On January 30, 2019, the Centers for Medicare & Medicaid Services (CMS) announced that it had elected not to extend its temporary moratoria on the enrollment of new Medicare Part B non-emergency ground ambulance providers and suppliers in the states of New Jersey and Pennsylvania. These enrollment moratoria expired on January 29, 2019.
On August 20, 2018, the Centers for Medicare & Medicaid Services (CMS) published a notice in the Federal Register that it would be revising the terms of its Provider Enrollment Moratoria Access Waiver Demonstration (PEWD) Program. These revisions became effective on August 20, 2018.
Section 6401(a) of the Affordable Care Act granted CMS the authority to impose temporary moratoria on the enrollment of new Medicare providers and suppliers to the extent doing so was necessary to combat fraud or abuse. Based on this authority, CMS has implemented temporary moratoria on the enrollment of new non-emergency ambulance providers in the states of New Jersey and Pennsylvania.
Under the Provider Enrollment Moratoria Access Waiver Demonstration (PEWD) Program, CMS has the authority to grant waivers to statewide enrollment moratorium on a case-by-case basis in response to access to care issues. However, since the implementation of the PEWD Program in 2016, CMS has identified a handful of technical issues that have complicated the implementation of the PEWD Program. The revisions in this notice are intended to resolve these technical issues.
The specific revisions CMS is making include:
The Centers for Medicare & Medicaid Services (CMS) has announced that it intends to extend the temporary moratoria on the enrollment of new Medicare Part B non-emergency ground ambulance providers and suppliers in the states of New Jersey and Pennsylvania. The extended moratoria will run through January 29, 2019. Notice of the extension of the temporary moratorium will appear in the Federal Register on August 2, 2018.
Section 6401(a) of the Affordable Care Act granted CMS the authority to impose temporary moratoria on the enrollment of new Medicare providers and suppliers to the extent doing so was necessary to combat fraud or abuse. On July 31, 2013, CMS used this new authority to impose a moratorium on the enrollment of new ambulance providers in Houston, Texas and the surrounding counties. On February 4, 2014, CMS imposed a second moratorium on newly enrolling ambulance providers in the Philadelphia metropolitan areas. These moratoriums were subsequently extended on August 1, 2014, February 2, 2015, July 28, 2015, and February 2, 2016.
On August 3, 2016, CMS announced changes to the moratoria on the enrollment of new ground ambulance suppliers. Specifically, CMS announced that: (1) the enrollment moratoria would be lifted for the enrollment of new emergency ambulance providers and supplier and (2) the enrollment moratoria on non-emergency ambulance services would be expanded to cover the entire states of New Jersey, Pennsylvania, and Texas. At the same time, CMS announced the creation of a new “waiver” program that would permit the enrollment of new non-emergency ambulance providers in these states under certain circumstances. The revised moratorium on newly enrolling non-emergency ground ambulance providers was subsequently extended on January 9, 2017 and July 28, 2017.
On September 1, 2017, CMS issued a notice on its website indicating that it had elected to lift the moratorium on the enrollment of new Part B non-emergency ambulance suppliers in Texas, effective September 1, 2017. CMS indicated that this decision was made to assist in the disaster response to Hurricane Harvey. CMS published formal notice of the lifting of this moratorium on November 3, 2017.
On January 30, 2018, CMS announced an extension of the moratorium on the enrollment of new Part B non-emergency ambulance suppliers in New Jersey and Pennsylvania.
CMS will need to make a determination on whether to extend or lift the enrollment moratorium on or before January 29, 2019.
CMS held its latest Open Door Forum on Wednesday, March 7, 2018. As with past Open Door Forums, CMS started the call with the following series of announcements:
Medicare Fee Schedule – CMS indicated that the Bipartisan Budget Act of 2018, enacted on February 9, 2018, contained several provisions that impacted the payment of ambulance claims under the Medicare Ambulance Fee Schedule:
Temporary Enrollment Moratorium – CMS indicated that the temporary moratorium on the enrollment of new ground non-emergency ambulance providers in Texas was lifted on September 1, 2017. CMS further indicated that the enrollment moratorium was extended for the states of New Jersey and Pennsylvania for an additional six months on January 29, 2018. CMS will need to make a determination on or before July 29, 2018 on whether to lift the moratorium or extent it for an additional six months in that state.
Following the announcements, CMS moved into a brief Question & Answer period. Most of the questions were not answered on the call; instead, CMS took the contact information of the person asking the question, and indicated that they would respond directly to them at a later date. However, the following questions were answered:
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On January 30, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a notice in the Federal Register extending the temporary moratoria on the enrollment of new Medicare Part B non-emergency ground ambulance providers and suppliers in the states of New Jersey and Pennsylvania. The extended moratoria will run through July 29, 2018.
Section 6401(a) of the Affordable Care Act granted CMS the authority to impose temporary moratoria on the enrollment of new Medicare providers and suppliers to the extent doing so was necessary to combat fraud or abuse. On July 31, 2013, CMS used this new authority to impose a moratorium on the enrollment of new ambulance providers in Houston, Texas and the surrounding counties. On February 4, 2014, CMS imposed a second moratorium on newly enrolling ambulance providers in the Philadelphia metropolitan areas. These moratoriums were subsequently extended on August 1, 2014, February 2, 2015, July 28, 2015, and February 2, 2016.
On August 3, 2016, CMS announced changes to the moratoria on the enrollment of new ground ambulance suppliers. Specifically, CMS announced that: (1) the enrollment moratoria would be lifted for the enrollment of new emergency ambulance providers and supplier and (2) the enrollment moratoria on non-emergency ambulance services would be expanded to cover the entire states of New Jersey, Pennsylvania, and Texas. At the same time, CMS announced the creation of a new “waiver” program that would permit the enrollment of new non-emergency ambulance providers in these states under certain circumstances. The revised moratorium on newly enrolling non-emergency ground ambulance providers was subsequently extended on January 9, 2017 and July 28, 2017.
On September 1, 2017, CMS issued a notice on its website indicating that it had elected to lift the moratorium on the enrollment of new Part B non-emergency ambulance suppliers in Texas, effective September 1, 2017. CMS indicated that this decision was made to assist in the disaster response to Hurricane Harvey. CMS published formal notice of the lifting of this moratorium on November 3, 2017.
On or before July 29, 2018, CMS will need to make a determination on whether to extend or lift the enrollment moratorium.
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Is CMS Ending the Temporary Moratorium on Enrollment of New Non-Emergency Ground Ambulance Providers in Texas?
On September 2, 2017, the Centers for Medicare and Medicaid Services (CMS) posted a notice on its website that it was lifting the temporary moratorium on the enrollment of new Part B non-emergency ambulance suppliers in Texas, effective September 1, 2017. CMS indicated that the lifting of this temporary moratorium was intended to aid in the disaster response to Hurricane Harvey.
For reasons I will discuss in greater detail below, this explanation has struck a number of commentators as curious. These commentators have speculated that this may notice may foretell a permanent elimination of the enrollment moratorium for non-emergency ground ambulance providers in Texas.
The Affordable Care Act granted CMS several new tools to combat fraud, waste, and abuse in the Medicare, Medicaid, and Children’s Health Insurance Programs. This included Section 6401(a), which granted the CMS Secretary the authority to impose temporary moratoria on the enrollment of new Medicare, Medicaid, or CHIP providers to the extent the Secretary determined that doing was necessary to prevent fraud and abuse.
The implementation of the first enrollment moratorium under this new authority was made on July 30, 2013, when CMS announced enrollment moratoria on new home health agencies in Chicago, Illinois, and Miami, Florida, as well as on new ground ambulance suppliers in the Houston, Texas metropolitan area. On January 30, 2014, CMS expanded the enrollment moratorium on new ground ambulance suppliers to the Philadelphia, Pennsylvania metropolitan area. CMS subsequently extended these enrollment moratoria every 6 months thereafter, up to July 29, 2016. On that date, CMS announced that it was making several significant changes to the enrollment moratoria:
CMS further announced the creation of an “Enrollment Moratoria Access Waiver Demonstration” program that would permit non-emergency ambulance providers in those states to apply for a waiver (i.e., to permit them to enroll in the Medicare, Medicaid, or CHIP Programs) to the extent they could demonstrate an access to care issue.
The Medicare enrollment process is a lengthy one. Following the submission of an enrollment form (CMS-855b), it typically takes the Medicare contractor up to 60 days to review the form and approve it. Moreover, the Medicare contractor will frequently request additional information, which can add up to several months to the process. Once approved by the Medicare contractor, the application is passed along to the Site Review Contractor for a visit to the enrollee’s physical practice locations. All told, it is not unusual for the process to take 4-6 months from start to finish. The time limits for enrollment in Medicaid and CHIP are similar.
It seems unlikely that a ground ambulance supplier that temporarily responded to the areas affected by Hurricane Harvey would go through the enrollment process, especially considering they would likely be seeking reimbursement for their efforts either directly through the Federal Emergency Management Agency (FEMA) and its contractor, or through the existing 1135a waiver program. For this reason, it seems logical to assume that an ambulance supplier would only go through the enrollment process only if it intends to permanently establish operations in the affected area.
Editor’s Note: it is possible that CMS intended to address storm damage to an enrolled provider’s existing practice locations, i.e., the lifting of the moratorium would make it easier for these providers to add additional practice locations while they repaired their existing facilities. However, there is nothing in CMS’ website notice that suggests that this was intended to be limited to existing enrolled providers. This is simply speculation on my part.
CMS indicated that it would be publishing a notice in the Federal Register formally announcing the lifting of the enrollment moratorium. A month ago, it was assumed by most commentators (myself included) that the notice would make clear that the lifting of the moratorium was temporary, and that it would set a date for its re-establishment. However, it has now been more than a month since CMS announced the lifting of the moratorium, and that notice has yet to appear in the Federal Register. The longer we go without an announcement from CMS, the more this starts to look like a permanent lifting of the moratorium.
The lifting of this moratorium applies to new enrollments in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). Therefore, as of today, and pending a subsequent re-establishment of the enrollment moratorium by CMS, Part B ground ambulance suppliers in Texas that are not otherwise enrolled as non-emergency ground ambulance suppliers will now be permitted to enroll in the Medicare, Medicaid, and CHIP Programs. The lifting of the moratorium will also permit companies that are already enrolled as non-emergency ambulance suppliers to add additional practice locations throughout the state. CMS has indicated that both new enrollments and changes in enrollment to add additional practice locations will be subject to “high” screening under 42 C.F.R. §424.518(c)(3)(iii).
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In order to assist with the disaster response to Hurricane Harvey, CMS has announced that it has lifted the temporary moratorium on the enrollment of new Part B non-emergency ambulance suppliers in Texas, effective September 1, 2017. The lifting of this moratorium applies to new enrollments in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). CMS indicated that it will publish a notice in the Federal Register to formally announce the lifting of the moratorium.
As a result, Part B ambulance suppliers that are not otherwise already enrolled as non-emergency ambulance provider in the State of Texas will be permitted to enroll in the Medicare Program. The lifting of the moratorium will also permit companies that are already enrolled as non-emergency ambulance suppliers to add additional practice locations throughout the state. CMS has indicated that both new enrollments and changes in enrollment to add additional practice locations will be subject to “high” screening under 42 C.F.R. §424.518(c)(3)(iii).
On July 28, 2017, the Centers for Medicare & Medicaid Services (CMS) issued a notice in the Federal Register extending the temporary moratoria on the enrollment of new Medicare Part B non-emergency ground ambulance providers and suppliers in the states of New Jersey, Pennsylvania, and Texas. The extended moratoria will run through January 29, 2018.
Section 6401(a) of the Affordable Care Act granted CMS the authority to impose temporary moratoria on the enrollment of new Medicare providers and suppliers to the extent doing so was necessary to combat fraud or abuse. On July 31, 2013, CMS used this new authority to impose a moratorium on the enrollment of new ambulance providers in Houston, Texas and the surrounding counties. On February 4, 2014, CMS imposed a second moratorium on newly enrolling ambulance providers in the Philadelphia metropolitan areas.
On August 3, 2016, CMS announced changes to the moratoria on the enrollment of new ground ambulance suppliers. Specifically, CMS announced that: (1) the enrollment moratoria would be lifted for the enrollment of new emergency ambulance providers and supplier and (2) the enrollment moratoria on non-emergency ambulance services would be expanded to cover the entire states of New Jersey, Pennsylvania, and Texas. At the same time, CMS announced the creation of a new “waiver” program that would permit the enrollment of new non-emergency ambulance providers in these states under certain circumstances. The moratoria have been extended on these terms every six months thereafter.
On or before January 29, 2018, CMS will need to make a determination on whether to extend or lift the enrollment moratorium.
The Centers for Medicare & Medicaid Services Lifts Moratoria on Enrollment of Part B Emergency Ground Ambulance Suppliers in All Geographic Locations; Moratoria for Part B Non-Emergency Ground Ambulance Suppliers Extended
Effective July 29, the Centers for Medicare & Medicaid Services (CMS) has lifted the temporary moratoria in all geographic locations for Part B emergency ground ambulance suppliers. Beginning in 2013, CMS placed moratoria on Medicare Part B ground ambulance suppliers in Harris County, Texas, and surrounding counties (Brazoria, Chambers, Fort Bend, Galveston, Liberty, Montgomery, and Waller). In February 2014, CMS announced it would add six more months to these moratoria and add Philadelphia, Pennsylvania, and surrounding counties (Bucks, Delaware, and Montgomery), as well as the New Jersey counties of Burlington, Camden, and Gloucester. Since that date, CMS extended the moratoria four additional times, most recently in February of this year.
CMS considers qualitative and quantitative factors when determining if there is a high risk of fraud, waste, and abuse in a particular area and whether or not it should establish a moratorium. If CMS identifies an area as posing an increased risk to the Medicaid program, the State Medicaid agency must impose a similar temporary moratorium as well. CMS also consults with the Office of the Inspector General (OIG) within the Department of Health and Human Services (HHS) and the Department of Justice (DOJ) when identifying potential areas and providers/suppliers that should be subject to a temporary moratorium. Finally, CMS also considers whether imposing a moratorium would have a negative impact on beneficiary access to care. In areas where there is a temporary moratorium, the policy does not apply to changes in practice location, changes to provider/supplier information (e.g., phone number, address), or change in ownership. Temporary moratoria remain in place for six months, unless CMS extends the policy through notice in the Federal Register.
CMS may lift a moratorium at any time if the President declares an area a disaster under the Robert T. Stafford Disaster Relief and Emergency Assistance Act, if circumstances warranting the imposition of a moratorium have abated, if the Secretary of HHS has declared a public health emergency, or if, in the judgment of the Secretary of HHS, the moratorium is no longer needed. After a moratorium is lifted, providers/suppliers previously subject to it will be designated to CMS’s “high screening level” for six months from the date on which the moratorium was lifted.
CMS has announced it will lift the moratoria on new Part B emergency ambulance suppliers in all geographic locations because the Agency’s evaluation has shown the primary risk of fraud, waste, and abuse comes from the non-emergency ambulance supplier category and that there are potential access to care issues for emergency ambulance services in the areas with moratoria. New emergency ambulance suppliers seeking to enroll as Medicare suppliers will be subject to “high risk” screening. If enrolled, these suppliers will be permitted to bill only for emergency transportation services. They will not be permitted to bill for non-emergency services.
The moratoria remain in place for Medicare Part B non-emergency ground ambulance suppliers for all counties in which moratoria already are in place in New Jersey, Pennsylvania, and Texas.
On July 25, 2015, CMS issued a notice extending the temporary moratorium for enrollment of new ambulance suppliers in the Texas counties of Brazoria, Chambers, Fort Bend, Galveston, Harris, Liberty, Montgomery and Waller, as well as in Philadelphia and the surrounding counties of Bucks, Delaware, Montgomery (Pennsylvania), Burlington, Camden and Gloucester (New Jersey). This notice will appear in the Federal Register on July 28, 2015.