VA Issues Rule Expanding Coverage of Ambulance Services

Veterans Administration Issues Interim Final Rule Expanding
Coverage of Ambulance Services under Millennium Bill

On January 9, 2018, the Department of Veterans Affairs issued an interim final rule that would amend its policy for payment of Millennium Bill claims. The Millennium Bill authorizes the Veterans Administration (VA) to pay for emergency care provided to veterans in non-VA facilities — including emergency ambulance transportation — provided the veteran has no other health insurance that would cover the costs of such emergency care. These changes were necessitated, in part, by a recent decision of the U.S. Court of Appeals for Veterans’ Appeals (Staab v. McDonald, 28 Vet. App. 50, 2016).

The two major changes being made by the interim final rule are: (1) the expansion of payment eligibility to include veterans who received partial payment or reimbursement from a health plan for their non-VA emergency care and (2) the expansion of payment eligibility for emergency transportation associated with a veteran’s receipt of emergency treatment in a non-VA facility.

These changes went into effect on January 9, 2018.

Relevant Background

38 U.S.C. §1725 authorizes the VA to reimburse veterans for the costs of emergency treatment for non-service connected conditions furnished in a non-VA facility, provided certain criteria were met. One requirement was that the veteran be personally liable for the costs of that emergency treatment. As originally enacted in 1999, the statute indicated that the veteran would be personally liable if the veteran: (1) has no entitlement to care or services under a health-plan contract and/or (2) the veteran had no contractual or legal recourse against a third party that would, in part or in whole, extinguish such liability. The VA historically interpreted its payment obligations under the Millennium Bill to be limited to situations where the veteran had no entitlement to coverage under their health insurance or any other contractual or legal recourse against a third party.

The Expansion of Veteran Eligibility for Reimbursement Act of 2010 amended the requirements related to non-health insurance payments to remove the phrase “in part”. As a result, the VA revised its regulations to permit it to make a payment under the Millennium Bill in situations where automobile or other forms of non-health insurance made a partial payment, and where the veteran remained liable for the balance of the health care provider’s bill. However, there was no corresponding change made to the provisions related to health insurance contracts. As a result, the VA continued to view partial payment by a health plan as a bar to payment by the VA.

In Staab, the Court of Appeals adopted a more lenient interpretation of the statute, i.e., a more restrictive view of the VA’s statutory bar on reimbursement. Specifically, the Court held that the reimbursement bar would only apply when the payment from the health plan fully extinguished the veteran’s liability. The practical effect was to place health insurance plans on equal footing with other forms of insurance. The Court remanded the case back to the lower court for further proceedings.

The VA subsequently appealed the Court of Appeals decision. However, on June 14, 2017, Veterans Affairs Secretary David Shulkin announced that the Department would drop its appeal.  Reversing course, Secretary Shulkin indicated that the VA had drafted regulations to implement the expanded Millennium Bill coverage. Those regulations form the basis of this interim final rule.

Provisions of Interim Final Rule

Partial Payment from Health Insurance Plan

The VA revised its regulations at 38 C.F.R. §17.1002(f) to indicate that the VA will make payment under the Millennium Bill to the extent the veteran otherwise qualifies for coverage to the extent that the veteran “does not have coverage under a health-plan contract that would fully extinguish the medical liability for the emergency treatment.” The VA retained the reimbursement bar for situations where the veteran would have been covered under a health plan had the veteran or the provider failed to comply with the requirements of that health plan, e.g., by failing to submit a timely claim. This change will apply to: (1) all claims pending with the VA as of April 8, 2016 or (2) submitted after that date.

Expansion of Payment Authority for Emergency Transportation

The VA historically viewed emergency ambulance transportation to the non-VA facility as part of the overall emergency treatment of the veteran. As a result, the VA believed that a health plan’s payment for the hospital care, in whole or in part, triggered its reimbursement bar. One common situation that impacts ambulance suppliers involves veterans that have Medicare Part A benefits (which cover the costs of their hospital care), but where the veteran has elected to forego paying for Medicare Part B.  In these situations, Medicare would pay for the hospital care. The VA took the position that this triggered the reimbursement bar, and therefore prevented it from making payment for the emergency ambulance transportation.

Because the interim final rule expands Millennium Bill coverage to include situations where a health plan makes a partial payment, the VA found it necessary to amend its regulations governing the payment of ambulance claims. Specifically, the VA amended its regulations at 38 C.F.R. 17.1003 to provide that ambulance providers will now be eligible for payment provided the following conditions are met:

  1. Payment for emergency care provided at the non-VA facility is authorized or would have been authorized had:
  2. The veteran’s personal liability for the emergency treatment was not fully extinguished by payment by the health plan or other third-party; or
  3. Death not occurred before emergency treatment (at the hospital) could be provided);
  4. The veteran is financially liable to the ambulance provider;
  5. The veteran does not have coverage under a health insurance plan that would fully extinguish the medical liability for the emergency transport (and further provided that the veteran or the provider has timely filed a claim with the health plan);
  6. If the emergency transportation is the result of an accident or work-related injury, the veteran must have reasonably exhausted his remedies against a third-party payor (e.g., auto insurance policy or workers’ compensation policy); and
  7. The veteran remains liable for all copayments and deductibles.
Effect of Coinsurance and Deductibles

The A.A.A. has confirmed that the VA does not consider the coinsurance or deductible obligations imposed by a veteran’s health plan for the purposes of determining whether the veteran’s liability has been fully extinguished by the health plan’s payment.

Therefore, in situations where the veteran has health care coverage, payment by the VA is likely to be limited to situations where the ambulance provider is permitted under state and local laws to bill patients for the difference between their billed charges and the amounts allowed by the health insurer, i.e., those areas that currently permit balance billing. This would also mean that the VA would be unlikely to have any payment responsibility in situations where Medicare has made payment on the ambulance claim (although it leaves open the possibility that the VA may be responsible for non-covered Medicare services such as excess mileage).

Amount of Payment

 When the VA pays under this expanded Millennium Bill authority, its payment will be based on the following methodology:

  1. When the veteran has no coverage under a health plan or other third-party payor, the VA will pay the lesser of: (a) the amount for which the veteran is personally liable or (b) 70% of the applicable Medicare allowable;
  2. When partial payment is made by a health plan or other third party payer, the VA will pay the difference between: (a) the amount the VA would have paid under the preceding bullet point (typically 70% of the Medicare allowable) or (b) the amount paid (or payable) by the health plan or other third-party payor; provided that amount is greater than zero;
  3. If the calculation in the preceding bullet point would not result in the VA making a payment (i.e., because the resulting amount would be less than zero), the VA will pay the lesser of: (a) the veteran’s personal liability after the third-party payment (excluding deductibles and copayments) and (b) 70% of the applicable Medicare allowable;
  4. In the absence of a corresponding allowable, the VA will be the lesser of: (a) the amount for which the veteran is personally liable or (b) the amount calculated by the VA Fee Schedule in 38 C.F.R. 17.56(a)(2)(i)(B).

Payment from the VA is generally considered to be payment-in-full, and extinguishes the veteran’s remaining liability to the provider for unpaid amounts. Note: the veteran would remain liable for unpaid co-payments and deductibles. If the provider does not wish to accept the VA’s payment, it has 30 days from its receipt of such payment to reject and refund the payment.


Have any Medicare questions? Contact Brian at bwerfel@aol.com

Rep. Coffman Reintroduces VA Emergency Ambulance Service Bill

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.

House Holds Hearing on Veterans Choice Program

The House VA Committee hearing started at 7:30 p.m., but it was well-attended and lasted until 10 p.m. The witnesses included Senator John McCain (R-AZ), VA Secretary David Shulkin, and representatives of the VA Office of Inspector General and the Government Accountability Office. Senator McCain and Secretary Shulkin were both warmly welcomed by Members of…

This content is available only to AAA members.
Log In or Register

February Employment Law Updates

Last month I suggested that many of our states are the incubators for employment legislation and that ambulance services need to keep an eye on legislation at the local level and get involved if the legislation effects your business.  The leader in employment legislation from a state perspective is California.  This article highlights several pieces of legislation that were filed this year that will impact employers.

As I have stated several times in prior posts, webinars, and live sessions, the “Ban the Box” movement is growing momentum.  California has introduced a bill that will extent current “Ban the Box” protections applicable to State and City employers to private employers.  This would prohibit inquiries about a candidate’s criminal history until after a conditional offer of employment was made.

This is just one of the bills that were introduced.  The other include, Right to Work, Veteran’s Preference, and Employees and dependents Reproductive Health protections.  In addition, Assemblyman Freddie Rodriguez introduced legislation that may drastically impact private EMS providers and how they operate their service.

Last December the Department of Labor released final rule revising the claims procedure requirements for disability benefit plans under the Employee Retirement Income Security Act (ERISA).  The new rules are intended to add more procedural safeguards and protections for those filing claims under the plan.  For most employers who purchase or utilize a fully funded disability plan, these new requirements will fall to the insurer.  However, employers should be sure that the carrier is including these requirements in their plans as they are ultimately the plan fiduciaries.  The Society for Human Resource Management has a great article which summarizes the new rule requirements.

Maximizing VA Reimbursements on Emergency Conditions

Asbel Montes, AAA Payment Reform Committee co-chair and all-around reimbursement expert, recently developed some great quick tips on billing the US Department of Veterans Affairs for ambulance services.

Do you have a process in place to identify when a transported individual is a veteran being carried to a non-VA facility? In an emergency condition, it may prove very beneficial for you to have a consistent process within your billing department to ensure that you can identify these patients in order to maximize reimbursement, while also avoid billing the patient inappropriately… READ MORE►

downloadRead Asbel’s full article over on www.reimbursementanswers.com, or learn more in person at the upcoming June 9 AAA Regional Workshop in the San Francisco area!

Boustany (R-LA 3rd) Introduces the Timely Payment for Veterans’ Emergency Care Act

On March 3, 2016, Congressman Charles W. Boustany, Jr., MD, republican representative of Louisana’s 3rd district, introduced the Timely Payment for Veterans’ Emergency Care Act. According to data obtained by Boustany from the VA’s Chief Business Office, the VA has a nationwide emergency claims payment backlog of over $788 million.

When the VA fails to pay these medical bills on time, veterans’ credit ratings are put at risk.

Read more about Representative Boustany’s proposed solution on his website.