Tag: Coronavirus Aid Relief and Economic Security Act (CARES Act)

COVID-19 Uninsured Program Now Includes Air, Water

HHS Updates Guidance on Provider Relief Funding for Uninsured to include Air and Water Ambulance

The Department of Health and Human Services recently updated its guidance on the disbursement of provider relief funds under the CARES Act for the testing and treatment of the uninsured.  Previously, HHS indicated that this allocation was only available for the reimbursement of emergency and non-emergency ground ambulance transportation.  However, in its most recent update, HHS has removed the restriction that limited participation to ground ambulance providers and suppliers.  The new guidance indicates that the relief funds are now available for all emergency ambulance transportation and non-emergency patient transfers via ambulance.

Thus, it appears that air and water ambulance providers and suppliers are now eligible to receive funding for the treatment of COVID-19 patients. 

Is there anything my air or water ambulance organization needs to do to claim reimbursement for treatment of uninsured COVID patients?

Yes.  In order to be eligible for payments for the treatment of uninsured COVID patients, you must enroll as a participant in the program.  Enrollment must be done through an online portal that can be accessed at: http://www.coviduninsuredclaim.hrsa.gov.

Once my organization enrolls, when can we start submitting claims for reimbursement for treatment of uninsured COVID patients?

HHS has indicated that it will begin to accept claims for reimbursement for treatment of the uninsured on May 6, 2020.


Innovative 9-1-1 Call Handling for COVID-19


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Federal Healthcare Resilience Task Force EMS/Prehospital Team: As the COVID 19 pandemic continues to evolve, Public Safety Answering Points (PSAPs)/Emergency  Communications Centers (ECC) may need to revise procedures and redirect resources for handling  incoming calls for COVID-19 Information and Low Acuity Medical Complaints. These revisions may  require administrative, technical and operational protocols, policies and procedures to be  modified. This document provides guidance and considerations for these modifications and examples of how a sample of a few individual PSAPs/ECCs have handled/redirected these calls in response to the COVID-19 pandemic.

Developed By
The Federal Healthcare Resilience Task Force (HRTF) is leading the development of a comprehensive strategy for the U.S. healthcare system to facilitate resiliency and responsiveness to the threats posed by COVID-19. The Task Force’s EMS/Pre-Hospital Team is comprised of public and private-sector Emergency Medical Service (EMS) and 911 experts from a wide variety of agencies and focuses on responding to the needs of the pre-hospital community. This Team is composed of subject matter experts from NHTSA OEMS, National 911 Program, CISA, CDC, FEMA, USFA, US Army, USCG, and non-federal partners representing stakeholder groups and areas of expertise. Through collaboration with experts in related fields, the team develops practical resources for field providers, supervisors, administrators, medical directors, and associations to better respond to the COVID-19 pandemic.

How to use this document: The general guidance and examples included in this document can be used to assist PSAP/ECC directors with the implementation and/or modification in Standard Operating Procedures (SOPs) and Emergency Medical Dispatch (EMD) protocols, for receiving and responding to two types of calls:
1. Calls for COVID-19 Information.
2. Calls for patients with Low Acuity Medical Complaints.

It is very important that PSAP/ECC directors refer to local medical direction, health department and other local COVID initiatives to ensure that the PSAP/ECC does not sustain any liability for the redirection of calls. This document was completed by representatives from the Association for Public Safety Communications Officials (APCO), the APCO Institute, the International Academies of Emergency Dispatch (IAED), the National Association of State 911 Administrators (NASNA), the National Emergency Number Association (NENA), and Power Phone; as well as their members and some of their clients.

I. Calls for COVID Information
  • Purpose/Goal: To provide guidance for the redirection of callers requesting COVID-19
    information to local and state health departments, COVID-19 hotlines, websites, links, and
    non-emergency lines such as 311, 211, 411 or other 10-digit lines.

    • General Considerations:
      • Administrative
        • Coordinate messaging to be provided with the Medical Director, health care facilities, and health departments to ensure appropriate changes are consistent as the COVID-19 pandemic evolves.
        • Identify appropriate local health departments and/or other local agencies’ resources (e.g., those that administer non-emergent support lines, e.g. 211/311/411), to understand what links, websites, hotlines, three-digit lines, and 10-digit lines are available/operational.
        • Ensure relationships are established and supported and conduct information sharing sessions by all mission partners to be effective and provide continuous communications.
        • Frequently update local PSAPs/ECCs, emergency medical services (EMS) agencies, fire departments, public health (PH) agencies, emergency management agencies (EMA) and emergency operations centers (EOC), to ensure consistent messaging and evolving needs are met.
        • Establish an ongoing mechanism for updating/changing information as the COVID-19 pandemic evolves.
        • Identify any agreements/contracts/policies/ SOPs that need to be established. Agreements among emergency services organizations for 211, 311, and 411 should be consistent.
        • Review employee contracts/ collective bargaining agreements, to understand possible impacts due to changes in protocols, policies, and/or SOPs.
      • Technical
        • Implement a mechanism for collecting and aggregating data (such as number of calls by incident type, EMD codes, etc.) for program evaluation and decision. Establish a mechanism for collecting/reporting data on calls received exclusively seeking information. Utilize that data to develop public service announcements and post the response to FAQs on appropriate websites.
        • Toll-free numbers typically receive Automatic Number Information (ANI). If the PSAP/ECC transfers a 911 call to a toll free number via their selective router, the entity receiving the call may be able to call back the PSAP/ECC, using the ANI received upon call transfer. Work with service providers and receiving agencies, if possible, to ensure this function.
      • Operational
        • Promote the use of Public Safety Telecommunicator (PST) “Just-in-time” education, training and awareness of the technological tools available and changes in procedures.
        • Public education, training, and awareness may be key for public acceptance of alternate call handling. Examples of available resources include:

        • CDC self-checker, or other decision tree approved by a locally designated authority for the general public, on when to call 911 versus nurse/primary care provider/health dept./info line.
        • CDC Phone Advice Line Tool for possible COVID-19 patients
          • PSAP/ECC, who dispatch EMS, should know the status of all hospitals i.e., COVID only hospitals, which hospitals have no hospital beds or ICU units.
          • Utilize COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns
          Hopkins University* to understand COVID case locations
          • Consider HIPAA constraints (if the PSAP/ECC/EOC and/or their personnel fall under the category of “health care providers who transmit any health information electronically in connection with certain transactions”), seek/coordinate with legal counsel. Please see the COVID-19 and HIPAA:
          Disclosures to law enforcement, paramedics, other first responders and public health authorities.
II. Low Acuity Medical Complaints Requests

Purpose/Goal: To provide guidance for the redirection of low acuity medical complaints to alternate medical resources (e.g., Nurse Triage/Call Line, Telemedicine, Paramedic Triage) due to increase in call volume and/or decline in hospital, EMS and other resources as a result of the
COVID-19 pandemic.

  •  General Considerations:
    • Administrative
      • Work with local Medical Director to determine specific criteria for referral.
      • Work with current EMD personnel and local Medical Director to identify questions to be asked and the specific criteria the caller must meet to be transferred to alternate medical resources such as Nurse Call Line or Telemedicine Triage Line.
  •  Confirm local Medical Director approval for changes to the medical call handling process,
    and/or response changes, including changes in EMD questions and referrals to alternate medical resources.
  • Identify and execute any agreements/contracts that need to be established.
  • Revise current policies and procedures and/or implement temporary procedures for PSTs.
  • Consider additional security requirements if the alternate medical resource will be located in the PSAP/ECC (e.g. Criminal Justice Information Systems (CJIS), National Crime Information Center (NCIC), etc.)
  • For Triage/Call Lines not already established: ensure notification of completion of training for nurse triage and PSAP staff —to understand how referral process will work; and how processes may change due to evolving circumstances. (Example: as COVID expands within a specific jurisdiction, is the behavioral hotline still active for referral?)
  • Ensure agreements and arrangements with the alternate care resource to ensure they are ready to take calls.
  • Facilitate consistent interaction among local PSAPs/ECCs, EMS, PHs, EMAs and EOCs is essential, to ensure evolving needs are met.
  • If the medical resource line is not a 24 hours/7 days a week call line, develop a working schedule, and communicate often between the call line side and the PSAP/ECC side.
  • Consider Syndromic Surveillance1 processes where available.


  • Technical
    • Work with 911 service providers to ensure call transfer can be made
      while keeping the caller’s call-back number.
    • Ensure call transfer works both ways in the event that the call needs to be transferred back to the PSAP/ECC.
    • Implement one-button transfers of calls, if feasible.
    • Work with information technology (IT) services to accommodate any necessary changes to computer-aided dispatch (CAD) systems
  • Operational
    • Develop and execute 911 Public Safety Telecommunicator (PST) training on all new processes and procedures.
    • Update pandemic guide cards/protocols with COVID-19 related questions and transfer instructions—modifiable at agency level and approved by the local Medical Director.
    • Anticipate frequent changes as the pandemic progresses, which may include modified response criteria for EMS due to the depletion of personnel and other resources.
Examples of Low Acuity Call Redirection Protocols: The following are examples of PSAPs/ECCsthat have implemented protocols to redirect low acuity calls alternate medical resources:

1. Location: Seattle/King County Washington

  • Description: Referral Program
    For COVID-19, the Seattle Fire Department’s Mobile Integrated Health program stood up a referral program to address the secondary impacts of the COVID-19 pandemic. This included generally concerned 9-1-1 callers as well as individuals who have been cut off from social services,
    healthcare, caregivers, substance abuse resources, critical supplies, or other services due to quarantine/isolation/shelter-in-place, or ill family members. The city has a team of two firefighters and four case managers who are fielding these referrals and reach out to callers by phone or in person. It is believed that non-emergent 9-1- 1 calls will likely continue throughout the duration shelter-in-place lengthens.

Seattle is in the early stages of exploring how to use nurse triage (either on-site in the 911 center or remotely) to further handle non-emergent calls, however, such a program has not been operationalized.

  • Point of Contact:
    Jon Ehrenfeld
    Mobile Integrated Health Program Manager Seattle Fire Department
    O: 206-233-7109 | M: 206-771-0269

2. Location: Washington, DC; Office of Unified Communications (OUC)

  • Description: DC Nurse Triage Line
    Since 2018, DC’s Office of Unified Communications currently transfers a portion of their basic life support (BLS) calls to a nurse triage line (NTL), with the goal of keeping people out of the emergency department and treating people at home. While the nurses are housed within the 911 call center, this is a program under DC’s Fire and EMS Department. Other relevant points about this

    • Additional goal: Savings relate to not mobilizing EMS
    • Program has resulted in both a financial and human resources savings.
    • Office of Unified Communications (OUC) has incrementally increased the types of calls redirected to NTL. Now transferring 60-90 calls per day (approximately 6-10% of medical calls)
    • Public Service Ads – important to explain to the public the advantages of EMS tiered medical response that an RN answers NTL in advance of implementation to avoid caller resistance to call transfer.
    • Both OUC and EMS field units can call the NTL and initiate the process
    • Nurses answer calls from work stations within the OUC, and if needed, can access backup nurse triage personnel in TX and FL. Part of their protocol includes asking for insurance information, so patients can be coupled with appropriate clinics, MDs). Nurses also are able to schedule appointments for callers.
    • Targeting calls that were responded to, but not transported.
    • Now looking at how to anticipate changes in call volume relevant to COVID- 19 and how to change current protocols
    • A strong relationship with Fire & EMS and Medical Director is essential
    • Not a failure if NTL screens and determines that the patient needs a response. This is the safety net.
  • Point of Contact:
    Cleo Subido, Chief
    Office of Professional Standards and Development Office of Unified Communications
    2720 Martin Luther King Jr. Ave. SE Washington DC, 20032
    O: 202-340-7916

3. Location: Orleans Parish Communication District (New Orleans 9-1-1)

  • Description:
    All Orleans Parish Communication District (OPCD) Operations Staff are certified Emergency Medical
    Dispatchers (EMD) using protocols from the International Academies of Emergency Dispatch (IAED)*.
    Within those protocols are both a pandemic surveillance tool and a response protocol referred to as
    Protocol 36*.

Two directives and one guidance document enable the video medical triage process:
1. Emergency Directive 20-01 – Advising staffing to start using the surveillance tool.
(Issued 2/5/20)
2. Emergency Directive 20-02- Formally activating Protocol 36 (Issued 3/9/20)
3. Special Guidance advising elevating the pandemic level to Level 1

The pandemic protocol identifies calls that are low acuity for which an emergency department is not the best option. At that time, a paramedic initiates a video call with the patient and reviews their symptoms. In the current situation, in most cases, they are being advised to self-quarantine
and not go to an emergency
department. The process then places that person on a “self-quarantine registry” and someone from the staff calls the person daily to check on them. If their conditions get worse, the person is triaged again as a new patient and they may then get transported if needed.

  • Point of Contact:
    Tyrell T. Morris, MBA CPE Executive Director
    Orleans Parish Communication District (New Orleans 9-1-1) 118 City Park Ave.
    New Orleans, LA 70119 O: 504-671-3615
    tmorris@911nola.org www.opcdla.gov*


4. Location: Orange County Virginia Fire and EMS Department

  • Description: Area hospitals color code their status availability.
    • Code Green: Open
    • Code Yellow: Busy, not accepting trauma patients, running out of beds
    • Code Red: Very busy, only accepting life critical illness/injury
    • Code Black: Hospital lock down (i.e. pandemic), cannot accept more patients

PSAP/ECC receive fax updates of hospital status. PSTs page out the status of the hospital to the responders. Life or death situations can still go to the closest hospital and override the color codes except in Code Black situations.

  • Contact:
    Chief Nathan Mort
    Orange County Virginia Fire and EMS Department Cell: 540-406-1484

5. Location: New York City – Northwell Health

  • Description: The Northwell Health Center for EMS, Clinical Call Center, Centralized Transfer
    Center, Telehealth Center and Health Solutions provide NYC 311 and FDNY EMS 911 with an emergent stand up of call center operations in order to provide telemedicine-based services to callers seeking medical advice, clinical navigation of clinical care on the COVID-19 virus as well as work
    with the FDNY to take New York City-based low and medium acuity groups of 911 callers, as possible, and cleared with Medical Director. This system of care includes a comprehensive integrated system of 911 Emergency Medical Dispatcher (AEMD) Triage, Nurse based telephonic triage, care navigation and advice, Qualified Healthcare Provider (QHP – MD, NP, PA, LCSW telephonic/telemedicine services, QHP based telemedicine services, Community Paramedicine services, traditional EMS services and home-based Primary Care services.
  • At the Clinical Call Center, 12 RNs manage a steady flow of calls from patients and employees seeking clinical advice and navigation services including recently discharged patients whose multiple, chronic health issues make them a high risk for hospital readmission and patients seeking care during off hours from our physician practices. Using Emergency protocols, The International Academies of Emergency Dispatch’s (IAED) certified Emergency Communication Nurse System (ECNS), the nurses telephonically screen patients for priority symptoms and determine the level of care that
    the caller needs, weighing additional factors such as medication use and allergies. Once the type of care is determined, the Nurse can provide care instructions or arrange the appropriate level of care based on the patient’s clinical needs.
    Northwell 911 Telemedicine Resources*
  • Point of Contact:
    Jonathan Washko
    Assistant Vice President of the Center for EMS at Northwell Health

EMS Education Pipeline

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National Highway Traffic Safety Administration (NHTSA) staff prepared this summary document on the
status of the Emergency Medical Services (EMS) education pipeline during a series of recent conference
calls with EMS stakeholder organizations. Included is a list of national, state, and local considerations
for EMS stakeholders. These considerations do not necessarily reflect official policy positions of the
organizations that participated during the conference calls. This document is intended to serve as an
informational resource for EMS stakeholders. This summary does not establish legal requirements or
obligations, and its content does not necessarily reflect agency recommendations or policy.

Contributors to its content included representatives from the National Registry of Emergency Medical
Technicians (NREMT), the National Association of EMS Educators (NAEMSE), the Committee on
Accreditation for the EMS Professions (CoAEMSP), the Commission on Accreditation for Pre-Hospital
Continuing Education, the National Association of State EMS Officials, the International Association of
Fire Chiefs, the American Ambulance Association, the National Association of Emergency Medical
Technicians, the American College of Surgeons, and the Interstate Commission for EMS Personnel

Challenges Facing EMS Education
Nationwide social distancing measures have led to closures, delays, and other impacts on the national
EMS education system. National, State, and local EMS organizations are collaborating to address these
challenges, but prolonged delays are likely in the education, certification, and licensing of tens of
thousands of entry-level EMS clinicians.

EMS Education Programs Closed
Community colleges, universities, fire academies, and other programs that provide EMS education
throughout the country closed in response to social distancing measures. Many of these institutions
created distance learning programs to help current students complete their didactic education.
However, not every EMS education program has the resources to support online or distance learning

To assist EMS education programs, NAEMSE has led a webinar series on transitioning to the online
classroom2 and is collaborating with NREMT to develop best practices for distance education.
EMS students must also complete in-hospital and pre-hospital clinical rotations to graduate.
Unfortunately, most clinical and field internship sites remain closed to students based on a combination
of factors, such as government restrictions and recommendations on traveling and social distancing, lack
of personal protective equipment (PPE) for students, or the decision of the clinical site to restrict
student access.

CoAEMSP acknowledged the need for its 706 accredited paramedic education programs to modify
current graduation requirements.

On April 5th, 2020, the CoAEMSP Board of Directors issued a
statement regarding Coronavirus Disease 2019 (COVID-19) to clarify that Paramedic educational programs may employ a broad array of approaches, including simulation, in determining competency in
didactic, laboratory, clinical, field experience, and capstone field internship.
Another option suggested by stakeholders for increasing the number of competent, entry-level EMS
clinicians to enter the workforce with advanced life support (ALS) skills may be allowing paramedic
students to graduate early and be tested as Advanced EMTs (AEMTs).

Testing and Certification Delayed
NREMT is the national certification agency for EMS clinicians. NREMT testing and certification (after
completion of approved education) is a requirement for EMS clinician licensure in most States. NREMT’s
cognitive (computer-based written) exam is administered by Pearson VUE. On March 17, 2020, Pearson
VUE closed most of its nearly 700 testing centers nationwide. Over the subsequent weeks,
approximately 450 of Pearson VUE’s testing centers have re-opened at reduced capacity, with more
projected to open in the future. Many testing sites remain closed under State government orders that
closed State colleges and universities. Allowing sites to remain open for the sole purpose of testing EMS
and other healthcare professionals would help alleviate the lack of testing capacity. Open testing centers
are operating at approximately 50% capacity due to social distancing measures.

NREMT is temporarily not requiring the psychomotor (hands-on skills) examination due to social
distancing guidelines. It is offering a provisional certification that requires only the successful completion of
the EMS education course and the cognitive exam. NREMT has accelerated plans for remote proctoring
of the cognitive exam, which will be available for the AEMT examination and the EMT examination in
May 2020. These emergency measures will help to continue certifying new EMS professionals.

Historically, the NREMT tests over 60,000 EMS clinicians in the spring season. NREMT projects that a
significantly lower number of EMS clinicians will be tested this year due to the cancellation of EMS
education courses. Consequently, local EMS agencies will face a severe workforce supply shortage
within the next three months.

Recertification Deadlines Extended
NREMT has approved a 90-day extension on EMS certifications that were due to expire on March 31,
2020, and waived continuing education requirements for face-to-face instruction. States are beginning
to modify relicensing requirements in line with NREMT’s actions.

Specialty certification courses (such as Cardio Pulmonary Resuscitation, Pediatric Advanced Life Support,
Pre-Hospital Trauma Life Support, Advanced Cardiac Life Support, etc.) are often required as part of EMS
education, certification, licensure, or affiliation. Many specialty certification course providers have
created online courses for didactic materials, and either waived hands-on skills requirements or
provided guidance on safely facilitating in-person instruction. Most have also extended or waived
current expiration dates.

Licensure Modifications Underway
State EMS offices license EMS clinicians, regulate local EMS agencies, and support EMS system
development. Many State EMS staff are currently deployed to state operations centers supporting the
COVID-19 response, including guiding statewide efforts to support crisis standards of care (CSC) planning
for EMS. Multiple States have temporarily waived or modified licensure policies to streamline licensure.

Emergency Medical Service (EMS) Education Pipeline
Twenty States are accepting NREMT provisional certification as a condition of licensure; however, some
States4 have reported that their laws and rules prohibit issuing licenses to holders of the NREMT
provisional certification.

A few states require fingerprinting and a criminal background check as a condition for licensure;
however, social distancing measures and public building closures have made fingerprinting services
largely unavailable. Some States5 are offering provisional licensure that defers a criminal background
check until the public health emergency ends. Employers cannot assume a provisional licensee had a
background check and may now need to do this as part of their hiring process. States are also
reactivating expired licenses within specified time frames.

Twenty States are members of the Interstate EMS Licensure Compact (Compact), which was formally
activated in response to COVID-19. The Compact will enable interstate recognition of EMS clinician
licensure between member States. However, the Compact does not address practice by EMS clinicians in
non-traditional settings, such as hospitals. Many States6 grant physicians authority to delegate certain
aspects of medical practice, which may give hospitals flexibility to use EMS personnel in an expanded
clinical role.

Service Impact
In the United States, more than 18,200 EMS agencies, staffed by a total licensed workforce of more than
1.03 million EMS clinicians, provide ubiquitous 24/7 coverage of the entire Nation. In 2019, these EMS
agencies responded to more than 28.5 million 911 dispatches.

Stakeholders have reported an average 30 percent decline in EMS transports in areas not yet severely
impacted by the public health emergency, which they attribute to less public willingness to be
transported to hospitals. This decline in EMS transports has led to a decline in insurance reimbursement
revenue9 accompanied by an anticipated decline in State and local tax revenue. As a result, EMS
stakeholders have reported widespread hiring freezes and potential future furloughs and layoffs.
Despite the need for 24/7 service, stakeholders anticipate that the inability to hire, coupled with
workforce supply shortages (attributed to the shutdown of EMS education programs), will lead to
prolonged EMS staffing shortfalls. In some cases, these staffing shortfalls may take effect as COVID-19
peaks locally resulting in potentially insufficient staffing to respond to an expected surge of EMS calls.
As components of the workforce pipeline partially resume operations, employers will face additional
challenges, such as delays in fingerprint-based background checks and remedial education and testing
for provisionally certified and licensed EMS personnel.

The long-term impact of system accommodations (e.g., deferred background checks, proctored exams,
provisional certification and licensing) is unknown. In addition, there is also growing concern that the
pandemic may increase EMS workforce turnover.
State and Local Considerations for EMS Stakeholders
Based on the issues and challenges discussed above, stakeholders may consider the following
measures at the State and local levels:
1. Enable EMS clinicians with a NREMT provisional certification to pursue provisional State
2. Enable EMS clinicians with expired licenses to pursue provisional State licensure.
3. Prioritize the reopening of EMS clinical skills labs when reopening educational institutions.
4. Encourage EMS education programs to provide distance learning resources to all students. Front-load didactic education for EMS students until clinical skills labs, clinical internships, and field
internships can resume.
5. Enable States, colleges, and educational programs to allow modified approaches to clinical skills
labs, clinical internships, and field internships, when they can be conducted safely.
6. Encourage the sharing of best practices by State and local authorities.
7. Encourage collaboration between educational programs to develop online education
8. Permit public and private education testing centers to administer the NREMT examination
within local jurisdictions, while following strict social distancing protocols.
9. Explore the ability to verify course completion and/or testing paramedic students at the AEMTlevel,
provided the state has approved an AEMT course.

National Considerations for EMS Stakeholders
In addition, stakeholders may consider the following measures at the national level to the extent
permitted by applicable law:
1. Permit fingerprinting centers to open to support criminal background checks for EMS clinicians
as a condition of licensure or employment. Explore other innovative solutions for conducting
criminal background checks.
2. Continue convening national EMS organizations to facilitate collaborative and innovative
problem-solving. Engage additional stakeholders, such as the Accreditation Council for Graduate
Medical Education, to coordinate healthcare education efforts.
3. Consider, as essential critical infrastructure workers, those workers involved in the certification,
licensing, and credentialing of EMS personnel and other healthcare workers.
4. Consider, as essential critical infrastructure workers, those workers supporting public and
private education testing centers for EMS personnel and other healthcare workers.
5. Share EMS educational best practices nationally.
6. Support technology for EMS education programs to conduct remote training, high-fidelity
simulation and other tools for effective training while also supporting social distancing.

AAA Sends COVID-19 Relief Request Letter to President Trump

On April 28, the American Ambulance Association sent a letter to President Donald Trump with four requests as to how his Administration can best help ground ambulance service providers mitigate the COVID-19 pandemic. The AAA requested the following:

Increase Financial Assistance Related to COVID-19 for Ground Ambulance Services

Increase the percentage of the general allocation of funds under the Public Health and Social Services Emergency Fund (PHSSEF) for ground ambulance services providers and suppliers to equal a total of $2.89 billion in funds for our industry. The $2.89 billion reflects $48,000 per ambulance with an estimated 60,000 registered vehicles. We greatly appreciate the recent payments under the Fund which will help with our current situation. However, the ground ambulance services industry is only 0.90% of Medicare fee-for-service annual outlays which resulted in $270 million for our industry in round one of PHSSEF payments. This figure is disproportional to the large role of ground ambulance service providers and suppliers in responding to COVID-19 and our increased costs and reduced revenues during the PHE.

Priority Access for Paramedics and EMTs to PPE, COVID-19 Testing and Tax Relief

Protect paramedics and EMTs by directing federal agencies to provide them with higher priority access to PPE and COVID-19 testing. Paramedics and EMTs are too often not given primary access to PPE and testing even though they are frequently the first health care professionals to come into contact with COVID-19 patients. We also requested tax relief for frontline healthcare responders and to ensure that all governmental and nongovernmental responders are eligible for any additional essential worker compensation specific to the Public Health Emergency (PHE).

Coverage for Treatment in Place During COVID-19 Pandemic

Direct the Centers for Medicare and Medicaid Services (CMS) to reimburse ground ambulance service providers and suppliers for performing protocol-driven treatments in place during the PHE. This coverage will help limit the spread of COVID-19 by keeping patients with mild cases of COVID-19 at home and out of overcrowded hospitals or other facilities where they could expose others to the virus.

Direct Access to FEMA COVID-19 Grants for All Ground Ambulance Services

Allow private for-profit EMS agencies to apply directly to the Federal Emergency Management Agency (FEMA) for Public Assistance program grants during the PHE and waive the matching requirement for emergency response providers. This will allow all EMS agencies to apply for financial assistance and for state and local governments to focus their limited resources on directly combating the pandemic.

The AAA continues to advocate through multiple channels within the Administration and the Congress for relief related to COVID-19 for ground ambulance service providers and suppliers.

Read the Letter

Healthcare Resilience Task Force: Three New Documents Released

The Prehospital [911 and Emergency Medical Services (EMS)] Team of the Healthcare Resilience Task Force has released three more informational documents. The first contains guidance for emergency communications stakeholders on available funding in the CARES Act. The second is a summary document on the status of the Emergency Medical Services (EMS) education pipeline during a series of recent conference calls with EMS stakeholder organizations. The third is a corrected version of the COVID-19 Crisis Standards of Care.

These documents will also be posted on EMS.gov and/or 911.gov (as appropriate).  Two portals for COVID Resources were created which we will continue to update three times a week, with new links and documents containing information on a variety of COVID-related topics.  You will find COVID resources here on EMS.gov, and here on 911.gov.

Read Below:

SAFECOM and NCSWIC Guidance on CARES Act Grants

The Cybersecurity and Infrastructure Security Agency (CISA), in partnership with SAFECOM and the National Council of Statewide Interoperability Coordinators (NCSWIC), prepared guidance for emergency communications stakeholders on available funding in the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). Stakeholders are encouraged to review this guidance and apply for funding, where applicable. CARES Act money is available to all 50 states, five territories, and the District of Columbia, with several fast-approaching application deadlines

NHTSA EMS Education_Pipeline_Final

National Highway Traffic Safety Administration (NHTSA) staff prepared this summary document on the status of the Emergency Medical Services (EMS) education pipeline during a series of recent conference calls with EMS stakeholder organizations. Included is a list of national, State, and local considerations for EMS stakeholders.

EMS14_EMS Crisis Standards of Care_Final – (Corrected 4/28/2020)

In response to the COVID-19 pandemic, emergency medical services (EMS) agencies (including fire service, third government service, hospital-based, private for-profit, and private non-profit services) may need to adjust operations and standards of care in order to preserve and effectively allocate limited EMS and healthcare system resources in the face of overwhelming demand due to the national pandemic response. This document provides an overview of general considerations, potential strategies, and existing resources that EMS agencies may use to inform changes to their operations and standards of care.

COVID-19 Financial Impact Calculator

The American Ambulance Association is working nonstop on advocating for financial relief from the impact of the Coronavirus (COVID-19) for our members. Now that ground ambulance service providers and suppliers are receiving federal funding to help partially offset the negative financial impact of the Coronavirus (COVID-19), the Congress is asking for information to substantiate that additional funding is necessary. Instead of providing just anecdotal information on the increased costs and lost revenue from COVID-19, we need to provide more wide-ranging data demonstrating the dire financial situation facing our industry.

To this end, the American Ambulance Association has developed a Financial Impact Calculator to gather information from our members to help us make our case for additional financial relief. The Calculator is also designed for members to use in completing the application for more funding under the General Allocation second distribution of the Public Health and Social Services Emergency Fund.

Download the  Excel Version of the Financial Impact Calculator as a reference. The Instructions include definitions for fields in both the Excel and online calculators.

WE STRONGLY RECOMMEND USE OF THE CONVENIENT ONLINE CALCULATOR as this enables AAA to  synthesize data from ambulances across the country for use in advocacy efforts on behalf of mobile healthcare. Your data will be safely stored, and will  be shared only in aggregate.

Please DO NOT enter commas or dollar signs  when providing data. The system will format automatically. 

General Allocation Calculator & PPP Loan Estimator

HHS Provider Relief Tranche 2 Calculator

Use the American Ambulance Association’s simple form to estimate relief you may receive from the second tranche of HHS COVID-19 funding. Please note that not all providers will receive funds.

More information about this program as well as access to the form you must complete in the General Allocation Portal can be found on the HHS website.

For-profit and non-profit non-governmental providers,  to determine your Net Patient Revenue for the portal, use the following information from your most recently filed tax return. (2019 if filed, otherwise use 2018 numbers).

Governmental providers,  enter your revenue generated for the last audited financial year. When completing the form in the portal,  select Tax Exempt Organization. When asked to upload a return at the end, upload your most recent audited financials.

Please do not enter commas or dollar signs. A negative number or zero in the Tranche 2 box indicates that you WILL NOT receive funding in tranche  2.

AAA Sends Letter Requesting Priority Testing for EMS

AAA Sends Letter to Requesting Priority Testing for First Responders

Earlier today, the AAA sent a letter to the U.S. Public Health Service (USPHS) requesting that first responders with COVID-19 symptoms be given priority one status in the order of groups to be tested for COVID-19. The USPHS had issued guidance that assigned first responders a level two status. The AAA stated paramedics and EMTs should be included in the top level with other health care professionals who are on the front lines of caring for patients with COVID-19.  Read the Letter HERE.


Read the Letter

Watch now: HHS Funding For EMS

HHS Funding For EMS: What You Need to Know & How to Calculate Net Patient Revenue

Join Asbel Montes, Brian Werfel, Steve Wirth as they discuss how to register, apply, and calculate net patient revenue correctly to maximize the amount of revenue you can receive from the second allocation of general funds. Panelists will also review the process of submitting claims for uninsured patients which begins on May 6th.

Hear straight from the experts on the dos and don’ts of revenue calculation, reporting periods, definition of terms and strategies to overcome the challenge of providing data from 2018 in a way that meets the criteria of CMS.

This webinar is a must for all ambulance service providers as they navigate the sometimes complex, oftentimes confusing avenues of relief offered through the Cares Act. Download the slides for the presentation HERE

Congress Provides More PPP and Health Care Funds

Congress Provides More PPP and Health Care Funds

Moments ago, the U.S. House of Representatives passed by a vote of 388 to 5 the Paycheck Protection Program and Health Care Enhancement Act. The United States Senate had passed the legislation by unanimous consent on Tuesday evening. The legislation is a bridge package between the CARES Act and Stimulus Package 4 which is still under development.

The Paycheck Protection Program and Health Care Enhancement Act provides an additional $310 billion for the Paycheck Protection Program (PPP) established under the CARES Act. The PPP had run out of its initial funding on April 9 and the program has been closed to new applications. The PPP provides businesses with fewer than 500 employees, including ambulance service organizations, with access to loans at favorable terms to cover employee payroll for eight weeks. A borrower can have all or a portion of the loan forgiven depending on the percentage of retained employees.

The legislation also allocates an additional $75 billion in funds for the Public Health and Social Services Emergency Fund (PHSSEF). Like the initial $100 billion funding from the CARES Act, these funds are intended to provide economic relief to health care providers during the COVID-19 public health emergency. AAA members received direct grant money a few weeks ago under the PHSSEF in the form of an additional Medicare payment. The Department of Health and Human Services (HHS) will have the discretion to determine how the additional $75 billion is made available to health care providers. The AAA continues to advocate directly with senior HHS officials for ground ambulance service suppliers and providers to receive a share of funds proportional to our role health care providers on the front line of the pandemic.

The final provision of the Paycheck Protection Program and Health Care Enhancement Act provides additional funding for testing and research related to COVID-19 through the remainder of 2020.

The AAA with the help of our members had pushed for additional funding under the PHSSEF and were successful. We now need to ensure that the actual funds make their way to our members.

The AAA leadership and staff will continue to tirelessly advocate for the much-needed relief to ensure that our members can keep their doors open, receive the equipment necessary to protect their staff, and the resources to provide excellence in mobile healthcare. We will keep you abreast of our advocacy efforts as well as how to access funding under the PHSSEF as soon as the details become available.

HHS Announces Plans for Distribution of Remaining CARES Act Provider Relief Funding

HHS Announces Plans for Distribution of Remaining CARES Act Provider Relief Funding
By Brian S. Werfel, Esq.

March 27, 2020, President Trump signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act).  As part of that Act, Congress allocated $100 billion to the creation of a “CARES Act Provider Relief Fund,” which will be used to support hospitals and other healthcare providers on the front lines of the nation’s coronavirus response.  These funds will be used to fund healthcare-related expenses or to offset lost revenue attributable to COVID-10.  These funds will also be used to ensure that uninsured Americans have access to testing a treatment for COVID-19.  Collectively, this funding is referred to as the “CARES Act Provider Relief Fund.”

The Department of Health and Human Services (HHS) began the disbursement of the first $30 billion tranche of the CARES Act Provider Relief Funding on April 10, 2020, with full disbursement of this tranche being completed by April 17, 2020.  The American Ambulance Association has issued a Frequently Asked Question that provides additional details on how the payments under this first tranche were calculated, as well as the terms and conditions that are applicable to this disbursement.

On April 22, 2020, HHS announced its plans for the disbursement of the remaining $70 billion in CARES Act Provider Relief Funding.  These monies will be distributed using four broad categories:

  1. General Allocation. HHS indicated that it will be supplementing the initial $30 billion tranche with an additional $20 billion.  Ultimately, HHS’ intent is to distribute this $50 billion to all eligible healthcare providers and suppliers (including ambulance providers and suppliers) based on the provider’s or supplier’s 2018 net patient revenue.  “Net patient revenue” is a term of art in the Medicare world, and is used to describe all patient revenues (from whatever source) minus: (i) provision for bad debts, (ii) contractual adjustments, (iii) charity discounts, (iv) teaching allowances, (v) policy discounts, (vi) administrative adjustments, and (vii) other deductions from revenue.  HHS indicated that it would calculate every provider’s and supplier’s proportionate share of the entire $50 billion would be using their 2018 net patient revenue.  HHS would then subtract the amounts that the provider or supplier received during the first tranche, and pay the unpaid balance over the next few weeks.  For institutional providers that have already submitted 2018 cost reports, these payments will go out on April 24, 2020.  Providers or suppliers that do not have adequate cost report data on file will need to submit their revenue information using an online portal that will become available this week, with payments to follow on a rolling basis once a provider’s or supplier’s information has been validated.  As with the first tranche, recipients of relief funding will be required to sign an attestation confirming receipt of the funds, and agreeing to the terms and conditions, including the restrictions on surprise medical billing.
  2. Targeted Allocations. HHS indicated that it would be setting aside an additional $20.4 billion for certain targeted segments of the health care industry.  This includes: (i) $10 billion being allocated to hospitals in areas that have been particularly hard-hit by the COVID-19 outbreak, (ii) $10 billion for rural health clinics and hospitals, and (iii) $400 for the Indian Health Service.
  3. Reimbursement for Uninsured Patients. HHS indicated that it will allocate an undisclosed portion of the remaining $29.6 billion to reimburse healthcare providers and suppliers for COVID-related treatment of the uninsured.  This allocation is available for the reimbursement of emergency and non-emergency ground ambulance transportation furnished to uninsured COVID-19 patients; however, air and water ambulance providers are not eligible to participate.  Reimbursement will be available for COVID-related care furnished with dates of service on or after February 4, 2020.  Payments will be made at the Medicare rates, subject to available funding.  To be eligible for reimbursement for care furnished to uninsured COVID-19 patients, ambulance providers and suppliers will need to enroll as a provider participant, which can be done starting on April 27, 2020.  Claims will be accepted starting in early May 2020.  As a condition to receiving reimbursement for the care of uninsured COVID-19 patients, you will be required to accept HHS’ payment as payment-in-full, i.e., you will not be permitted to balance bill the patient.  Additional information on HHS’ reimbursement for uninsured COVID-19 patients can be found at: http://www.coviduninsuredclaim.hrsa.gov.
  4. Reimbursement for Certain Medicaid-Only Providers. HHS indicated that it will allocate an undisclosed portion of the remaining $29.6 billion to reimburse skilled nursing facilities, dentist, and provides that only participate in State Medicaid Programs.

Upcoming Important Dates

 To participate in these future funding tranches, AAA Members will need to keep the following dates in mind:

  1. On or after April 23/24 – You will need to access the online portal to submit your revenue information in order to receive the second tranche of the $50 billion general allocation of provider relief funds.
  2. April 27, 2020 – You will need to register for the COVID-19 Uninsured Reimbursement Allocation. Once open, the online portal can be accessed from the following webpage: http://www.coviduninsuredclaim.hrsa.gov.
  3. Early May 2020 – You will be able to start submitting claims to the COVID-19 Uninsured Reimbursement Allocation.


NREMT Statement to National Governors Association

COVID-19 Impact on Essential Critical Infrastructure Workers and Requested URGENT Action of Governors to Ensure Continuity of the Supply of Certified Emergency Medical Services Professionals (EMTs & Paramedics) and other Essential Critical Infrastructure Workers.

Statement by the National Registry of Emergency Medical Technicians. Download PDF

Problem: The national COVID-19 pandemic containment efforts inadvertently impact a vital component of the licensure pathway for Essential Critical Infrastructure Workers like emergency medical services (EMS) responders (EMTs and paramedics) and many other health professions. Without immediate intervention, thousands of professionals – prepared and scheduled to take their final certification exams – could be prohibited from responding to the national public health crisis.

Facts bearing on the problem:
• Essential Critical Infrastructure Workers like EMTs, Paramedics, and other health professionals – in the interest of public safety – are required to take certification or licensure examinations prior to state licensure. For over 70 health professions, these examinations are administered by Pearson VUE in either a Pearson VUE owned facility (PPC) or its network of independent third-party test centers (PVTCs).
• During the week of March 9th, most colleges and universities in the United States closed; consequently, this closed many PVTCs co-located on these campuses where many EMT and Paramedic candidates take their national certification examinations.
• On Tuesday, March 17, 2020, in response to the national guidance calling for social distancing, Pearson VUE closed their facilities in the United States, including its PPCs, thus significantly diminishing the licensing pathway for Essential Critical Infrastructure Workers.
• Based on the nation-wide closure of Pearson VUE and college and university test centers,
12,000+ EMT and Paramedic candidates are currently unable to test or have a significantly diminished ability to test, plus an additional 60,000+ EMTs and Paramedic candidates will be unable to test between now and June 30.
• Essential Critical Infrastructure Workers like healthcare professionals, including EMTs and Paramedics, are required to obtain necessary education, clinical experience, and successfully complete certification examinations prior to being eligible for state licensure. State licensing and regulatory agencies for EMS professionals, represented by NASEMSO, are dependent on the national boards/certifications to assess competence (protection of the public) for licensure. Similar licensing and regulatory agencies exist for various others Essential Critical Infrastructure Workers.
• EMTs and Paramedics, as well as other public safety and healthcare personnel (i.e., Nurses) are defined as “Essential Critical Infrastructure Workers” in the “Guidance on the Essential Critical Infrastructure Workforce: Ensuring Community and National Resilience in COVID-19 Response” (03/19/2020; under theauthority of Presidential Directive 7)
• The COVID-19 pandemic is already straining the nation’s healthcare system. Over 1,400 EMS professionals are currently quarantined, and we anticipate these numbers to quickly rise.
• Pearson VUE and college and universities can implement measures and recommended guidelines at PPCs and PVTCs during the COVID -19 emergency including appropriate social distancing, hygiene, and disinfection. However, the closing of many colleges and universities, as well as closing of commercial businesses resulted in reduction of Essential Critical Infrastructure Workers. The services provided by Pearson VUE are essential in allowing Essential Critical Infrastructure Workers to enter the workforce and provide the necessary services which are vital during the pandemic.

• We ask that the Governors promptly designate the services provided by Pearson VUE in conjunction with the licensing and certification of Essential Critical Infrastructure Workers as “Essential Services” and/or “Life-Sustaining Services” according to the applicable state definitions and to open colleges and universities that operate test centers which have historically administered EMT and Paramedic certification examinations. Once the Governors designate Pearson VUE’s services as Essential and/or Life-Sustaining Services, and authorize the opening of the colleges and universities that operate test centers that deliver exams on behalf of Pearson VUE, EMT and Paramedic certification examinations, other certification and licensing examinations for “Essential Critical Infrastructure Workers”, as well as those services provided in conjunction with such certification and licensing may be offered by Pearson VUE and its test centers.
• Pearson VUE and its PPCs, owned and operated through Pearson VUE, and its PVTCs need to be viewed as a critical infrastructure as they allow the continuity of certifying and licensing of critical infrastructure workers (EMTs, Paramedics, Nurses, and more). Further, the employees working for Pearson VUE who provide these services in conjunction with certifying and licensing Essential Critical Infrastructure Workers need to be identified as“Essential Critical Infrastructure Workers.”
o “Functioning critical infrastructure is imperative during the response to the COVID-19 emergency for both public health and safety as well as community well-being. Certain critical infrastructure industries have a special responsibility in these times to continue operations.” “Guidance on the Essential Critical Infrastructure Workforce: Ensuring Community and National Resilience in COVID-19 Response” (03/19/2020; under the authority of Presidential Directive 7)

Taking these actions to recognize Pearson VUE and its test centers as critical infrastructures, as well as authorizing the re-opening of Pearson VUE and its test centers so that essential critical infrastructure workers can re-start taking certification examinations will help to preserve the fragile, but critical pipeline of new EMS and other healthcare professionals during this national emergency.

CMS NEWS: Trump Administration Launches New Healthcare Toolkit

Trump Administration Launches New Toolkit to Help States Navigate COVID-19 Pre-Hospital/Emergency Medical Services (EMS) Resources

At President Trump’s direction, the Centers for Medicare & Medicaid Services (CMS) and the Assistant Secretary of Preparedness and Response (ASPR) released a new toolkit to help state and local healthcare decision-makers maximize workforce flexibilities when confronting 2019 Novel Coronavirus (COVID-19) in their communities. This toolkit includes a full suite of available resources to maximize responsiveness based on state and local needs, building on President Trump’s commitment to a COVID-19 response that is locally executed, state-managed, and federally supported. This work was developed by the Healthcare Resilience Task Force as part of the unified government’s response to COVID-19.

This Topic Collection focuses on plans, tools, templates, and other immediately implementable resources to help with COVID-19 preparedness, response, recovery, and mitigation efforts, focusing on pre-hospital and emergency medical services (EMS) settings, including public safety answering points (PSAPs).

Please refer to CDC’s Coronavirus Disease 2019 webpage for the most up-to-date clinical guidance on COVID19 outbreak management.

If you have COVID-19 promising practices, plans, tools, or templates to share with your peers, please visit the ASPR TRACIE Information Exchange COVID-19 Information Sharing Page (registration required) and place your resources under the relevant topic area. Resources specific to pre-hospital and EMS can be placed under the COVID-19 Pre-Hospital/EMS Resources Topic.

View EMS Resources

FAQs – HHS CARES Act Provider Relief Funding

Frequently Asked Questions (FAQs) related to HHS CARES Act Provider Relief Funding

By Brian S. Werfel, Esq.

In March 27, 2020, President Trump signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act).  As part of that Act, Congress allocated $100 billion to the creation of a “CARES Act Provider Relief Fund,” which will be used to support hospitals and other healthcare providers on the front lines of the nation’s coronavirus response.  These funds will be used to fund healthcare-related expenses or to offset lost revenue attributable to COVID-10.  These funds will also be used to ensure that uninsured Americans have access to testing a treatment for COVID-19.  Collectively, this funding is referred to as the “CARES Act Provider Relief Fund.”

On April 9, 2020, the Department of Health and Human Services (HHS) began the disbursement of the first $30 billion of this provider relief funding.  This disbursement was made to all healthcare providers and suppliers that were enrolled in the Medicare Program, and who received Medicare Fee-for-Service reimbursements during Calendar Year 2019.  For most ambulance providers and suppliers, these relief funds were automatically deposited into their bank accounts.

In this Frequently Asked Question (FAQ), the AAA will address some of the more common questions that have arisen with respect to the Cares Act Provider Relief Funds.

Question #1: My organization received relief funds through an ACH Transfer.  Is there anything our organization needs to do?

Answer #1: Yes.  Within thirty (30) days of receiving the payment, you must sign an attestation confirming your receipt of the provider relief funds.  As part of that attestation, you must also agree to accept certain Terms and Conditions.  The attestation can be signed electronically by clicking here.

Question #2: Am I required to accept these funds?  What happens if I am not willing to accept the Terms and Conditions imposed on the receipt of these funds?

 Answer #2: You are not obligated to accept the provider relief funds.  The purpose of these funds was to provide healthcare providers and suppliers with an immediate cash infusion in order to assist them in paying for COVID-related expenses and/or to offset lost revenues attributable to the COVID-19 pandemic.

If you are not willing to abide by the Terms and Conditions associated with these funds, you must contact HHS within thirty (30) days of receipt of payment, and then return the full amount of the funds to HHS as instructed.  The CARES Act Provider Relief Fund Payment Attestation Portal provides instructions on the steps involved in rejecting the funds.  Please note that your failure to contact HHS within 30 days to arrange for the return of these funds will be deemed to be an acceptance of the Terms and Conditions. 

 Question #3: Our organization has elected to retain the provider relief funds.  Are there any major restrictions on how we can use these funds?

 Answer #3: Yes.  In the Terms and Conditions, HHS has indicated that you must certify that the funds will only be used to prevent, prepare for, and respond to coronavirus.  You are also required to certify that the funding will only be used for health-care related expenses and/or to offset lost revenues that are attributable to coronavirus.

You are specifically required to certify that you will not use the relief funding to reimburse expenses or losses that have been reimbursed from other sources or that other sources are obligated to reimburse.

While the language in the Terms and Conditions are somewhat ambiguous, the AAA interprets this to mean that you must certify that your organization’s operations have been impacted, in some way, by the national response to the coronavirus.  The AAA further interprets this language as requiring that, on net, the coronavirus pandemic has had an adverse impact on either your operations (in terms of added costs) or your revenues (in terms of decreased revenues).  At the present time, the AAA believes that most, if not all, of our members that are currently providing services in response to the coronavirus pandemic will meet this standard.

Note: one situation where a provider may not be eligible for provider relief funding would be a situation where the provider ceased operations prior to January 31, 2020.  For example, a provider that ceased operations on December 31, 2019.  Because the ambulance provider was paid for Medicare FFS services furnished in 2019, it may receive provider relief funding.  However, if the organization’s operations ceased prior to the onset of the current state of emergency, it would not be able to meet the requirement that it provided diagnoses, testing, or care for individuals with possible or actual cases of COVID-19.  In this situation, the ambulance provider would likely be obligated to reject the provider relief funding.

 Question #4: Are there any other restrictions on our use of provider relief funding?

 Answer #4: Yes.  In addition to the restrictions discussed in Answer #3 above, you are also restricted from using the provider relief funding for any of the following purposes:

  1. The provider relief funds may not be used to pay the salary of an individual at a rate in excess of Executive Level II (approximately $189,600);
  2. The provider relief funds may not be used, in whole or in part, to advocate or promote gun control;
  3. The provider relief funds may not be used, in whole or in part, for lobbying activities;
  4. The provider relief funds may not be used to fund abortions (subject to certain exceptions);
  5. The provider relief funds may not be used for embryo research;
  6. The provider relief funds may not be used for the promotion of the legalization of controlled substances;
  7. The provider relief funds may not be used to maintain or establish a computer network, unless such network blocks the viewing, downloading, and exchanging of pornography;
  8. The provider relief funds may not be provided to the Association of Community Organizations for Reform Now (ACORN), or any of its affiliates, subsidiaries, allied organizations, or successors;
  9. The provider relief funds may not be used to purchase sterile needles or syringes for hypodermic injections of illegal drugs.

Question #5: How will HHS verify that the provider relief funding is being used for an appropriate purpose?

 Answer #5: HHS will require all recipients of provider relief funding to submit reports “as the Secretary determines are needed to ensure compliance with the conditions imposed.”  HHS indicated that it will provide future program instructions to recipients that specifies the form and content of these reports.  Recipients will also be required to maintain appropriate records and cost documentation to substantiate how provider relief funds were spent, and to provide copies of such records to HHS upon request.

In addition, ambulance providers and suppliers that receive, in the aggregate, more than $150,000 in funds under the CARES Act, the Coronavirus Preparedness and Response Supplemental Appropriations Act, the Families First Coronavirus Response Act, and any other legislation that makes appropriations for coronavirus response and related activities will be required to submit a report within 10 days of the end of each calendar quarter.  These reports must specify: (1) the total amount of funds received from HHS under each of these pieces of legislation, (2) the amount of funds received that was spent or obligated to be spend, and (3) a detailed list of all projects or activities for which large covered funds were expended or obligated.

Question #6: We understand that one of the conditions associated with the provider relief funding is that we agree not to balance bill patients.  Is our understanding correct?

 Answer #6:  The Terms and Conditions do contain provisions that would likely place restrictions on your ability to balance-bill patients.

In order to understand these restrictions, it is probably helpful to understand the underlying purpose of the restriction.  The actual language from the Terms and Conditions reads as follows:

The Secretary has concluded that the COVID-19 public health emergency has caused many healthcare providers to have capacity constraints. As a result, patients that would ordinarily be able to choose to receive all care from in-network healthcare providers may no longer be able to receive such care in-network. Accordingly, for all care for a presumptive or actual case of COVID-19, Recipient certifies that it will not seek to collect from the patient out-of-pocket expenses in an amount greater than what the patient would have otherwise been required to pay if the care had been provided by an in-network Recipient.”

 As the language makes clear, HHS was not focused primarily on the practice of balance-billing.  Rather, HHS’ concern was that many healthcare providers would have capacity restraints.  As a result, patients may be restricted in their ability to receive care from their normal providers (who are presumably in-network with the patient’s insurer).   HHS’ intent was to ensure that the patient does not suffer any adverse financial consequences as a result of seeking care for presumptive or actual cases of COVID-19.  It accomplishes this goal by requiring the recipient of provider relief funds to agree not to collect from the patient out-of-pocket expenses that are greater than what the patient would have incurred has the care been provided by an in-network provider.

This is being interpreted as a ban on “balance-billing” because most commercial insurers require their contracted providers to accept the plan’s allowed amount as payment-in-full, i.e., to agree to only bill the patient for applicable copayments and deductibles.

Ambulance providers and suppliers should keep in mind that this will not impact the payment of claims from: (1) Medicare, Medicaid or other state and federal health care programs that already require you to accept the program’s allowed amount as payment-in-full, (2) commercial insurers with which the organization currently contracts, and (3) the uninsured.  In other words, this requirement only impacts payments from commercial insurers with which the organization currently does not contract.

At this point in time, it is expected that non-contracted commercial insurers will process your claim and make a determination as to whether the claim is related to the treatment and care of a presumptive or actual case of COVID-19.  If the plan determines that the services you furnished were COVID-related, they will likely pay you the in-network rate they have established with contracted providers in your services area.  The plan will likely then issue a remittance notice that indicates that you may not bill the patient for any balance over the insurer’s payment.  Note: many of the larger commercial insurers have indicated that they will waive the copayments and deductibles due from patients for COVID-related claims.  If the plan waives the copayment and deductibles, they will pay these amounts to you as part of their payment of the claim.  If they do not waive the copayment and deductible, you will be permitted to seek to collect these amounts from the patient.  If the plan determines that the services you furnished were not COVID-related, they will continue to pay your claims using their normal claims processing, and you would be permitted to balance bill the patient to the extent otherwise permitted under state and local law.

There is still a good deal of confusion related to this aspect of the CARES Act Provider Relief Funding.  It is expected that HHS will be issuing further clarification in the days to come.  The AAA will update this FAQ to reflect any updated guidance from HHS.

Supplemental Funding for Emergency Medical Services

COVID-19: Supplemental Funding for Emergency Medical Services

Developed by the Healthcare Resilience Task Force Emergency Medical Services (EMS) Prehospital Team. Download PDF

1. Purpose: This paper outlines two supplemental funding options for Emergency Medical Services (EMS) agencies affected by the COVID-19 pandemic.

2. Scope: This information applies to private non-profit organizations as well as for-profit EMS agencies. This guidance does not apply to government-owned and operated EMS agencies.

3. Overview of Existing Supplemental Funding Opportunities:
a. Stafford Act Emergency and/or Major Disaster Declaration (Stafford Act): Emergency protective measures to save lives and protect public health (including emergency medical care and transport) are eligible for reimbursement under the Federal Emergency Management Agency’s (FEMA) Public Assistance program. State, territorial, tribal, and local government entities and certain private non-profit organizations are eligible to apply for Public Assistance. FEMA assistance will be provided at a 75 percent federal cost-share and may not duplicate assistance provided by the U.S. Department of Health and Human Services or other federal agencies.

b. Coronavirus Aid, Relief, and Economic Security Act (CARES Act): The Paycheck Protection
Program is a loan program administered by the U.S. Small Business Administration (SBA) to incentivize small businesses to keep workers on the payroll. The SBA will forgive loans under this program if certain conditions are met. Private for-profit companies and private non-profit EMS agencies (including tribal ambulance services) are eligible. The maximum amount available to borrow under this program is 2.5 times the average total monthly payroll costs, not to exceed $10 million.

CISA Releases Version 3.0 of the Essential Critical Infrastructure Workers List

Private Sector Update

Created and distributed by the U.S. Department of Homeland Security Private Sector Office private.sector@dhs.gov

April 17, 2020

The Cybersecurity and Infrastructure Security Agency (CISA) has released Version 3.0 of the Essential Critical Infrastructure Workers list. Version 3.0 provides clarity around a range of positions needed to support the critical infrastructure functions laid out in the original guidance and Version 2.0. This iteration includes a reorganization of the section around Healthcare and Public Health and more detail to clarify essential workers; emphasis for Emergency Medical Services workers; and adds lawyers and legal aid workers. Also included is language focused on sustained access and freedom of movement; a reference to the CDC guidance on safety for critical infrastructure workers; and a statement saying sick employees should avoid the workplace and the workforce. In worker categories, all references to “employees” or “contractors” have been changed to “workers.” Other additions include a reference to the USCG Marine Safety Information Bulletin on essential maritime workers; clarified language including vehicle manufacture; and many other small changes to clarify language.

CISA issued initial guidance on Essential Critical Infrastructure Workers on March 19, which was developed to help state, local, tribal, and territorial authorities as they decide who to allow freedom of movement in areas that are under restrictions such as shelter-in-place or quarantine. That initial guidance was developed with input from our government and industry partners, on the assumption that we would need to update the guidance as we received additional feedback from stakeholders.

CISA moved quickly to incorporate feedback to update the list of Essential Critical Infrastructure Workers to expand and specify additional categories of essential workers who are key to maintaining a community’s safety, public health, and economy. These changes were included in Version 2.0 of this guidance, released March 28, generally represented minor clarifications or additions that did not shift the overall scoping of critical infrastructure activity as highlighted in the initial release. Specifically, clarity was provided around a range of supporting and enabling activity for infrastructure resilience – the commodity, services, and logistical supply chains of other infrastructure functions. This included more direct call outs for essential sanitation and hygiene production and services, as well as manufacturing of critical products.

The Guide continues to be a resource for state and local decision makers and is in no way a binding document. Ultimately, all final decisions rest with state and local authorities, who must use their own judgment to balance public health and safety with the need to maintain critical infrastructure.

The degree to which state and local orders have leveraged our guidance when defining essential workers is encouraging. A common national picture will ultimately benefit us all. We hope this updated Guide helps as your communities grapple with the impacts of COVID-19. Please direct any questions to CISA.CAT@cisa.dhs.gov.


911 and Emergency Medical Services (EMS) Algorithms

911 and Emergency Medical Services (EMS) Algorithms

Developed by the Healthcare Resilience Task Force Emergency Medical Services (EMS) Prehospital Team. Download PDF

Attached, please find the latest document released by the Health Systems Resiliency Task Force.  Please use the communication mechanisms at your disposal to share this information with your members, constituents and clients.  All Task Force documents will also be posted on EMS.gov and/or 911.gov (as appropriate).  The NHTSA created these two portals for COVID Resources and will continue to update them three times a week, with new links and documents containing information on a variety of COVID-related topics.  You will find COVID resources here on EMS.gov, and here on 911.gov.

Considerations for State Emergency Medical Service Offices in Response to COVID-19

Considerations for State Emergency Medical Service Offices in Response to COVID-19

Developed by the Healthcare Resilience Task Force Emergency Medical Services (EMS) Prehospital Team. Download PDF

  • Integration of Emergency Medical Services (EMS) into the state emergency management structure
    • Ensure that the state EMS Office, including the state EMS medical director, is represented in, or has direct input into, the state Emergency Operations Center (EOC) and its public health equivalent.
    • Define the chain of command within the EOC to ensure EMS input to leadership.
    • Clarify the roles and responsibilities of EMS medical directors (local/state/regional) to the state emergency management office.
  • Potential need for waiver/suspension of EMS laws and regulations relating to:
    • Public Safety Answering Points (PSAP) operations.
    • Personnel licensure (and re-licensure).
    • Out-of-state reciprocity.
    • Medical oversight.
    • Ambulance staffing.
    • Patient treatment/scope of practice.
    • Patient transport.
    • Training and education.
    • Protocol adherence.
  • EMS licenses and certifications
    • Develop guidance re: temporary extensions of state EMS licenses that are expiring.
    • Develop guidance re: provisional licensing of EMS clinicians in certain circumstances (e.g., licensed out-of-state, completed course requirements but not testing, recently expired license).
    • Identify which EMS certifications (e.g., CPR, PALS, ITLS, PHTLS, ACLS) have been automatically extended by a certification organization.
  • Provide guidance on potential strategies for managing limited EMS resources, including:
    • Caller screening, triage, and prioritized dispatch.
    • Referral or re-direction of calls to non-emergency resources.
    • Utilization of telemedicine resources.
    • Modified staffing and response models.
    • Modified treatment protocols.
    • Alternative transport, no transport, and transport to alternative destinations.
    • Follow-up and leave-behind information, including telemedicine resources, for patients that are not transported.
  • Other COVID-19 guidance, including:
    • Guidance on testing and quarantine or self-isolation of EMS providers.
    • Guidance on limiting physical access to PSAPs and other EMS/public safety buildings.
    • Guidance directing EMS clinicians to resources as needed for mental health and family support.
  • Management of PPE Supply
    • Relay guidance on how to request PPE supplies, including:
      • Direction to continue to submit requests through normal distribution channels.
      • Direction on how to submit unmet requests to local and state emergency management officials for transmittal to FEMA.
    • Relay guidance on the optimization and preservation of existing PPE supplies.
    • Coordinate with state and local emergency management officials on the prioritization of PPE requests from EMS agencies (public, private, and volunteer).
  • Regular communication to EMS agencies and stakeholders.
    • Conduct webinars or conference calls to assure that EMS stakeholders are kept informed.
    • Maintain consistent communication with EMS agencies to monitor the implementation of strategies for managing limited EMS resources.

Public Service Answering Points (PSAPs)/Emergency Communications Centers (ECCs) Call Screening

Public Service Answering Points (PSAPs)/Emergency Communications Centers (ECCs) Call Screening

Document Developed by the Healthcare Resilience Task Force
Emergency Medical Services (EMS) Prehospital Team. Download PDF

This document is intended to provide procedural guidance to Public Safety Answering Points (PSAPs) and Emergency Medical Service (EMS) agencies on practices that could result in improved call screening and EMS care with the potential to decrease unnecessary COVID-19 transports to hospitals. If adopted these could alleviate a significant load on the currently strained healthcare system, and decrease additional infectious disease exposures among the community and healthcare providers. NOTE: protocols would have to be approved by state or local medical oversight

This guidance applies to all PSAP and EMS delivery models including but not limited to; free standing, third-service; fire-based, hospital-based, independent volunteer, private and related emergency medical service providers.

  •  For all requests for emergency care (including interfacility transports) the dispatcher/call taker should ask the following questions:
    • Has the Patient had a positive COVID-19 test?
    • Is the Patient A COVID-19 Person Under Investigation (PUI)? – (PUI is defined as: A patient who has been tested for COVID-19 but has not received their result).
    • Does the patient have Flu-like symptoms (fever, chills, tiredness, cough, muscle aches, headaches, sore throat or runny nose)?
    • The dispatcher/call taker should document any positive findings in their report.
    • NOTE: Recent travel is no longer a recommended question
  •  If the caller answers YES to ANY of the above, this information should be relayed to response agencies and the Modified COVID-19 Response Procedure should be followed
  • If the caller answers NO to ALL of the above – response agencies should follow their normal response procedure
    Modified COVID-19 Response (Caller answered YES to ANY PSAP/Dispatch screening questions)
  •  First Responders/Emergency Medical Responders (non-transport)
    • It is recommended First Responders/Emergency Medical Responders NOT respond to limit potential exposures.
    •  If First responders/Emergency Medical Responders respond, it is recommended that their response is limited to life safety only.
  •  Emergency Medical Services (transport units)
    •  It is recommended that, when possible, only one EMS clinician make contact with the patient using PPE (while N95, eye protection, gown, gloves, and face shield continue to be the recommended standard, during times of limited supplies or limited availability of resupply, eye protection, gloves and surgical mask are acceptable alternatives).
      o If treatment and transport are required, consider having a single EMS clinician, in PPE, approach and treat the patient while isolating other EMS clinicians, family members and bystanders away from the patient.
    • If transporting, it is advised that family members should not accompany the patient. Consideration may be given if the patient is a minor or vulnerable adult. However, the CDC recommends against family members riding in the ambulance. For more information, see the Interim Guidance for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points (PSAPs) for COVID-19.
      o Consider treat-in-place/treat-no-transport guidelines (as approved by state or local medical oversight) for medically stable patients with the CDC identified COVID-19 signs and symptoms:

      •  Fever as defined as 100.4 or greater without fever medications
      • Dry cough
      • Aches
      • Fatigue
  • Examples of PSAP/ECC Resources: