5: How will HHS verify that the provider relief funding is being used for an appropriate purpose?

 Answer #5: HHS will require all recipients of provider relief funding to submit reports “as the Secretary determines are needed to ensure compliance with the conditions imposed.”  HHS indicated that it will provide future program instructions to recipients that specifies the form and content of these reports.  Recipients will also be required to maintain appropriate records and cost documentation to substantiate how provider relief funds were spent, and to provide copies of such records to HHS upon request.

In addition, ambulance providers and suppliers that receive, in the aggregate, more than $150,000 in funds under the CARES Act, the Coronavirus Preparedness and Response Supplemental Appropriations Act, the Families First Coronavirus Response Act, and any other legislation that makes appropriations for coronavirus response and related activities will be required to submit a report within 10 days of the end of each calendar quarter.  These reports must specify: (1) the total amount of funds received from HHS under each of these pieces of legislation, (2) the amount of funds received that was spent or obligated to be spend, and (3) a detailed list of all projects or activities for which large covered funds were expended or obligated.

Question #6: We understand that one of the conditions associated with the provider relief funding is that we agree not to balance bill patients.  Is our understanding correct?

 Answer #6:  The Terms and Conditions do contain provisions that would likely place restrictions on your ability to balance-bill patients.

In order to understand these restrictions, it is probably helpful to understand the underlying purpose of the restriction.  The actual language from the Terms and Conditions reads as follows:

The Secretary has concluded that the COVID-19 public health emergency has caused many healthcare providers to have capacity constraints. As a result, patients that would ordinarily be able to choose to receive all care from in-network healthcare providers may no longer be able to receive such care in-network. Accordingly, for all care for a presumptive or actual case of COVID-19, Recipient certifies that it will not seek to collect from the patient out-of-pocket expenses in an amount greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network Recipient.”

 As the language makes clear, HHS was not focused primarily on the practice of balance-billing.  Rather, HHS’ concern was that many healthcare providers would have capacity restraints.  As a result, patients may be restricted in their ability to receive care from their normal providers (who are presumably in-network with the patient’s insurer).   HHS’ intent was to ensure that the patient does not suffer any adverse financial consequences as a result of seeking care for presumptive or actual cases of COVID-19.  It accomplishes this goal by requiring the recipient of provider relief funds to agree not to collect from the patient out-of-pocket expenses that are greater than what the patient would have incurred has the care been provided by an in-network provider.

This is being interpreted as a ban on “balance-billing” because most commercial insurers require their contracted providers to accept the plan’s allowed amount as payment-in-full, i.e., to agree to only bill the patient for applicable copayments and deductibles.

Ambulance providers and suppliers should keep in mind that this will not impact the payment of claims from: (1) Medicare, Medicaid or other state and federal health care programs that already require you to accept the program’s allowed amount as payment-in-full, (2) commercial insurers with which the organization currently contracts, and (3) the uninsured.  In other words, this requirement only impacts payments from commercial insurers with which the organization currently does not contract.

At this point in time, it is expected that non-contracted commercial insurers will process your claim and make a determination as to whether the claim is related to the treatment and care of a presumptive or actual case of COVID-19.  If the plan determines that the services you furnished were COVID-related, they will likely pay you the in-network rate they have established with contracted providers in your services area.  The plan will likely then issue a remittance notice that indicates that you may not bill the patient for any balance over the insurer’s payment.  Note: many of the larger commercial insurers have indicated that they will waive the copayments and deductibles due from patients for COVID-related claims.  If the plan waives the copayment and deductibles, they will pay these amounts to you as part of their payment of the claim.  If they do not waive the copayment and deductible, you will be permitted to seek to collect these amounts from the patient.  If the plan determines that the services you furnished were not COVID-related, they will continue to pay your claims using their normal claims processing, and you would be permitted to balance bill the patient to the extent otherwise permitted under state and local law.

There is still a good deal of confusion related to this aspect of the CARES Act Provider Relief Funding.  It is expected that HHS will be issuing further clarification in the days to come.  The AAA will update this FAQ to reflect any updated guidance from HHS.

Supplemental Funding for Emergency Medical Services

COVID-19: Supplemental Funding for Emergency Medical Services

Developed by the Healthcare Resilience Task Force Emergency Medical Services (EMS) Prehospital Team. Download PDF

1. Purpose: This paper outlines two supplemental funding options for Emergency Medical Services (EMS) agencies affected by the COVID-19 pandemic.

2. Scope: This information applies to private non-profit organizations as well as for-profit EMS agencies. This guidance does not apply to government-owned and operated EMS agencies.

3. Overview of Existing Supplemental Funding Opportunities:
a. Stafford Act Emergency and/or Major Disaster Declaration (Stafford Act): Emergency protective measures to save lives and protect public health (including emergency medical care and transport) are eligible for reimbursement under the Federal Emergency Management Agency’s (FEMA) Public Assistance program. State, territorial, tribal, and local government entities and certain private non-profit organizations are eligible to apply for Public Assistance. FEMA assistance will be provided at a 75 percent federal cost-share and may not duplicate assistance provided by the U.S. Department of Health and Human Services or other federal agencies.

b. Coronavirus Aid, Relief, and Economic Security Act (CARES Act): The Paycheck Protection
Program is a loan program administered by the U.S. Small Business Administration (SBA) to incentivize small businesses to keep workers on the payroll. The SBA will forgive loans under this program if certain conditions are met. Private for-profit companies and private non-profit EMS agencies (including tribal ambulance services) are eligible. The maximum amount available to borrow under this program is 2.5 times the average total monthly payroll costs, not to exceed $10 million.

CISA Releases Version 3.0 of the Essential Critical Infrastructure Workers List

Private Sector Update

Created and distributed by the U.S. Department of Homeland Security Private Sector Office private.sector@dhs.gov

April 17, 2020

The Cybersecurity and Infrastructure Security Agency (CISA) has released Version 3.0 of the Essential Critical Infrastructure Workers list. Version 3.0 provides clarity around a range of positions needed to support the critical infrastructure functions laid out in the original guidance and Version 2.0. This iteration includes a reorganization of the section around Healthcare and Public Health and more detail to clarify essential workers; emphasis for Emergency Medical Services workers; and adds lawyers and legal aid workers. Also included is language focused on sustained access and freedom of movement; a reference to the CDC guidance on safety for critical infrastructure workers; and a statement saying sick employees should avoid the workplace and the workforce. In worker categories, all references to “employees” or “contractors” have been changed to “workers.” Other additions include a reference to the USCG Marine Safety Information Bulletin on essential maritime workers; clarified language including vehicle manufacture; and many other small changes to clarify language.

CISA issued initial guidance on Essential Critical Infrastructure Workers on March 19, which was developed to help state, local, tribal, and territorial authorities as they decide who to allow freedom of movement in areas that are under restrictions such as shelter-in-place or quarantine. That initial guidance was developed with input from our government and industry partners, on the assumption that we would need to update the guidance as we received additional feedback from stakeholders.

CISA moved quickly to incorporate feedback to update the list of Essential Critical Infrastructure Workers to expand and specify additional categories of essential workers who are key to maintaining a community’s safety, public health, and economy. These changes were included in Version 2.0 of this guidance, released March 28, generally represented minor clarifications or additions that did not shift the overall scoping of critical infrastructure activity as highlighted in the initial release. Specifically, clarity was provided around a range of supporting and enabling activity for infrastructure resilience – the commodity, services, and logistical supply chains of other infrastructure functions. This included more direct call outs for essential sanitation and hygiene production and services, as well as manufacturing of critical products.

The Guide continues to be a resource for state and local decision makers and is in no way a binding document. Ultimately, all final decisions rest with state and local authorities, who must use their own judgment to balance public health and safety with the need to maintain critical infrastructure.

The degree to which state and local orders have leveraged our guidance when defining essential workers is encouraging. A common national picture will ultimately benefit us all. We hope this updated Guide helps as your communities grapple with the impacts of COVID-19. Please direct any questions to CISA.CAT@cisa.dhs.gov.


911 and Emergency Medical Services (EMS) Algorithms

911 and Emergency Medical Services (EMS) Algorithms

Developed by the Healthcare Resilience Task Force Emergency Medical Services (EMS) Prehospital Team. Download PDF

Attached, please find the latest document released by the Health Systems Resiliency Task Force.  Please use the communication mechanisms at your disposal to share this information with your members, constituents and clients.  All Task Force documents will also be posted on EMS.gov and/or 911.gov (as appropriate).  The NHTSA created these two portals for COVID Resources and will continue to update them three times a week, with new links and documents containing information on a variety of COVID-related topics.  You will find COVID resources here on EMS.gov, and here on 911.gov.

HealthAffairs | Ambulance Balance Billing

HealthAffairs is a  subscription-based publication, so a paid subscription is required to view the full article. The abstract is reproduced below.

Most Patients Undergoing Ground And Air Ambulance Transportation Receive Sizable Out-Of-Network Bills

Karan R. Chhabra, Keegan McGuire, Kyle H. Sheetz, John W. Scott, Ushapoorna Nuliyalu, and Andrew M. Ryan


“Surprise” out-of-network bills have come under close scrutiny, and while ambulance transportation is known to be a large component of the problem, its impact is poorly understood. We measured the prevalence and financial impact of out-of-network billing in ground and air ambulance transportation. For members of a large national insurance plan in 2013–17, 71 percent of all ambulance rides involved potential surprise bills. For both ground and air ambulances, out-of-network charges were substantially greater than in-network prices, resulting in median potential surprise bills of $450 for ground transportation and $21,698 for air transportation. Though out-of-network air ambulance bills were larger, out-of-network ground ambulance bills were more common, with an aggregate impact of $129 million per year. Out-of-network air ambulance bills averaged $91 million per year, rising from $41 million in 2013 to $143 million in 2017. Federal proposals to limit surprise out-of-network billing should incorporate protections for patients undergoing ground or air ambulance transportation.

Paycheck Protection Program Funding Update

The Department of Treasury has announced that the $350 billion appropriated under the CARES Act for the Paycheck Protection Program has been exhausted. However, Congressional leaders are currently negotiating an economic stimulus package to act as a bridge between the CARES Act and the next comprehensive package stimulus package. A core provision of the bridge package is an allocation of an additional $250 billion for the Paycheck Protection Program. If your operation is in the process or plans to apply for a loan under the Paycheck Protection Program, you should move forward with your efforts. The AAA is advocating that the bridge package or next comprehensive package include more funding for ambulance services.

Considerations for State Emergency Medical Service Offices in Response to COVID-19

Considerations for State Emergency Medical Service Offices in Response to COVID-19

Developed by the Healthcare Resilience Task Force Emergency Medical Services (EMS) Prehospital Team. Download PDF

  • Integration of Emergency Medical Services (EMS) into the state emergency management structure
    • Ensure that the state EMS Office, including the state EMS medical director, is represented in, or has direct input into, the state Emergency Operations Center (EOC) and its public health equivalent.
    • Define the chain of command within the EOC to ensure EMS input to leadership.
    • Clarify the roles and responsibilities of EMS medical directors (local/state/regional) to the state emergency management office.
  • Potential need for waiver/suspension of EMS laws and regulations relating to:
    • Public Safety Answering Points (PSAP) operations.
    • Personnel licensure (and re-licensure).
    • Out-of-state reciprocity.
    • Medical oversight.
    • Ambulance staffing.
    • Patient treatment/scope of practice.
    • Patient transport.
    • Training and education.
    • Protocol adherence.
  • EMS licenses and certifications
    • Develop guidance re: temporary extensions of state EMS licenses that are expiring.
    • Develop guidance re: provisional licensing of EMS clinicians in certain circumstances (e.g., licensed out-of-state, completed course requirements but not testing, recently expired license).
    • Identify which EMS certifications (e.g., CPR, PALS, ITLS, PHTLS, ACLS) have been automatically extended by a certification organization.
  • Provide guidance on potential strategies for managing limited EMS resources, including:
    • Caller screening, triage, and prioritized dispatch.
    • Referral or re-direction of calls to non-emergency resources.
    • Utilization of telemedicine resources.
    • Modified staffing and response models.
    • Modified treatment protocols.
    • Alternative transport, no transport, and transport to alternative destinations.
    • Follow-up and leave-behind information, including telemedicine resources, for patients that are not transported.
  • Other COVID-19 guidance, including:
    • Guidance on testing and quarantine or self-isolation of EMS providers.
    • Guidance on limiting physical access to PSAPs and other EMS/public safety buildings.
    • Guidance directing EMS clinicians to resources as needed for mental health and family support.
  • Management of PPE Supply
    • Relay guidance on how to request PPE supplies, including:
      • Direction to continue to submit requests through normal distribution channels.
      • Direction on how to submit unmet requests to local and state emergency management officials for transmittal to FEMA.
    • Relay guidance on the optimization and preservation of existing PPE supplies.
    • Coordinate with state and local emergency management officials on the prioritization of PPE requests from EMS agencies (public, private, and volunteer).
  • Regular communication to EMS agencies and stakeholders.
    • Conduct webinars or conference calls to assure that EMS stakeholders are kept informed.
    • Maintain consistent communication with EMS agencies to monitor the implementation of strategies for managing limited EMS resources.

Public Service Answering Points (PSAPs)/Emergency Communications Centers (ECCs) Call Screening

Public Service Answering Points (PSAPs)/Emergency Communications Centers (ECCs) Call Screening

Document Developed by the Healthcare Resilience Task Force
Emergency Medical Services (EMS) Prehospital Team. Download PDF

This document is intended to provide procedural guidance to Public Safety Answering Points (PSAPs) and Emergency Medical Service (EMS) agencies on practices that could result in improved call screening and EMS care with the potential to decrease unnecessary COVID-19 transports to hospitals. If adopted these could alleviate a significant load on the currently strained healthcare system, and decrease additional infectious disease exposures among the community and healthcare providers. NOTE: protocols would have to be approved by state or local medical oversight

This guidance applies to all PSAP and EMS delivery models including but not limited to; free standing, third-service; fire-based, hospital-based, independent volunteer, private and related emergency medical service providers.

  •  For all requests for emergency care (including interfacility transports) the dispatcher/call taker should ask the following questions:
    • Has the Patient had a positive COVID-19 test?
    • Is the Patient A COVID-19 Person Under Investigation (PUI)? – (PUI is defined as: A patient who has been tested for COVID-19 but has not received their result).
    • Does the patient have Flu-like symptoms (fever, chills, tiredness, cough, muscle aches, headaches, sore throat or runny nose)?
    • The dispatcher/call taker should document any positive findings in their report.
    • NOTE: Recent travel is no longer a recommended question
  •  If the caller answers YES to ANY of the above, this information should be relayed to response agencies and the Modified COVID-19 Response Procedure should be followed
  • If the caller answers NO to ALL of the above – response agencies should follow their normal response procedure
    Modified COVID-19 Response (Caller answered YES to ANY PSAP/Dispatch screening questions)
  •  First Responders/Emergency Medical Responders (non-transport)
    • It is recommended First Responders/Emergency Medical Responders NOT respond to limit potential exposures.
    •  If First responders/Emergency Medical Responders respond, it is recommended that their response is limited to life safety only.
  •  Emergency Medical Services (transport units)
    •  It is recommended that, when possible, only one EMS clinician make contact with the patient using PPE (while N95, eye protection, gown, gloves, and face shield continue to be the recommended standard, during times of limited supplies or limited availability of resupply, eye protection, gloves and surgical mask are acceptable alternatives).
      o If treatment and transport are required, consider having a single EMS clinician, in PPE, approach and treat the patient while isolating other EMS clinicians, family members and bystanders away from the patient.
    • If transporting, it is advised that family members should not accompany the patient. Consideration may be given if the patient is a minor or vulnerable adult. However, the CDC recommends against family members riding in the ambulance. For more information, see the Interim Guidance for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points (PSAPs) for COVID-19.
      o Consider treat-in-place/treat-no-transport guidelines (as approved by state or local medical oversight) for medically stable patients with the CDC identified COVID-19 signs and symptoms:

      •  Fever as defined as 100.4 or greater without fever medications
      • Dry cough
      • Aches
      • Fatigue
  • Examples of PSAP/ECC Resources:

CMS: Medical Necessity & Patient Signature Requirements During COVID-19

CMS Clarifies Medicare Requirements Related to Medical Necessity and the Patient Signature Requirement during Current National State of Emergency

By Brian S. Werfel, Esq.

On April 9, 2020, CMS updated its Frequently Asked Questions (FAQs) for billing Medicare Fee-For-Service Claims during the current national state of emergency.  This document includes guidance for numerous industry types, including ambulance services.  The ambulance-specific questions start on page 11.

Two of the more common questions that A.A.A. members have asked during the current crisis are:

  1. Whether the transportation of a patient known or suspected to be infected with the COVID-19 virus would automatically justify medical necessity for the ambulance? And,
  2. Whether CMS will be waiving the requirement that ambulance providers and suppliers obtain the patient’s signature (or an acceptable alternative signature) to consent to the submission of a claim?

CMS did provide some guidance on both of these issues.

CMS addressed the issue of medical necessity in its answer to Question #9 on page 13.  The question posed to CMS was whether an ambulance provider/supplier could consider any COVID-19 positive patient to meet the medical necessity requirements for an ambulance.  CMS responded as follows:

“Answer: The medical necessity requirements for coverage of ambulance services have not been changed. For both emergency and non-emergency ambulance transportation, Medicare pays for ground (land and water) and air ambulance transport services only if they are furnished to a Medicare beneficiary whose medical condition is such that other forms of transportation are contraindicated. The beneficiary’s condition must require both the ambulance transportation itself and the level of service provided for the billed services to be considered medically necessary.”

Basically, CMS declined to offer a blanket waiver of the medical necessity requirements for COVID-19 patients.  In doing so, CMS seems to be suggesting that COVID-19 status, in and of itself, is not sufficient to establish Medicare coverage for an ambulance transport.

Fortunately, CMS did offer specific relief on the Medicare patient signature requirement.  The question posed to CMS on page 16 (Question #14) was whether an ambulance provider/supplier could sign on the patient’s behalf to the extent the patient was known or suspected to be infected with COVID-19, and, as a result, asking the patient (or an authorized representative) to sign the Tablet would risk contaminating the device for future patients and/or ambulance personnel.  CMS responded as follows:

Answer: Yes, but only under specific, limited circumstances. CMS will accept the signature of the ambulance provider’s or supplier’s transport staff if that beneficiary or an authorized representative gives verbal consent. CMS has determined that there is good cause to accept transport staff signatures under these circumstances. See 42 CFR 424.36(e). CMS recommends that ambulance providers and suppliers follow the Centers for Disease Control’s Interim Guidance for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points (PSAPs) for COVID-19 in the United States, which can be found at the following link: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-for-ems.html. This guidance includes general guidelines for cleaning or maintaining EMS transport vehicles and equipment after transporting a patient with known or suspected COVID-19. However, in cases where it would not be possible or practical (such as a difficult to clean surface) to disinfect the electronic device after being touched by a beneficiary with known or suspected COVID-19, documentation should note the verbal consent.”

Essentially, CMS is indicating that you can accept a patient’s verbal consent to the submission of a claim in lieu of a written signature.  In these instances, CMS is indicating that the crew must clearly document that they have obtained the patient’s (or the authorized representative’s) verbal consent.

Hotline to Check Status of CARES Direct Deposit

If you have not yet received your CARES Act direct deposit as described here, there is now a hotline to check the status.   Please call 866-569-3522 and have your tax ID# and the name of your ambulance service as registered with PECOS. According to HHS, all Medicare providers and suppliers should receive their deposit by April 17.

Thank you to AAA Payment Reform Chair Asbel Montes for sharing this information!

2% Payment Adjustment Suspended (Sequestration)

Medicare FFS Claims: 2% Payment Adjustment Suspended (Sequestration)

Section 3709 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act temporarily suspends the 2% payment adjustment currently applied to all Medicare Fee-For-Service (FFS) claims due to sequestration. The suspension is effective for claims with dates of service from May 1 through December 31, 2020.

NASEMSO 2020 National EMS Assessment Released!

The National Association of State EMS Officials (NASEMSO) has released its 2020 EMS Assessment, updating the 2011 report. This report  provides unparalleled insights into the EMS systems that  provide mobile healthcare across our nation. We highly recommend that you download the full report at  www.nasemso.org/2020-assessment.

(Falls Church, Va.) In the midst of the COVID-19 pandemic and applause for first responders in the United States, the National Association of State Emergency Medical Services Officials (NASEMSO) has released the 2020 National EMS Assessment updating the 2011 assessment. The 2020 assessment provides a comprehensive accounting by state/territory of the numbers and types of all 911 ambulance services and emergency medical services (EMS) professionals.

The 2020 National EMS Assessment is the first set of documentation about these critical emergency medical response personnel and agencies to be published in nearly 20 years. Every year in times of disasters, disease outbreaks and daily medical emergencies, such as heart attacks and car crashes, out-of-hospital emergency medical care systems make life-and-death differences in the lives of millions of Americans. EMS systems are the safety net for hospital emergency departments and public health as the front lines of response to 911 calls. Additionally, responders place themselves in high risk situations on a daily basis, as well as during communicable disease outbreaks and pandemics.

Data collection for this assessment was completed in 2019 by NASEMSO members, who are the staff of the state agencies that license America’s critical EMS personnel and agencies. State EMS offices protect the public by regulating the human and organizational components of EMS systems across the United States, as well as executing their legislative mandates to implement and improve systems of care for time-sensitive emergencies in order to offer every patient an opportunity for survival and optimal outcomes. The assessment provides the following key findings:

  • More than 18,200 local EMS agencies respond to 911 calls for medical emergencies and injuries, utilizing nearly 73,500 ground vehicles such as ambulances and fire engines.

  • Local EMS agencies respond to nearly 28.5 million 911 dispatches every year in 41 states.

  • More than 750 services are licensed by state EMS offices to fly patients, using helicopters and fixed-wing aircraft to provide rapid transportation to critical care.

  • More than 1.03 million personnel are licensed as emergency medical technicians, paramedics, and other levels of EMS patient care capability within all 50 states, the District of Columbia, Puerto Rico and American Samoa.

  • More than 9,300 physicians serve as local EMS Medical Directors, assuring that contemporary and quality care is provided to patients.

  • Sixty percent of 53 state EMS offices participated or expect to participate in mass casualty exercises involving a biological threat during the 18-month evaluation period.

  • The report is available from NASEMSO at www.nasemso.org/2020-assessment.