Tag: Medicare

CMS Posts 2023 Public Use File

On November 23, 2022, CMS posted the 2023 Ambulance Fee Schedule Public Use Files. These files contain the amounts that will be allowed by Medicare in the calendar year 2023 for the various levels of ambulance service and mileage. These allowable reflect an 8.7% inflation adjustment over the calendar 2022 rates. The 2023 Ambulance Fee Schedule Public Use File can be downloaded from the CMS website by clicking here.

Please note that these files reflect the Medicare allowable based on current federal law.  Accordingly, the 2023 Public Use Files do not include the current add-ons (i.e., 2% for urban, 3% for rural, and the super-rural bonus), as these add-ons are currently scheduled to expire on December 31, 2022.

The AAA is actively working with congressional offices to not only extend but hopefully increase, the Medicare ambulance add-ons by the end of the year. If you have not already written to your members of Congress about extending the add-ons at increased levels, please do so today by using the AAA online advocacy tool by clicking here.

Unfortunately, in recent years, CMS has elected to release its Public Use Files without state and payment locality headings. As a result, in order to look up the rates in your service area, you would need to know the CMS contract number assigned to your state. This is not something the typical ambulance service would necessarily have on hand. For this reason, the AAA will be publishing a reformatted version of the CMS Medicare Ambulance Fee Schedule that includes the state and payment locality headings. The reformatted fee schedule will be available on the AAA website in the coming days.

The AAA will also be publishing an updated version of its Medicare Rate Calculator, which we expect to have available on our website once we have a better sense of the timing of the extension of the add-ons.

CMS Update-CY 2023 Final Ambulance Fee Schedule

Member Advisory:  CMS Issues CY 2023 Final Ambulance Fee Schedule Rule Updated Data Ground Ambulance Data Collection System

by Kathy Lester, JD, MPH

CMS has released the “CY 2023 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Medicare and Medicaid Provider Enrollment Policies, Including for Skilled Nursing Facilities; Conditions of Payment for Suppliers of Durable Medicaid Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS); and Implementing Requirements for Manufacturers of Certain Single-dose Container or Single-use Package Drugs to Provide Refunds with Respect to Discarded Amounts” (Final Rule).  The Final Rule includes proposals affecting ground ambulance services in terms of medical necessity requirements and documentation requirements, as well as to the ground ambulance cost collecting tool.

I.           Medical Necessity and Documentation Requirements for Nonemergency, Scheduled, Repetitive Ambulance Services

              CMS finalizes the modifications to the documentation requirements codified in regulation pertaining to the medical necessity and documentation requirements for nonemergency, scheduled, repetitive ambulance services, such as those to/from dialysis facilities.  The Final Rule clarifies that the Physician Certification Statement (PCS), and additional documentation from the beneficiary’s medical record, may be used to support a claim that transportation by ground ambulance is medically necessary.  It also notes that the PCS and additional documentation must provide detailed explanations that: (1) are consistent with the beneficiary’s current medical condition; and (2) explain the beneficiary’s need for transport by an ambulance.  Coverage includes observation or other services rendered by qualified ambulance personnel.  It maintains the following requirements:

  • In all cases, the provider or supplier must keep appropriate documentation on file and, upon request, present it to CMS;
  • The ambulance service must meet all program coverage criteria including vehicle and staffing requirements; and
  • A signed PCS does not alone demonstrate that transportation by ground ambulance was medically necessary.

             CMS declines to “confine this regulatory clarification to the RSNAT prior authorization program, as there may be non-emergent, scheduled, repetitive ambulance transport services outside of that program that would be affected.” (Display Copy 1756)  CMS also does not provide further clarification about what it means by the term “additional documentation” because it believes that “the data elements needed will vary depending upon the beneficiary’s specific conditions and needs.” (Id.)  CMS also states that “[t]his proposal does not establish new obligations for documentation; rather, it merely clarifies existing requirements.” (Id. at 1757).  In response to a comment, CMS also writes, “In addition, our pre-proposal language and proposed regulatory language both reflect that the presence of a PCS alone is not sufficient to demonstrate medical necessity, and, therefore, must be supported by medical documentation.” (Id.)  CMS also declined to extend authorization to nurse practitioners and physicians’ assistants, stating that to do so would be outside of the scope of the rule.

II.         Ground Ambulance Data Collection Instrument

            CMS finalizes the proposed changes to the ground ambulance data collection instrument and instructions with a few additional modifications in response to comments.  They fall within four areas:  (1) editorial changes for clarity and consistency; (2) updates to reflect the web-based system; (3)  clarifications responding to feedback from questions from interested parties and testing; and (4) typos and technical corrections.  The updated instrument that includes all of the CY 2023 proposed changes to review and provide comments on is posted on the CMS website at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AmbulanceFeeSchedule/Downloads/Medicare-Ground-Ambulance-Data-Collection-System-Instrument.pdf.

            One of these modification is to Section 5, Question 3c, which now reads: Does your organization respond to calls with another non- transporting agency such as a local fire department that is not part of your organization? After the question, the following instructions will be provided: This includes joint responses with other ground ambulance organizations as well as cases where a fire, police, or other public safety department responses to calls for service with your organization. Only consider cases where your ground ambulance does or would have transported the patient, if necessary.

            The Final Rule notes that the system already includes an “autosave” feature that saves responses as they are entered. The system also allows the same user to enter information at different times, and/or multiple users to enter information at different times. The system also already includes many validation and error checking steps that are automatically applied as respondents enter information. CMS also noted that it has no plans to adopt additional import functionality prior to the launch of the system, but that it will continue to explore the option of an API.  CMS also indicates that the final written tool and web-based platform will align before the system goes live.  A print function will also be available for the online submissions.

            CMS indicates that the data from the collection system will be made available to the public through posting on the CMS website at least every 2 years.  Summary results will be posted by the last quarter.  The data collected under the ground ambulance data collection system will be publicly available beginning in 2024.

            CMS also indicates that it will not require a ground ambulance organization to fill the data entry submitter and data certifier roles with different individuals.

            CMS has also provided additional guidance, including FAQs available at:  https://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/AmbulanceFeeSchedule/Downloads/Medicare-Ground-Ambulance-FAQs.pdf.

            CMS also finalizes its proposal for an automated process for submitting a hardship exemption request and informal review request.

III.        Origin and Destination Requirements Under the Ambulance Fee Schedule

            In the Final Rule, CMS also responds to comments it received on the Interim Final Rule that expanded the origin and destination requirements.  It finalizes the interim final policy that the expanded list of covered destinations for ground ambulance transports including, but are not limited to, any location that is an alternative site determined to be part of a hospital, CAH or SNF, community mental health centers, FQHCs, RHCs, physician offices, urgent care facilities, ASCs, any location furnishing dialysis services outside of an ESRD facility when an ESRD facility is not available, and the beneficiary’s home.  The policy will be In effect for the duration of the PHE for the COVID-19 only.

CMS Announces 2023 Ambulance Inflation Factor

On October 14, 2022, CMS issued Transmittal 11642 (Change Request 12948), which announced the Medicare Ambulance Inflation Factor (AIF) for the calendar year 2023.

The AIF is calculated by measuring the increase in the consumer price index for all urban consumers (CPI-U) for the 12-month period ending with June of the previous year.  Starting in the calendar year 2011, the change in the CPI-U is now reduced by a so-called “productivity adjustment”, which is equal to the 10-year moving average of changes in the economy-wide private nonfarm business multi-factor productivity index (MFP).  The MFP reduction may result in a negative AIF for any calendar year.  The resulting AIF is then added to the conversion factor used to calculate Medicare payments under the Ambulance Fee Schedule.

For the 12-month period ending in June 2022, the Federal Bureau of Labor Statistics (BLS) has calculated that the CPI-U increased by 9.1%.  CMS further indicated that the CY 2023 MFP would be 0.4%.  Accordingly, CMS indicated that the Ambulance Inflation Factor for the calendar year 2023 will be 8.7%. 

This is the largest inflation update since the implementation of the current Medicare Ambulance Fee Schedule in April 2002.  The increase from last year’s 5.1% increase is also the single largest year-over-year increase on record.

Administration Includes Ambulance Add-Ons Extension on CR List

The Biden Administration has issued a list of expiring programs and items that they would like to see or have no objection to being, extended as part of the FY2023 Continuing Resolution.  The list includes “Medicare add-on payments for ground ambulance services”. The list also includes a “Suspension of Medicare Sequestration” on which the AAA has been advocating. Congress will need to pass a CR by September 30 to avoid a partial government shutdown.

No determination has been made by congressional decision-makers as to when Congress will address Medicare extenders that expire at the end of the year but most key congressional staff believe extenders will be addressed after the election. Even if extenders are not included in the CR, the list demonstrates the overall support and/or recognition of the Administration for the listed programs and items including the Medicare ambulance add-on payments and suspension of sequestration.

Authorization Issues

Note: The following list is provided for your information. In the event that authorizing
legislation is not enacted in a timely manner, these items will allow either for the
continuation of programs that will be funded in the continuing resolution (CR) or for other
legislative fixes.

Agriculture/Rural Development:

Necessary For Extension or Inclusion in the CR if Not Enacted First in Other Legislation
Agriculture, Livestock Mandatory Reporting

No Objection to Inclusion in a CR if Not Enacted First in Other Legislation
HHS, FDA User Fees
HHS, Exclusivity of Certain Drugs Containing Single Enantiomers
HHS, Medical device programs expiration: 1) Authority to accredit 3rd parties to review certain medical device applications; 2) Conformity Assessment Pilot Program for Devices; 3) Device Postmarket Pilot Projects; 4) Inspections by Accredited Persons; 5) Modification to Humanitarian Device Exemption

Commerce/Justice/Science:

Necessary For Extension or Inclusion in the CR if Not Enacted First in Other Legislation
Justice, Additional Special Assessment (Expires 9/11/22)
Justice, U.S. Parole Commission (NOTE: Extension for two years is recommended)
Justice, Protection of certain facilities and assets from unmanned aircraft (Also DHS)
Justice, Extending Temporary Emergency Scheduling of Fentanyl Analogues Act (Expires 12/31/22)

Defense:

Necessary For Extension or Inclusion in the CR if Not Enacted First in Other Legislation
Defense, North Atlantic Treaty Organization Security Investment Program (NSIP)
Defense, Authority to Provide Temporary Adjust in Rates of Basic Allowance for Housing (BAH) if the Actual Costs of Adequate Housing for Civilians in That Military Housing Area or Portion Thereof Differs from the Current BAH Rates by More than 20 Percent
Defense, Authority for reimbursement of certain coalition nations for support provided to United States military operations (Expires 12/31/22)
Defense, Authority to provide assistance to counter the Islamic State in Iraq and Syria (Expires 12/31/22)
Defense, Authority to provide assistance to the vetted Syrian groups and individuals. (Expires 12/31/22)
Defense, Authority to provide temporary increase in rates of Basic Allowance for Housing (BAH) under certain circumstances (Expires 12/31/22)
Defense, Authority to Support Operations and Activities of the Office of Security Cooperation In Iraq (Expires 12/31/22)
Defense, Authority to waive annual limitation on premium pay and aggregate limitation on pay for Federal civilian employees working overseas (Expires 12/31/22)
Defense, Extension of Certain Expiring Bonus and Special Pay Authorities (Expires 12/31/22)
Defense, Income Replacement Payments for Reserve Component Members Experiencing Extended and Frequent Mobilization for Active Duty Service (Expires 12/31/22)

No Objection to Inclusion in a CR if Not Enacted First in Other Legislation
Defense, Information Operations, and Engagement Technology Demonstrations
Defense, One-time Uniform Allowance for Officers Who Transfer to the Space Force
Defense, Increased Percentage of Sustainment Funds Authorized for Realignment to Restoration and Modernization at Each Installation
Defense, Pilot Program for the Temporary Exchange of Cyber and Information Technology Personnel
Defense, Reauthorization of Authority to Order Retired Members to Active Duty in Highdemand, Low-density Assignments

Financial Services/General Government:

Necessary For Extension or Inclusion in the CR if Not Enacted First in Other Legislation
FCC, FCC General, and Incentive Auction Authority Continuation (NOTE: Extension of auction authority through 9/30/2024 is recommended)
GSA, Pilot Programs for Authority to Acquire Innovative Commercial Items Using General Solicitation Competitive Procedure (NOTE: also covered by DHS)
SBA, Assistance for Administration, Oversight, and Contract Processing Costs
SBA, Commercialization Readiness Pilot Program for Civilian Agencies
SBA, Phase 0 Proof of Concept Partnership Pilot Program
SBA, Pilot Program to Accelerate DOD Awards
SBA, SBIR Commercialization Assistance Pilot Programs
SBA, SBIR Phase Flexibility
SBA, Small Business Innovation and Research (SBIR)
SBA, Small Business Technology Transfer (STTR)

Homeland Security:

Necessary For Extension or Inclusion in the CR if Not Enacted First in Other Legislation
Homeland Security, DHS Joint Task Forces
Homeland Security, E-Verify Program
Homeland Security, National Computer Forensics Institute
Homeland Security, National Flood Insurance Program
Homeland Security, Raising the H-2B Cap
Homeland Security, National Cybersecurity Protection System (NCPS) Authorization, including EINSTEIN
Homeland Security, Counter Threats Advisory Board
Homeland Security, Pilot Programs for Authority to Acquire Innovative Commercial Items Using General Solicitation Competitive Procedure (NOTE: also covered by GSA)
Homeland Security, Protection of certain facilities and assets from unmanned aircraft (Also DOJ)

No Objection to Inclusion in a CR if Not Enacted First in Other Legislation
Homeland Security, Authority to grant special immigrant status to religious workers other than ministers
Homeland Security, Waiver of Foreign Residence Requirements for Physicians Working in Underserved Areas (“Conrad State 30” Program)

Interior/Environment:

Necessary For Extension or Inclusion in the CR if Not Enacted First in Other Legislation
Interior, Omnibus Public Land Management Act of 2009

Labor/HHS/Education:

Necessary For Extension or Inclusion in the CR if Not Enacted First in Other Legislation
Labor, Trade Adjustment Assistance (TAA) for Workers Program (Expired 7/1/22)
HHS, TANF
HHS, Promoting Safe and Stable Families Program
HHS, Liability protections for health professional volunteers at community health centers (HRSA)
HHS, Medical Countermeasures Innovations Partner
HHS, Maternal, Infant, and Early Childhood Home Visiting Program
HHS, Interdepartmental Serious Mental Illness Coordinating Committee
HHS, Increase in Medicaid FMAP for territories
SSA, Demonstration Project Authority (Expires 12/31/22)

No Objection to Inclusion in a CR if Not Enacted First in Other Legislation
HHS, Additional support for Medicaid home and community-based services during the COVID-19 emergency (Expired 3/31/22)
HHS, Suspension of Medicare Sequestration (Expired 3/31/22)
HHS, Medicare IPPS adjustment for low-volume hospitals
HHS, Medicare-dependent hospital (MDH) program
HHS, Puerto Rico Medicaid Payment
HHS, Restriction on Alaska Native Regional Health Entities
HHS, Tick-Borne Diseases Working Group
HHS, Exception for eligible professionals based in ambulatory surgical centers with respect to incentives for meaningful use of certified EHR technology (Expires 12/31/22)
HHS, Incentives for Qualifying Alternative Payment Model Participants (Expires 12/31/22)
HHS, Medicare add-on payments for ground ambulance services (Expires 12/31/22)
HHS, Medicare add-on payments for rural home health services (Expires 12/31/22)
HHS, Temporary Increase in Medicare Physician and Non-physician Practitioners Payments (Expires 12/31/22)

Military Construction/VA:

Necessary For Extension or Inclusion in the CR if Not Enacted First in Other Legislation
VA, Adaptive Sports Assistance Program (formerly limited to Paralympics)
VA, Co-Pays for Hospital and Nursing Home Care
VA, Homeless and Seriously Mentally Ill Veterans- Additional Services at Certain Locations
VA, Homeless and Seriously Mentally Ill Veterans- Treatment/ Rehab
VA, Manila, Philippines Regional Office
VA, SAH – Assistive Technology Grants
VA, Transportation of Beneficiaries
VA, Advisory Committee on Minority Veterans
VA, Advisory Committee on Education (Expires 12/31/22)
VA, Advisory Committee on Homeless Veterans (Expires 12/31/22)
VA, SAH for Veterans Temporarily Residing with Family (Expires 12/31/22)

Transportation/HUD:

Necessary For Extension or Inclusion in the CR if Not Enacted First in Other Legislation
Transportation, Next Generation 9-1-1

CMS Medicare, Medicaid, and CHIP Enrollment

Centers for Medicare & Medicaid Services

Today, the Centers for Medicare & Medicaid Services (CMS) released the latest enrollment figures for Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). These programs serve as key connectors to care for more millions of Americans.

Medicare

As of May 2022, 64,553,288 people are enrolled in Medicare. This is an increase of 103,837 since the last report.

34,893,853 are enrolled in Original Medicare.

29,659,435 enrolled in Medicare Advantage or other health plans. This includes enrollment in Medicare Advantage plans with and without prescription drug coverage.

50,086,253 are enrolled in Medicare Part D. This includes enrollment in stand-alone prescription drug plans as well as Medicare Advantage plans that offer prescription drug coverage.

About 12 million individuals are dually eligible for Medicare and Medicaid, so are counted in the enrollment figures for both programs.

Detailed enrollment data can be viewed here: https://data.cms.gov/summary-statistics-on-beneficiary-enrollment/medicare-and-medicaid-reports/medicare-monthly-enrollment

Medicaid and Children’s Health Insurance Program (CHIP)

As of May 2022, 88,978,791 of people are enrolled in Medicaid and CHIP. This is an increase of 677,711 since the last report.

81,904,569 are enrolled in Medicaid

7,074,222 are enrolled in CHIP

For more information on Medicaid/CHIP enrollment, including enrollment trends, visit https://www.medicaid.gov/medicaid/program-information/medicaid-chip-enrollment-data/medicaid-and-chip-enrollment-trend-snapshot/index.html

Every day, CMS ensures that people across the U.S. have coverage that works. See the latest coverage totals across all CMS programs at https://www.cms.gov/pillar/expand-access. This information is updated on a monthly basis. Enrollment data for CMS programs are compiled on different timelines owing to the unique nature of each program.

AAA 2022 Legislative Priorities

Yesterday, the American Ambulance Association Board of Directors approved the Association’s advocacy priorities for 2022. Our key initiatives reflect the challenges we face this year, including short-sighted threats to EMS balance billing, a worsening workforce shortage, the expiration of the temporary Medicare increases, and potential sequestration cuts.

We also continue to fight for you as you care for people first on the frontlines of the COVID-19 pandemic. We will sustain our efforts at securing additional funding for ground ambulance services to help address the increased costs of providing medical care and transport during the Public Health Emergency.

To achieve our collective goals, the AAA Board will need to mobilize the full voice of influence of the EMS community this year. If you have not already sent an email using the AAA advocacy system to your members of Congress, please do so today!

Staff will be reaching out to you at key points later in the year about letter writing for specific individual policy requests. But it is important that they hear from you now on all the top issues for ground ambulance services.  They are:

Top AAA Advocacy Priorities for 2022

EMS Workforce Shortage

With the persistent shortage of ground ambulance service field personnel raising to a crisis level with the COVID-19 pandemic, the AAA moved the issue to a top policy priority. The AAA is currently working with key Congressional Committees of jurisdiction to hold hearings on the EMS workforce shortage. We are also developing legislation to specifically target increasing access for ground ambulance service organizations to federal programs and funding for the retention and training of health care personnel.

Balance Billing

The AAA successfully educated the Congress on the role of local government oversight and other unique characteristics of providing ground ambulance service organizations. As a result, the Congress directed the establishment of a Ground Ambulance and Balance Billing Advisory Committee to address the issue. The Committee is in the process of being formed and then has 180 days in which to make recommendations to the Congress. The AAA will be involved with the Committee and advocating that the Congress implement policies that meet the needs of our members.

Additional COVID-19 Financial Assistance

The AAA is advocating for additional financial assistance for ground ambulance service organizations to help address the increased costs of labor and other higher costs associated with providing health care during the COVID-19 pandemic.

Medicare Ambulance Relief

The temporary Medicare ambulance increases of 2% urban, 3% rural and the super rural bonus payment expire at the end of the year. The AAA will continue to push for passage of the provisions of the Preserving Access to Ground Ambulance Medical Services Act (S. 2037, H.R. 2454) before the provisions expire as well as for the adoption of language to ensure truly rural areas remain rural following changes to geographical designations based on the 2020 census.

Sequestration Cuts

The Congress delayed the additional 4% sequestration cut for only one yea. The AAA is working with other EMS and health care provider and supplier groups to permanently prevent the cut from going into effect as well as further extending the moratorium on the long-standing 2% cut.

Ambulance Cost Data Collection

With the 2-year delay of ambulance data collection due to the pandemic, the Medicare Payment Advisory Committee (MedPAC) will have little to no data to analyze in March 2023 in which to make recommendations to the Congress on Medicare ambulance payment policy and rates. The AAA is asking the Congress to push back the date of the MedPAC report and also expand the modified data collection timeline of two years to the intended four years.

On behalf of my fellow board members, I again thank you for your continued membership and participation. We look forward to serving you for many years to come.

We also encourage all of our AAA members to contact their members of Congress through our online advocacy tool. 

Should you have any questions regarding our advocacy priorities, please contact AAA Senior Vice President of Government Affairs Tristan North at tnorth@ambulance.org.

HHS Provides More Details on Phase 4 and Rural Provider Relief Fund Distribution

As previously reported by the AAA, the Department of Health and Human Services (HHS) has announced that it will open on September 29, Phase 4 of the Provider Relief Fund (PRF) to allocate $17 billion dollars for COVID-19 relief. In addition, it will provide $8.5 billion specifically for rural providers. On September 15, HHS held a stakeholder call on the PRF in which the agency provided more details on the distribution.

The application process will remain open for 4 weeks. Providers will be able to use the funding through December 31, 2022.  The Administration’s goal is to release the rural funds before Thanksgiving and the Phase four funds by mid-December 2021. The agency indicated it has additional funding it is holding back to reimburse for the uncompensated care fund for which providers and suppliers can still apply.

The AAA has been advocating relentlessly for the Administration to open a fourth phase of funding and support rural providers and suppliers.  As described below, these phases of funding will rely upon data from Medicare, Medicaid, and the State Children’s Health Insurance Program (CHIP).  It is important that all AAA members who qualify not only submit applications, but also make sure that you have appropriately submitted claims to these programs, including when allowed, claims under the ground ambulance treatment in place waiver. We strongly recommend that all AAA members apply for funding.

Phase 4 Funding

The Phase 4 PRF methodology and application will primarily follow the same rules set forth for Phase 3.  It will apply for Q2 2020 through Q1 2021.  The funding will be available for the same broad set of providers and suppliers that were eligible under Phase 3.

Phase 4 will have two components.  The Acting Administrator of HRSA has explained that 75 percent of the funding for Phase 4 will be determined based on a provider’s lost revenues and expenses that the provider submits through the application process.  HRSA will calculate the amount awarded based on the number of applications received.  However, it will establish a base for all providers and then adjust that base up for medium and small providers who have lower volumes over which to spread their costs.  The determination of provider size will be based on patient revenues.

The second component of Phase 4 funding will allocate 25 percent for bonus payments to providers serving Medicare, Medicaid, and CHIP patients.  The final amounts awarded will be determined based on the volume of services provided to these patient populations.

The Acting Administrator also noted that once again providers who have higher values compared to their peer group will be flagged and may have the amount they receive capped or may not receive any funding.  There will be a reconsideration process for these providers as well.

Rural Funding

In addition to Phase 4, HRSA will provide rural-specific relief to providers and suppliers serving rural patients.  The determination of whether a provider qualifies will be based on the patient’s location, not that of the providers.  HRSA will use Medicare, Medicaid, and CHIP data to calculate the payment, so the application process will be simplified and providers required to submit less information.  The amounts will be determine based on the number of patients served and the number of applicants.

Additional Relief

The Acting Administrator also indicated that HRSA will provide a 60-day grace period for those providers who received funds already and are required to report if they cannot meet the current reporting deadline.  She also noted that HRSA is establishing a reconsideration process for Phase 3 as well.  Details will be available on the HRSA website.

Additional Information

HRSA will be posting information on its website.  It will also host two webinars on September 30 and October 5 to provide more information about how providers can apply to these programs.

Medicare Ambulance Relief Bill Introduced in House

Yesterday, Congresswoman Terri Sewell (D-AL) introduced the Protecting Access to Ground Ambulance Medical Services Act of 2021 (H.R. 2454). Congresswoman Sewell was joined by Congressmen Devin Nunes (R-CA), Peter Welch (D-VT) and Markwayne Mullin (R-OK) as primary cosponsors and leads on the legislation.

H.R. 2454 would extend the temporary Medicare ground ambulance increases of 2% urban, 3% rural and the super rural bonus payment for five years. The increases are currently scheduled to expire on December 31, 2022. The five-year extension would allow for the increases to remain in place during the two-year delay on ambulance data collection period due to the COVID-19 public health emergency.  It would also permit the cost collection program to move forward so that the statutorily mandated MedPAC analysis could be completed before the Congress would have to act to either further extend the add-ons or make them permanent through reforming the Medicare ambulance fee schedule.

The legislation would help address potential problems that rural zip codes in large urban counties could face as a result of the 2020 census data.  As we saw after the 2010 Census, the new Census data collection methodology resulted in geographical changes under the fee schedule that shifted rural ZIP codes to urban, despite there being no significant change in their population. The current definition using rural urban commuting areas (RUCA) in Goldsmith Modification areas would be modified to ensure ZIP codes with 1,000 people or less per square mile would remain rural. Ground ambulance service providers and suppliers could also petition the Centers for Medicare and Medicaid Services (CMS) to make the argument that a specific ZIP code should remain rural. It is vital that this provision be implemented before CMS makes changes from the 2020 Census data which will likely occur in 2023.

The AAA has been leading the effort on the legislation with the support of the Congressional Fire Services Institute, International Association of Fire Chiefs, International Association of Fire Fighters, National Association of EMTs and the National Volunteer Fire Council.

The AAA is working with champions of the effort in the Senate on introduction of a companion bill. We expect the bill to be introducing in the coming weeks.

The legislation is one of the policy issues being raised as part of EMS on the Hill Day and the AAA will be launching a Call To Action shortly requesting AAA members to ask their members of Congress to cosponsor the bill.

We greatly appreciate the leadership of Representatives Sewell, Nunes, Welch and Mullin on this vital issue.

CMS: Revised Repayment Terms for Medicare Accelerated Payments

On October 8, 2020, the Centers for Medicare and Medicaid Services (CMS) issued a Fact Sheet setting forth the repayment terms for advances made under the Medicare Accelerated and Advance Payments Program (AAPP).  These changes were mandated by the passage of the Continuing Appropriations Act, 2021 and Other Extensions Act, which was enacted on October 1, 2020.

Background

On March 28, 2020, CMS expanded the existing Accelerated and Advance Payments Program to provide relief to Medicare providers and suppliers that were experiencing cash flow disruptions as a result of the COVID-19 pandemic, and associated economic lockdowns.  Under the AAPP, Medicare providers and suppliers were eligible to receive an advance of up to three months of their historic Medicare payments.  These advances are structured as “loans,” and are required to be repaid through the offset of future Medicare payments.

CMS began accepting applications for Medicare advances in mid-March 2020, before ending the program in late April following the passage of the CARES Act.  CMS ultimately approved more than 45,000 applications for advances totaling approximately $100 billion, before it suspended the program in late April 2020.

Under the pre-existing terms of the AAPP, repayment through offset was required to commence on the 121st day following the provider or supplier’s receipt of the advance funds.  The program also called for a 100% offset until all advanced funds had been repaid.

Revised Payment Terms

Under the revised payment terms announced by CMS, providers and suppliers will not be subject to recoupment of their Medicare payments for a period of one year from the date they received their AAPP payment.  Starting on the date that is one year from their receipt of the AAPP payment, repayment will be made out of the provider’s or supplier’s future Medicare payments.  The schedule for such repayments will be as follows:

  • 25% of the provider’s or supplier’s Medicare payments will be offset against the outstanding AAPP balance for the next eleven (5) months; and
  • 50% of the provider’s or supplier’s Medicare payments will be offset against the outstanding AAPP balance for the next six (6) months

To the extent there remains an outstanding AAPP balance after that 17 month period (i.e., 29 months after the date the provider or supplier received its AAPP payment, the provider or supplier will receive a letter setting forth their remaining balance.  The provider or supplier will have 30 days from the date of that letter to repay the AAPP balance in full.  To the extent the AAPP balance is not repaid in full within that 30-day period, interest will begin to accrue on the unpaid balance at a rate of 4%, starting from the date of the letter.

Medicare providers and suppliers are also permitted to repay their accelerated or advance payments at any time by contacting their Medicare Administrative Contractor.

 

2020 Medicare Reference Manual & Medicare Update Webinar

The 2020 Medicare Reference Manual and the 2020 Medicare Update Webinar are both available for purchase. Please see details below!

2020 Medicare Update Webinar

Thursday, April 30, 2020 | 2:00pm EST
Presenter: Brian Werfel, Esq.
$99 for AAA-Members | $198 for Non-Members

Join A.A.A. Medicare Consultant Brian S. Werfel, Esq. for an update on recent changes to Medicare’s coverage of ambulance services. This webinar coincides with the American Ambulance Association’s release of its 2020 Medicare Reference Manual. Brian will discuss recent changes in Medicare policy, including changes to the rules governing the enforcement of fraud and abuse, the appeals process, etc. We will also discuss Medicare’s proposed plan for the ET3 Program, the national expansion of the prior authorization model for scheduled non-emergency transports, and much more.

Of course, we will also discuss Medicare’s coverage of ambulance services during the current COVID-19 process. This will include a frank discussion of the issues related to medical necessity for the transportation of known or suspected COVID-19 patients, the coverage of transports to field hospitals and other alternative destinations, the current status of certain administrative rules like the Medicare patient signature requirement and the Notice of Privacy Practices, etc.

The session will include an extended Q&A period to address any and all questions from attendees. Purchase Webinar► 

*2020 Medicare Reference Manual Sold Separately* 

 

2020 Medicare Reference Manual 

$200 for AAA-Members | $400 for Non-Members
By David Werfel, Esq & Brian Werfel, Esq

The American Ambulance Association’s 2020 Medicare Reference Manual is a must-have for ambulance services that bill Medicare for transports.

CMS Releases Update Guidance on Hospital EMTALA Obligations Related to COVID-19

On March 9, 2020, CMS published a memorandum to State Survey Agency Directors that provides updated guidance on the obligations of hospitals and critical access hospitals (CAHs) under the Emergency Medical Treatment and Labor Act (EMTALA).  This guidance was issued in response to numerous inquiries regarding the EMTALA obligations of these facilities as they struggle to respond to the COVID-19 pandemic.

Under EMTALA, hospitals and CAHs with emergency departments have an obligation to provide an appropriate medical screening examination to any individual that comes into the emergency department seeking examination or treatment of an emergency medical condition.  Hospitals and CAHs are further required to make a determination as to whether the patient actually has an emergency medical condition, and, if so, to provide stabilizing treatment within the hospital’s capabilities, or make appropriate arrangements to transfer the patient to a facility that does have the necessary capabilities.

The hospitals and CAHs had requested guidance on how they can fulfill their basic EMTALA obligations while minimizing the risks of exposure from COVID-19 infected individuals to their staff and other patients in their emergency departments.

Note: in summarizing the CMS guidance document, references to a “hospital” will include both hospitals and CAHs.

Acceptance of Patients Suspected or Confirmed to be Infected with COVID-19

 CMS indicated that hospitals with the capacity and the specialized capabilities needed to provide stabilizing treatments are required to accept transfers from hospitals without the necessary capabilities. CMS indicated that it would take into account the recommendations of the Centers for Disease Control (CDC) in assessing a hospital’s capabilities and capacity.  CMS further indicated that the presence or absence of negative pressure rooms (Airborne Infection Isolation Room (AIIR)) would not be the sole determining factor related to determining when an EMTALA transfer is required.  CMS is advising hospitals to coordinate with their state and local public health officials regarding the appropriate placement of individuals who meet specific COVID-19 assessment criteria, as well as the most current standards for treating patients confirmed to be infected with COVID-19.

CMS is further confirming that hospitals have the ability to set up alternative screening sites on the hospital campus, i.e., the initial medical screening exam does not need to take place in the emergency department.  CMS is confirming that individuals may be redirected to an alternative screening site after being logged into the emergency department.  This redirection can even take place outside the entrance to the emergency department.  Medical screening exams conducted in alternative screening sites must still be conducted by qualifying personnel (i.e., physicians, NPs, Pas, or RNs).

CMS is also indicating that hospitals may set up screening sites at “off-campus, hospital-controlled” sites.  Hospitals and community officials may encourage the public to go to these sites instead of the hospital for screening for influenza-like illnesses.  However, a hospital cannot tell an individual that has already presented at their emergency department to go to an off-site location for their medical screening exam.  Unless the off-campus site is already considered to be a dedicated ED (e.g., a free-standing ED) under EMTALA regulations, the EMTALA regulations would not apply to these off-site screening areas; however, the hospital would be required under its Medicare Conditions of Participation to arrange a referral/transfer to an appropriate hospital if the patient has a need for emergency medical attention. 

 Finally, communities may set up screening clinics at sites not under the control of a hospital.  These sites would not be subject to EMTALA.

EMTALA Obligations when a Screening Suggests Possible COVID-19 Infection

 To the extent a hospital determines, following a medical screening exam that a patient may be a possible COVID-19 case, the hospital is expected to isolate the patient immediately.  CMS indicated that it expects that all hospitals will be able to provide medical screening exams and initiate stabilizing treatment while maintaining isolation requirements.

Once an individual is admitted to the hospital or the emergency medical condition ends, the hospital has no further obligations under EMTALA.

CMS is further reminding hospitals that the latest screening guidance from the CDC calls for hospitals to contact their State or local public health officials when they have a case of suspected COVID-19.

CMS Grants State of Florida’s 1135 Waiver Request for Coronavirus Response

On March 16, 2020, CMS approved an 1135 Waiver request submitted by the State of Florida. The State had requested the flexibility to waive prior authorization requirements, streamline its Medicaid enrollment process, and allow care to be provided in alternative settings to the extent an existing health care facility needs to be evacuated. The key provisions of the waiver are summarized below:

1. Payments to Out-of-State Providers: Under current CMS coverage guidelines, the Florida Medicaid Program had the authority to reimburse out-of-state providers that were not enrolled in the Florida Medicaid Program provided certain criteria were met. However, this authority was limited to situations involving: (a) a single instance of care furnished over a 180-day period or (b) multiple instances of care furnished to a single Florida Medicaid beneficiary over a 180-day period. Under the waiver, CMS is removing the 180-day restriction for the duration of the emergency.

2. Expedited Enrollments: With respect to providers that are not currently enrolled in the Medicare Program or with another State Medicaid Agency, CMS is waiving the following screening requirements: (a) the payment of the application fee, (b) the fingerprint-based criminal background checks, (c) the required site visits, and (d) the in-state/territorial licensing requirements. Under the waiver, the state would still be required to check enrolling providers against the OIG exclusion list, and confirm that the out-of-state provider is properly licensed in their home state.

3. Cessation of Revalidation Efforts: CMS granted Florida the authority to temporarily cease the revalidation of enrolled in-state Medicaid providers and suppliers who are directly impacted by the emergency.

4. Waiver of Prior Authorization Requirements: CMS has granted Florida the right to waive any prior authorization requirements that are currently part of the State Medicaid Plan. This waiver applies to services provided on or after March 1, 2020, and will continue through the termination of the emergency declaration.

5. Waiver Allowing Evacuating Facilities to Provide Services in Alternative Settings: CMS will allow facilities, including nursing facilities, intermediate care facilities for individuals with intellectual and developmental disabilities, psychiatric residential treatment facilities, and hospitals to be reimbursed for services rendered during an emergency evacuation to an otherwise unlicensed facility. This waiver will extend for the duration of the declared emergency; however, CMS will require the unlicensed facility to seek licensure with the state after 30 days.