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HHS: Availability of Add’l $25.5 Billion in COVID-19 Provider Funding

Written by Scott Moore on . Posted in Advocacy Priorities, Executive, Government Affairs, Legislative, Regulatory.

HHS Announces the Availability of $25.5 Billion in COVID-19 Provider Funding

This morning the Department of Health and Human Services (HHS) announced that it will be making $25.5 billion in new funding available for healthcare providers affected by the COVID-19 pandemic. The funding, available through the Health Resources and Services Administration (HRSA) will include $8.5 billion in American Rescue Plan Act (ARPA) resources for providers who serve rural Medicaid, Children’s Health Insurance Program (CHIP), or Medicare patients, and an additional $17 billion for Provider Relief Fund (PRF) Phase 4 for a broad range of providers who can document revenue loss and expenses associated with the pandemic.

Getting additional financial relief for ground ambulance service providers who are still struggling from the lost revenue and increased expenditures resulting from being on the frontlines of responding to the pandemic has been a top priority for the AAA. The AAA along with the International Association of Fire Chiefs, International Association of Firefighters, National Associations of EMTs and National Volunteer Fire Association have continually pressed HHS to release the remaining funds. We strongly encourage all AAA members to submit an application regardless of whether you have applied for previous rounds of funding.

Consistent with the requirements included in the Coronavirus Response and Relief Supplemental Appropriations Act of 2020, PRF Phase 4 payments will be based on providers’ lost revenues and expenditures between July 1, 2020, and March 31, 2021 (Q3 – Q4 2020 and Q1 2021). The PRF Phase 4 will reimburse smaller providers, who tend to operate on thin margins and often serve vulnerable or isolated communities, for their lost revenues and COVID-19 expenses at a higher rate compared to larger providers. PRF Phase 4 will also include bonus payments for providers who serve Medicaid, CHIP, and/or Medicare patients, who tend to be lower- income and have greater and more complex medical needs. HRSA will price these bonus payments at the generally higher Medicare rates to ensure equity for those serving low-income children, pregnant women, people with disabilities, and seniors.

Consistent with the focus of the ARPA, HRSA will make ARPA rural payments to providers based on the amount of Medicaid, CHIP, and/or Medicare services they provide to patients who live in rural areas as defined by the HHS Federal Office of Rural Health Policy. As rural providers serve a disproportionate number of Medicaid and CHIP patients who often have disproportionately greater and more complex medical needs, many rural communities have been hit particularly hard by the pandemic. Accordingly, ARP rural payments will also generally be based on Medicare reimbursement rates.

In the announcement, HHS stated that it would “expedite and streamline” the application process and minimize administrative burdens, providers will apply for both programs in a single application. HRSA will use existing Medicaid, CHIP and Medicare claims data in calculating payments. The application portal will open on September 29, 2021. HHS has stated that to ensure that these provider relief funds are used for patient care, PRF recipients will be required to notify the HHS Secretary of any merger with, or acquisition of, another health care provider during the period in which they can use the payments. They have stated that providers who report a merger or acquisition may be more likely to be audited to confirm their funds were used for coronavirus-related costs.

To promote transparency in the PRF program, HHS also released detailed information about the methodology utilized to calculate PRF Phase 3 payments. Providers who believe their PRF Phase 3 payment was not calculated correctly according to this methodology will now have an opportunity to request a reconsideration. HHS announced that additional details on the PRF Phase 3 reconsideration process will be released at a later date.

In addition, many of you attended the PRF Reporting Q&A AAA webinar yesterday with Asbel Montes, Brian Werfel, and Scott Moore.  HHS has acknowledged the challenges facing many providers across the country due to recent natural disasters and the Delta variant, HHS announced a final 60-day grace period to help providers come into compliance with their PRF Reporting requirements if they fail to meet the deadline on September 30, 2021. While the deadlines to use funds and the Reporting Time Period will not change, HHS will not initiate collection activities or similar enforcement actions for non-compliant providers during this grace period.

Members can access more information about eligibility requirements, the documents and information providers will need to complete their application, and the application process for PRF Phase 4 and ARP Rural payments by visiting the HRSA website.

The combined application for American Rescue Plan rural funding and Provider Relief Fund Phase 4 will open on September 29, 2021.  Like we have done with the previous rounds of HHS funding, we encourage all ambulance service providers to submit an application for this Phase 4 funding.  If you have questions regarding this or any COVID-19 related questions, please contact hello@ambulance.org.

Provider Relief Fund Reporting Requirement Deadline is Approaching

Written by Brian Werfel on . Posted in Executive, Government Affairs, Legislative.

The American Ambulance Association wants to remind our members that the deadline to submit your initial report on your use of HHS Provider Relief Funds is fast approaching.  Any ambulance provider or supplier that received more than $10,000 in aggregate funds from the first two rounds of General Distribution funding will need to submit a report on their use of such funds by September 30, 2021.  This initial report will detail the expenditure of PRF funds through June 30, 2021.

Relevant Background

On 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.  An additional $75 billion was allocated as part of the Paycheck Protection Program and Health Care Enhancement Act, with subsequent legislation adding further amounts to this fund.  In total, the Provider Relief Fund (PRF) will distribute $178 billion to health care providers and suppliers to fund healthcare-related expenses or to offset lost revenue attributable to COVID-10.

To date, HHS has distributed approximately $148.4 billion through three rounds of General Distribution funds ($92.5 billion) and multiple smaller Targeted Distributions.  A portion of the PRF is also being used to reimburse health care providers for the costs of testing, treating, and vaccinating the uninsured.

Summary of Final Reporting Requirements

On June 11, 2021, HHS issued its final PRF Reporting Requirements.  Under these new guidelines, health care providers will be required to report for any “Payment Received Period” in which they received one or more PRF payments that, in the aggregate, exceed $10,000.  Providers meeting this threshold for any Payment Received Period will report on their use of such funds during the corresponding “Reporting Time Period.”

The following table sets forth the applicable Payment Received Periods and corresponding Reporting Time Periods.  The table also sets forth the deadline to use funds received within each Payment Receiving Period.

 

Period Payment Received Period Deadline for use of Funds Reporting Time Period
1 April 10, 2020 – June 30, 2020 June 30, 2021 July 1, 2021 – September 30, 2021
2 July 1, 2020 – December 31, 2020 December 31, 2021 January 1, 2022 – March 31, 2022
3 January 1, 2021 – June 30, 2021 June 30, 2022 July 1, 2022 – September 30, 2022
4 July 1, 2021 – December 31, 2021 December 31, 2022 January 1, 2023 – March 31, 2023

 

PRF payments received in the first two rounds of General Distribution funding will fall within the first reporting period.  PRF payments received in the third round of General Distribution funding will fall within either the second or third reporting periods, depending on when the funds were actually received.

As a result, ambulance providers and suppliers that received more than $10,000 in the aggregate from the first two rounds of General Distribution funding will need to submit an initial report during the 90-day period starting on July 1, 2021.  This initial report will detail all expenditures of PRF funds through June 30, 2021.

Ambulance providers and suppliers that received between $10,001 and $499,999 in aggregated PRF funds during each Payment Received Period are required to report on their use of such funds in two categories: (1) General and Administrative Expenses and (2) Health Care Related Expenses.  Ambulance providers and suppliers that received $500,000 or more in aggregated PRF funds during each Payment Received Period will be required to submit more detailed information for each of these general categories.

Specific Instructions Related to Reporting of Lost Revenues

The American Ambulance Association has received numerous questions from members regarding the appropriate methodology to report lost revenues attributable to the coronavirus.  Specifically, many members have inquired as to the appropriate methodology for calculating their lost revenues.

HHS has indicated that health care providers must report their lost revenues using one of three methodologies:

  1. The difference between actual patient care revenues;
  2. The difference between budgeted patient care revenues and actual patient care revenues; or
  3. An alternative methodology selected by the provider for estimating lost revenues.

Based on HHS guidance, it appears that the default methodology is to measure the difference between actual patient care revenues for each calendar quarter during the applicable period.  The provider will also be asked to further break down patient care revenues by applicable payer.  In basic terms, the first methodology will compare: (i) your actual calendar year 2019 patient care revenues to (ii) your actual calendar year 2020 patient care revenues.  The A.A.A. suggests that all members start by conducting this basic revenue analysis.  To the extent your lost revenues in 2020 equal or exceed (in combination with your increased expenses, if any) the total PRF funds received during the first Payment Received Period, no additional revenue analysis is required. 

In some instances, you may find that your actual revenue losses for calendar year 2020 do not fully offset the PRF funds received during the First Payment Received Period.  In that event, it may be beneficial to conduct a separate revenue analysis using the budgeted vs. actual methodology.  Note: you are only eligible to use this methodology to the extent you had a formal budget approved prior to March 27, 2020. 

This methodology is likely to be beneficial to ambulance providers or suppliers that, pre-pandemic, were projecting significant revenue growth in calendar year 2020.  For example, consider the case of a hypothetical “ABC Ambulance Service, Inc.”  ABC Ambulance had $1 million in patient care revenues in calendar year 2019.  However, in November 2019, the company signed an agreement to be the preferred provider of a major hospital system in its service area.  As a result, the company was projecting significant revenue growth in calendar year 2020.  Specifically, when it created its 2020 budget in December 2019, it projected that its patient care revenues would rise to $1.5 million in 2020.

When the pandemic hit in mid-March 2020, the company saw a significant slowdown in its transport volume.  Like many ambulance providers, it saw its transport volume rebound somewhat in the 3rd and 4th quarters of 2020.  As a result, it ended the year with $1.2 million in patient care revenues.

A revenue analysis using the default methodology would show an increase in revenues, i.e., its revenues increased by $200,000 over 2019.  However, its 2020 actual revenues were $300,000 less than it projected in its 2020 budget.  Using this second methodology, the company would be able to claim $300,000 in lost revenues to offset against its PRF funds.

Please note that any ambulance provider or supplier using this second methodology will be required to submit additional documentation with its initial PRF report.  Specifically, you will be required to submit a copy of the 2020 budget relied upon to show the lost revenue, together with an attestation from its CEO, CFO, or other authorized official attesting to the fact that this budget was formally established prior to March 27, 2020.

HHS will also permit ambulance providers or suppliers to utilize an alternative methodology created by the entity for calculating their lost revenues.  However, to utilize an alternative methodology, the provider or supplier will be required to submit additional documentation explaining not only the methodology, but also the justification for why this methodology was reasonable.  HHS has indicated that providers or suppliers electing to use an alternative methodology will face an increased risk of audit.  As a good rule of thumb, the use of an alternative methodology is likely to limited to situations where the EMS agency’s business is extremely seasonal, or where there was some major change in their operations during the 2020 calendar year (e.g., a partial sale of the company, a large acquisition, etc.).

Further Information Related to PRF Reporting

HHS updated its instructions for how ambulance providers and suppliers should complete their PRF Reporting obligations.  These updated instructions start on Page 4 of the Revised Reporting Requirements.

HHS also recently updated its Frequently Asked Questions (FAQs) associated with the PRF Reporting Program.

 

 

Letter to Senate HELP Committee Leadership on Provider-Type Equity

Written by AAA Staff on . Posted in Emergency Preparedness, Legislative.

The Honorable Patty Murray
Chair, United States Senate Committee on Health, Education, Labor and Pensions

The Honorable Richard Burr
Ranking Member
United States Senate Committee on Health, Education, Labor and Pensions

Dear Chairwoman Murray and Ranking Member Burr:

The American Ambulance Association (AAA) appreciates the opportunity to provide suggestions for bipartisan legislation to improve medical preparedness and response programs. The AAA is the primary association for ground ambulance service suppliers/providers, including governmental entities, volunteer services, private for-profit, private not-for-profit, and hospital-based ambulance services. Our members provide emergency and non-emergency medical transportation services to more than 75 percent of the U.S. population. AAA members serve patients in all 50 states and provide services in urban, rural, and super-rural areas. As the National Highway Transportation Safety Administration identified in its 2013 report on emergency services, EMS-only systems – such as our members – provide the vast majority of emergency ambulance services throughout America.

Our members are often the first health care teams to encounter patients who are sick and/or suspect they might have COVID-19. In addition to responding to 911 emergencies and transporting patients to appropriate destinations, they are also being asked to provide health care services within their existing State-defined scope of practice without transporting patients to help reduce hospital surge, as well as to protect high-risk patients from potential exposure to COVID-19. State and Local governments and public health authorities are also enlisting ground ambulance organizations to assist with testing suspected COVID-19 patients. In addition, ground ambulances provide important medical transitional care for patients moving between facilities in both emergency and non-emergency situations.

During this pandemic, our members have experienced first-hand the gaps in the public health infrastructure and the medical preparedness and response systems and programs. One of the most frustrating aspects of the current system has been the lack of recognition and support for communities that contract with non-governmental ground ambulance providers/suppliers in everything from federal grant programs to the distribution of personal protective equipment for EMTs and paramedics.

Many of the federal grant programs triggered during the pandemic have fallen short of their promise because the statutes and regulations governing them do not recognize non-governmental ground ambulance providers/suppliers as eligible entities. This distinction remains confusing because in other areas of health care, federal grant programs are accessible by private, for-profit health care providers and suppliers.

Outdated statutes and regulations often assume that first responders are governmental or not-for-profit entities and ignore the decisions of State and Local governments to contract with private ground ambulance providers/suppliers to provide 911 or equivalent services. As others have recognized, “State and Local officials know what works best in their communities – what works best in New York City may be much different than what works in rural Tennessee.”1 The federal government should respect these local decisions and support all first responders.

An example of this problem arose early during the COVID-19 pandemic. The FEMA public assistance grant program reimburses first responders for PPE and other expenses related to the response to COVID-19. When public and private non-profit emergency ambulance providers/suppliers sought direct reimbursement under the program, they were turned away. Private emergency ambulance providers/suppliers were required to have a State or Local government agency apply on their behalf. As State and Local governments responded to the public health emergency, it was understandably difficult for them to allocate resources to work through the application process on behalf of their contractors.

This differential treatment impacts communities across the United States, including those in Arkansas, California, Colorado, Florida, Georgia, Indiana, Louisiana, Massachusetts, Mississippi, Nevada, New York, Oregon, Texas, and Wisconsin, among others.

In contrast to statutes like the one government FEMA allocations, the Homeland Security Act of 2002 (6 U.S.C. § 101) includes language that recognizes the decision of State and Local governments to contract with private not-for-profit and for-profit ground ambulance providers/suppliers within the definition of “emergency response providers.”

The AAA urges the Congress to adopt the Homeland Security Act definition of “emergency response providers” throughout the U.S. Code as applicable. Such language will help to make sure that when funding is available to help State and Local governments prepare and respond, the allocation mechanisms governing the funding permit all types of first responders, including non-governmental ground ambulance providers/suppliers, to access the dollars quickly and with minimal burden.

Recommendation

The Committee should carefully review federal public health programs and revise them as necessary to ensure that the funds may be used to support both non-governmental and governmental ground ambulance providers/suppliers to ensure that all communities, regardless of their individual decisions related to the entities operating their EMS systems, have federal funds to support their response efforts during public health emergencies.

On behalf of the AAA, I want to thank you for your ongoing support of EMS and ground ambulance providers/suppliers, as well as the leadership demonstrated by your work to prepare for the next pandemic. Over the years, the Congress has consistently recognized the vital and unique role that ground ambulance providers/suppliers play in protecting their communities and providing mobile health care services. In light of the lessons learned during this pandemic, we encourage you and your colleagues to revise antiquated language that no longer represents the innovations and progress that have led to State and Local governments to rely upon ground ambulance providers/suppliers, including non-governmental organizations.

The AAA and its volunteer leaders would welcome the chance to discuss this recommendation. We would also be pleased to participate in any fact-finding discussion or hearing that the Congress plans to host to better understand how the problems experienced during the current pandemic can be avoided in the future. Please do not hesitate to reach out to Tristan North at (202) 486-4888 or tnorth@ambulance.org, or Kathy Lester at (202) 534-1773 or klester@lesterhealthlaw.com to schedule a time for further discussion.

Sincerely,

Shawn Baird
President, American Ambulance Association
Vice President of Rural Services, Metro West Ambulance

1The Honorable Lamar Alexander, “Preparing for the Next Pandemic” White Paper” 4 (June 9, 2020).

EMS Balance Billing Quick Take—July 7, 2021

Written by Kathy Lester on . Posted in Advocacy Priorities, Balance Billing, Executive, Legislative, Regulatory.

Webinar July 7, 2021 | 13:00–13:30 ET | Free to AAA Members
Speakers: Kathy Lester, Esq. & Asbel Montes

On July 1, CMS issued a proposed rule on Surprise Billing which applies to those providers and physicians identified in the No Surprises Act. This statute subjected ground ambulance suppliers to an HHS Advisory Committee process prior to any rulemaking addressing these services.

The consultants and staff of the American Ambulance Association are doing a deep dive into the 400+ page rule and evaluating its nuances. We continue to understand from our conversations that ground ambulances are not included and instead are subjected to the Advisory Committee.

The American Ambulance Association will soon provide a summary to members, and will address any confusion with the Administration. Join AAA for a quick take live webinar on July 7 at 13:00 ET to learn more!

Register Now

 

Medicare Ambulance Relief Bill introduced in Senate

Written by AAA Staff on . Posted in Advocacy Priorities, Government Affairs, Legislative, Medicare.

Yesterday, Senators Catherine Cortez Masto (D-NV) and Susan Collins (R-ME) introduced the Protecting Access to Ground Ambulance Medical Services Act of 2021 (S. 2037). Senators Cortez Masto and Collins were joined by Senators Debbie Stabenow (D-MI), Bill Cassidy (R-LA), Patrick Leahy (D-VT) and Bernie Sanders (D-VT) as primary cosponsors and leads on the legislation.

S. 2037 is identical to H.R. 2454 by Representatives Terri Sewell (D-AL), Devin Nunes (R-CA), Peter Welch (D-VT) and Markwayne Mullin (R-OK) and would extend the temporary Medicare ground ambulance increases of 2% urban, 3% rural and the super rural bonus payment for five years. The increases are currently scheduled to expire on December 31, 2022. The five-year extension would allow for the increases to remain in place during the two-year delay on ambulance data collection due to the COVID-19 public health emergency, an analysis of the data by MedPAC and subsequent action by the Congress to reform the Medicare ambulance fee schedule.

The legislation would also help ensure that rural zip codes in large urban counties remain rural following geographical changes under the fee schedule as a result of the 2020 census data. The current definition using rural urban commuting areas (RUCA) in Goldsmith Modification areas would be modified for zip codes with 1,000 people or less per square mile would also be rural. Ground ambulance service providers and suppliers could also petition the Centers for Medicare and Medicaid Services (CMS) to make the argument that a specific zip code should be rural. It is vital that this provision be implemented before CMS makes changes from the 2020 census data which will likely occur in 2023.

The AAA has been leading the effort on the legislation with the support of the International Association of Fire Chiefs, International Association of Fire Fighters, National Association of EMTs, National Rural Health Association and the National Volunteer Fire Council.

The AAA will be launching a Call to Action shortly requesting AAA members to ask their Senators to cosponsor S. 2037, and reach out to their Representatives to cosponsor H.R. 2454 if they have not already done so.

We greatly appreciate the leadership of Senators Cortez Masto, Collins, Stabenow, Cassidy, Leahy, and Sanders on this vitally important legislation.

CNN | Rural ambulance crews are running out of money and volunteers

Written by AAA Staff on . Posted in Advocacy Priorities, Executive, Government Affairs, Legislative, News, Press, Regulatory.

From CNN on May 22, 2021

Rural ambulance crews are running out of money and volunteers. In some places, the fallout could be nobody responding to a 911 call

America’s rural ambulance services, often sustained by volunteers, are fighting for their survival — a crisis hastened by the impact of Covid-19.

More than one-third of all rural EMS are in danger of closing, according to Alan Morgan, CEO of the National Rural Health Association. “The pandemic has further stretched the resources of our nation’s rural EMS.”

Read Full Article

US Treasury | Coronavirus State and Local Fiscal Recovery Funds to Deliver $350 Billion

Written by AAA Staff on . Posted in Legislative.

From the US Treasury on May 10, 2021

Treasury Launches Coronavirus State and Local Fiscal Recovery Funds to Deliver $350 Billion

Aid to state, local, territorial, and Tribal governments will help bring back jobs, address pandemic’s economic fallout, and lay the foundation for a strong, equitable recovery 

 

WASHINGTON — Today, the U.S. Department of the Treasury announced the launch of the Coronavirus State and Local Fiscal Recovery Funds, established by the American Rescue Plan Act of 2021, to provide $350 billion in emergency funding for state, local, territorial, and Tribal governments.  Treasury also released details on the ways funds can be used to respond to acute pandemic-response needs, fill revenue shortfalls among state and local governments, and support the communities and populations hardest-hit by the COVID-19 crisis. Eligible state, territorial, metropolitan city, county, and Tribal governments will be able to access funding directly from the Treasury Department in the coming days to assist communities as they recover from the pandemic.

“Today is a milestone in our country’s recovery from the pandemic and its adjacent economic crisis. With this funding, communities hit hard by COVID-19 will able to return to a semblance of normalcy; they’ll be able to rehire teachers, firefighters and other essential workers – and to help small businesses reopen safely,” said Secretary Janet L. Yellen.  “There are no benefits to enduring two historic economic crises in a 13-year span, except for one: We can improve our policymaking. During the Great Recession, when cities and states were facing similar revenue shortfalls, the federal government didn’t provide enough aid to close the gap. That was an error. Insufficient relief meant that cities had to slash spending, and that austerity undermined the broader recovery. With today’s announcement, we are charting a very different – and much faster – course back to prosperity.”

While the need for services provided by state, local, territorial, and Tribal governments has increased —including setting up emergency medical facilities, standing up vaccination sites, and supporting struggling small businesses—these governments have faced significant revenue shortfalls as a result of the economic fallout from the crisis. As a result, these governments have endured unprecedented strains, forcing many to make untenable choices between laying off educators, firefighters, and other frontline workers or failing to provide services that communities rely on. Since the beginning of this crisis, state and local governments have cut over 1 million jobs.

The Coronavirus State and Local Fiscal Recovery Funds provide substantial flexibility for each jurisdiction to meet local needs—including support for households, small businesses, impacted industries, essential workers, and the communities hardest-hit by the crisis. Within the categories of eligible uses listed, recipients have broad flexibility to decide how best to use this funding to meet the needs of their communities. In addition to allowing for flexible spending up to the level of their revenue loss, recipients can use funds to:

  • Support public health expenditures, by – among other uses – funding COVID-19 mitigation efforts, medical expenses, behavioral healthcare, mental health and substance misuse treatment and certain public health and safety personnel responding to the crisis;
  • Address negative economic impacts caused by the public health emergency, including by rehiring public sector workers, providing aid to households facing food, housing or other financial insecurity, offering small business assistance, and extending support for industries hardest hit by the crisis
  • Aid the communities and populations hardest hit by the crisis, supporting an equitable recovery by addressing not only the immediate harms of the pandemic, but its exacerbation of longstanding public health, economic and educational disparities
  • Provide premium pay for essential workers, offering additional support to those who have borne and will bear the greatest health risks because of their service during the pandemic; and,
  • Invest in water, sewer, and broadband infrastructure, improving access to clean drinking water, supporting vital wastewater and stormwater infrastructure, and expanding access to broadband internet.

Insufficient federal aid and state and local austerity under similar fiscal pressures during the Great Recession and its aftermath undermined and slowed the nation’s broader recovery. The steps the Biden Administration has taken to aid state, local, territorial, and Tribal governments will create jobs and help fuel a strong recovery. And support for communities hardest-hit by this crisis can help undo racial inequities and other disparities that have held too many places back for too long.

For an overview of the Coronavirus State and Local Fiscal Recovery Funds program including an expanded use of eligible uses, see the fact sheet released today. Find additional details on the state, local, territorial, and Tribal government allocations on the Coronavirus State and Local Fiscal Recovery Funds Webpage.

 

Medicare 2% Cut Freeze Extended

Written by Tristan North on . Posted in Legislative.

Yesterday, Presiden Biden signed into law legislation (H.R. 1868) to extend the current temporary freeze on the 2% Medicare sequestration cut. H.R. 1868 extends the deadline of the freeze from today until December 31. Contractors had been holding Medicare claims to avoid any issues but will again start processing claims. The AAA as well as other national EMS and fire organizations had pushed for the extension of the freeze.

Congress Recognizes Ambulance Services as Health Care Services in “The American Rescue Plan Act of 2021”

Written by Kathy Lester on . Posted in Government Affairs, Legislative, News.

Also Adds Dollars to the Provider Relief Fund to Support Rural Providers and Suppliers

March 10, 2021

Moments ago, the House of Representatives joined the Senate in passing “The American Rescue Plan.” Among the many provisions, this legislation includes waiver authority to allow the Medicare program to reimburse for ground ambulance services provided during the COVID-19 public health emergency when the beneficiary has not been transported under certain circumstances. It also increases the Provider Relief Fund by $8.5 billion, targeting the money to rural providers and suppliers, including ground ambulance services.

The American Ambulance Association (AAA) worked diligently with Centers for Medicare & Medicaid Services (CMS) and the Department of Health and Human Services (HHS) to reimburse ground ambulance services when they provide health care services to a beneficiary, but because of the pandemic the beneficiary was not transported. CMS concluded and communicated in a Frequently Asked Question (FAQ) that the Social Security Act requires the beneficiary to be transported in order for Medicare to reimburse the ground ambulance provider or supplier for the care provided.

To address this problem during the pandemic, Sens. Catherine Cortez Masto (D-NV) and Bill Cassidy (R-LA) introduced S. 149 that would allow CMS to waive the statutory provision creating the barrier to reimbursement during the pandemic. More specifically, it would allow CMS to reimburse ground ambulance services responding to a 9-1-1 or equivalent emergency call even when the beneficiary is not transported when a community-wide EMS protocol prohibiting the transport is in place. Reps. Cindy Axne (D-IA), John Larson (D-CT), and Bruce Westerman (R-AR) introduced the companion bill, H.R. 1609, in the House.

The Senate included S. 149 in “The American Rescue Plan Act of 2021,” which passed the Senate 50-49 on March 6. This amended version passed the House along party lines earlier today and the President is expected to sign the bill into law before March 14.

CMS must exercise its authority under the waiver for the provision to be implemented. The AAA has already begun working with CMS to urge it to act as quickly as possible and we are coordinating this effort with the International Association of Fire Chiefs, International Association of Fire Fighters, National Association of EMTs, National Volunteer Fire Council and the Congressional Fire Services Institute.

In addition to the waiver allowing for reimbursement for treatment in place, the final bill includes $8.5 billion additional dollars for the Provider Relief Fund directed to rural health care providers and suppliers. The funds can be used for health care related expenses and lost revenues that are attributable to COVID–19.  To be eligible for a payment, an eligible rural health care provider or supplier must be enrolled Medicare or Medicaid and submit to the Secretary an application that includes a justification statement, documentation of the expenses or losses, the tax identification number, assurance required by the Secretary, and any other information the Secretary requires.  The expenses and losses cannot have been reimbursed from another source or another source cannot already be obligated to reimburse.

“The American Rescue Act” marks an important step forward for ground ambulance organizations who have been on the front line of the pandemic and offers important relief recognizing the unique and essential role these organizations play in community response to the pandemic.

For more information on the provisions of the bill that impact ground ambulance services, please sign up for the webinar on “The American Rescue Plan and EMS” scheduled for this Friday, March 12, at 2:00 pm (eastern).

Senate Passes Ambulance Treatment in Place Language

Written by Tristan North on . Posted in Legislative.

On Saturday, the U.S. Senate passed language for Medicare coverage of emergency treatment in place of lower acuity patients by ground ambulance services providers and suppliers during the COVID-19 public health emergency (PHE). The language is from S. 149 by Senators Cortez Masto (D-NV) and Cassidy (R-LA) and passed as part of the $1.9 Trillion American Rescue Plan (H.R. 1319). The House is scheduled to vote and expected to pass the package tomorrow.

The American Ambulance Association along with the International Association of Fire Chiefs, International Association of Firefighters, National Association of EMTs and National Volunteer Fire Council pushed for passage of the bill language.

S. 149 would authorize the Centers for Medicare and Medicaid Services (CMS) to waive the transport requirement under Medicare for treatment in place for 9-1-1 or equivalent ambulance responses in which community EMS protocols dictate that the patient not be transported to a facility. The waiver would apply during the public health emergency.

Similar to other waivers provided by Congress for Medicare coverage during the pandemic, CMS would not be required to implement the policy. However, CMS has done so in all other situations and has also made the coverage retroactive to the beginning of the PHE. Upon passage of the language, the AAA will strongly advocate for CMS to implement the waiver and make it retroactive.

The AAA will be offering educational services to our members on the requirements of the proposed new policy and how to bill for covered services.

America First Healthcare Executive Order on Surprise Coverage

Written by Kathy Lester on . Posted in Advocacy Priorities, Executive, Finance, Legislative, Regulatory.

President Trump’s “An America-First Healthcare Plan” Executive Order on Surprise Billing Policy

by Kathy Lester, J.D., M.P.H.

As the American Ambulance Association (AAA) reported yesterday, President Trump issued an Executive Order (EO) “An America-First Healthcare Plan.”  The EO includes several provisions, including related to drug importation generally and for insulin specifically.  It also includes statements that indicate if the Congress does not act before the end of the year, the President will have the Department of Health and Human Services (HHS) “take administrative action to prevent a patient from receiving a bill for out-of-pocket expenses that the patient could not have reasonably foreseen.”  It does not mention ground ambulances.

In addition to suggesting action if the Congress does not pass legislation, the EO also states that within 180 days, the Secretary will update the Medicare.gov Hospital Compare website to inform beneficiaries of hospital billing quality, including:

  • Whether the hospital is in compliance with the Hospital Price Transparency Final Rule;
  • Whether, upon discharge, the hospital provides patients with a receipt that includes a list of itemized services received during a hospital stay; and
  • How often the hospital pursues legal action against patients, including to garnish wages, to place a lien on a patient’s home, or to withdraw money from a patient’s income tax refund.

The narrative related to balance billing (surprise coverage) reads as follows:

My Administration is transforming the black-box hospital and insurance pricing systems to be transparent about price and quality.  Regardless of health-insurance coverage, two‑thirds of adults in America still worry about the threat of unexpected medical bills.  This fear is the result of a system under which individuals and employers are unable to see how insurance companies, pharmacy benefit managers, insurance brokers, and providers are or will be paid.  One major culprit is the practice of “surprise billing,” in which a patient receives unexpected bills at highly inflated prices from providers who are not part of the patient’s insurance network, even if the patient was treated at a hospital that was part of the patient’s network.  Patients can receive these bills despite having no opportunity to select around an out-of-network provider in advance.

On May 9, 2019, I announced four principles to guide congressional efforts to prohibit exorbitant bills resulting from patients’ accidentally or unknowingly receiving services from out-of-network physicians.  Unfortunately, the Congress has failed to act, and patients remain vulnerable to surprise billing.

In the absence of congressional action, my Administration has already taken strong and decisive action to make healthcare prices more transparent.  On June 24, 2019, I signed Executive Order 13877 (Improving Price and Quality Transparency in American Healthcare to Put Patients First), directing certain agencies — for the first time ever — to make sure patients have access to meaningful price and quality information prior to the delivery of care.  Beginning January 1, 2021, hospitals will be required to publish their real price for every service, and publicly display in a consumer-friendly, easy-to-understand format the prices of at least 300 different common services that are able to be shopped for in advance.

We have also taken some concrete steps to eliminate surprise out‑of-network bills.  For example, on April 10, 2020, my Administration required providers to certify, as a condition of receiving supplemental COVID-19 funding, that they would not seek to collect out-of-pocket expenses from a patient for treatment related to COVID-19 in an amount greater than what the patient would have otherwise been required to pay for care by an in-network provider.  These initiatives have made important progress, although additional efforts are necessary.

Not all hospitals allow for surprise bills.  But many do.  Unfortunately, surprise billing has become sufficiently pervasive that the fear of receiving a surprise bill may dissuade patients from seeking appropriate care.  And research suggests a correlation between hospitals that frequently allow surprise billing and increases in hospital admissions and imaging procedures, putting patients at risk of receiving unnecessary services, which can lead to physical harm and threatens the long-term financial sustainability of Medicare.

Efforts to limit surprise billing and increase the number of providers participating in the same insurance network as the hospital in which they work would correspondingly streamline the ability of patients to receive care and reduce time spent on billing disputes.

The AAA will continue to advocate for the resources necessary to sustain life-saving mobile healthcare.

U.S. House of Representatives Approves Continuing Resolution

Written by Brian Werfel on . Posted in Government Affairs, Legislative.

On September 22, 2020, the U.S. House of Representatives approved a continuing resolution to keep the government funded through December 11, 2020.  Under current law, government funding is set to expire at midnight on September 30, 2020.

The House resolution is a stopgap measure that would maintain funding for most government programs at their current Fiscal Year 2020 levels.  However, the Continuing Resolution omits $30 billion in agricultural aid sought by the Trump Administration and Senate Republicans.  As of last week, it appeared that a compromise had been struck between the Administration and Speaker Pelosi under which the agricultural aid would be tied to the extension of special food benefits to recipients of free or reduced-price school lunches authorized by the Families First Coronavirus Response Act.  The Continuing Resolution also does not include new spending on economic aid for those impacted by the coronavirus.

The Continuing Resolution will now go to the U.S. Senate for consideration.

Impact on Repayment of Medicare Accelerated and Advance Payments

In response to the COVID-19 pandemic, CMS announced that it would be opening the Medicare Accelerated and Advance Payment Program (AAPP) to all health care providers and suppliers that were impacted financially by the pandemic.  Under the AAPP, Medicare-enrolled providers and suppliers were eligible to receive an advance of up to three months of their historic Medicare payments.  These advances were structured as “loans,” and were required to be repaid through the offset of future Medicare payments.  CMS began accepting applications for Medicare advances in mid-March 2020, before ending the program in late April following the passage of the CARES Act.  CMS ultimately approved more than 45,000 applications for advances totaling approximately $100 billion, before it suspended the program in late April 2020.

Under the existing terms of the AAPP, repayment through offset was required to commence on the 121st day following the provider or supplier’s receipt of the advance funds.  The program also called for a 100% offset until all advanced funds had been repaid.

The American Ambulance Association, the American Hospital Association, the Association of American Medical Colleges, and numerous other advocacy groups have advocated that the AAPP be revised to give health care providers and suppliers greater flexibility to repay the advanced funds.  The AAA and others argued that these changes were necessary to avoid a financial crisis when CMS began offsetting Medicare payments to repay the advanced funds.  A copy of the AAA’s letter to CMS Administrator Seema Verma can be viewed by clicking here.

In the Continuing Resolution, the House addressed this issue by making the following changes to the AAPP:

  • Hospitals and Other Part A Providers: Upon request of the hospital or other Part A provider: (1) provide for 1 year before claims are offset to recoup the advanced funds, (2) limit the offset to not more than 25% of the payment on a future claim for the first 11 months during which offsets are required, (3) limit the offset to not more than 50% during the next 6 months, (4) provide for up to 29 months (from the date the advanced payments were first received) before requiring that the outstanding balance be paid-in-full, and (5) limit the interest charged on the unpaid principal balance of any advanced funds to 4%.
  • Part B Suppliers: Upon request of the supplier: (1) provide for 1 year before claims are offset to recoup the advanced funds, (2) limit the offset to not more than 25% of the payment on a future claim for the first 11 months during which offsets are required, (3) limit the offset to not more than 50% during the next 6 months, (4) provide for up to 29 months (from the date the advanced payments were first received) before requiring that the outstanding balance be paid-in-full, and (5) limit the interest charged on the unpaid principal balance of any advanced funds to 4%.

The Continuing Resolution would require the HHS Secretary to post within 2 weeks of enactment (and updated every 2 weeks thereafter) the following information related to the AAPP on the CMS website:

  • The total amount of such payments under each part of the program, including the specific percentage of such payments made out of the Federal Hospital Insurance Trust Fund and the Federal Supplementary Insurance Trust Fund;
  • The total amount of payments under each part of the program, by industry type;
  • The CMS identifier and the amounts received by each health care provider or supplier.

HHS would also be required to post periodic reports, starting in July 2021 and every six months thereafter until all AAPP amounts have been repaid, that contain the following:

  • The total amounts yet to be repaid;
  • The total amounts yet to be repaid, by industry type;
  • The total amounts repaid under each program, including the specific percentage of such repayments deposited back to the Federal Hospital Insurance Trust Fund or the Federal Supplementary Insurance Trust Fund; and
  • The total interest collected on all repayments

The Senate will most likely approve the House CR before the September 30, 2020 deadline.

 

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