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EMS1: National associations join forces to tell the story of the front line

AAA Communications Chair Rob Lawrence shared his insights about recent  EMS and fire association joint advocacy efforts in EMS1. Don’t miss the full article!

Last week, the AAA were approached, via EMS1, by U.S. News, a national publication represented by journalist Gaby Galvin, asking about COVID-19 as it affects the front lines, rates of infection and quarantine, and generally life on the street. This opportunity provided the chance to bring together three national organizations who are all working hard to represent their members, lobby Congress and highlight the challenges at the tip of the spear.

Keep reading on EMS1►

HHS Announces Release of Initial Tranche of CARES Act Provider Relief Funding

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.  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) indicated that it would be disbursing the first $30 billion of relief funding to eligible providers and suppliers starting on April 10, 2020.  This money will be disbursed via direct deposit into eligible providers and supplier bank accounts.  Please note that these are outright payments, i.e., these are not loans that will need to be repaid. 

Who is Eligible to Receive Relief Fund Payments?

HHS indicated that any healthcare provider or supplier that received Medicare Fee-For-Service reimbursements in 2019 will be eligible for the initial allocation.  Payments to practices that are part of larger medical groups will be sent to the group’s central billing office (based on Medicare enrollment information).  HHS indicated that billing organizations will be identified by their Taxpayer Identification Numbers (TINs).

Are There Any Conditions to Receipt of this Funding?

Yes.  As a condition to receiving relief funding, a healthcare provider or supplier must agree not to seek to collection out-of-pocket payments from COVID-19 patients that are greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network provider.

How is the Amount of Relief Funding an Entity will Receive Determined?

HHS indicated that the amounts healthcare providers and suppliers will receive will be based on their pro-rata share of total Medicare FFS expenditures in 2019.  HHS indicated that Medicare FFS payments totaled $484 billion in 2019.

Providers and suppliers can estimate their initial relief payment amount by dividing their 2019 Medicare FFS reimbursement by $484 billion, and then multiplying that “ratio” by $30 billion.  Note: payments from Medicare Advantage plans are not included in the calculation of a provider’s/supplier’s total 2019 Medicare payments.

As an example, HHS cited a community hospital that received $121 million in Medicare payments in 2019.  HHS indicated that this hospital’s ratio would be 0.00025.  That amount is then multiplied by $30 billion to come up with its initial relief fund payment of $7.5 million.

The AAA has created a CARES Act Provider Relief Calculator
that you can use to estimate your initial relief payment.  |
USE DOWNLOADABLE EXCEL CALCULATOR►

Do I Need to do Anything to Receive Relief Funds?

No.  You do not need to do anything to receive your relief funding.  HHS has partnered with UnitedHealth Group (UHG) to disburse these monies using the Automated Clearing House (ACH) system.  Payments will be made automatically to the ACH account information on file with UHG or CMS.

Providers and suppliers that are normally paid by CMS through paper checks will receive a check from CMS within the next few weeks.

How Will I Know if I Received My Relief Funds?

The ACH deposit will come to you via Optum Bank.  The payment description will read “HHSPayment.”

Do I Need to do Anything Once I Receive My Relief Funds?

Yes.  You will need to sign an attestation statement confirming relief of the funds within 30 days.  These attestations will be made through a webportal that HHS anticipates opening the week of April 13, 2020.  The portal will need to be accessed through the CARES Act Provider Relief Fund webpage, which can be accessed by clicking here.

You will also be required to accept the Terms and Conditions within 30 days.  Providers and suppliers that do not wish to accept these terms and conditions are required to notify HHS within 30 days, and then remit full repayment of the relief funds.  The Terms and Conditions can be reviewed by clicking here.

How will HHS Distribute the Remaining $70 Billion in Relief Funds?

HHS has indicated that it intends to use the remaining relief funds to make targeted distributions to providers in areas particularly impacted by the COVID-19 outbreak, rural providers, providers of services with lower shares of Medicare reimbursement or who predominantly serve Medicaid populations, and providers requesting reimbursement for the treatment of uninsured Americans.

CMS Announces Delay to ET3 Start Date

On April 8, 2020, the Centers for Medicare and Medicaid Services (CMS) announced that it will be delaying the start of the Emergency Triage, Treat and Transport (ET3) Model until Fall 2020.  The ET3 Model was previously set to start on May 1, 2020.  CMS cited the national response to the COVID-19 pandemic as the reason for this delay.

In its delay notice, CMS also reminded the EMS industry that it has issued a number of temporary regulatory waivers and new rules that are designed to give health care providers and suppliers maximum flexibility to respond to the current national emergency.  This includes a number of flexibilities offered specifically to the ambulance industry.

CMS Waives Restrictions on Ground Ambulances During COVID-19 Pandemic

The Centers for Medicare and Medicaid Services (CMS) promulgated an interim final rule with comment period (IFC) entitled “Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency.”  Consistent with the recommendations the AAA made to CMS, for the duration of the public health emergency (PHE), the IFC allows ground ambulance service providers and suppliers to transport patients both on an emergency or non-emergency basis to any destination that is equipped to treat the condition of the patient consistent with Emergency Medical Services (EMS) protocols established by state and/or local laws where the services will be furnished.  In related guidance, CMS has suspended most Medicare Fee-For-Service (FFS) medical review during the emergency period due to the COVID-19 pandemic, waived patient signature requirements, and is pausing the Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model. The policies of the IFC are effective retroactively to March 1, 2020.

On March 11, the AAA sent CMS a letter specifically requesting for the agency to waive during the COVID-19 pandemic the regulatory restrictions that prevent coverage for transport to alternative destinations.  Separately, the AAA has been pressing CMS to provide relief from signature requirements. The AAA had also been working with CMS to lifting of these restrictions and others to eliminate barriers the current Medicare regulations in responding to the COVID-19 crisis.

Paying for Transports to Alternative Destinations.  During the duration of the crisis, CMS has expanded the list of destinations for which Medicare covers ambulance transportation to include all destinations, from any point of origin, that are equipped to treat the condition of the patient consistent with Emergency Medical Services (EMS) protocols established by state and/or local laws where the services will be furnished.

These destinations may include, but are not limited to: any location that is an alternative site determined to be part of a hospital, critical access hospital (CAH) or skilled nursing facility (SNF), community mental health centers, federal qualified health clinic (FQHCs), rural health clinics (RHCs), physicians’ offices, urgent care facilities, ambulatory surgery centers (ASCs), any location furnishing dialysis services outside of an ESRD facility when an ESRD facility is not available, and the beneficiary’s home.

This expanded list of destinations applies to medically necessary emergency and non-emergency ground ambulance transports of beneficiaries during the PHE for the COVID-19 pandemic.  The IFC does not waive the medically necessary requirements for ground ambulance transport of a patient in order for an ambulance service to be covered.

The AAA is working closely with CMS to confirm that patients who require isolation meet the medical necessity requirements.

Suspension of Audits and Relief on Patient Signatures.  In guidance released separately, CMS indicates that it is suspending nearly all audits of providers and suppliers for the duration of the PHE.

CMS has suspended most Medicare Fee-For-Service (FFS) medical review during the emergency period due to the COVID-19 pandemic. This includes pre-payment medical reviews conducted by Medicare Administrative Contractors (MACs) under the Targeted Probe and Educate program, and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractor (SMRC) reviews and Recovery Audit Contractor (RAC). No additional documentation requests will be issued for the duration of the PHE for the COVID-19 pandemic. Targeted Probe and Educate reviews that are in process will be suspended and claims will be released and paid. Current postpayment MAC, SMRC, and RAC reviews will be suspended and released from review. This suspension of medical review activities is for the duration of the PHE. However, CMS may conduct medical reviews during or after the PHE if there is an indication of potential fraud.

CMS also indicates in this guidance that a beneficiary’s signature will not be required for proof of delivery, as it relates to durable medical equipment services, during the PHE.  In a follow-up exchange with CMS, the AAA has confirmed that this policy of not requiring a beneficiary’s signature also applies to ground ambulance providers and suppliers. The AAA has requested that this clarification for ground ambulances also be provided in a written FAQ.

Pause in the Non-Emergency Prior Authorization Model.  CMS has paused the claims processing requirements for the Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model, effective March 29 until the end of the PHE.  During this pause, claims for repetitive, scheduled non-emergent ground ambulance transports for the COVID-19 pandemic in States in which the model operates will not be stopped for pre-payment review if prior authorization has not been requested by the fourth round trip in a 30-day period. During the pause, the MAC will continue to review any prior authorization requests that have already been submitted, and ambulance suppliers may continue to submit new prior authorization requests for review during the pause. Claims that have received a provisional affirmative prior authorization decision and are submitted with an affirmed unique tracking number (UTN) will continue to be excluded from future medical review. Following the end of the PHE for the COVID-19 pandemic, the MACs will conduct postpayment review on claims otherwise subject to the model that were submitted and paid during the pause.

Telehealth Services.  While CMS does not provide authority for ambulance organizations to bill directly for telehealth services, it does modify for the duration of the PHE the “direct supervision” requirements to allow physicians enter into a contractual arrangement with an entity that provides ambulance services to allow the physician to use the ambulance organization’s personnel as auxiliary personnel under a leased agreement.  Under such circumstances, the provider or supplier would seek payment for any services it provided from the billing physician and would not submit claims to Medicare for such services directly.

Ongoing work of the AAA.  The rule does not address two critical issues:  (1) reimbursement for treatment in place and (2) direct reimbursement for telehealth services.  The AAA will continue to work with CMS and the Congress to address these issues that are critical to meeting the needs of patients and your community during the epidemic.

URGENT – CALL TO ACTION Congress Still Negotiating Stimulus Package Ambulance Specific Relief Not Yet Included: Act Now!

None of the proposals offered so far on an economic stimulus package to address the impact of COVID-19 include our specific provisions to provide ambulance relief! Negotiators on a final package failed to reach an agreement over the weekend. There is still time to influence the final outcome! Please write to your members of Congress!

There are provisions in the packages that would help businesses, first responders and Medicare providers and suppliers. However, the AAA is advocating for specific help for ambulance services with the prioritization of COVID-19 resources, coverage of services, as well as direct financial assistance. The Congress has heard directly from the AAA about our requests and they need to hear from their constituents about assistance to your operations. If you have not yet contacted your members of Congress, please do so today!

Please e-mail today the health aides for your members of Congress!

It will take you only a few minutes per congressional office to email a letter. Just follow these steps.

1. USE LETTER TEMPLATE: CLICK HERE to access a draft letter. Please customize your letter including the cities and towns you serve, if you are sending to the office of a Senator or Representative and any additional details as to services you are providing during the COVID-19 outbreak and the financial impact on your operation.

2. LOOK UP HEALTH STAFFER AND EMAIL ADDRESS: CLICK HERE to access a list of the name of the health staffer and email address for all congressional offices.

3. SEND E-MAILS TO STAFFERS: Copy and paste the email address of the health staffer and copy and paste the letter as the body of the e-mail and send.

While the Congress may not include all of our requests in this stimulus package, there are likely to be future legislative vehicles in which the AAA will continue to press for passage of additional relief for ambulance service organizations and personnel.

Federal Coronavirus Stimulus Measures

Read a summary of President Trump’s proposed stimulus package developed by analysts from AAA lobbying firm Akin Gump.

As was the case following September 11, and during the Great Recession, President Trump and Congress have managed to bridge partisan divides and quickly develop several legislative packages to address the expanding impact of the coronavirus (COVID-19) on America’s public health system and the broader economy. Phase 1—the supplemental appropriations bill—has already become law. Phase 2—targeted relief for individuals, including paid family leave—has passed the House and is poised to pass the Senate this week. Phase 3—broader economic stimulus designed to deliver cash to individuals to help them weather the downturn, as well as industry-specific relief—is being crafted as we write, hopefully with a bipartisan agreement and quick enactment in a matter of days, not weeks. Continue reading►

COVID-19 Message from President Aarron Reinert

Aarron Reinert
President
American Ambulance Association

Dear Fellow AAA Members,

I write to you today during what we all recognize as an extraordinary time for EMS. As we collectively serve on the very front lines of the COVID-19 epidemic, we know that the most challenging times are still ahead. However, I am heartened by the collective resolve of the members of the American Ambulance Association to provide 24/7 on-demand mobile healthcare, no matter the circumstances.

As President of the Association, I am sharing below a brief summary of the AAA’s activities to support its members in the face of this devastating disease.

COVID-19 Content & Approach

  • Coronavirus Working Group—AAA Region III Director Tom Tornstrom, Executive Director of Gundersen Tri-State Ambulance, has been appointed to lead the AAA Coronavirus Working Group. The team includes AAA’s lobbyists, leadership, staff, and members from across the nation. We meet frequently and collaborate constantly to track challenges and find solutions to EMS issues relating to COVID-19 response. Sample topics include:
    • First responder safety and wellness
    • Reimbursement for alternative destinations, treatment in place, and mobile testing
    • Paperwork reduction / waivers
    • Advocating for policies in federal legislation that support mobile healthcare and redacting those that can negatively impact the industry

Members will receive updates via our Digest e-newsletter as we continue to make progress on these and other issues.

  • Representation in Stakeholder Groups—From CMS to Congress to local mayors, AAA has representatives and members working with legislators, regulators, and officials at every level of government to advocate for EMS. Simultaneously, AAA leaders are working to showcase mobile healthcare’s unique strengths and capabilities for addressing the viral threat.
  • Member Newsletter—The frequency of our member Digest e-newsletter has been increased from weekly to near-daily to ensure that we are curating and communicating the most relevant and important information.
  • COVID-19 Archive—All AAA posts related to the virus can be found on our website. A COVID-19 resource link has been added to the top navigation of the AAA website for easy access by providers.

Association Events & Operations

  • Stars of Life—Out of an abundance of caution, the Stars of Life event in Washington has been canceled. All blocked rooms will be canceled and refunded by the hotel, and all attendee registration fees will be refunded by diflucan. Staff is working on the development of meaningful ways to celebrate 2020 Stars outside of the context of an in-person event.
  • Ambulance Cost Education (Cost Collection)—A plan is in place to move ACE Gold cost collection education from face-to-face to an interactive online learning environment. Subscribers can expect additional updates in early April.
  • Headquarters—Association staff is all working remotely whenever possible. Staff is adhering to strict health, hygiene, and social distancing. All order fulfillment, mail processing, and other functions have been moved offsite.

Please don’t hesitate to reach out to staff at info@ambulance.org or 202-802-9020 if we can be of any assistance. Thank you again for your service to your communities during this very difficult time.

Aarron Reinert
President, American Ambulance Association

AAA Sends Letter to CMS on COVID-19 Response

The AAA has sent a letter to CMS on how the agency can most help ground ambulance service providers and suppliers be better prepared to respond to potential cases of COVID-19. The AAA has requested priority access to personal protection equipment for EMS personnel and COVID-19 test kits and results, as well as easing Medicare and Medicaid policies on alternative destinations and treatment in place. The letter was also sent to the National Highway Traffic Safety Administration (NHTSA) and the Assistant Secretary for Preparedness and Response (ASPR). Read the letter HERE.

Read the Letter

COVID-19 Update II for EMS

First Case of 2019 Novel Coronavirus in the United States

The New England Journal of Medicine has rapidly published a peer-reviewed paper on the Snohomish County WA ‘Patient 1’. This was the first reported case of COVID 19 in the US. This seminal document, which given the magnitude of the case and its initial findings is released in full here

The work by Michelle L. Holshue, M.P.H., Chas DeBolt, M.P.H., Scott Lindquist, M.D., Kathy H. Lofy, et al for the Washington State 2019-nCoV Case Investigation Team was turned round in just over 5 weeks and below is an ‘Executive summary’ ( as extracted from the paper) but the full paper and range of results should be read in full.

Patient Presentation

On January 19, 2020, a 35-year-old man presented to an urgent care clinic in Snohomish County, Washington, with a 4-day history of cough and subjective fever. On checking into the clinic, the patient put on a mask in the waiting room. After waiting approximately 20 minutes, he was taken into an examination room and underwent evaluation by a provider. He disclosed that he had returned to Washington State on January 15 after traveling to visit family in Wuhan, China. The patient stated that he had seen a health alert from the U.S. Centers for Disease Control and Prevention (CDC) about the novel coronavirus outbreak in China and, because of his symptoms and recent travel, decided to see a health care provider.

On admission, the patient reported persistent dry cough and a 2-day history of nausea and vomiting; he reported that he had no shortness of breath or chest pain. Vital signs were within normal ranges. On physical examination, the patient was found to have dry mucous membranes. The remainder of the examination was generally unremarkable. After admission, the patient received supportive care, including 2 liters of normal saline and ondansetron for nausea.

Viral Presence

Both upper respiratory specimens obtained on illness day 7 remained positive for 2019-nCoV, including persistent high levels in a nasopharyngeal swab specimen (Ct values, 23 to 24).

Stool obtained on illness day 7 was also positive for 2019-nCoV (Ct values, 36 to 38).

Nasopharyngeal and oropharyngeal specimens obtained on illness days 11 and 12 showed a trend toward decreasing levels of virus

Day 8: Condition Improves

On hospital day 8 (illness day 12), the patient’s clinical condition improved. Supplemental oxygen was discontinued, and his oxygen saturation values improved to 94 to 96% while he was breathing ambient air. The previous bilateral lower-lobe rales were no longer present. His appetite improved, and he was asymptomatic aside from intermittent dry cough and rhinorrhea. As of January 30, 2020, the patient remains hospitalized. He is afebrile, and all symptoms have resolved with the exception of his cough, which is decreasing in severity.

History Taking

This case report highlights the importance of clinicians eliciting a recent history of travel or exposure to sick contacts in any patient presenting for medical care with acute illness symptoms, in order to ensure appropriate identification and prompt isolation of patients who may be at risk for 2019-nCoV infection and to help reduce further transmission. Finally, this report highlights the need to determine the full spectrum and natural history of clinical disease, pathogenesis, and duration of viral shedding associated with 2019-nCoV infection to inform clinical management and public health decision making.

Conclusion

There is little doubt that this paper is about to become a globally sited document as we continue to deal with COVID 19. As far as EMS and our first response to it goes, the paper reinforces the key actions currently being taken

 

Sample COVID-19 Policies for Mobile Healthcare Providers

Thank you to the following organizations for sharing their policies as examples.

Global Medical Response maintains a COVID-19 page to provide information to all members of the GMR community—clinicians and non-clinicians.

Updates from GMR Chief Medical Officer, Dr. Ed Racht

GMR Procedures

General Information for Caregivers

Compliance

HIPAA Reminder

FirstWatch Solutions

The intention of the COVID-19 Process/Policy Template is to provide agencies, medical directors, or others who want to utilize it, an outline/template on which to build an agency-specific policy/protocol to address COVID-19. This includes suggestions for development and/or oversight committees, outside partners and stakeholders, as well as preparation and process for EMS workers who provide best practice care for patients as well as providing for the protection of pre-hospital providers and medical director(s). Its application is totally up to the user.

This document is meant to be a living document that can be revised as circumstances or guidance changes. It can also be a discussion piece for those who choose to develop a different type of policy but may want to use some of the components of the document as a starting point.

Agency Guidance

CDC Interim Guidance for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points (PSAPs) for COVID-19 in the United States
NEW March 6, 2020: CMS COVID-19 FAQs for Healthcare Providers (PDF Download)

March 5, 2020: CMS issued a second Healthcare Common Procedure Coding System (HCPCS) code for certain COVID-19 laboratory tests, in addition to three fact sheets about coverage and benefits for medical services related to COVID-19 for CMS programs.  https://www.cms.gov/newsroom/press-releases/cms-develops-additional-code-coronavirus-lab-tests

March 4, 2020: CMS issued a call to action to healthcare providers nationwide and offered important guidance to help State Survey Agencies and Accrediting Organizations prioritize their inspections of healthcare. https://www.cms.gov/newsroom/press-releases/cms-announces-actions-address-spread-coronavirus

February 13, 2020: CMS issued a new HCPCS code for providers and laboratories to test patients for COVID-19.  https://www.cms.gov/newsroom/press-releases/public-health-news-alert-cms-develops-new-code-coronavirus-lab-test

February 6, 2020: CMS gave CLIA-certified laboratories information about how they can test for SARS-CoV-2. https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/notification-surveyors-authorization-emergency-use-cdc-2019-novel-coronavirus-2019-ncov-real-time-rt

February 6, 2020: CMS issued a memo to help the nation’s healthcare facilities take critical steps to prepare for COVID-19.  https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and-memos-states-and/information-healthcare-facilities-concerning-2019-novel-coronavirus-illness-2019-ncov

President signs law providing funds to combat Corona Virus

President Donald Trump today signed H.R. H.R. 6074 into law, approving $8.3 billion in supplemental appropriations to fund programs in response to the COVID-19 illness. The bill would bolster vaccine development, research, equipment stockpiles, and state and local health budgets as government officials and health workers fight to contain the outbreak, which has claimed 11 lives in the U.S. and sickened more than 160 people across more than a dozen states.

The AAA advocated to negotiators of the bill that first responders needed to be included in the funding package and that all communities be eligible for the funding. Due in part to our outreach, the emergency funding provides a transfer of no less than $10 million to the National Institute of Environmental Health Sciences for worker-based training aimed at preventing exposure of the virus to emergency first responders, and others at risk of exposure (i.e., hospital employees).

The supplemental also appropriates $1 billion for state and local preparedness, which will allow state and local governments to carry out preparedness and response activities, with each State receiving a minimum of $4 million. Of the $1 billion, $300 million is allocated for global disease detection and emergency response, and FY 2019 Public Health Emergency Preparedness grantees.

Member Advisory: CMMI Releases Initial List of ET3 Participants

The Centers for Medicare and Medicaid Services (CMMI) has released its initial list of applicants selected to participate in the ET3 pilot program. CMMI notes that the list is not final as it still needs to execute participation agreements with the applicants. CMMI will issue a final list once it completes the process.

Applicants from 36 states and the District of Columbia were selected to participate in the program. Approximately 200 applicants were approved with instances in which the same ambulance service organization submitted applications for multiple counties as well as more than one organization submitting an application for the same county. CMMI has sent notifications to each of the applicants letting them know to expect a follow up email with the partnership agreement, program guidance and additional details.

The ET3 program is a five-year voluntary pilot program designed to test the potential benefit to the Medicare program and patients of ambulance service providers and suppliers furnishing treatment in place as well as transport to alternative destinations. For more information about the ET3 program, please go the ET3 website.

CMS Announces New Healthy Adult Opportunity Initiative

On January 30, 2020, the Centers for Medicare and Medicaid Services (CMS) announced the roll-out of its “Healthy Adult Opportunity” (HAO) initiative.  Under the initiative, participating states will have a portion of their current federal Medicaid funding converted to block grants.  In return, the states will gain greater flexibility in providing for the health care needs of certain portions of their existing Medicaid populations.

In a letter directed to State Medicaid Directors, CMS outlined the details of how the HAO initiative would operate.  The initiative will be operated under CMS’ 1115 waiver authority.  In order to participate, a state must submit an application setting forth the specific demonstration projects it intends to implement.  CMS reiterated that participation in the HAO initiative is voluntary.  CMS further indicated that it will review state applications on a case-by-case basis and make an independent decision on whether the proposed policies merit approval.  States with existing Section 1115 waivers that cover eligible populations will be permitted to transition existing demonstrations into the HAO initiative.

CMS indicated that HAO demonstrations will generally be approved for an initial 5-year period, and successful demonstrations may be renewed for a period of up to 10 years.

A summary of some of the major provisions of this initiative is provided below.

Federal Funding

The Medicaid Program is a joint federal and state program that provides free or low-cost health coverage to nearly 65 million Americans.  The Program is administered by each state, with the federal government reimbursing states for a percentage of their qualifying Medicaid expenditures.  The amount of federal matching funds is based on a statutory formula that compares a state’s per capita income to the national average.  States with lower per capita incomes receive a higher Federal Medical Assistance Percentage (FMAP).  FMAPs range from 50% to a maximum of 83%.  In addition, the federal government provides higher matching rate (called an Enhanced FMAP) for certain services or populations.  For example, the federal government currently pays 90% of the costs of providing health care to those covered by the Medicaid expansion included in the Affordable Care Act.

Under the HAO initiative, participating states would forego the FMAP for certain Medicaid populations.  Instead, these states would receive a fixed amount of federal funding (i.e., a block-grant), which will be calculated based on either a total expenses or per-enrollee basis.  To the extent the state spends more than its budgeted amount, it would not be eligible for additional federal matching funds.  To the extent the state ends up spending less than its budgeted amount, the state would participate in the cost-savings.

Eligible Medicaid Populations

The HAO initiative is focused on the non-mandatory adult Medicaid populations, i.e., individuals that are under the age of 65, and who are not eligible for Medicaid on the basis of disability, or their need for long term care, and who are not otherwise eligible under a State Medicaid Plan.  In other words, this initiative is largely targeted at those individuals that become eligible for Medicaid as a result of the Affordable Care Act.

Benefit Package Design

Under the HAO initiative, states will have the ability to design benefit packages that closely resemble the benefit packages provided by private insurers.  At a minimum, this would include benefit packages that cover all of the Essential Health Benefits (EHBs) required for commercial insurances sold on the State ACA Exchanges.  States may also design federally qualified health center coverages that facilitate the use of value-based payment design among safety-net providers.

Beneficiaries that are shifted into HAO demonstration projects will retain certain beneficiary protections, including all federal disability and civil rights laws, fair hearing rights, and limits on their mandatory cost-sharing amounts.

Coverage of Prescription Drugs

One major change would be to state’s coverage of prescription drugs.  The initiative would give states the flexibility to offer formularies under an HAO demonstration project similar to those provided in commercial health insurance markets.  This would remove the current mandate that states provide a so-called “open formulary.”  States that elect to establish their own formulary would be required to comply with the EHB requirements regarding prescription drug benefits.  States would also be required to cover substantially all drugs used to treat: (1) mental health disorders (i.e., antipsychotics and antidepressants), (2) HIV (i.e., antiretroviral drugs), and (3) opioid use disorders (i.e., all forms, formulations, and delivery mechanisms) where there are rebate agreements in place with the manufacturers.

In theory, this would permit states to cover only a single drug for many pharmaceutical classes.

Cost-Sharing Amounts

States would have the flexibility to impose additional cost-sharing obligations on beneficiaries covered under a demonstration program, subject to two broad limitations:

  1. Aggregate out-of-pocket costs for beneficiaries covered under an HAO demonstration must not exceed 5% of the beneficiary’s household income, measured on a monthly or quarterly basis; and
  2. Premiums and cost-sharing charges for tribal beneficiaries, those beneficiaries living with HIV, those beneficiaries needing treatment for substance use disorders, and the cost-sharing charges for prescription drugs used to treat mental health conditions must not exceed amounts permitted under the implementing regulations. States would also not be permitted to suspend enrollment for these individuals if they fail to pay their premiums or cost-sharing amounts.

Wrap-Around Services (Including NEMT)

States would be given the flexibility to discontinue the coverage of Alternative Benefit Plan wrap-around services, including non-emergency medical transportation (NEMT) and early and periodic screening, diagnostic and treatment services (EPSDT) for individuals aged 19-20.

CMS Posts 2020 Public Use File

On December 2, 2019, CMS posted the 2020 Ambulance Fee Schedule Public Use Files. These files contain the amounts that will be allowed by Medicare in calendar year 2020 for the various levels of ambulance service and mileage. These allowables reflect a 0.9% inflation adjustment over the 2018 rates.

The 2020 Ambulance Fee Schedule Public Use File can be downloaded from the CMS website by clicking here.

Unfortunately, CMS has elected in recent years to release its Public Use Files without state and payment locality headings. As a result, in order to look up the rates in your service area, you would need to know the CMS contract number assigned to your state. This is not something the typical ambulance service would necessarily have on hand. For this reason, the AAA has created a reformatted version of the CMS Medicare Ambulance Fee Schedule, which includes the state and payment locality headings. AAA members can access this reformatted fee schedule at the link below.

2020 Ambulance Fee Schedule▶

 

Ambulance Cost Collection Rule Summary

The proposed rule sets the foundation for the data collection system for ground ambulances.  It proposes a stratified random sample method, that is very similar to the one the AAA proposed via the work we commissioned through The Moran Company. We are working through the stratification categories, which are slightly different than those we identified.

CMS also proposes the cost and revenue data elements it plans to use.  There are some details in the proposed rule text and others will be in the proposed tool that will be posted the CMS website today.

CMS also proposes the collection period and penalties for failing to report.

While the data collection provision was the key component for ground ambulance services, CMS also proposed changes to the PCS requirement sought by the AAA. CMS is proposing to reference the PCS also as non-physician certification agreements. The agency is further proposing to clarify that the focus is on the certification of the medical necessity provisions and the form of the certification statement is not prescribed.  As part of the non-physician statement, CMS is proposing expanding the staff of you may sign the statement when an attending physician is unable to sign.

Download Full PDF Summary by Kathy Lester, Esq.

CMS Releases Proposed Cost Collection Rule

Today, CMS has released the proposed rule that would establish the ambulance fee schedule cost collection system as required by statute. The AAA is currently reviewing the rule and will provide a more detailed summary in the coming days.

On Tueusday, July 30 at 12:00pm Eastern, the AAA will be hosting a free webinar during which AAA counsel will provide an overview of the proposals in the rule. Do not miss out on this chance for the most up to date information.

Read the Proposed Rule

Sign Up for the Webinar

Questions?: Contact Us:

If you have questions about the legislation or regulatory initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.

Tristan North – Senior Vice President of Government Affairs
tnorth@ambulance.org | (202) 802-9025

Ruth Hazdovac – AAA Senior Manager of Federal Government Affairs
rhazdovac@ambulance.org | (202) 802-9027

Aidan Camas – Manager of State & Federal Government Affairs
acamas@ambulance.org | (202) 802-9026

Thank you for your continued membership and support.

2019 Ambulance Ride-Along Toolkit

AAA ambulance emt member legislation

2019 Ride-Along Toolkit Now Available!

Educating your members of Congress about ambulance industry issues makes them much more likely to support your efforts. An easy and effective way to educate them is to invite them to participate in a local Ambulance Ride-Along!

Congress is scheduled to adjourn on July 27 for their August congressional recess with members of Congress returning home to their districts and states. This is the perfect opportunity for you to educate your members of Congress about those issues, in particular the Public Safety Officers Benefit (PSOB), permanent ambulance relief and ambulance cost data collection which are important to your operation. The most effective way to deliver these key messages is to host your member of Congress or their staff on a tour of your operation and an ambulance ride-along. The AAA has made the process of arranging a ride-long or scheduling a meeting easy for you with our 2019 Congressional Ride-Along Toolkit.

Are you willing to host a Member of Congress at your service but unsure of how to set it up? Email or call Aidan Camas at acamas@ambulance.org – (202) 802-9026 and Aidan can help you set up a meeting.

Everything you need to arrange the ride-along or schedule a meeting is included in the Toolkit. Act now and invite your elected officials to join you on an Ambulance Ride-Along!

Update on AAA Legislative Priorities

The American Ambulance Association has been working hard to accomplish the legislative goals of the membership in the 116th Congress. The AAA would like to take this opportunity to provide an update on what we have accomplished thus far in the 116th Congress.

Balance/Surprise Billing

Balance/surprise billing is a hot button issue that recently came into the spotlight at the start of the 116th Congress. With the President’s announcement calling for Congress to pass legislation that would end surprise billing for patients, there has been an increase in Congressional action on the issue including introduced legislation, discussion drafts and hearings in all committees of jurisdiction. The AAA has been working tirelessly with the Congressional committees of jurisdiction to educate Members and staff on the unique characteristics of EMS systems and that it would be inappropriate to apply the same restrictions on balanced billing to ground ambulance services.

The AAA has formed a working group comprised of AAA member volunteers that have worked on policy and messaging on balance billing. The working group has submitted comments to the Energy and Commerce Committee and Senate HELP committees advocating that the ambulance industry is unique from other stakeholders, and as such, should be looked at differently. Ambulance service providers and suppliers are required by law to treat and transport all patients, regardless of their ability to pay and are heavily regulated at the local level. The AAA has been working to communicate these factors that place the ambulance industry in a different situation than many other stakeholders.

Public Safety Officers Death Benefit (PSOB)

The Public Safety Officers Death Benefit (PSOB), a one-time benefit paid to families of first responders killed in the line of duty, is an issue that the AAA has passionately advocated for over many years. In the 116th Congress, the AAA has secured introduction of legislation in the House of Representatives, H.R. 2887, the Emergency Medical Service Providers Protection Act. H.R. 2887 would extend the PSOB to first responders employed by private for-profit EMS agencies. The AAA was able to secure several commitments from Members of Congress to cosponsor the legislation during Stars of Life meetings in Washington, DC. In addition to taking action to move H.R. 2887 through the legislative process, the AAA will be engaging in an outreach campaign in the next few weeks.

Dialysis Off-Set Restructuring

The AAA has worked toward reintroduction of legislation to restructure the offset that was passed into law in the Bipartisan Budget Act of 2018 (H.R. 1892) in the 115th Congress. This offset included a total cut of 23% to the Medicare reimbursement for basic life support (BLS) non-emergency transports performed by all ambulance service suppliers and providers to and from dialysis centers. This cut served as an offset to the 5-year extension of Medicare add on payments that our industry worked hard to get extended.

The AAA has secured introduction of legislation in both the House and Senate. H.R. 3021 was introduced by Representatives LaHood (R-IL) and Sewell (D-AL) and S. 228 by Senators Cassidy (R-LA) and Jones (D-AL). If passed, this legislation would change the cut that is currently in place so that it applies specifically to companies conducting over 50% ESRD non-emergency transports. Those ambulance services with over 50% ESRD transports would get a cut of 29.5%, while those doing less would receive a 15.5% cut. The AAA will continue to work toward movement and passage of this legislation that would better distribute the reduction to those providers which do almost exclusively non-emergency dialysis transports and thus have a lower cost of providing services.

Medicare Priorities Bill

The AAA has crafted legislation that is specifically aimed at addressing major Medicare ambulance industry issues. The issues that will be included in future legislation include making Medicare ambulance add-ons permanent, implementing a prior-authorization program across the nation, allowing for transportation to alternative destinations, reducing regulatory burdens, and providing relief through maintaining many zip codes as rural following the next census. The AAA is working to get this Medicare priorities legislation introduced in the coming months so that we can get to work on solving these Medicare issues that impact our industry as a whole.

VA Legislation

Another priority that that the AAA has been diligently working toward getting introduced is Veterans Affairs (VA) legislation. The Veterans Reimbursement for Emergency Ambulance Services Act (VREASA) introduced by Congressman Tipton (R-CO) would provide veterans with reimbursement for emergency ambulance services when a Prudent Layperson would have a reasonable expectation that a delay in seeking immediate medical attention will jeopardize the life or health of the veteran. This legislation was introduced as a result of the VA consistently requiring all medical records be provided, including the records of treatment after the emergency service has taken place. Should those records show that it was not a life threatening emergency or a false alarm, the claim for reimbursement is being denied. The VA legislation would mandate that the VA apply the “prudent layperson” definition of emergency to determine coverage of ambulance claims.

The AAA is also working toward addressing two other issues with the VA to enforce more prompt payment by the VA and treating the VA as the first payor, similar to Medicare, as it is determined whether there is a different primary payor. The AAA has been working with Senators Collins and Tester on language help solve this ongoing and serious reimbursement issue.

In our next update, we will be reporting on the progress the AAA has made this year on regulatory issues.

Questions? Contact Us

If you have questions about the discussion draft or balance billing initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.

Tristan North – Senior Vice President of Government Affairs
tnorth@ambulance.org | (202) 802-9025

Ruth Hazdovac – AAA Senior Manager of Federal Government Affairs
rhazdovac@ambulance.org | (202) 802-9027

Aidan Camas – Manager of State & Federal Government Affairs
acamas@ambulance.org | (202) 802-9026

Thank you for your continued membership and support

Member Update on Balance Billing

This morning Ruth Hazdovac and Aidan Camas of AAA staff and Kathy Lester, Esq, Healthcare Consultant to the AAA attended a briefing held by the House Energy & Commerce Committee on the issue of surprise/balance billing. At the briefing, staff for Chairman Frank Pallone (D-NJ) and Ranking Member Greg Walden (R-OR) announced that they would be releasing a bipartisan discussion draft, the No Surprises Act, which would “protect consumers from surprise medical bills and increase transparency in our health care system.”

As of now, ground and air ambulances are NOT included in the discussion draft. However, the committee is asking for comments on ground and air ambulance and recommendations on how to provide relief to the consumer in this area. The AAA has a Balance Billing Work Group that is hard at work developing a policy recommendation that will work for our members.

The House Ways and Means Health Subcommittee Chairman Lloyd Doggett also announced today that the Health Subcommittee will hold a hearing next week entitled “Hearing on Protecting Patients from Surprise Medical Bills.” AAA Staff will be at the briefing and provide a timely update to membership on any developments.

The AAA team will be submitting comments and policy recommendations based off the work of the Balance Billing Work Group to both the Energy & Commerce and Ways & Means Committee to ensure that the views of our members are well represented. We will also be reaching out to AAA members in the states of key policymakers on the Committees to submit comments, as well. The AAA will also provide members with key talking points in the event they are contact by their Members of Congress or their staff.

Questions? Contact Us

If you have questions about the discussion draft or balance billing initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.

Tristan North – Senior Vice President of Government Affairs
tnorth@ambulance.org | (202) 802-9025

Ruth Hazdovac – AAA Senior Manager of Federal Government Affairs
rhazdovac@ambulance.org | (202) 802-9027

Aidan Camas – Manager of State & Federal Government Affairs
acamas@ambulance.org | (202) 802-9026

Thank you for your continued membership and support.

President’s Perspective April 2019

Aarron Reinert
President,  AAA

Dear Fellow AAA Members,

Spring is in full bloom in Washington, D.C., and the American Ambulance Association is hard at work in our nation’s capital advocating for mobile healthcare providers. I am pleased to share with you several updates from your association.

Advocacy Progress

The AAA continues to forge ahead advocating for the legislative and regulatory priorities of our membership. Earlier this month, more than forty AAA volunteer leaders and members came to Washington, D.C., meeting with more than 100 congressional offices to advocate for Medicare policies and improved claims processing by the Department of Veterans Affairs for emergency ambulance services. (View photos on Facebook.)

The AAA has also taken an active role in responding to potentially harmful “surprise billing” legislation. The AAA has been urging Members of Congress to recognize the unique and essential nature of emergency ambulance services and ambulance interfacility mobile healthcare transports. Ambulance service suppliers and providers are already heavily regulated at the local level and struggle with receiving adequate reimbursement. The Congress should protect patient access to ground ambulance services and continue to allow us to balance bill.

The AAA is working closely with CMS and the RAND corporation on the development of the ambulance cost data collection system in order to ensure that the end survey and methodology is feasible for our industry. The AAA has established itself and our membership as an important stakeholder throughout the cost data collection development process, and we look forward to remaining involved this year.

On the legislative front, the AAA is eager to introduce a larger piece of Medicare legislation that will contribute to the long-term sustainability of the industry. This legislation will address issues such as inadequate reimbursement, the need for innovative payment models, the lack of equitable polices, rural zip code classifications, and more. Buy Diamox 250 mg https://www.rpspharmacy.com/product/diamox/

Legislation to restructure the offset included in the Bipartisan Budget Act of 2018 to pay for the 5-year extension of Medicare add-on payments has been reintroduced in the Senate (S. 228) and should be re-introduced in the House soon. The AAA is also working on updating the Veterans Reimbursement for Emergency Ambulance Services Act (VREASA) to adequately address issues regarding reimbursement from the VA.

With many important legislative priorities, we will continue to lean on our members for their support and encourage you all to continue to build relationships with your Members of Congress.

Ambulance Cost Education (ACE)

Time is running out to prepare for the new federal cost data collection requirements for ambulance services which go into effect January 1, 2020. To help ambulance services ready themselves, our expert faculty has developed comprehensive Ambulance Cost Education (ACE) webinars, regional workshops, and online resources. With AAA ACE, your service will have all the tools needed to comply with federally mandated cost collection. An ACE subscription is the turn-key solution to prepare for ambulance cost collection. Learn more about our affordable packages today.

Stars of Life

Every year, the American Ambulance Association’s Stars of Life program showcases the value of mobile healthcare to legislators and the general public. I look forward to seeing many of you this June in Washington D.C., for the 2019 celebration. Follow the 2019 AAA Stars of Life on Facebook and Twitter in the coming months! Levitra generic http://www.gastonpharmacy.com/levitra.php

Annual Conference & Trade Show

Preparations are in full swing for the 2019 AAA Annual Conference & Trade Show in exciting Nashville, Tennessee. AAA Annual is the can’t-miss educational experience for ambulance leaders interested in bringing excellence in reimbursement, operations, and human resources to their services! I hope that you will join me and hundreds of our colleagues for networking, learning, and fun November 4-6Early bird registration is open now!

Thank You, Members!

It continues to be my pleasure to serve so many talented, dedicated health care professionals. Thank you for your service to your communities, and I wish you continued success in 2019!

Aarron Reinert
President
American Ambulance Association

Federal District Court Judge Strikes Down the ACA

On December 14, 2018, a federal district court judge for the Northern District of Texas issued a ruling striking down the Affordable Care Act (ACA) on the grounds that the Individual Mandate was unconstitutional, and that the rest of the law cannot withstand constitutional scrutiny without the Individual Mandate.

District Court Judge Reed O’Connor’s decision relates to a lawsuit filed earlier this year by 20 states and two individuals. The plaintiffs argued that the Tax Cuts and Jobs Act of 2017 — which amended the Individual Mandate to eliminate the penalty on individuals that failed to purchase qualifying insurance effect January 1, 2019 — rendered the Individual Mandate unconstitutional. The plaintiffs further argued that the Individual Mandate was inseverable from the rest of the ACA, and, therefore, that the entire ACA should be struck down.

The defendants in this case were the United States of America, the U.S. Department of Health and Human Services (HHS), Alex Azar, in his capacity as the Secretary of HHS, and David J. Kautter, in his capacity as the Acting Commissioner of the Internal Revenue Service (IRS). 16 states and the District of Columbia intervened as additional defendants.

In order to properly understand the district court’s ruling, it is necessary to revisit the Supreme Court’s 2012 decision on the constitutionality of the ACA, National Federal of Independent Business v. Sebelius (NFIB). In that case, 26 states, along with several individuals and a business organization challenged the ACA’s Individual Mandate and Medicaid expansion provisions as exceeding Congress’ enumerated powers. In a complicated decision, the majority of Justices ruled that the Individual Mandate was unconstitutional under Congress’ authority to regulate interstate commerce, but that the provision could be salvaged under Congress’ authority to lay and collect taxes. In reaching this conclusion, the majority of Justices focused on the “shared responsibility payment” aspect of the Individual Mandate, which imposed a tax on those individuals that failed to purchase or otherwise obtain qualifying health insurance. The majority of Justices concluded that the shared responsibility payment was a “tax.” It was therefore constitutional under the Congress’ general taxing authority.

In sum, the Supreme Court ruled that Congress lacked the power to compel individuals to buy qualifying health insurance, but that it could constitutionally impose a tax on those that failed to purchase or otherwise obtain qualifying health insurance.

In the current case, the court was asked to reconsider the Individual Mandate in light of the TCJA, which “zeroed” out of the shared responsibility payment, effective January 1, 2019. The plaintiffs argued that the Individual Mandate could no longer be justified as a valid exercise of Congress’ taxing authority. The federal government and its agents did not necessarily contest the plaintiffs’ argument with respect to the Individual Mandate. By contrast, the intervening states and the District of Columbia argued that the Individual Mandate could continue to be construed as a tax because it continues to satisfy the factors set forth by the Supreme Court in NFIB.

Judge O’Connor sided with the plaintiffs, holding that, because the Individual Mandate would no longer trigger a tax beginning in 2019, the Supreme Court’s ruling on this point in NFIB was no longer applicable. He therefore concluded that the Individual Mandate could no longer be upheld under Congress’ taxing authority. Judge O’Connor then fell back on the Supreme Court’s previous holding that the Individual Mandate, as a stand-alone command, remained unconstitutional under the Interstate Commerce Clause. Judge O’Connor then ruled that the Individual Mandate could not be severed from the rest of the ACA. On this point, the judge cited the express provisions of the ACA, as well as the Supreme Court’s decisions in NFIB and King v. Burwell.

What this decision means

On its face, the decision strikes down the Affordable Care Act in its entirety. However, the ruling is likely to be appealed to the Fifth Circuit Court of Appeals. Most legal experts expect that, regardless of the decision at the Circuit Court, the case is likely to make its way up to the Supreme Court.

Pending the resolution of these appeals, the Administration has adopted a “business as usual” approach. The White House has already indicated that it will not attempt to enforce the ruling during the appeals process. CMS Administrator Seema Verma recently tweeted that the decision will have “no impact to current coverage or coverage in a 2019 plan.”

The American Ambulance Association will continue to monitor this case as it makes its way through the appeals process, and we will notify our members of any new developments.

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