Reports of Ambulance Pilot Programs

Written by AAA Staff on . Posted in Medicaid, Medicare, Member Advisories, News, Regulatory, Reimbursement.

Earlier this week, health care trade press reported that the Centers for Medicare and Medicaid Innovation (CMMI) will be rolling out in the coming weeks several innovation pilot programs including a couple related to ambulance services. Over the last several months, the AAA has been meeting with CMMI and CMS officials about a pilot or change in policy to allow for coverage of transports by ambulance to destinations other than emergency departments. These efforts have coincided with efforts by others in the industry on alternative destination as well as reimbursement on some form of treat and refer of a patient.

The AAA is pleased that CMMI and CMS have listened to the recommendations of the AAA and other groups in moving forward on testing different policy changes. However, it is critical that the AAA and our members see the specifics of any pilot programs before we determine whether to support the initiative. CMMI cannot provide details of the program until available publicly and all the specifics of such programs are critical to whether they will be a success and if it will be a positive change for the industry and our ability to provide quality patient care.

We will provide you details of the pilot programs and the position of the AAA as soon as the details are made public. 

CMS Extends Moratorium on Non-Emergency Ground Services

Written by Brian Werfel on . Posted in Medicaid, Medicare, Member Advisories, Member-Only, News.

CMS Extends Temporary Moratorium on Non-Emergency Ground Ambulance Services in New Jersey and Pennsylvania

The Centers for Medicare & Medicaid Services (CMS) has announced that it intends to extend the temporary moratoria on the enrollment of new Medicare Part B non-emergency ground ambulance providers and suppliers in the states of New Jersey and Pennsylvania.  The extended moratoria will run through January 29, 2019.  Notice of the extension of the temporary moratorium will appear in the Federal Register on August 2, 2018.

Section 6401(a) of the Affordable Care Act granted CMS the authority to impose temporary moratoria on the enrollment of new Medicare providers and suppliers to the extent doing so was necessary to combat fraud or abuse.  On July 31, 2013, CMS used this new authority to impose a moratorium on the enrollment of new ambulance providers in Houston, Texas and the surrounding counties.  On February 4, 2014, CMS imposed a second moratorium on newly enrolling ambulance providers in the Philadelphia metropolitan areas.  These moratoriums were subsequently extended on August 1, 2014, February 2, 2015, July 28, 2015, and February 2, 2016.

On August 3, 2016, CMS announced changes to the moratoria on the enrollment of new ground ambulance suppliers.  Specifically, CMS announced that: (1) the enrollment moratoria would be lifted for the enrollment of new emergency ambulance providers and supplier and (2) the enrollment moratoria on non-emergency ambulance services would be expanded to cover the entire states of New Jersey, Pennsylvania, and Texas.  At the same time, CMS announced the creation of a new “waiver” program that would permit the enrollment of new non-emergency ambulance providers in these states under certain circumstances.  The revised moratorium on newly enrolling non-emergency ground ambulance providers was subsequently extended on January 9, 2017 and July 28, 2017.

On September 1, 2017, CMS issued a notice on its website indicating that it had elected to lift the moratorium on the enrollment of new Part B non-emergency ambulance suppliers in Texas, effective September 1, 2017.  CMS indicated that this decision was made to assist in the disaster response to Hurricane Harvey.  CMS published formal notice of the lifting of this moratorium on November 3, 2017.

On January 30, 2018, CMS announced an extension of the moratorium on the enrollment of new Part B non-emergency ambulance suppliers in New Jersey and Pennsylvania.

CMS will need to make a determination on whether to extend or lift the enrollment moratorium on or before January 29, 2019.

Physician Fee Schedule Proposed Rule 2018

Written by Kathy Lester on . Posted in Cost Data Collection, Government Affairs, Medicaid, Member Advisories, Member-Only, News, Reimbursement.

On Thursday, July 12, the Centers for Medicare & Medicaid Services (CMS) released the “Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment Program; and Medicaid Promoting Interoperability Program” Proposed Rule (Proposed Rule).

As you know, the American Ambulance Association worked closely with the Congress to ensure passage of the Bipartisan Budget Act of 2018 (BBA) (Pub. L. 115-123, enacted on February 9, 2018). The BBA not only extended the ambulance add-ons for 5 years, but also authorized a cost collection system that would not be overly burdensome on ambulance providers and suppliers, but would provide sufficient information ideally to support the permanent extension of the add-ons and set the basis for new payment models, including alternative destinations, treatment/assessment without transport, and community paramedicine.

After passage of the BBA, the AAA engaged immediate with CMS to ensure the smooth implementation of these provisions. Those contacts resulted in guidance earlier this year implementing the add-ons retroactively to January 1, 2019.

Consistent with the statute and already-released guidance, the Proposed Rule extends the three add-ons: the 2 percent urban, 3 percent rural, and 22.6 percent super-rural add-ons.  The Proposed Rule would codify the extension of the add-ons through December 31, 2022.

The Proposed Rule would implement the increase in the reduction in rates for non-emergency ambulance transports to/from dialysis facilities for services furnished on or after October 1, 2018. The 10 percent reduction applies for these transports furnished during the period beginning on October 1, 2013 and ending on September 30, 2018. The reduction will increase to 23 percent to conform the regulations to the statutory requirement for services furnished on or after October 1, 2018.

CMS does not request any information about the cost collection system in the Proposed Rule, but has been soliciting comments and recommendations through informal provider/supplier calls.  Additionally, the AAA has been in regular contact with CMS on the structure, design, and data elements to ensure the successful implementation of this critically important system as well.

CMS Open Door Forum & Follow Up AAA Member Q&A Call – Thursday, June 14

Written by AAA Staff on . Posted in Medicaid, Medicare.

The Centers for Medicare and Medicaid Services has scheduled its next Ambulance Open Door Forum for Thursday, June 14 at 2:00 PM Eastern. If you plan to attend, please dial in at least 15 minutes before the call.

CMS Ambulance Open Door Forum

June 14 | 2:00 PM ET
Participant Dial-In Number:  1-800-837-1935
Conference ID #: 33271311

Questions?

Have more questions? The AAA is here to help! Following the Open Door Forum, the AAA will host a Q&A conference call open to all members.

AAA Follow Up Q&A

June 14 | 3:00 PM ET
1-800-250-2600
Pin: 73556603#
Speakers: AAA Senior Vice President of Government Affairs, Tristan North; AAA Medicare Consultant, Brian Werfel, Esq.; AAA Healthcare Lobbyist, Kathy Lester, Esq.; AAA Medicare Regulatory Committee Chair, Rebecca Williamson; and AAA Medicare Regulatory Committee Vice-Chair, Angie McLain

March CMS Ambulance Open Door Forum & Follow Up Q&A

Written by AAA Staff on . Posted in Government Affairs, Medicaid, Medicare, News, Reimbursement.

CMS LogoThe next CMS Ambulance Open Door Forum is scheduled for Wednesday, March 7 at 2:00 PM Eastern. Please dial in at least 15 minutes before the call. View Agenda.

CMS Ambulance Open Door Forum
March 7 | 2:00 PM ET
1-800-837-1935
Conference ID: 31612304

Questions?

Have questions after the CMS Open Door Forum? The AAA is here to help! Following the Open Door Forum, the AAA will host a Q&A conference call open to all members.

AAA Follow Up Q&A
March 7 | 3:00 PM ET
1-800-250-2600
Pin: 73556603#

December CMS Ambulance Open Door Forum & Follow Up Q&A

Written by AAA Staff on . Posted in Government Affairs, Medicaid, Medicare, News, Reimbursement.

CMS LogoThe next CMS Ambulance Open Door Forum is scheduled for Thursday, December 14 at 2:00 PM Eastern. Please dial in at least 15 minutes before the call. View Agenda.

CMS Ambulance Open Door Forum
December 14 | 2:00 PM ET
1-800-837-1935
Conference ID: 61764351

Questions?

Have questions after the CMS Open Door Forum? The AAA is here to help! Following the Open Door Forum, the AAA will host a Q&A conference call open to all members.

AAA Follow Up Q&A
December 14 | 3:00 PM ET
1-800-250-2600
Pin: 82802314#

Response to Kaiser Health News Ambulance Billing Article

Written by Mark Postma on . Posted in Medicaid, Medicare, News, Press, Private Insurance, Reimbursement.

Below is the American Ambulance Association’s Response to a recent Kaiser Health News article on ambulance billing. It was reprinted in several metropolitan areas on November 20, 2017.

To the Editor:

I write today in response to Melissa Bailey’s November 20 piece about ambulance balance (“surprise”) billing. While we disagree with the characterization of ambulance services in the article, we welcome the ongoing public dialogue about how unsustainable reimbursement for emergency medical services results in cost-shifting to patients.

Missing from the article is a true understanding of the sky-high cost of readiness for emergency medical services. Ambulance service providers offer their communities 24/7/365 on-demand mobile healthcare. Skilled staff and ambulances—high-tech emergency rooms on wheels—are ready to respond to a 9-1-1 call at a moment’s notice to help patients with issues ranging from stroke to heart attack to trauma to childbirth. EMS is also on the very front lines of the surge in opioid overdoses, providing naloxone (Narcan) to hundreds of patients each day. Keeping supplies, medications, equipment, and personnel at-the-ready requires a significant ongoing investment, regardless of whether or not an ambulance is out responding to a call. Cost comparisons between EMS and the rideshare app Uber may make for catchy sound bites, but they are misleading and misguided.

The piece states that our nation’s 14,000 ambulance service providers received 1,200 Better Business Bureau complaints spread over three years. While certainly not optimal, this is a tiny, unrepresentative fraction of the tens of millions of responses ambulance service providers conduct annually. In fact, BBB 2016 statistics show that ambulance services receive far fewer complaints than hospitals, physicians, dentists, and many other trusted healthcare providers.

The article also offhandedly mentions that balance billing occurs when private insurers and ambulance service providers are unable to agree about fair reimbursement rates. This glosses over the dark reality that it would be hard to categorize the process that occurs between the insurer and ambulance services as a “negotiation.” Instead, insurers often present an all-or-nothing proposition to force ambulance service providers to accept contracts at unsustainably low reimbursement rates. Unlike the multi-billion dollar insurance behemoths, most ambulance services are small and operate on razor-thin margins. In fact, 73% of ambulance services provide fewer than 1,000 Medicare transports per year—just three per day. Ambulance services do not turn down insurance network contracts out of greed, but instead out of necessity. Facing reimbursement rates below the cost of the services they provide, they must decline these agreements in order to keep their doors open and continue to provide healthcare to their communities. Unfortunately, this sometimes creates a situation where out-of-network ambulance costs are shouldered by patients via balance billing, instead of insurers.

In addition to challenges receiving fair compensation from private insurance, EMS is stretched thin by ultra-low Medicare and Medicaid reimbursement rates. In fact, in 2007 and 2012 GAO studies showed that without temporary, Congress-authorized percentage increases in EMS payments, ambulance services would receive reimbursement from government payors below the cost of operations. These are often the very same unsustainable rates that private insurers are attempting to strong-arm EMS providers into accepting for network contracts.

Finally, when someone calls 9-1-1 in need of emergency medical care, it is key to recall that, unlike in other industries, an ambulance responds regardless of the patient’s ability to pay. In many cases, the patient does not have insurance and is financially unable to reimburse the ambulance service provider. Therefore, EMS provides a significant amount of uncompensated care, the cost of which must be spread across all payors in order for them to continue their life-saving operations.

Ambulance services provide an essential, on-demand healthcare benefit to their communities. Unfortunately our current healthcare payment structure means that much of this care is not compensated equitably, resulting in the necessity of balance billing patients. While there are no quick fixes for this issue, we encourage consumers to educate themselves about their own insurance coverage. We also ask for your support of legislation that provides sustainable reimbursement for ambulance providers, including the bipartisan US Senate Bill 967. Together, we can ensure the future of mobile healthcare in our great nation.

Mark Postma
President
American Ambulance Association
“Representing EMS In America”

 

Time to handle 911 call demands with Paramedics

Written by Scott McConnell on . Posted in Community, Legislative, Medicaid, Medicare, News, Training.

When discussing this new and growing field of pre-hospital care, there seems to be two unique paths that services are following. The first is the hospital-owned or contracted service, where community providers seek ways to decrease readmission rates for CHF, COPD, Pneumonia, Sepsis, MI and other chronic illnesses.

When a patient discharged with one of these targeted conditions is readmitted within a 30 day window, “hospitals face penalties of up to 3 percent of Medicare payments in 2018” (Gluck, 2017, para. 10). That is a lot of money. Consider, “Lee Health, Southwest Florida’s largest hospital operator, which is expected to lose $3.4 million in payments” (Gluck, 2017, para. 2). This model represents the if, or, and type of service, meaning if we can do it for less and there are providers willing to do this type of medicine, then we can save the expensive penalties from CMC.

The other model of community paramedicine is 911 abuse reduction. For years EMS has conditioned the public to call 911 for any emergency. But today, what we consider an emergency is far from the public’s perception of an emergency. “EMS has experienced a 37% increase in 911 calls since 2008.” (White, 2016, para. 6) Yet have we increased staffing proportionally to meet the demand? Afraid not since “only 50% of EMS services in 2008 were fully staffed, and more than 63% had a volunteer component as part of their staffing level” (“Critical Staffing Shortages,” 2015, para. 2).

The article references increasing wages to help compensate for the decrease in trained providers by attracting more professionals to the field. With the CMC limiting payments and the major insurance companies following suit, doubtful this will be an option in the near future.

To reduce calls and increase levels of service, we can try to reeducate the public to what is a true emergency, but that is a long and slow process. For example, Philadelphia has started the trend and placed several billboards up around neighborhoods that contribute an ordinarily high amount of non-emergent 911 calls. Will this work? Time will tell but I would believe not enough to affect the volume of calls.

What about enlisting Community Paramedics in these situations? I believe this is a viable solution with nurses triaging the low acuity calls in the 911 center. Dispatching Community Paramedics armed with not only the usual equipment, but also the knowledge base to connect these patients with primary care physicians, social workers, and the programs that are available to them. This will help people receive the long-term care they deserve.

Scott F. McConnell is Vice President of EMS Education for OnCourse Learning and one of the Founders of Distance CME. Since its inception in 2010, more than 10,000 learners worldwide have relied on Distance CME to recertify their credentials. Scott is a true believer in sharing not only his perspectives and experiences but also those of other providers in educational settings.

References
* Critical Staffing Shortages (2015)
* Gluck, F. (2017, February 7th, 2017). Lee Health will lose $3.4 million in Medicare payments because of readmission rates. USA Today
* White, D. (2016, February 16th, 2016). Community paramedic? program intended to reduce 911 calls. Manatee Technical College

Medicaid Replacement Plans

Written by Stacey Bickford on . Posted in Medicaid, Reimbursement.

Medicaid billing in emergency medical services is unavoidable. From trauma trips to non-emergency transports, ambulance providers face a multitude of hurdles when trying to identify, verify and bill the correct payor for Medicaid patients. Guesswork is often used instead of real-time insurance verification.

This can be especially true when commercial payors such as United Healthcare and Blue Cross Blue Shield manage the Medicaid plan, commonly termed Medicaid Replacement Plans. This article provides four valuable tips for successfully processing EMS claims when a Medicaid Replacement Plan is involved.

The Challenge for EMS Billing: Benefits Verification

Just as commercial payers see growth opportunities in managing Medicare Advantage (MA) plans, they are also overseeing hundreds of Medicaid programs. According to the annual CMS-64 Medicaid expenditure report, in federal fiscal year (FFY) 2016, Medicaid expenditures across all 50 states and 6 territories exceeded $548 billion, with nearly half of all spending now flowing through Medicaid managed care programs. On average 54.67% of Medicaid dollars are spent on managed care, whether to manage the transition or fund plans. This ranged from 97.9% in Puerto Rico, down to 12.1% in Colorado.

A single trip may have Medicaid benefits, but also managed by United Healthcare or another third-party commercial payer. The result? Blended coverage for Medicaid patients and confusion for providers.

Four Tips to Expedite Medicaid Verification

 When checking benefits for Medicaid patients, carefully review the standard eligibility response. Payors usually note benefit management by a commercial payer in the response, but there is no consistency in format or location. The Medicaid Replacement Plan notification may be placed at the top, middle or very bottom of the file. Furthermore, unnecessary additional information may be provided by the payor causing more confusion and time delays for EMS billers. For example, Cigna often includes dental, pharmaceutical and other specialty coverage details even though this information is never required for ambulance trips.

To avoid reimbursement delays with Medicaid Replacement Plans, implement the following four tactics:

Ask the eligibility vendor to place replacement plan information at the top of the file. If notification is placed in the same location and in the same format for every eligibility response, billers save time searching for coverage.

  1. Request that only pertinent coverage for the claim be included in the eligibility notification. If this is not possible, ask the payer to prioritize eligibility information by placing only the relevant coverage at the top.
  2. Take time to check and verify eligibility up front. Ensuring a clean and correct claim saves EMS providers back-end expense and expedites reimbursement due to fewer payor rejections and denials.
  3. Ask your EMS software vendor to integrate eligibility checking directly in your system’s workflow for real-time access during the pre-bill and billing processes. Technology integration saves billing time by eliminating the need to access and enter data into an outside payor portal or insurance discovery application.

Numerous EMS providers struggle with insufficient billing staff to manage claims. Take every step possible to streamline efforts and reduce duplicate work due to denied or rejected claims. When checking eligibility, proper identification and billing of Medicaid Replacement Plans is an essential step.

About the Author:
Stacey Bickford is the Operations and Client Coordinator at Payor Logic. She has been involved with medical billing since a teenager with prior experience in data entry, billing and office management for physicians’ practices, hospitals and especially EMS agencies. Prior to joining Payor Logic in 2016, Stacey started with ZOLL in 2008 as a support technician moving to Product Manager of RescueNet Billing through 2016.

In her free time, Stacey enjoys travelling with her family, Michael and their dogs Benjamin and Poncho. They’ve visited 21 states in the last 15 months! She loves hiking, gardening and being outdoors as much as possible.

 

CBO Estimates Senate Bill Would Leave 22M More Uninsured

Written by AAA Staff on . Posted in Government Affairs, Legislative, Medicaid, Medicare, News.

From Akin Gump:

The Congressional Budget Office (CBO) this afternoon released its cost estimate of the Senate’s health care bill, the Better Care Reconciliation Act (BCRA), projecting that the legislation would increase the number of uninsured by 22 million in 2026 relative to the number under current law. This is slightly fewer than the number of uninsured estimated for the House-passed American Health Care Act (AHCA). CBO also estimates that the BCRA would reduce federal deficits by $321 billion over 10 years, $202 billion more than estimated net savings for the House bill.

According to the Senate Budget Committee, below is a brief summary of the changes that were made to the previous draft:

  • Conforming amendments to Sec. 106 – Changes made to better align the purposes of stability funding to the underlying CHIP statute.
  • Adds a new Sec. 206 – Starting in 2019, individuals who had a break in continuous insurance coverage for 63 days or more in the prior year will be subject to a six month waiting period before coverage begins.  Consumers will not have to pay premiums during the six month period.
  • Redesignates Secs. 206-208 to Secs. 207-209, to accommodate for the new Sec. 206 on continuous coverage.

Read the CBO report.

 

CMS – MLN Ambulance Transports Booklet

Written by David Werfel on . Posted in Medicaid, Medicare, News, Reimbursement.

CMS has issued an MLN Ambulance Transports Booklet. The booklet (36 pages) can be downloaded here.

Download MLN Ambulance Transports Booklet

One section of the Booklet that you might want to keep handy involves Free-Standing Emergency Departments. Specifically, on page 15, CMS states the following:

Freestanding Emergency Department (ED)
If a freestanding ED is provider based (a department of the hospital), the ambulance transport from the freestanding ED to the hospital is not a separately payable service under Part B if the beneficiary is admitted as an inpatient prior to ambulance transport. For more information about criteria for coverage of ambulance transports separately payable under Part B or as a packaged hospital inpatient service under Part A, refer to Chapter 10, Section 10.3.3, of the Medicare Benefit Policy Manual.

This may be useful, along with the Manual section cited, when you have a free-standing ED that is part of a hospital and they call for transports to the main building for the patient to be admitted, but the hospital lists the time of admission as being prior to the time of your transport. When the hospital admits the patient prior to your transport, the hospital becomes responsible for the ambulance charges. It may be useful to show the hospital and ED the booklet and Manual section to prove to them that the hospital is responsible if the patient is admitted to the hospital prior to your transport.

UnitedHealthCare Denials for ALS-2 Claims

Written by Brian Werfel on . Posted in Medicaid, Medicare, Member-Only, Private Insurance, Reimbursement, Talking Medicare.

Talking Medicare

with Brian S. Werfel, AAA Medicare Consultant

Over the past few weeks, we have received emails from ambulance providers across the country reporting that UnitedHealthCare (UHC) has started to deny claims for the ALS-2 base rate. Affected claims include both commercial and Medicare Advantage claims. These providers are reporting that UHC is requiring the use of Current Procedural Terminology (CPT) Codes to support the ALS-2 level of service.

When these providers call UHC to question the denials, the customer service representative refers them to UHC’s online policies and procedures manual. The section of that manual devoted to the ALS-2 base rate largely mirrors Medicare’s definition. For example, it indicates that ALS-2 can be billed based on three separate administrations of one or more medications by IV push/bolus or continuous infusion, or upon provision of one or more of the designated ALS-2 procedures (e.g., an endotracheal intubation).

However, the manual section then goes on to indicate that “Ambulance Providers or Suppliers are required to report CPT or HCPCS codes… when reporting A0433.  Ambulance transport services that do not include the services described in criteria 1 or 2 above should be reported with a more appropriate ambulance transport code.”

The manual section concludes with links to two lists of CPT codes. The first list, designated as “ALS2 Criteria 1 Codes” relate to the intravenous administration of various medications. These codes fall within the range of: 96365 – 96376. The second list, designated as “ALS2 Criteria 2 Codes” correspond to the various ALS interventions:

CPT Code:                            Description:
31500                                    Endotracheal Intubation, Emergency
31603                                    Under Incision Procedures on Trachea and Bronchi
31605                                    Under Incision Procedures on Trachea and Bronchi
36000                                    Under Intravenous Vascular Introduction & Injection Procedure
36555                                    Central Venous Catheter Placement, Patient Under Five Years
36556                                    Central Venous Catheter Placement, Patient Over Five Years
36568                                    Insertion of Central Venous Access Device
36569                                    PICC Line Insertion
36680                                    Intraosseous Line Infusions
92950                                    Cardiopulmonary Resuscitation
92953                                    Other Therapeutic Cardiovascular Services
92960                                    External Electrical Cardioversion, Non-Emergency
92961                                    External Electrical Cardioversion, Emergency

The ambulance providers have indicated that they have questioned UHC on the necessity of including CPT codes on these claims. These providers argue, correctly, that CMS does not require the use of CPT codes on Medicare claims. Instead, Medicare requires the ambulance provider to document in the billing narrative the justification for billing ALS-2. For example, a provider might list multiple administrations of epinephrine, the use of an intraosseous line, etc.

The fact that UHC is asking for the CPT codes suggests that it does not currently review the billing narratives. Instead, UHC appears to be using the CPT codes to ensure that the ALS-2 criteria are met.

Is UHC correct to insist upon the use of CPT codes? Probably not, at least for its Medicare Advantage claims. However, I think the more appropriate question to ask ourselves is whether it is worth fighting UHC on this issue? If using CPT codes ensure that UHC correctly processes and pays these claims with minimal delay, my opinion is that it is probably easier just to comply with their policy.

Have an issue you would like to see discussed in a future Talking Medicare blog? Please write to me at bwerfel@aol.com.

CMS Letter Regarding Merit-Based Incentive Payment System

Written by Brian Werfel on . Posted in Medicaid, Medicare, Member Advisories, Member-Only, News, Regulatory.

Over the past week, multiple members have contacted the American Ambulance Association to report that they have received a letter from the Centers for Medicare and Medicaid Services (CMS) related to their participation in the Merit-Based Incentive Payment System (MIPS). The letter appears to have been sent to any entity with a taxpayer identification number (TIN) that is enrolled in the Medicare Part B Program. The stated purpose of the letter is to inform the provider whether it is exempt from participation in the MIPS program.

This member advisory is being issued to advise ambulance suppliers that:

(1) they are not eligible to participate in the MIPS program
(2) no positive or negative adjustments will be made to the ambulance suppliers Medicare payments
(3) no further action is required on their part

Therefore, AAA members that received this letter can safely disregard it. 

 

CMS Issues Final Market Stabilization Rule

Written by AAA Staff on . Posted in Government Affairs, Medicaid, Medicare, News, Regulatory.

On Thursday, April 13, the Centers for Medicare & Medicaid Services (CMS) released the final “Marketplace Stabilization Rule”. This is the final version of a rule that was first proposed on February 15, 2017. Last month, AAA consultant, Kathy Lester, published a blog post explaining the then proposed rule (“Administration’s Proposed Rule on Marketplace Stabilization”).

The final rule makes several policy changes to improve the market and promote stability, including:

    • 2018 Annual Open Enrollment Period: The final rule adjusts the annual open enrollment period for 2018 to more closely align with Medicare and the private market. The next open enrollment period will start on November 1, 2017, and run through December 15, 2017, encouraging individuals to enroll in coverage prior to the beginning of the year.
    • Reduce Fraud, Waste, and Abuse:  The final rule promotes program integrity by requiring individuals to submit supporting documentation for special enrollment periods and ensures that only those who are eligible are able to enroll. It will encourage individuals to stay enrolled in coverage all year, reducing gaps in coverage and resulting in fewer individual mandate penalties and help to lower premiums.
    • Promote Continuous Coverage: The final rule promotes personal responsibility by allowing issuers to require individuals to pay back past due premiums before enrolling into a plan with the same issuer the following year. This is intended to address gaming and encourage individuals to maintain continuous coverage throughout the year, which will have a positive impact on the risk pool.
    • Ensure More Choices for Consumers:  For the 2018 plan year and beyond, the final rule allows issuers additional actuarial value flexibility to develop more choices with lower premium options for consumers, and to continue offering existing plans.
    • Empower States & Reduce Duplication:  The final rule reduces waste of taxpayer dollars by eliminating duplicative review of network adequacy by the federal government.  The rule returns oversight of network adequacy to states that are best positioned to evaluate network adequacy.

Read the Final Rule

HHS Letter to Governors on Medicaid Changes

Written by Mark Postma on . Posted in Government Affairs, Medicaid, Member Advisories, Regulatory, Reimbursement.

On Monday evening, the Senate confirmed Seema Verma, MPH, as the new Administrator of the Centers for Medicare and Medicaid Services (CMS). She has a strong background in Medicaid, and prior to her appointment worked as a consultant to several States seeking Medicaid waivers.

One of her first acts was to issue a letter to governors with Secretary Tom Price, MD, regarding the Medicaid program. The letter highlights several initiatives on which they are focusing with regard to Medicaid. Perhaps of most importance to the ambulance community is the section on “Aligning Medicaid and Private Insurance Policies for Non-Disabled Adults.” In this section, the Secretary and Administrator suggest that States:

may consider creating greater alignment between Medicaid’s design and benefit structure with common features of commercial health insurance, to help working age, non-pregnant, non-disabled adults prepare for private coverage. These state-led reforms could include, as allowed by law: …waivers of non-emergency transportation benefit requirements.

While it may be meaningful that the reference does not include “medical,” before transport, it is critically important that the AAA work to protect Medicaid beneficiary access to medically necessary non-emergency medical transports. Thus, the Medicare Regulatory Committee is developing a letter and considering additional engagement with CMS to clarify that the reference is to programs related to providing beneficiaries with the cost of taxis, buses, or other transportation options, but not to medically necessary non-emergency ambulance transports.

It is important that AAA members speak out on this issue with their governors and State Medicaid officials. The AAA has developed draft talking points to assist with these contacts as well.

Thank you for your attention to this critical issue.

Mark Postma
President, American Ambulance Association
Representing EMS in America

Thank you to AAA Consultant Kathy Lester, JD, of Lester Health Law for the analysis of this issue.

Rep. Coffman Reintroduces VA Emergency Ambulance Service Bill

Written by AAA Staff on . Posted in Government Affairs, Legislative, Medicaid, Medicare, Reimbursement, Veterans Affairs.

On March 9, 2017, Rep. Mike Coffman [R-CO-6] reintroduced the Veterans Reimbursement for Emergency Ambulance Services Act (H.R. 1445).

The VREASA (Veterans Reimbursement for Emergency Ambulance Services Act) 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.

Currently, prior to reimbursement, the Department of Veterans Affairs (VA) requires 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 denied. The veteran is stuck with the bill.

Medicare, Medicaid, and other major payers adhere to the “prudent layperson” standard for the reimbursement of emergency ambulance services. The VA is the only major payer to not follow this standard. It is time we ensure our veterans are not stuck with the bill for their emergency ambulance service.

AAA Member, American Medical Response and their ‎VP Federal Reimbursement & Regulatory Affairs, Deb Gault, have been working with Rep. Coffman’s office to get this bill reintroduced.

Administration’s Proposed Rule on Marketplace Stabilization

Written by Kathy Lester on . Posted in Government Affairs, Medicaid, Medicare, Member Advisories, Member-Only, Private Insurance, Regulatory.

The Centers for Medicare & Medicaid Services (CMS) has released the “Marketplace Stabilization Proposed Rule” (Proposed Rule). Overall, the rule proposes a series of modifications to the Marketplaces that align with requests made by issuers in an attempt to keep them in the Marketplaces. The background section of the Proposed Rule emphasizes the concerns of issuers and the Agency’s interest in making sure that consumers have more plan options for 2018. Comments are due March 7.

While ambulance services are not directly mentioned, the Proposed Rule could affect the ability of individuals in the marketplace to enroll and remain enrolled in plans. Another provision that could impact the ambulance industry is the proposal to rely more upon the States to enforce the network adequacy requirements of the ACA.  

Changes to Open Enrollment/Special Enrollment Periods

CMS proposes to tighten the enrollment rules in several ways. First, the Proposed Rule would change the open enrollment period to November 1 – December 15 to “increase the incentives for individuals to maintain enrollment in health coverage and decrease the incentives for individuals to enroll only after they discover they require services.”[1]  Individuals may still be eligible for a special enrollment period that would allow them to enroll outside of these dates.

CMS would increase the States’ pre-enrollment verification from 50 percent to 100 percent beginning June 1, 2017, and require consumers’ enrollment requests to be “pended” until verification is complete. CMS encourages State-based Exchanges to adopt a similar policy. The Proposed Rule would also limit the ability of existing Exchange enrollees to change plan metal levels during the coverage year.  It would allow Exchanges to require enrollees that qualify for a special enrollment period because of a dependent to be add only to the current Qualified Health Plan (QHP) or allow the enrollee and the new dependent to enroll in another QHP within the same level of coverage.[2]

The Proposed Rule would also require that if an enrollee or the dependent is not enrolled in a silver level QHP and becomes newly eligible for cost-sharing reductions and qualifies for the special enrollment periods, the Exchange may allow the enrollee and dependent to enroll in only a QHP at the silver level.[3] CMS also proposes a new restriction that would allow the Exchange only to allow an enrollee and dependents who qualify for remaining special enrollment periods to make changes to their enrollment in the same QHP or to change to another QHP within the same level of coverage, if other QHPs at that metal level are available.[4]

CMS would allow consumers to start their coverage one month later than their effective date would ordinarily have been, if the special enrollment period verification process results in a delay in their enrollment such that they would be required to pay two or more months of retroactive premium to effectuate coverage or avoid termination for non- payment. [5]

Additionally, CMS would permit the issuer to reject an enrollment for which the issuer has a record of termination due to non-payment of premiums unless the individual fulfills obligations for premiums due for previous coverage.

The Proposed Rule also expresses concern that some consumers not seeking coverage until they are married. CMS proposes that if consumers are newly enrolling in QHP coverage through the Exchange through the special enrollment period for marriage, at least one spouse must demonstrate having had minimum essential coverage for 1 or more days during the 60 days preceding the date of marriage. There is a special rule for individuals who may not have been living in the United States prior to their marriage.[6]

The Proposed Rule would also significantly limit the use of the exceptional circumstances special enrollment period. In previous years, this special enrollment period has been used to address eligibility or enrollment issues that affect large cohorts of individuals where they had made reasonable efforts to enroll, but were hindered by outside events. If the proposal were adopted, CMS would apply a more rigorous test for future uses of the exceptional circumstances special enrollment period, including requiring supporting documentation where practicable. It would grant this special enrollment period only if provided with sufficient evidence to conclude that the consumer’s situation was truly exceptional and in instances where it is verifiable that consumers were directly impacted by the circumstance, as practicable.[7]

CMS is also exploring ways to incentivize consumers to maintain continuous coverage.

These proposed special enrollment changes would not apply to special enrollment periods under the Small Business Health Options Program (SHOP).[8]

Network Adequacy

CMS proposes changes to the oversight of network adequacy requirements to “affirm the traditional role of States in overseeing their health insurance markets while reducing the regulatory burden of participating in Exchanges for issuers.”[9]

CMS proposes to rely on State reviews for network adequacy in States in which an FFE is operating, provided the State has a sufficient network adequacy review process, rather than performing a time and distance evaluation. Beginning in plan year 2018, it would defer to the States’ reviews in States with the authority that is at least equal to the “reasonable access standard” and means to assess issuer network adequacy, regardless of whether the Exchange is a State-based Exchange or federally facilitated, and regardless of whether the State performs plan management functions.

In States without the authority or means to conduct sufficient network adequacy reviews, CMS would rely on an issuer’s accreditation (commercial or Medicaid) from an HHS-recognized accrediting entity. HHS has previously recognized 3 accrediting entities for the accreditation of QHPs: the National Committee for Quality Assurance, URAC, and Accreditation Association for Ambulatory Health Care. An unaccredited issuer would have to submit an access plan.

Interpretation of the Guaranteed Availability Requirement

CMS proposes revising the interpretation of the guaranteed availability requirement to allow issuers to apply a premium payment to an individual’s past debt owed for coverage from the same issuer enrolled in within the prior 12 month. CMS argues this change is necessary to “remov[e] economic incentives individuals may have had to pay premiums only when they were in need of health care services and to encourag[e] individuals to maintain continuous coverage throughout the year and prevent gaming.”[10]

De Minimis Variation in the Actuarial Values

CMS proposes increasing the de minimis variation in the actuarial values (AVs) used to determine metal levels of coverage for the 2018 plan year to “allow issuers greater flexibility in designing new plans and to provide additional options for issuers to keep cost sharing the same from year to year.”[11]

Essential Community Providers

CMS proposes allowing issuers to use a write-in process to identify essential community providers (ECPs) who are not on the HHS list of available ECPs for the 2018 plan year; and lower the ECP standard to 20 percent (rather than 30 percent).[12] 

[1] CMS Patient Protection and Affordable Care Act; Market Stabilization Proposed Rule.

[2]Id.

[3]Id.

[4]Id.

[5]Id.

[6]Id.

[7]Id.

[8]Id.

[9]Id.

[10]Id.

[11]Id.

[12]Id.

CMS Proposes Rule to Increase Patients’ 2018 Insurance Choices

Written by AAA Staff on . Posted in Government Affairs, Medicaid, Medicare, News, Regulatory.

This morning, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule for 2018. The AAA is currently drafting a member advisory on this proposed rule and it will be released soon. The text of the rule is below.

The rule proposes new reforms that are critical to stabilizing the individual and small group health insurance markets to help protect patients. This proposed rule would make changes to special enrollment periods, the annual open enrollment period, guaranteed availability, network adequacy rules, essential community providers, and actuarial value requirements; and announces upcoming changes to the qualified health plan certification timeline.

“Americans participating in the individual health insurance markets deserve as many health insurance options as possible,” said Dr. Patrick Conway, Acting Administrator of the Centers for Medicare & Medicaid Services.  “This proposal will take steps to stabilize the Marketplace, provide more flexibility to states and insurers, and give patients access to more coverage options. They will help protect Americans enrolled in the individual and small group health insurance markets while future reforms are being debated.”

The rule proposes a variety of policy and operational changes to stabilize the Marketplace, including:

  • Special Enrollment Period Pre-Enrollment Verification: The rule proposes to expand pre-enrollment verification of eligibility to individuals who newly enroll through special enrollment periods in Marketplaces using the HealthCare.gov platform. This proposed change would help make sure that special enrollment periods are available to all who are eligible for them, but will require individuals to submit supporting documentation, a common practice in the employer health insurance market. This will help place downward pressure on premiums, curb abuses, and encourage year-round enrollment.
  • Guaranteed Availability: The rule proposes to address potential abuses by allowing an issuer to collect premiums for prior unpaid coverage, before enrolling a patient in the next year’s plan with the same issuer. This will incentivize patients to avoid coverage lapses.
  • Determining the Level of Coverage: The rule proposes to make adjustments to the de minimis range used for determining the level of coverage by providing greater flexibility to issuers to provide patients with more coverage options.
  • Network Adequacy: The proposed rule takes an important step in reaffirming the traditional role of states to serve their populations. In the review of qualified health plans, CMS proposes to defer to the states’ reviews in states with the authority and means to assess issuer network adequacy. States are best positioned to ensure their residents have access to high quality care networks.
  • Qualified Health Plan (QHP) Certification Calendar: In the rule, CMS announces its intention to release a revised proposed timeline for the QHP certification and rate review process for plan year 2018. The revised timeline would provide issuers with additional time to implement proposed changes that are finalized prior to the 2018 coverage year. These changes will give issuers flexibility to incorporate benefit changes and maximize the number of coverage options available to patients.
  • Open Enrollment Period: The rule also proposes to shorten the upcoming annual open enrollment period for the individual market. For the 2018 coverage year, we propose an open enrollment period of November 1, 2017, to December 15, 2017.  This proposed change will align the Marketplaces with the Employer-Sponsored Insurance Market and Medicare, and help lower prices for Americans by reducing adverse selection.

Read the Proposed Rule

The Future of Prior Authorization

Written by Brian Werfel on . Posted in Medicaid, Medicare, Member Advisories, Member-Only, Reimbursement.

In May 2014, CMS announced the creation of a three-year demonstration project that calls for the prior authorization of repetitive scheduled non-emergency ambulance transports. The demonstration project was first implemented in the states of New Jersey, Pennsylvania, and South Carolina. These states were selected based on their higher-than-average utilization rates for repetitive ground ambulance transportation. For example, in a June 2013 report to Congress, the Medicare Payment Advisory Commission (MedPAC) cited these states as having particular high utilization rates for dialysis transports. Prior authorization went live in these states on December 15, 2014.

Congress Acts to Expand the Prior Authorization Regime

On April 16, 2015, President Barack Obama signed into law the Medicare Access and CHIP Reauthorization Act of 2015. Section 515 of that law required CMS to expand the demonstration program into five additional states (Delaware, Maryland, North Carolina, Virginia, and West Virginia) and the District of Columbia on or before January 1, 2016. The law further instructed CMS to expand the prior authorization regime to the rest of the country beginning no earlier than January 1, 2017. However, the national expansion was conditioned on CMS determining that the demonstration project has been effective in reducing Medicare expenditures without jeopardizing patient’s access to necessary medical care.

Short Term Prospects for Expansion

As of the end of January 2017, CMS has yet to issue its report on the effectiveness of the prior authorization program in the original 8 states and the District of Columbia. Therefore, there it is highly unlikely that CMS will be expanding the program nationally in the foreseeable future. However, CMS has not officially ruled out the possibility of expanding the program at some point during 2017.

While CMS has not officially ruled out a national expansion in 2017, I rate the prospect as unlikely. I base this statement simply on the calendar. Even if CMS were to issue the required certifications tomorrow, it would still need to give its contractors instructions on how to implement the program. It would also need to give some advance notice to the provider community. If you assume it would want to give everyone involved at least a month to prepare, it would be April at the earliest before it could expand the program. Personally, I have a hard time believing that CMS would go through all that trouble—not to mention allocating the necessary funding—for 8 months.

Long Term Prospects for Prior Authorization

While I rate the short term prospects for prior authorization to be unlikely, I think that our industry should expect prior authorization for repetitive patients to be part of our long term future.

The data thus far suggests that prior authorization is highly effective at reducing Medicare expenditures. In 2014, the last year before prior authorization went into effect, Medicare paid more than $106 million for dialysis transports in New Jersey alone. In 2015, total spending on dialysis decreased to slightly more than $15 million, a decrease of more than 85%. While there has been anecdotal reports of patients in the state being unable to obtain transportation to their dialysis appointments, there is little empirical evidence to suggest that these are anything other than isolated occurrences, or that prior authorization is contributing to a systematic lack of access. The data from Pennsylvania and South Carolina shows similar dramatic decreases in spending on dialysis.

Collectively, total spending on dialysis in these three states was approximately $140 million less in 2015 than 2014. This corresponds to nearly 20% of total dialysis spending in 2014. To put these reductions in their proper perspective, it may be helpful to remember that the Congressional Budget Office scores the cost of our existing temporary adjustments (i.e., the 2% urban, 3% rural and super rural adjustments) at approximately $100 million a year.

Some will argue that the 2015 reductions in these states were magnified by what can be charitably described as “friction” in the implementation of the program. (We recognize that affected providers in these states are likely to use far less charitable descriptions.) These people would argue that the reductions in subsequent years is likely to be less dramatic. CMS will be releasing 2016 payment data in a few months; at which point we will know whether this prediction proves true. Regardless of whether the data shows an uptick in payments in these states, that same data is almost guaranteed to show a dramatic decrease in total spending on dialysis in these states over the 2014 base year.

In sum, the data makes clear that prior authorization offers substantial cost savings to the federal government. Moreover, the overwhelming majority of these cost savings come from dialysis transports, an area that CMS has long-identified with fraud, abuse, and overutilization. This represents a tempting target for both CMS and Congress when looking for future cost-savings.

Have an issue you would like to see discussed in a future Talking Medicare blog? Please write to me at bwerfel@aol.com.

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