Last night, the U.S. House of Representatives followed soon after by the United States Senate passed an approximately $900 billion legislative package to provide additional economic relief to businesses and individuals struggling from the COVID-19 pandemic. The package also contained numerous unrelated policy changes with several provisions on interest to ground ambulance service organizations. The AAA is currently analyzing the legislative text of the massive 3,000 plus page package and will provide members with the final analysis. In the meantime, below are some highlights.
Sequestration, which reduces Medicare reimbursement by 2% for Medicare providers and suppliers, is suspended through March 31, 2021.
Provider Relief Fund
An additional $3 billion is added to the Provider Relief Fund administered by the Department of Health and Human Services.
Health care providers will no longer be able to balance bill patients with private insurance. Rates will be determined through an arbitration process. The restrictions do not apply to ground ambulance services. The AAA along with the International Association of Fire Chiefs, International Association of Firefighters and National Association of EMTs successfully educated lawmakers about the oversight role of local governments in 911 EMS systems. The legislation instead establishes an Advisory Committee on Ground Ambulance Billing which will issue a report to Congress on its findings. The AAA will be pushing for representatives of the AAA to be on the Committee.
Paycheck Protection Program (PPP)
Another round of $284 billion in PPP funding is made available to small businesses hit especially hard by the pandemic. Businesses must employ 300 or fewer employees and report losses of 25% or more in order to qualify. For ground ambulance service organizations which receive PPP funds under the past round or the current one, expenses covered by forgiven funds will now be deductible.
Today’s AAA webinar, “Wrapping Up a Year for the Record Books”, will include an overview of the stimulus package. This webinar is free for AAA members. Register Here!
It appears that members of Congress on the House Ways & Means, Energy & Commerce, and Education & Labor Committees along with the Senate Health, Education, Labor, & Pensions Committee have reached a compromise agreement that will allow “surprise” billing legislation to be considered for passage before the end of the year. While the details of the legislation have yet to be unveiled, the American Ambulance Association has learned that it is likely to include provisions related to ground ambulance service and air ambulance service providers and suppliers.
Earlier legislation moved forward by the House Education & Labor Committee included a requirement for the Administration to create a Federal Advisory Committee to review ways to increase transparency around fees and charges for ground ambulance services and to better inform consumers about their treatment options. We believe that this language will be included in the compromise, but that there may be an opportunity to suggest modifications to make it more balanced and fairer in terms of the charge of the Committee and the types of individuals and organizations who will be selected to participate on it. The AAA is recommending that the Advisory Committee have at least a year to study and report on issues related to balance billing by ground ambulance service providers and suppliers, including the role of local and state governments in EMS systems amongst other considerations. It is also important that the Committee members include representatives from all types, sizes, and geographical areas of ground ambulance service providers and suppliers, as well as state EMS officials, and paramedics and EMTs.
It is likely that if the congressional leadership agree to move this legislation forward, it would be attached to the end of the year packages that may also include COVID-19 relief, Medicare extenders, and the annual spending bills.
As reported in various media outlets, on December 1 the Center for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) voted 13-1 to recommend that health care providers, expressly including EMS personnel, be prioritized to receive the COVID-19 vaccines during Phase 1a of the vaccine distribution plan. The complicating factor is that State and local governments have the final say in whether these recommendations are incorporated into their own distribution plans. Thus, we encourage all AAA members to engage actively with their State and local governments to urge the adoption of the CDC recommendation. The AAA has developed a toolkit for members to use in reaching out to their state and local government officials.
The AAA has been engaging with ACIP and other federal policy makers to urge them to prioritize EMS in the vaccine distribution plan. On November 19, the AAA submitted a comment letter to the ACIP advocating that the advisory committee specifically include EMS personnel in their recommendation of groups in the first phase of receiving the vaccination. Even though States and local governments will create their own list, having EMS listed in Phase 1a CDC recommendations is a critically important step toward influencing the State and local process.
During its second emergency meeting in less than a month, ACIP met to develop recommendations on the prioritization of vaccines, given that it will be impossible to provide access to everyone in the United States immediately after the vaccines are approved. In both virtual meetings, Committee members noted the importance of EMS personnel having access to the vaccine in the very top tier for prioritization. Other health care personnel on this list are defined as hospitals, long-term care facilities, outpatient clinics, home health care, pharmacies, and public health. The Phase 1a tier also includes residents of nursing homes, assisted living facilities, and other residential care settings, given that approximately 40 percent of all COVID-19 deaths have occurred in these settings. The final recommendation approved states:
When a COVID-19 vaccine is authorized by FDA and recommended by ACIP, vaccination in the initial phase of the COVID-19 vaccination program (Phase 1a) should be offered to both 1) health care personnel§ and 2) residents of long-term care facilities.
Health care personnel are defined as paid and unpaid persons serving in health care settings who have the potential for direct or indirect exposure to patients or infectious materials.
Long-term care facility residents are defined as adults who reside in facilities that provide a variety of services, including medical and personal care, to persons who are unable to live independently.
The CDC plans to publish this recommendation in the Morbidity Mortality Weekly Report as well.
The only controversial issue related to whether long-term care facility residents should receive the vaccine given the limited information available about its effectiveness and safety in these populations.
Because President Trump has indicated that State and local governments do not have to follow the CDC recommendations, it is critically important that AAA members work closely with their State and local governments to ensure that the CDC recommendations with regard to EMS are adopted by them as well. The AAA has posted a tool kit on our website to help our members provide the necessary information to their State and local governments as they are making these decision.
ACIP will continue to evaluate the distribution prioritization for Phase 1b, which will likely be non-health care essential workers, and Phase 1c, which will include adults with high-risk medical conditions and adults 65 years or older.
Educating your members of Congress about ambulance industry issues makes them more likely to support our policy efforts. An easy and effective way to educate them is to invite them to participate in a local Ambulance Ride-Along!
Congress is adjourned this week and will then again starting on August 7 for an entire month 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 our issues, in particular the need for additional COVID-19 financial relief, reimbursement for Treatment in Place during the pandemic, access to FEMA Public Assistance grants and coverage for all paramedics and EMTs under the Public Safety Officers Benefit (PSOB) program.
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. While COVID-19 has made a traditional ride-along difficult, you can still host them for a virtual site visit to show your operation and how you are handling the public health emergency. The AAA has made the process of arranging a ride-long or scheduling a meeting easy for you with our 2020 Congressional Ride-Along Toolkit.
Everything you need to arrange the ride-along or schedule a meeting during this time of social distancing and virtual participation is included in the Toolkit. Act now and invite your elected officials to join you on an Ambulance Ride-Along!
On June 12, 2020, the Office of Civil Rights (OCR) of the Department of Health and Human Services (HHS) published the long-awaited final rule which significantly changes several of the anti-discrimination provisions of Section 1557 of the Affordable Care Act. The final rule, which is a departure from the agency’s previous interpretation of the rules which were enacted 2016 during the Obama administration. Since, the enactment of the 2016 rules, there have been numerous legal challenges to these provisions in federal court. HHS believes that these final rules will reduce or eliminate provisions that they state were ineffective, unnecessary, and confusing and will save roughly covered entities roughly $2.9 billion in costs.
2016 Section 1557 Requirements
Section 1557 of the ACA were the anti-discrimination provisions geared at ensuring all individuals had access to essential benefits. When originally released in 2016, the Section 1557 rules prohibited discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs or activities, including discrimination on the basis of pregnancy, gender identity, and sex stereotyping. The 2016 Rule also required that covered entities:
2020 Section 1557 Final Rule
The Final Rule eliminated several key provisions of the 2016 Rule. The provisions that were eliminated included:
In addition to eliminating certain provisions, the final rule also relaxed the requirements relative to providing meaningful access to interpreter services for individuals with Limited English Proficiency (LEP). Under the 2016 rule, the agency assessed compliance with the meaningful access requirement by whether a covered entity established and implemented a Language Access Plan. This included providing access to interpreter services to individuals with LEP. The 2020 final rule requires covered entities only make “reasonable efforts” to ensure meaningful access to aides and services for individuals with LEP. However, the final rule does not change the requirements for meaningful access for individuals with disabilities or communication related disabilities.
The Bottom Line for EMS Providers
When the 2016 Section 1557 rule was enacted, the AAA sought guidance from OCR due to what we perceived to be compliance challenges for mobile-based healthcare providers. Our concerns were related to how mobile-based healthcare providers can ensure that the public and the patients we serve receive adequate notice of the protections afforded under Section 1557. As is often the case, when new regulations are enacted, they are enacted for standard “brick and mortar” healthcare providers, not ambulance services. At the time, our guidance was to post the required notices and taglines on your organization’s website and in the patient signature areas of your patient care report.
From a practical perspective, the enactment of this final rule will have limited impact for ambulance providers. Presuming an ambulance service’s compliance with the provisions of the 2016 rule, member companies can decide if they wish to eliminate their existing Compliance Coordinator position and Grievance Procedure. However, OCR still requires a covered entity to have written process for handling discrimination complaints. Therefore, it may be beneficial to simply maintain the 2016 requirements to ensure you can demonstrate compliance.
One welcome change is the elimination of the need to include the Section 1557 non-discrimination notices and taglines in every “substantial communication” with individuals. Many members voiced that they incurred a significant expense mailing the nondiscrimination notice and tagline requirements in every invoice or patient communication. This often added several additional pages to all patient communications which increased printing and postage costs substantially. Our recommendation is for ambulance providers to continue to make the non-discrimination notices and taglines available on your organizational website and in any electronic communications as these mediums do not significantly increase costs.
OCR has numerous compliance assistance documents on their website. Additionally, members can contact the AAA for assistance with these regulatory changes.
The Equal Employment Opportunity Commission (EEOC) issued updated guidance yesterday titled, What You Should Know About COVID-19 and the ADA, the Rehabilitation Act, and Other EEO Laws yesterday. The updated guidance addresses employers who wish to require employees to have a COVID-19 antibody tests prior to re-entering the workplace. The guidance consists of seventeen pages of Frequently Asked Questions (FAQ) to assist employers as they navigate this truly unprecedented time for employers and employees during a pandemic.
The updated guidance alerts employers that they may not require employees to undergo COVID-19 antibody testing as this would constitute an unlawful “medical examination” under the Americans with Disabilities Act (ADA). Under the ADA, employers are limited in the medical related inquiries that they can make of employees. Medical related inquiries can be considered a Medical Examination and are strictly regulated under the ADA and the Rehabilitation Act. Under the ADA, an employer “shall not require a medical examination and shall not make inquiries of an employee as to whether such employee is an individual with a disability or as to the nature and severity of the disability, unless such examination or inquiry is shown to be job-related and consistent with business necessity.” 29 CFR § 1630.14. The reason certain medical examinations are prohibited is due to the likelihood that the examination may identify medical conditions that constitute a protected disability under the ADA.
The EEOC has issued previous guidance that permits COVID-19 viral testing in the employment setting. The distinction between the antibody test and the viral test is the presence of active virus and the obligation of employers to provide a workplace that is free from known hazards. The viral tests are generally administered prior to the employee entering the workplace and are considered “job related and consistent with business necessity.” Additionally, employers may take the body temperatures of employees as they enter the workplace and at intervals during their shift. However, employers must be aware that some individuals with COVID-19 are asymptomatic and may not have an elevated body temperature. Additionally, the records related to taking employee temperatures are confidential and should be maintained with other employee medical records.
The best practice for employers, have a documented plan. Ensure that all employees understand their role in controlling the spread of the virus.
Be sure employees:
If you have questions or your organization needs assistance in determining if you have the appropriate safeguards in place, be sure to reach out to the AAA for help.
On April 27, the CDC issued an update to its Guidance on “Evaluating and Testing Persons for Coronavirus Disease 2019” in which “first responders with symptoms” are now in the category of “highest priority” as to the prioritization of groups who should be tested for COVID-19. The AAA has been advocating to federal agencies and the Congress to move first responders to the highest level of priority for COVID-19 testing. The update can be viewed at HERE.
On April 9, the AAA and the National Association of Emergency Medical Technicians (NAEMT) sent a letter to U.S. Attorney General William Barr requesting the Department of Justice extend coverage under the Public Safety Officers’ Benefits (PSOB) program to all paramedics and EMTs during the COVID-19 national health emergency. While paramedics and EMTs employed by governmental and non-profit EMS agencies are currently eligible for the program, those employed by private for-profit organizations and on the front lines of responding to COVID-19 pandemic are not covered. Read Letter HERE.
The National Association of State EMS Officials (NASEMSO) has released its 2020 EMS Assessment, updating the 2011 report. This report provides unparalleled insights into the EMS systems that provide mobile healthcare across our nation. We highly recommend that you download the full report at www.nasemso.org/2020-assessment.
(Falls Church, Va.) In the midst of the COVID-19 pandemic and applause for first responders in the United States, the National Association of State Emergency Medical Services Officials (NASEMSO) has released the 2020 National EMS Assessment updating the 2011 assessment. The 2020 assessment provides a comprehensive accounting by state/territory of the numbers and types of all 911 ambulance services and emergency medical services (EMS) professionals.
The 2020 National EMS Assessment is the first set of documentation about these critical emergency medical response personnel and agencies to be published in nearly 20 years. Every year in times of disasters, disease outbreaks and daily medical emergencies, such as heart attacks and car crashes, out-of-hospital emergency medical care systems make life-and-death differences in the lives of millions of Americans. EMS systems are the safety net for hospital emergency departments and public health as the front lines of response to 911 calls. Additionally, responders place themselves in high risk situations on a daily basis, as well as during communicable disease outbreaks and pandemics.
Data collection for this assessment was completed in 2019 by NASEMSO members, who are the staff of the state agencies that license America’s critical EMS personnel and agencies. State EMS offices protect the public by regulating the human and organizational components of EMS systems across the United States, as well as executing their legislative mandates to implement and improve systems of care for time-sensitive emergencies in order to offer every patient an opportunity for survival and optimal outcomes. The assessment provides the following key findings:
More than 18,200 local EMS agencies respond to 911 calls for medical emergencies and injuries, utilizing nearly 73,500 ground vehicles such as ambulances and fire engines.
Local EMS agencies respond to nearly 28.5 million 911 dispatches every year in 41 states.
More than 750 services are licensed by state EMS offices to fly patients, using helicopters and fixed-wing aircraft to provide rapid transportation to critical care.
More than 1.03 million personnel are licensed as emergency medical technicians, paramedics, and other levels of EMS patient care capability within all 50 states, the District of Columbia, Puerto Rico and American Samoa.
More than 9,300 physicians serve as local EMS Medical Directors, assuring that contemporary and quality care is provided to patients.
Sixty percent of 53 state EMS offices participated or expect to participate in mass casualty exercises involving a biological threat during the 18-month evaluation period.
The report is available from NASEMSO at www.nasemso.org/2020-assessment.
Earlier today, the AAA sent a letter to Treasury Secretary Mnuchin asking that he use his discretionary authority to apply the same terms of the Paycheck Protection Program (PPP) to ambulance service organizations with 500 or more employees. The PPP, established by the CARES Act, is only available to businesses with 500 or fewer employees and provides more favorable loan terms based on the retention of employees. Read the letter HERE.
The Centers for Medicare and Medicaid Innovation (CMMI) has announced the delay of the start of the ET3 Model Pilot Program. CMMI has delayed the program until the fall of this year. The program was set to begin on May 1. In its notice, CMMI also referenced the interim final rule providing waivers for transport to alternative destinations and other regulatory flexibility previously reported by the AAA.
ET3 Model Timeline Delay and Important Updates
ET3 Model Stakeholders,
Thank you for your engagement to date related to the ET3 Model. The Centers for Medicare & Medicaid Services (CMS) is seeking to support the community of organizations that are responding to the public health emergency stemming from the Novel Coronavirus Disease (COVID-19). As CMS and ET3 Model selected applicants work to respond to needs due to COVID-19, CMS has decided to delay the start of the ET3 Model from May 1, 2020 until Fall 2020.
CMS appreciates your continued support and enthusiasm for the innovations available under the ET3 Model, and as such, we will continue to communicate information and updates about the Model through this listserv.
Important Updates Regarding CMS Flexibilities to Fight COVID-19
In addition, we want to inform ET3 Model stakeholders that CMS recently announced in a press release an Interim Final Rule with Comment Period (IFC) that provides temporary regulatory waivers and new rules to equip the American healthcare system with maximum flexibility to respond to the 2019 COVID-19 pandemic. The IFC and all of CMS’s Coronavirus Waivers & Flexibilities can be found here.
The flexibilities offered specifically to ambulances during the Public Health Emergency (PHE) for the COVID-19 pandemic can be found at this link: Ambulances (PDF). This includes temporarily expanding the list of allowable destinations for ground ambulance transports during the COVID-19 PHE to include any destination that is equipped to treat the condition of the patient in a manner consistent with state and local Emergency Medical Services (EMS) protocols in use where the services are being furnished. These destinations may include, but are not limited to: any location that is an alternative site determined to be part of a hospital, CAH or SNF, community mental health centers, federally qualified health centers (FQHCs), rural health clinics (RHCs), physician’s offices, urgent care facilities, ambulatory surgical centers (ASCs), any location furnishing dialysis services outside of the ESRD facility when an ESRD facility is not available, and the beneficiary’s home. Home may be an appropriate destination for a COVID-19 patient who is discharged from the hospital to home to be under quarantine. There must be a medically necessary ground ambulance transport of a patient in order for an ambulance service to be covered.
These actions, and earlier CMS actions in response to COVID-19, are part of the ongoing White House Coronavirus Task Force efforts. To keep up with the important work the Task Force is doing in response to COVID-19, visit www.coronavirus.gov. For a complete and updated list of CMS actions, and other information specific to CMS, please visit the Current Emergencies website.
Thank you again for your interest in the Model and for your efforts to improve the quality of care in the EMS industry.
If you have any questions about this update, please contact the ET3 Model team at ET3Model@cms.hhs.gov.
|Centers for Medicare & Medicaid Services (CMS) has sent this Emergency Triage, Treat, and Transport (ET3) Model Update. To contact Centers for Medicare & Medicaid Services (CMS) go to our contact us page.|
On April 3, Congressman Bill Huizenga (R-MI) introduced the Helping Emergency Responders Overcome Emergency Situations Act of 2020 “HEROES Act of 2020” (H.R. 6433). H.R. 6433 would exclude from gross income, the wages (not to exceed $50,000) from February 15 to June 15 of qualified first responders. Those wages would therefore essentially be tax-free. A definition of a qualified first responder specifically includes paramedics and EMTs who provide services in a county with at least one confirmed case of COVID-19. The language would apply to all paramedics and EMTs regardless of their employer type. The AAA had reached out prior to the introduction of the bill to staff with Congressman Huizenga to ensure that would be the case.
On April 6, the AAA sent a letter to Health and Human Services Secretary Azar requesting that the Department distribute direct payments to all ambulance service providers and suppliers who are on the front lines of the COVID-19 pandemic. The AAA requested funding under the $100 Billion Public Health and Social Service Emergency Fund, established by the CARES Act, in the amount of $48,000 per ambulance registered as of April 1. The AAA estimates the payments would represent approximately $2.6 billion in desperately-needed relief for our industry. Read the letter HERE.
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.
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.
The American Ambulance Association is pleased to announce the release of its 2020 Medicare Rate Calculator tool. The AAA believes this is a valuable tool that can assist members in budgeting for the coming year. This calculator has been updated to account for recent changes in Medicare policies, including the 2020 Ambulance Inflation Factor (0.9%) and the continuation of the current temporary add-ons.
To access the Rate Calculator, please CLICK HERE.
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.
This past Tuesday and Wednesday, respectively, the House Ways & Means and Education & Labor Committees marked up their proposals on balance or “surprise” billing. As we reported on Monday of this week, the Ways & Means Committee proposal, the Consumer Protections Against Surprise Medical Bills Act (H.R. 5826), did not include a provision on ground ambulance services. The House Education & Labor proposal, The Ban Surprise Billing Act (H.R. 5800), however, included a provision to create a federal advisory committee to recommend restrictions on the ability of ground ambulance service providers and suppliers to balance bill.
The Ways & Means Committee reported out H.R 5826 favorably by voice vote. While the Education & Labor Committee also reported out H.R. 5800 favorably, the vote was 30 to 13 as a block of its Committee members preferred the approach of the Ways & Means proposal on how to address balance billing for other providers. It is now up to House leadership to determine next steps on how the chamber will approach a final package on balance billing.
While H.R. 5800 as reported out by the Education & Labor Committee still includes the provision on ground ambulance services, Chairman Scott (D-VA) and Ranking Member Foxx (R-NC) prior to mark up had removed the most problematic language in the bill. As introduced, H.R. 5800 would have given the Department of Health and Human Services the authority to issue regulations to restrict balance billing based on the findings of the advisory committee. This would have eliminated federal lawmakers from being able to evaluate the recommendations prior to the changes being implemented. The language was removed in the chairman’s mark of the bill, and thus the Congress would now have an opportunity to debate and craft legislation on the recommendations.
The AAA along with the International Association of Fire Chiefs (IAFC), International Association of Firefighters (IAFF) and National Association of EMTs (NAEMT) had advocated against the ground ambulance provision. We thank Chairman Scott, Ranking Member Foxx and members of the Committee for listening to our concerns and removing the regulation authority language.
Only one of the four pieces of legislation on balance billing reported out by congressional committees includes a provision on ground ambulance services. We will continue to advocate to preserve the ability of local governments to determine the rates and standards for their EMS systems and against the inclusion of a ground ambulance provision in a final package on balance billing.
We will keep you apprised of new developments on the issue.