GAPBAC | AAA Comment Letter on Final Recommendations
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PBS NewsHour | The No Surprises Act left out ground ambulances. Here’s what’s happening now
Thank you to American Ambulance Association Secretary @WayneJurecki for standing up for patients and #EMS providers. @NewsHour #SupportEMS #GAPBAC #AlwaysOpen #NotJustaRide https://t.co/L982QAYr3X @EMS1 @jemsconnect @UKROBL1 @AIMHI_MIH @EMSWorldOFCL
— AmericanAmbulanceAsc (@amerambassoc) August 24, 2023
GAPBAC | Follow Up from Committee Meeting #2
Ground Ambulance and Patient Billing (GAPB) Advisory Committee Public Meeting #2 (August 16, 2023)
The Ground Ambulance and Patient Billing (GAPB) Advisory Committee Second Public Meeting was held on August 16, 2023. Materials for this meeting are available for download on the CMS.gov GAPB website.
As we continue this webinar series, we look to you as industry experts to provide feedback and recommend information that would be beneficial in future webinars. Written public comments for consideration by the Advisory Committee may be emailed to: GAPBAdvisoryCommittee@
Public comments on the specific topics listed in the GAPB Advisory Committee Public Meeting #2 Agenda, should be submitted by September 5, 2023 for consideration by the GAPB Advisory Committee.
FAIR Health | Ground Ambulance Services in the United States
From FAIR Health in February 2022
“Currently, no federal law protects consumers against “surprise” bills from out-of-network ground ambulance providers. Some state and local governments regulate ground ambulance surprise billing practices; however, such laws may not apply to all health plans or ambulance providers in an area. Because of the substantial policy interest in ground ambulance services, FAIR Health drew on its vast database of private healthcare claims to illuminate multiple aspects of such services across the nation, including utilization, costs, age, gender, diagnoses and differences across states.”
KFF 2020 Employer Health Benefits Survey
From the Kaiser Family Foundation on October 8
This annual survey of employers provides a detailed look at trends in employer-sponsored health coverage, including premiums, employee contributions, cost-sharing provisions, offer rates, wellness programs, and employer practices. The 2020 survey included 1,765 interviews with non-federal public and private firms.
Annual premiums for employer-sponsored family health coverage reached $21,342 this year, up 4% from last year, with workers on average paying $5,588 toward the cost of their coverage. The average deductible among covered workers in a plan with a general annual deductible is $1,644 for single coverage. Fifty-five percent of small firms and 99% of large firms offer health benefits to at least some of their workers, with an overall offer rate of 56%.
Survey results are released in several formats, including a full report with downloadable tables on a variety of topics, a summary of findings, and an article published in the journal Health Affairs.
CNBC | Why Ambulance Rides Are So Expensive In The United States
Thank you to American Ambulance Association Payment Reform Chair Asbel Montes for eloquently representing the EMS perspective on surprise coverage in this video from CNBC:
It’s an open secret in America that calling for an ambulance can be a financial gamble because of surprise bills. There’s no way for patients to know how much an ambulance will cost before they get inside the vehicle, and the final bill can be thousands of dollars. Here’s why ambulances are so expensive in the United States and what can be done to change it.
Statement for NBC Nightly News Balance Billing Story 3/9/18
Last night, NBC Nightly News with Lester Holt ran a segment on ambulance balance billing. Although provided with a brief one-paragraph statement in advance, they chose to use less than one sentence of it during the broadcast. We have reproduced our original statement below to provide additional context.
For a better understanding of the forces driving the costs behind ambulance care, please see this recent longer media response by American Ambulance Association President Mark Postma.
Video Story
Original Statement Provided by American Ambulance Association
Emailed to Eric Salzman on January 28, 2018 | Very brief due to TV news format
Ambulance providers, both private and public, serve their communities with lifesaving on-demand mobile healthcare 24/7, regardless of patients’ ability to pay. Ambulance services are saddled with a high cost of readiness as they keep certified personnel, sophisticated technology, and costly medications ready round-the-clock. Medicare, Medicaid, and private insurance often reimburse ambulance services at rates below the costs of providing this care, endangering their ability to continue serving families in their time of extreme need. Ambulance services bill patients as a last resort: This necessity is driven by a complex combination of rising patient deductibles, reduced insurance coverage, and unfair contractual negotiation techniques employed by insurers that leave patients with uncovered balances. Like most issues in our healthcare landscape, there are no quick fixes for these challenges. However, as dedicated healthcare professionals, we welcome ongoing public dialogue about how to bring sustainable reimbursement to ambulance providers in order to reduce cost-shifting to patients.
AETNA/CVS Deal Along with Uber Concepts May Finally Change Ambulance Industry
Mark Postma, AAA President & Asbel Montes, AAA Payment Reform Chair
The recent merger of Aetna/CVS may be the catalyst that finally brings the change that the ambulance industry has been advocating for over the past several years. This new healthcare strategy supports the ambulance industry’s ideas that alternative patient destinations are needed in EMS.
To explain this better, one must understand the current state of ambulance reimbursement via the 911 system or equivalent. At this point in time most commercial payers of healthcare (Insurance) as well as Medicare will not pay for 911 ambulance transportation to any destination other than the “nearest appropriate” hospital based emergency room; arguably, the most expensive and least efficient form of healthcare. The continuation of this policy discounts the advanced capabilities of both EMS and new clinical settings and the savings that can be achieved through innovative change. In addition, at the same time that the cost of healthcare in general is increasing, reimbursement from all payers is decreasing, creating a significant challenge for providers. Medicare consistently pays providers below cost for providing life-saving services and state Medicaid agencies are consistently underfunding the critical services to the un- and under-insured populations that have allowed intermediaries to delay or not pay ambulance services.
Much of the U.S. population believes that vital 911 EMS services or the equivalent are provided free or included in their local property taxes. This is generally not the case. While EMS services must be at the ready on a 24/7/365 basis, they are not paid for being on call, but only when the service is used.
Many communities have governing rules that require 911, or the equivalent, paramedic services to arrive on-scene within 8-12 minutes of receiving the call. This cost of readiness is VERY expensive. Skyrocketing personnel costs, ambulances, equipment, and other high cost drugs only exacerbate an already fragile reimbursement structure. Although recent articles about calling Uber or Lyft sound intriguing, these drivers and cars are not prepared for any type of injury. Nor can they alert the hospital in critical situations to have the heart cath lab ready or a trauma surgeon on standby, shortening the time to definitive care when time matters most. Emergency paramedics are highly trained, are nationally and/or state certified, and provide services on state regulated ambulances equipped to manage all types of emergencies. Ambulances are also often strategically placed to arrive in that 8-12 minute response time requirement. However, there is one piece missing from the ambulance scenario that allows for Uber/Lyft to succeed; your personal credit card is on file with them. NO GUARANTEED PAYMENT, NO TRANSPORT. The cost of providing ambulance services “on call” with life-saving equipment, medications, and personnel at the ready is steep. When you consider the many regulations providers must adhere to outside of patient care, the cost increases even more. This misunderstanding of the cost often results in patients being stunned when they receive a bill for services provided and feel that it is excessive. However, comparing the cost of a life-saving ambulance transport to an Uber/Lyft ride is like comparing the cost of building a house to putting up a tent.
On the other hand, these highly trained paramedics, with vehicles that are comprehensively (medically) equipped to meet the highest safety standards, have no credit card on file. They do not treat you based on your ability to pay. In fact, approximately less than half of ambulance patients have insurance, and when commercial insurance does pay, they are increasingly paying only a percentage of the total bill, leaving their insured left to pay the balance. In a time of an emergency, insurers should not place an additional burden on their insured through underpayment or claiming out of network status. In addition, although many emergency 911 calls begin as a “frantic call for help,” not all are life threatening and require the highest level of care; however, they do need some type of a health care intervention.
It is this high volume of low acuity patients who do not have primary care physicians and who currently by law must be transported to hospitals that continue to bottleneck emergency rooms. This bottleneck then requires ambulances to be “on the wall” at local hospital emergency rooms. The cost to the 911 EMS system rapidly begins a domino effect where all the patients begin to be diverted/directed to other hospitals causing an overflow to the next hospital. In large EMS systems, this domino effect can bring emergency rooms at all available hospitals to capacity quickly. EMS units are unable to go on additional emergency calls because they are caring for a patient while waiting on hospital staff to become available to take over. They also cannot leave that hospital with the patient to go to another hospital due to federal laws that prohibit this movement.
So why does the AETNA/CVS excite the leaders of EMS organizations? Most people assume that since this acquisition just occurred, Walgreens will probably follow suit with another insurer. Other local pharmacy “CVS types” may partner with local hospitals or medical insurance cooperatives as well. This leads the ambulance industry to believe that the capacity to transport patients to alternative locations could greatly change the landscape of EMS. The idea that local CVS/Walgreens/clinics could receive low acuity patients breaks open the bottleneck and can provide several benefits for the ambulance service and patient. One benefit is that adding these stores/clinics greatly increases the resources for caring for low acuity patients and could potentially double the locations an ambulance can transport to, which will allow for quicker transport times and increase efficiencies. Lastly, and most importantly, diverting the low acuity patients to these additional community resources would reduce overflow in the emergency departments and allow true emergency patients to be transferred over more quickly to receive the higher level of care they require. This scenario is also a win for the patient. They could be transported to the most appropriate location to care for their needs and therefore can be billed more accurately for services they require rather than the emergency department fees which are usually costlier.
To make this happen, obviously the CVS system needs to evolve to receive these patients. More importantly, ambulance reimbursement by federal, state, and private payers must evolve to meet the demands of the market. Due to the complexities of how EMS services are provided because of state and local regulations, mandatory response times, service area parameters, and others, reimbursement for these services must be adequately paid for by Medicare, Medicaid, and private insurers. Today EMS agencies can only “hope” that their patients have a source of payment!
Although one would think that this state of concern for EMS services is being monitored, it currently has only a very small voice in the healthcare continuum. Federal agencies seem to want to look at what EMS will look like in 10 to 25 years rather than where EMS is today and where it can develop over the next few years. EMS reform needs to happen soon to save these systems from bankruptcy and/or the public from higher taxation.
We hope that this merger will be the beginning of alternative EMS/ambulance destinations with allocated reimbursements that meet the costs of providing high quality, efficient, and necessary 911 ambulance services.
Mark Postma, COO, Sunstar Paramedics
American Ambulance Association, President
Works for Sunstar Paramedics, Florida’s largest EMS provider
MPostma@sunstarems.com, 727-224-0295
Asbel Montes, Vice President, Acadian Ambulance Service, Inc.
American Ambulance Association, Chair-Payment Reform Committee
Works for Acadian Ambulance Service, Inc., Louisiana’s largest EMS provider
Asbel.Montes@acadian.com, 337-291-3310
Balance Billing: AAA EVP Maria Bianchi on WOSU Ohio
The American Ambulance Association continues to defend ambulance providers in the face of misunderstandings regarding balance billing.
Today, AAA’s Executive Vice President Maria Bianchi provided context on WOSU’s All Sides with Ann Fisher. Maria called in during an interview with Melissa Bailey, author of the November 20 Kaiser Health News article to which association President Mark Postma recently responded. Maria’s comments helped listeners understand the complex reality of EMS funding.
Response to Kaiser Health News Ambulance Billing Article
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”
Patient Satisfaction and the Collections Conundrum
Emergency Strikes
The year was 2001—seems like a distant me
mory. Expecting our first child, my wife and I were living in Modesto, California, thinking about cradles and nurseries. We were so excited—the little one we’d been expecting was on his way! Excitement quickly changed to deep concern as we learned there were some major complications with the pregnancy and our baby was in serious jeopardy. Life’s pause button was pushed as everything else in the world came to a screeching halt.
An ambulance transport and emergency delivery later, we found ourselves in our new home—the neonatal intensive care unit. For the next four months, we worked with medical teams around the clock to slowly usher our new 1-pound, 4-ounce son, Noah (now 15 years old), into the world.
Financial Domino Effects
This was an incredibly stressful time in our lives. Of all the things that burdened us, one of the most memorable was the nearly $5,000 invoice we received for a specific service. With no clue how we would pay this, I finally worked up the courage to pick up the phone and call the number on the invoice. The provider was demanding immediate payment before sending the bill to collections.
Me? Collections? But I’m the good guy, right? People should be reaching out to care for me. What just happened? After days of multiple information exchanges between me, the billing office and my insurance carrier, we finally figured it out—all charges were to be covered by insurance.
While our care through this time was generally very good, this unexpected charge put a cloud over the provider who lacked the proper information—despite a 120-day inpatient stay. Why did the provider send our bill to collections without contacting us? Where was the disconnect? Does this still happen today?
Fast Forward 15 Years to Smarter Billing and Collections
Sadly, this is not an isolated incident. Everyone knows a person with a similar story. But what if this patient billing story could be different? What if instead of multiple collection agency invoices demanding payment, I had been contacted early in the process? Or better yet, what if everything had occurred behind the scenes between provider and payor?
Technology advancements have narrowed the data gap that created these and other tensions for patients, providers and insurance carriers. Health care providers today can better serve their patients and communities through technology. The systems required to instantly supply insurance information and ensure patient-friendly billing are now available. It’s a matter of awareness and investment. Two key technology strategies are rapidly emerging to make collection letters and calls a thing of the past.
Real-Time Insurance Discovery
Insurance discovery solutions help providers find hidden insurance coverage for patients up front versus after the fact. Especially in emergency or self-pay situations, patients may have coverage the provider doesn’t know about. Finding coverage provides a tremendous boost to patient satisfaction and financial engagement.
For providers, finding and securing coverage early in the encounter helps billing teams circumvent months of patient statement and collection efforts. Operational costs are reduced and payor reimbursement is hastened. Best practices are rapidly emerging on how to incorporate real-time insurance discovery within patient registration and billing workflows.
Payment Likelihood Determinations
Where insurance coverage can’t be found or high deductibles result in exorbitant patient financial responsibilities, checking “payability” becomes crucial. Patients with minimal cash reserves or low propensity to pay can be moved to charity care, Medicaid, or account write-off. Families likely to qualify for financial assistance are also quickly identified by using payment likelihood applications.
Billers and collectors are more efficient and effective without damaging patient relations or community reputation. It is often a smarter long-term decision to write off patient balances in those cases where personal bankruptcy is only one medical bill away.
Proactive financial engagement, insurance discovery and smart collections are in the early stages in healthcare. However, provider organizations that embrace more patient-friendly billing strategies can significantly promote patient satisfaction and long-term community benefits.
Ted Williams has been a featured presenter at regional and national EMS conferences, including the state medical associations, ambulance networks, and technology user group conferences. Williams is a founder of Payor Logic, a national provider of healthcare revenue cycle solutions.
UnitedHealthCare Denials for ALS-2 Claims
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.
Administration’s Proposed Rule on Marketplace Stabilization
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.
WTAE Shows 25% of Ambulance Calls Unpaid
WTAE Pittsburgh’s Action News recently published a great video investigative piece by Paul Van Osdol on the realities of ambulance funding.
So who pays for these and other non-transport calls?
“The folks that go to the hospital end up paying for the 25 percent that we don’t transport,” Porter said.
But even that does not cover the entire cost, and as a result, ambulance companies are hurting.
A survey of Allegheny County EMS services found 75 percent of them are losing money. On average, they collect only 43 percent of the amount they bill.
“That is frightening when you think about the EMS system as a whole,” Porter said. “The risk is burnout of EMS crews, overworked EMS crews, delayed response time, inadequately trained staff.”
Read the full article, and see their fantastic video, over at WTAE.com.
