The Department of Veterans Affairs (VA) has notified Senate Committee on Veterans Affairs Chairman Jon Tester (D-MT) and Ranking Member Jerry Moran (R-KS) that the Department will be delaying implementation of the Final Rule on Special Modes of Transportation until February 16, 2029. The Committee has released a statement on the delay and the VA should be issuing a formal notification of the delay shortly in the Federal Register.
“I appreciate the VA providing the additional time to ensure a process for proper reimbursement of critical ambulance services for veterans and wholeheartedly thank Chairman Tester and Ranking Member Moran for their successful and tireless efforts in advocating for the delay,” stated AAA President Randy Strozyk. “Reimbursing ground ambulance services at Medicare rates would have a devasting impact on our members who are already struggling financially.”
The delay will allow time for a framework like the one outlined in the VA Emergency Transportation Access Act (S. 2757, H.R. 5530) to allow stakeholder input on future rates. “Our members appreciate the efforts of Senators Tester, Moran, Patty Murray, John Boozman and Susan Collins and Representatives Mike Bost and Ryan Zinke and the dozens of other members of Congress who helped push for the delay.”
The Final Rule on Special Modes of Transportation was originally scheduled to take effect on February 16, 2024, but in December 2023 the VA announced a one-year delay with the latest announcement delaying implementation for an additional four years. Under the final rule, the VA would reimburse for ambulance services provided through its beneficiary travel program at the lesser of the actual charges or Medicare rates.
We will provide more details about the delay when the VA issues its formal notice.
A Message from GAPBAC Committee Member Shawn Baird
Please see below for a video message from former American Ambulance Association President Shawn Baird, who participated on the Ground Ambulance Patient and Billing Advisory Committee. A formal analysis of the complete report to Congress is forthcoming.
Video Transcript
Hello, I’m Shawn Baird, past president of the American Ambulance Association.
Together with my fellow ambulance profession representatives Ted Van Horne, Regina Crawford, and Rhonda Holden, I was privileged to speak on behalf of AAA members and the EMS profession as a whole during the deliberations of the Ground Ambulance and Patient Billing Advisory Committee, also known as GAPBAC.
Today, I’m excited to share with you the culmination of our efforts—the release of a report to Congress that could transform how ground ambulance services are reimbursed, ensuring better protection for patients against surprise medical bills as well as fair compensation for the essential mobile healthcare we deliver daily.
We know that the patient care and transport we provide every day, 24/7, is vital to the health and welfare of our communities. In many parts of the country, we are the only healthcare available within hours. I am excited that if Congress acts on these recommendations, patients can not only continue to depend on our vital care, but also be relieved of the financial stress of the unknown bill when insurance falls short of appropriate payment. Quite frankly, if adopted by Congress, these recommendations would take patients out of the middle between providers and insurers, and free us to remain focused on what we do best; taking care of patients, 24/7.
Let me rewind a bit and give you the full context for this report.
GAPBAC was formed following the American Ambulance Association’s successful advocacy efforts to carve ground ambulance services out of the No Surprises Act. Through the dedication of AAA volunteer leaders made possible by your dues investment, we were able to successfully educate legislators about the unique nature of EMS. We effectively highlighted our inability to pick and choose patients, our role as the safety net provider in rural and medically underserved urban areas, as well as our sky-high costs of readiness. Instead of rolling ambulance services into a one-size-fits-all healthcare billing scheme that wouldn’t work for EMS, legislators had the vision and foresight to create the GAPBAC committee.
The group’s charter was signed in November 2021, and the roster was announced in December 2022. We are proud that former American Ambulance Association board member Asbel Montes was selected to take the helm as Chair.
Since then, our committee, composed of patient advocates, physicians, EMS experts, government officials, and insurance industry representatives, has worked collaboratively to address a critical issue—out-of-network billing for ground ambulance patients covered by non-ERISA health plans.
This discussion presented an extraordinary challenge as ambulance services face skyrocketing costs, flat reimbursement from Medicare, and an unprecedented workforce shortage. At the same time, our patients were sometimes confused by the complex health insurance landscape including copays, deductibles, and policy limitations.
But the GAPBAC panel, with the help of experts including AAA’s own Kathy Lester, persevered. Through research, dialogue, and compromise, GAPBAC’s team members developed 14 key recommendations that, if adopted by Congress, would protect patients, financially sustain EMS, enhance transparency, and empower state and local governments to determine fair reimbursement rates for their residents.
While I urge you to read the report to Congress in its entirety, rest assured that the AAA advocacy team will soon share a concise summary with our membership.
As I mentioned, the release of this report has been no small task. The collaboration across various stakeholder groups was unprecedented in EMS history, and every voice brought valuable insights, driving us toward solutions that consider all perspectives on the complex mobile healthcare reimbursement landscape. Together, we’ve laid down a framework that I believe will lead to significant improvements, ensuring that millions more Americans are fully covered during some of the most critical moments of their lives.
As we present our final findings, I hope that the recommendations will be met with thoughtful consideration by Congress and regulators—the well-being of our patients and the integrity of our out-of-hospital healthcare system depend on it. Thank you to American Ambulance Association President Strozyk, the AAA board and committee chairs, and you, the AAA membership, for the overwhelming support through this journey. Together, we will continue to advocate for a sustainable future for EMS!
Shawn Baird
Immediate Past President
American Ambulance Association
It is essential to understand that EMS directly bills patients instead of insurers only as a last resort. Sadly, as a frequent entry point to healthcare, EMS often faces the unenviable task of educating people about their limited insurance coverage or high deductibles, both of which are out of our control. As mobile healthcare is entirely decentralized in the United States, it is often unfeasible for small or volunteer-staffed ambulance services to negotiate sustainable in-network rates with dozens of insurance plans. The GAPB Advisory Committee’s recommendations seek to remedy this foundational disconnect between patients, EMS providers, and health plans.
The article notes that some EMS providers are owned by private equity, but overlooks that the vast majority of ambulance services in the United States are small, often conducting only a few dozen patient transports per day. These community-based services—some of which are the sole healthcare provider for miles—face skyrocketing costs for wages, fuel, and medical supplies that threaten their ability to keep their doors open. The collaborative work of the GAPB Advisory Committee sought to address these challenges by proposing recommendations that, if adopted by Congress, would help alleviate these financial pressures while also enhancing patient protection from surprise insurance denials.
The article implies that Patricia Kelmar was the only representative of the public interest on the panel. In fact, another Committee participant was explicitly appointed to represent patient advocacy groups, and as healthcare providers, EMS professionals and physicians consistently advocate for our patients’ well-being. The committee’s composition, as established by Congress within the No Surprises Act, was intentionally diverse and included stakeholders ranging from physicians to elected officials to insurance providers to ensure balance.
Additionally, it is important to clarify that the Health Affairs research cited in the article does not provide data on actual balance bills received by patients. Rather, it roughly estimates only potential balance bills as calculated based on a flawed estimation process. Even if we were to accept Health Affairs estimates as fact, the average balance bill calculated according to their methods would be just a few hundred dollars. This is far from the sole and extreme outlier bill cited in the piece. This distinction is critical as it underscores the need for data-driven policy decisions based on real-world evidence rather than projections and one-off examples.
Finally, the piece misses entirely the largest challenge with the Committee’s recommendations and their potential adoption by Congress. Based on longstanding legal precedent, ERISA plans, which cover about half of Americans through their employers, would not be bound by any legislation drafted based on our report. In Washington state and elsewhere, innovative “opt-in” clauses enable ERISA plans to voluntarily comply with state regulation. We encourage this and hope to see it replicated throughout the nation.
People become first responders because they have a passion for caring for others, and our communities trust them to do just that—24/7. Our Committee’s report to Congress includes 14 key recommendations designed to improve transparency, ensure fair reimbursement rates, and ultimately protect patients by strengthening state and local control. If these recommendations are adopted, they will help remove patients from the middle of billing disputes, allowing EMS providers to focus on our primary mission: delivering life-saving and life-sustaining healthcare around the clock.
For a detailed understanding of our recommendations and the Committee’s work, I encourage reading the full GAPB Advisory Committee report when it becomes available later this summer.
Shawn Baird Immediate Past President, American Ambulance Association Member, Advisory Committee on Ground Ambulance and Patient Billing Portland, Oregon
Ground Ambulance and Patient Billing (GAPB) Advisory Committee Public Meeting #2 (August 16, 2023)
The Ground Ambulance and Patient Billing (GAPB) Advisory Committee Second Public Meeting was held on August 16, 2023. Materials for this meeting are available for download on the CMS.gov GAPBwebsite.
As we continue this webinar series, we look to you as industry experts to provide feedback and recommend information that would be beneficial in future webinars. Written public comments for consideration by the Advisory Committee may be emailed to: GAPBAdvisoryCommittee@cms.hhs.gov .
Public comments on the specific topics listed in the GAPB Advisory Committee Public Meeting #2 Agenda, should be submitted by September 5, 2023 for consideration by the GAPB Advisory Committee.
On April 25, 2023, the HHS Office of the Inspector General (OIG) posted a notice in the Federal Register that it would be updating its publicly available resources, including its compliance program guidance documents. The OIG’s Compliance Program Guidances (CPGs) were developed as voluntary, non-binding guidance documents that can assist healthcare providers in developing their own internal controls to ensure adherence to federal laws, regulations, and program requirements.
Specifically, the OIG announced that it will no longer publish updated or new CPGs in the Federal Register. Instead, updates or new CPGs will now be made available on the OIG’s website. The OIG will also revise the format for CGS. The new format will consist of: (1) a General CPG (GCPG) that applies to all healthcare providers and (2) industry-specific CPGs (ICPGs) tailored to the fraud and abuse areas specific to that industry. The OIG indicated that it anticipates issuing the GCPG by the end of calendar year 2023, with ICPGs being issued starting in calendar year 2024. The OIG further indicated that it anticipates the first two ICPGs will address Medicare Advantage plans and nursing facilities.
Note: the OIG is not updating its 2003 guidance on compliance programs for ambulance suppliers. The OIG frequently cites this document in enforcement actions it takes against ambulance providers and suppliers. Thus, this guidance document remains relevant to this day. For that reason, A.A.A. members are strongly encouraged to review this document to ensure that their existing compliance program incorporates the elements cited by the OIG.
Previous Compliance Program Guidance for Ambulance Suppliers
In March 2003, the OIG issued its “Compliance Program Guidance for Ambulance Suppliers.” This document sets forth the basic elements that it believes should be included in any effective compliance program, and then discusses various fraud and abuse and compliance risks associated with the provision of ambulance services under the Medicare Program.
The 7 basic elements identified by the OIG are:
The development of compliance policies and procedures
The designation of a compliance officer or compliance committee
The implementation of education and training programs
The use of internal monitoring and reviews
Policies designed to respond appropriately to detected misconduct
Ensuring open lines of communication
The enforcement of disciplinary standards through well-publicized guidelines
The CPG then goes into greater detail on each of these elements, including specific recommendations on how to properly implement each of these elements. For instance, the OIG suggests that the organization’s compliance office be a high-level individual who reports directly to the organization’s CEO or Board of Directors.
With respect to the specific fraud and abuse risks associated with ambulance, the OIG highlighted the issue of medical necessity. The OIG also cited level of service issues (i.e., billing ALS vs. BLS), non-emergency transports, and coordination of benefit issues as particular areas of concern.
On February 16, 2023, the Department of Veterans published in the Federal Register the final rule to revise the payment methodology for beneficiary travel by ambulance and other so-called “special modes of transportation. The changes contained within the final rule were first included in a November 5, 2020 proposed rule.
The final rule will become effective on February 16, 2024.
Relevant Background
The VA currently pays for beneficiary travel under certain circumstances. To be eligible for reimbursement, the veteran must meet certain eligibility criteria. Specifically, the veteran must be traveling either: (i) for care at a VA health facility or (ii) for care at a non-VA facility that has been previously approved by the VA. The veteran must also meet one of the following additional criteria:
The veteran must have a VA disability rating of 30% or higher;
The veteran must be traveling for treatment of a service-related condition (if their VA disability rating is less than 30%);
The veteran receives a VA pension;
The veteran has an income below the maximum annual VA pension rate;
The veteran cannot otherwise afford to pay for their travel; or
The veteran is traveling for one of the following reasons: (i) to obtain a VA compensation and pension exam, (ii) to obtain a VA service dog, or (iii) to obtain VA-approved transplant care.
Beneficiary travel covers all modes of transportation, including transportation by private vehicle, common carriers (e.g., taxi, livery, and public transportation), mass transit, etc. Beneficiary travel also covers so-called “special modes of transportation,” which includes air and ground ambulance services, wheelchair vans services, and stretcher vans services.
The rules governing the payment for beneficiary travel services at set forth in 38 C.F.R. § 70.30.
Subpart (a)(4) sets forth the payment methodology for the reimbursement of special modes of transport, and simply provides that payment is based on “[t]he actual cost of a special mode of transportation. In the context of ambulance services, this has historically been interpreted to mean the ambulance provider’s full billed charges.
Provisions of Final Rule
Under the final rule, the VA would revise its existing payment methodology for beneficiary travel by ambulance and other special modes of transportation to no longer reimburse providers for their actual costs, and to instead base reimbursement on:
For ground and air ambulance services, the lesser of: (i) the actual charge for ambulance transportation (i.e., the provider’s billed charges) or (ii) the amount determined under the Medicare Ambulance Fee Schedule.
For other special modes of transportation (i.e., ambulette, wheelchair van, or stretcher van), the lesserof: (i) the provider’s actual charge, (ii) the applicable Medicaid rate in the state where the provider is domiciled (using the lowest Medicaid rate where the provider is domiciled in multiple states), or (iii) the applicable Medicaid rate in the state where the transport occurred (or the lowest Medicaid rate if the transport occurred in more than one state). Note: the revised regulations provide that if none of the states involved has a “posted rate,” the VA would continue to pay the provider’s full billed charges
The revised payment methodology for non-ambulance special modes of transport is intended to be temporary. In its proposed rule, the VA indicated that it would use this payment methodology for a minimum of 90 calendar days after a final rule was posted in the Federal Register. This period of time was intended to allow the VA to gather payment data. If the VA believes that it gathered sufficient payment data during this initial 90-day period, it indicated that it would develop a new payment methodology “using the lowest possible rate.” If the VA determined that it did not have sufficient payment data after the initial 90-day period, it would extend the proposed payment methodology for additional 90-day periods as needed until it believed it had sufficient data. The VA indicated that it did not anticipate needing more than 18 months from the effective date of the final rule to gather sufficient payment data to implement a new payment method
STATEMENT OF ADMINISTRATION POLICY H.R. 382 – A bill to terminate the public health emergency declared with respect to COVID-19
(Rep. Guthrie, R-KY, and 19 cosponsors)
H.J. Res. 7 – A joint resolution relating to a national emergency declared by the President on March 13, 2020
(Rep. Gosar, R-AZ, and 51 cosponsors)
The COVID-19 national emergency and public health emergency (PHE) were declared by the Trump Administration in 2020. They are currently set to expire on March 1 and April 11, respectively. At present, the Administration’s plan is to extend the emergency declarations to May 11, and then end both emergencies on that date. This wind-down would align with the Administration’s previous commitments to give at least 60 days’ notice prior to termination of the PHE.
To be clear, continuation of these emergency declarations until May 11 does not impose any restriction at all on individual conduct with regard to COVID-19. They do not impose mask mandates or vaccine mandates. They do not restrict school or business operations. They do not require the use of any medicines or tests in response to cases of COVID-19.
However, ending these emergency declarations in the manner contemplated by H.R. 382 and H.J. Res. 7 would have two highly significant impacts on our nation’s health system and government operations.
First, an abrupt end to the emergency declarations would create wide-ranging chaos and uncertainty throughout the health care system — for states, for hospitals and doctors’ offices, and, most importantly, for tens of millions of Americans. During the PHE, the Medicaid program has operated under special rules to provide extra funding to states to ensure that tens of millions of vulnerable Americans kept their Medicaid coverage during a global pandemic. In December, Congress enacted an orderly wind-down of these rules to ensure that patients did not lose access to care unpredictably and that state budgets don’t face a radical cliff. If the PHE were suddenly terminated, it would sow confusion and chaos into this critical wind-down. Due to this uncertainty, tens of millions of Americans could be at risk of abruptly losing their health insurance, and states could be at risk of losing billions of dollars in funding. Additionally, hospitals and nursing homes that have relied on flexibilities enabled by the emergency declarations will be plunged into chaos without adequate time to retrain staff and establish new billing processes, likely leading to disruptions in care and payment delays, and many facilities around the country will experience revenue losses. Finally, millions of patients, including many of our nation’s veterans, who rely on telehealth would suddenly be unable to access critical clinical services and medications. The most acutely impacted would be individuals with behavioral health needs and rural patients.
Second, the end of the public health emergency will end the Title 42 policy at the border. While the Administration has attempted to terminate the Title 42 policy and continues to support an orderly lifting of those restrictions, Title 42 remains in place because of orders issued by the Supreme Court and a district court in Louisiana. Enactment of H.R. 382 would lift Title 42 immediately, and result in a substantial additional inflow of migrants at the Southwest border. The number of migrants crossing the border has been cut in half, approximately, since the Administration put in place a plan in early January to deter irregular migration from Venezuela, Cuba, Nicaragua, and Haiti. The Administration supports an orderly, predictable wind-down of Title 42, with sufficient time to put alternative policies in place. But if H.R. 382 becomes law and the Title 42 restrictions end precipitously, Congress will effectively be requiring the Administration to allow thousands of migrants per day into the country immediately without the necessary policies in place.
The Administration strongly opposes enactment of H.R. 382 and H.J. Res. 7, which would be a grave disservice to the American people.
* * * * * * *
The National Advisory Committee on Seniors and Disasters (NACSD) and the National Advisory Committee on Individuals with Disabilities and Disasters (NACIDD) will soon host public meetings of these two advisory committees.
The next NACIDD meeting takes place on Friday, April 1 from 11:30 a.m. to 2:30 p.m. ET and the next NACSD meeting is on Wednesday, April 6 from 11:00 a.m. to 2:00 p.m. ET.
Join board members, distinguished guests, federal leaders, and other experts to discuss the challenges, opportunities, and priorities in meeting the unique health needs of older adult populations and people with disabilities during and after disasters and public health emergencies.
Advanced registration for these meetings is required and can be accessed, along with additional meeting agendas and public information, through the online event pages for the NACIDD and NACSD.
The agendas for each of the next meetings include time to hear from the public. The floor will be open to hear as many relevant comments as possible. To learn how to request a speaking time, please visit each committee’s event page. You can send questions about the NACSD to NACSD@hhs.gov and questions about the NACIDD to NACIDD@hhs.gov.
The Honorable Xavier Becerra
Secretary of Health and Human Services
Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201
Dear Secretary Becerra:
Ground ambulance service organizations and fire departments continue to struggle financially from the enduring economic effects of the COVID-19 public health emergency (PHE). Our respective members face sharp increases in the costs of fuel, equipment, medical supplies, and staffing as we deal with a severe shortage of paramedics and emergency medical technicians (EMTs) which has been an issue for years but exacerbated by the pandemic. We implore you to help ensure communities around the country have access to 9-1-1 emergency and non-emergency ground ambulance services through the remainder of the PHE and beyond with an infusion of $350 million from returned and/or unspent money in the Provider Relief Fund (PRF).
We greatly appreciate the funding that ground ambulance service organizations and fire departments have already received from the PRF. The funds have been a lifeline for many of our respective members and their ability to continue to serve their communities. However, as the Phase 4 distribution of funds demonstrated, more funding is needed for ground ambulance services. Our members indicate the funds they received in Phase 4 covered approximately 50% of their lost reimbursement and increased costs from July 1, 2020, to March 31, 2021, whereas previous distributions were closer to 88%. We therefore respectfully request an immediate distribution of $350 million or 10% of the annual Medicare expenditure on ground ambulance services.
We request that the funds be distributed in a similar manner as the Tranche 1 distribution from the PRF. The automatic, across-the-board deposit of funding was especially helpful for small and rural ground ambulance service organizations. These rural organizations provide care in underserved areas and are often daunted even by an abbreviated application process. To ensure equity for all communities, we support universal direct deposit.
Additionally, we encourage HHS to make these payments based on the National Provider Identification (NPI) number of the ground ambulance service organization or fire department rather than Tax ID Number (TIN). In the case of moderate and large cities, many municipal departments may share a TIN while maintaining distinct NPIs. Providing these payments according to TIN may unintentionally comingle funds intended for different departments such as fire departments, public health departments, and local government-run hospitals or clinics.
The American Ambulance Association (AAA), International Association of Fire Chiefs (IAFC), International Association of Fire Fighters (IAFF), National Association of Emergency Medical Technicians (NAEMT), and National Volunteer Fire Council (NVFC) represent the providers of vital emergency and non-emergency ground ambulance services and the paramedics, EMTs and firefighters who deliver the direct medical care and transport for every community across the United States.
Our members take on substantial risk every day to treat, transport, and test potential COVID-19 patients, and play a vital role in providing vaccinations to individuals in their homes. Ground ambulance service organizations and fire departments, however, urgently need the additional
$350 million to help offset the increased costs and lower reimbursement resulting from our vital response to the pandemic.
Thank you in advance for your consideration of this request.
Sincerely,
American Ambulance Association
International Association of Fire Chiefs
International Association of Fire Fighters
National Association of Emergency Medical Technicians
“Currently, no federal law protects consumers against “surprise” bills from out-of-network ground ambulance providers. Some state and local governments regulate ground ambulance surprise billing practices; however, such laws may not apply to all health plans or ambulance providers in an area. Because of the substantial policy interest in ground ambulance services, FAIR Health drew on its vast database of private healthcare claims to illuminate multiple aspects of such services across the nation, including utilization, costs, age, gender, diagnoses and differences across states.”
U.S. House of Representatives Hearing on “America’s Mental Health Crisis”
Statement of Shawn Baird, President, American Ambulance Association
February 2, 2022
Chairman Neal, Ranking Member Brady, and members of the Committee, on behalf of the members of the American Ambulance Association (AAA), I greatly appreciate the opportunity to provide you with a written statement on America’s Mental Health Crisis. Simply put, America’s hometown heroes who provide emergency medical services and transitional care need the Congress to recognize the significant stress and trauma paramedics and emergency medical technicians (EMTs) have experienced as a result of this pandemic. The AAA urges members of Congress not to forget these heroes and to expressly include allground ambulance service personnel in efforts to address America’s Mental Health Crisis.
Emergency medical services (EMS) professionals are ready at a moment’s notice to provide life-saving and life-sustaining treatment and medical transportation for conditions ranging from heart attack, stroke, and trauma to childbirth and overdose. These first responders proudly serve their communities with on-demand mobile healthcare around the clock. Ground ambulance service professionals have been at the forefront of our country’s response to the mental health crisis in their local communities. Often, emergency calls related to mental health services are triaged to the local ground ambulance service to address.
While paramedics and EMTs provide important emergency health care services to those individuals suffering from a mental or behavioral health crisis, these front-line workers have been struggling to access the federal assistance they need to address the mental health strain that providing 24-hour care, especially during a COVID-19 pandemic, has placed on them. We need to ensure that there is equal access to mental health funding for all EMS agencies, regardless of their form of corporate ownership so that all first responders can receive the help and support they need.
EMS’s Enhanced Role in the Pandemic
As if traditional ambulance service responsibilities were not enough, paramedics and EMTs have taken on an even greater role on the very front lines of the COVID-19 pandemic. In many areas, EMS professionals lead Coronavirus vaccination, testing, and patient navigation. As part of the federal disaster response subcontract, EMS personnel even deploy to other areas around the country to pandemic hotspots and natural disasters to bolster local healthcare resources in the face of extraordinarily challenging circumstances.
Mental & Behavioral Health Challenges Drive Staffing Shortages on the Front Line
Myriad studies show that first responders face much higher-than-average rates of post- traumatic stress disorder[1], burnout[2], and suicidal ideation[3]. These selfless professionals work in the field every day at great risk to their personal health and safety—and under extreme stress.
Ambulance service agencies and fire departments do not keep bankers’ hours. By their very nature, EMS operations do not close during pandemic lockdowns or during extreme weather emergencies. “Working from home” is not an option for paramedics and EMTs who serve at the intersection of public health and public safety. Many communities face a greater than 25% annual turnover[4] of EMS staff because of these factors. In fact, across the nation EMS agencies face a 20% staffing shortage compounded by near 20% of employees on sick leave from COVID-19. This crisis-level staffing is unsustainable and threatens the public safety net of our cities and towns.
Sadly, to date, too few resources have been allocated to support the mental and behavioral health of our hometown heroes. I write today to ask for Congressional assistance to help the helpers as they face the challenges of 2022 and beyond.
Equity for All Provider Types
Due to the inherently local nature of EMS, each American community chooses the ambulance service provider model that represents the best fit for its specific population, geography, and budget. From for-profit entities to municipally-funded fire departments to volunteer rescue squads, EMS professionals share the same duties and responsibilities regardless of their organizational tax structure. They face the same mental health challenges and should have equal access to available behavioral health programs and services.
Many current federal first responder grant programs and resources exclude the tens of thousands of paramedics and EMTs employed by for-profit entities from access. These individuals respond to the same 911 calls and provide the same interfacility mobile healthcare as their governmental brethren without receiving the same behavioral health support from
Federal agencies. To remedy this and ensure equitable mental healthcare access for all first responders, we recommend that:
During the current public health emergency and for at least two years thereafter, eligibility for first responder training and staffing grant programs administered by the U.S. Department of Health and Human Services (such as SAMHSA Rural EMS Training Grants and HHS Occupational Safety and Health Training Project Grants) should be expanded to include for-profit entities. Spending on training and services for mental health should also be included as eligible program
Congress should authorize the establishment of a new HHS grant program open to public and private nonprofit and for-profit ambulance service providers to fund paramedic and EMT recruitment and training, including employee education and peer-support programming to reduce and prevent suicide, burnout, mental health conditions and substance use
Any initiatives to fund hero pay or death benefits for first responders should be inclusive of all provider models—for-profit, non-profit, and
The rationale for the above requests is twofold. First, ensuring the mental health and wellness of all EMS professionals—regardless of their employer’s tax status—is the right thing to do.
Second, because keeping paramedics and EMTs employed by private ambulance agencies who are on the frontlines of providing vital medical care and vaccinations during this pandemic is the smart thing to do.
Thank you for considering this request to support ALL of our nation’s frontline heroes. They are ready to answer your call for help, 24/7—two years into this devastating pandemic, will Congress answer theirs?
Please do not hesitate to contact American Ambulance Association Senior Vice President of Government Affairs, Tristan North, at tnorth@ambulance.org or 202-486-4888 should you have any questions.
Prevalence of PTSD and common mental disorders amongst ambulance personnel: A systematic review and meta-analysis. Soc Psychiatry Psychiatr 2018;53(9):897-909.
ALmutairi MN, El Mahalli AA. Burnout and Coping Methods among Emergency Medical Services Professionals. J Multidiscip Healthc. 2020;13:271-279. Published 2020 Mar 16. doi:10.2147/JMDH.S244303
Stanley, I. H., Hom, M. A., & Joiner, T. E. (2016). A systematic review of suicidal thoughts and behaviors among police officers, firefighters, EMTs, and Clinical Psychology Review, 44, 25–44. https://doi.org/10.1016/j. cpr.2015.12.002
Doverspike D, Moore S. 2021 Ambulance Industry Employee Turnover Study. 3rd Washington, DC: American Ambulance Association; 2021.
Please see the below notice from FEMA on the extension of the Assistance to Firefighter Grant (AFG) Program:
“FEMA has been working with the General Services Administration to resolve interface issues related to SAM.gov that were affecting some applicants’ ability to begin inputting their federal fiscal year (FY) 2021 Assistance to Firefighters Grant (AFG) Program applications into the FEMA GO System. Specifically, this issue included applicants that received error messages stating their organizations were not found and that their Unique Entity Identifier (UEI)/Electronic Funds Transfer (EFT) combination did not exist despite the applicants’ SAM.gov accounts being fully active.
As this issue is ongoing, the FY 2021 AFG Program application period will remain open until January 21, 2022 5:00 p.m. ET. All applicants will automatically be granted this extension. This ensures that applicants affected by the UEI/EFT issue will have sufficient time to complete the online application. The extension to the application period will not affect the award timeline. In the meantime, FEMA continues to strongly encourage applicants to review the FY 2021 AFG Program Notice of Funding Opportunity and the associated tools posted on the FEMA website here: FY 2021 Assistance to Firefighters Grant (AFG) Application Guidance Materials | FEMA.gov. In preparation for application submission, applicants may also draft their narratives separately and cut and paste them into the appropriate areas of FEMA GO once the SAM.gov interface issue is resolved. The questions that are asked in the narrative section may be found in the FY 2021 AFG Program Narrative Get Ready Guide.
Fire Grants Help Desk: If you have questions about the NOFO or application process, call or email the Fire Grants Help Desk. The toll-free number is 1-866-274-0960; the e-mail address for questions is firegrants@fema.dhs.gov.The Fire Grants Help Desk is open Monday – Friday, 8 a.m. – 4:30 p.m. ET. “
On December 15, 2021, the United States Court of Appeals for the Fifth Circuit issued a ruling which modifies an earlier court national injunction related to the CMS mandatory vaccination rules. In the latest ruling, the court upheld the injunction issued by the United States District Court for the Eastern District of Missouri as it applied to the fourteen (14) plaintiff states, Louisiana, Montana, Arizona, Alabama, Georgia, Idaho, Indiana, Mississippi, Oklahoma, South Carolina, Utah, West Virginia, Kentucky, and Ohio. However, it overturned the lower court’s expansion of that injunction to other, non-plaintiff states, in the injunction. Meaning that between the 5th and 8th Circuit Court rulings, the CMS mandatory vaccination injunction only applies to the following 24 states:
5th Circuit Plaintiffs: Louisiana, Montana, Arizona, Alabama, Georgia, Idaho, Indiana, Mississippi, Oklahoma, South Carolina, Utah, West Virginia, Kentucky, Ohio
8th Circuit Plaintiffs: Missouri, Nebraska, Arkansas, Kansas, Iowa, Wyoming, Alaska, South Dakota, North Dakota and New Hampshire.
States not covered by the CMS mandatory vaccination injunction:
California, Colorado, Connecticut, Delaware, Florida, Hawaii, Illinois, Maine, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New Mexico, New York, North Carolina, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas, Vermont, Virginia, Washington, and Wisconsin
This decision, follows another mandatory vaccine related decision issued by the United States Court of Appeals for the Eleventh Circuit which criticized the Louisiana court for expanding the CMS vaccine mandate nationwide given that a Florida District Court had already refused to issue an injunction and because it felt that it was likely that the mandate was likely authorized under current CMS rules.
What does this mean for employers?
If you are an employer in one of the states not covered by an injunction, you should consult with any covered healthcare facility that your organization performs services under contract. These covered healthcare facilities will be required to mandate vaccination for their staff and for any contractor staff that interacts with their employees or patients. Additionally, they will be seeking proof that your staff is vaccinated against COVID-19, unless they have a protected medical or religious accommodation.
Employers should have already taken the initial steps toward compliance with the CMS mandatory vaccination rules, including having a list of all employees with their vaccination status. Additionally, employers should have an established policy related to mandatory vaccination and a procedure for requesting and processing an exception/accommodation requests. Lastly, healthcare institutions may independently institute mandatory vaccination rules for their employees and can require this of anyone entering their facility, including EMS staff.
We will continue to keep you post as these cases proceed through the legal system. These facilities may still independently require your staff to be vaccinated. If your organization has questions or need assistance deciphering or preparing for these requirements, please contact the AAA by emailing hello@ambulance.org.
The Health Resources & Services Administration (HRSA) has announced that it will begin distributing Phase 4 General Distribution Payments on Thursday, December 16, 2021. According to HRSA, approximately 75% of all Phase 4 applications have now been processed. HRSA indicated that the remaining 25% of applications require additional review under its risk mitigation and cost containment safeguards.
HRSA further indicated that it began distributing American Rescue Plan (ARP) Rural Payments on November 23, 2021. As of December 14, 2021, HRSA has indicated that it has processed approximately 96% of ARP applications. The ARP allocated a total of $8.5 billion to health care providers who serve rural Medicare, Medicaid and CHIP patients. HRSA indicated that it will distribute $7.5 billion of these funds in its initial distribution.
To the extent a provider was determined to be eligible for either a Phase 4 payment or an ARP Rural Payment, the provider will receive both an email notification and a paper letter with additional details on these payments. This will include the individual amounts attributed to any subsidiary TINs submitted as part of their application. To the extent HRSA determined that you were not eligible for a Phase 4 payment, the email notice will provide an explanation for why you were determined to be ineligible. These email notices will be sent to the email address provided in the Phase 4 application. Providers selected for additional review will receive email notification as soon as HRSA completes its review process, which it indicated would be completed in “early 2022.”
AAA members are encouraged to look for this email. If you have not received an email notification, we would suggest that you check your spam filter, as several of our members have indicated that the email was flagged as “spam” by their email system.
