Rep. Sewell Introduces Legislation to Protect Access to Ground Ambulance Medical Services for Rural and Underserved Communities
Washington, D.C. – This Congress, U.S. Rep. Terri Sewell (AL-07), along with Reps. Devin Nunes (CA-22), Peter Welch (VT-AL), and Markwayne Mullin (OK-02), introduced H.R. 2454, the Protecting Access to Ground Ambulance Medical Services Act of 2021. The bill would ensure that ambulance service providers, including rural providers and those in underserved communities, are able to continue delivering quality critical first responder and health care services.
“When tragedy strikes and medical emergencies happen, we should feel confident that our first responders have the resources they need to deliver life-saving care,” said Rep. Sewell. “Unfortunately, inadequate Medicare reimbursement rates are putting a strain on ambulance service providers in the most vulnerable communities across the country and making it harder for them to care for our neighbors.”
“The problem is particularly severe for rural communities and has been worsened by the demands of the COVID-19 pandemic,” continued Sewell. “That is why I am proud to introduce the Protecting Access to Ground Ambulance Medical Services Act of 2021. This bill would permanently adjust Medicare reimbursement practices so that vital ambulance services remain vibrant and available to all Americans.”
“This bipartisan bill includes key reforms to ensure that rural Americans are not harmed by the delay in updating the Medicare ground ambulance fee schedule due to the COVID-19 pandemic,” said Rep. Nunes, Lead Republican Co-Sponsor. “Extending these temporary Medicare ground ambulance add-on payments for another five years and expanding coverage for those who live in zip codes with fewer than 1,000 people per square mile will keep ambulance costs affordable for Americans when they need ground ambulance transportation.”
“Rural ambulance services save lives and provide needed care in underserved areas every day,” said Rep. Peter Welch, Lead Democratic Co-Sponsor. “This bipartisan bill will ensure that patients in rural areas have access to critical ambulance services and that the providers of these services receive fair, consistent reimbursement for their important work. It’s time for Congress to pass this bill and give ambulance services the certainty they need to continue serving all Americans.”
“Ambulance services are critically important to rural Americans who may live close to an hour away from the nearest emergency room,” said Rep. Mullin, Lead Republican Co-Sponsor. “Providing this care literally means the difference between life and death for many people. As we continue to battle the closures of critical access hospitals across Oklahoma, ambulance services are more important now than ever before. We must ensure that rural Americans receive the care they need. I’m proud to join my colleagues in support of this bill which would enhance and increase resources for first responders in Oklahoma.”
Currently, ambulance service providers across the country are reimbursed by Medicare at rates below the cost of providing services, as determined by the Government Accountability Office (GAO). Consequently, providers rely on “add-on” payments to continue providing services. Add-on payments vary depending on whether a provider is located in an urban, rural, or “super rural” ZIP Code.
Congress has extended current add-on payment rates through December 31, 2022, and planned to review Medicare cost data in considering whether they should be made permanent. However, due to the upcoming ZIP Code reclassification which will occur following the 2020 Census, providers are faced with uncertainty regarding the future of these payments. Additionally, the COVID-19 pandemic forced the Centers for Medicare and Medicaid Services (CMS) to delay the first two rounds of data collection, compounding this uncertainty.
Background on the Protecting Access to Ground Ambulance Medical Services Act of 2021
H.R. 2454, the Protecting Access to Ground Ambulance Medical Services Act of 2021, would end the band-aid approach and make permanent adjustments to the reimbursement methodology for services in urban, rural, and “super rural” areas by building the temporary add-ons into the base rate fee. Specifically, it would extend the current temporary Medicare ground ambulance increases of 2% urban, 3% rural, and the super rural bonus payments for five years and would ensure that rural zip codes continue to be classified as rural following the ZIP Code reclassification.
These payments are vital to the financial viability of the ambulance community and have been extended numerous times on a bipartisan basis, most recently for 5 years. This five-year extension would allow a new data cost collection system time to be put into place and collect meaningful data following the delays caused by the COVID-19 pandemic.
“NRHA applauds Representative Terri Sewell for her leadership in working to preserve ground ambulance services in rural America. Throughout the pandemic ambulance services have provided critical first responder services in our most rural communities. Passing H.R. 2454, the Protecting Access to Ground Ambulance Medical Services Act of 2021, is critical to ensuring that these important services remain in their communities long after the public health emergency,” said Alan Morgan, Chief Executive Officer of the National Rural Health Association.
“The Alabama Rural Health Association lends its full support behind the ‘Protecting Access to Ground Ambulance Medical Services Act of 2021’ (H.R. 2454). As rural EMS transportation is one of the greatest challenges for quality access to care in rural Alabama, support is greatly needed to reinforce the existing emergency transportation system. With additional funding and flexibility created in the system, states like Alabama will have the ability to provide improved emergency transportation in critically rural and underserved areas and allow patients to receive the care that they need in a timely manner. We are thankful for Rep. Sewell’s introduction of this language, and we encourage support for H.R. 2454,” said Ryan Kelly, Administrator of the Alabama Rural Health Association.
The legislation is also supported by the following organizations:
- American Ambulance Association (AAA)
- International Association of Fire Chiefs (IAFC)
- International Association of Fire Fighters (IAFF)
- National Association of Emergency Medical Technicians (NAEMT)
- National Volunteer Fire Council (NVFC)
H.R. 2454 can be found here.
Thank you to Reps @RepTerriSewell, @RepDevinNunes, @PeterWelch, and @RepMullin for their tireless advocacy in support of #EMS access for ALL Americans. #HR2454 #ruralhealth #SupportEMS #AlwaysOpen #NotJustaRide #MobileHealthcare https://t.co/L7uHcxyOXg @NRHA_Advocacy pic.twitter.com/qD6p4Hymjo
— AmericanAmbulanceAsc (@amerambassoc) May 7, 2021
Thank you to Representatives Rep. Terri Sewell, Congressman Devin Nunes, Peter Welch, and Congressman Markwayne Mullin…May 6, 2021Press Release
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.
Moments ago, Congresswoman Terri Sewell (D-AL) and Congressman Devin Nunes (R-CA) introduced the Medicare Ambulance Access, Fraud Prevention, and Reform Act of 2019 (H.R. 4938). Congressmen Peter Welch, (D-VT), Markwayne Mullin (R-OK), and Earl Blumenauer (D-OR) are original cosponsors of the legislation. Thank you to the bill sponsors for their continued support!
H.R. 4938 would help stabilize current and future Medicare reimbursement of ambulance services and set the stage for future reform of the Medicare ambulance fee schedule. If passed, this bill would:
- Make Medicare Add-ons Permanent – Current temporary 2 percent urban, 3 percent rural, and super rural bonus payments would be made permanent.
- Expand Prior Authorization Pilot Program Nationwide – To address fraud and abuse with the transportation of dialysis patients by ambulance, the bill expands the Centers for Medicare & Medicaid Services (CMS) national prior authorization program for repetitive non-emergency basic life support (BLS) dialysis transports. CMS has not yet exercised its authority to expand this successful pilot program nationwide. While CMS is considering exercising its authority to extend the program nationwide in a recent proposed rule, it has not made a final determination yet.
- Provide Regulatory Relief – Amend requirements under the 855 form to make change notifications less burdensome.
- Protect Access to Ambulance Services in Rural and Low Population Density Areas – Protect access to ambulance services in rural and super-rural areas, by establishing a policy to protect low volume areas and a process for CMS to review changes in the rural or super-rural status of an area after the next census occurs.
The AAA has worked diligently to get this legislation introduced and we are excited to share this news with the membership. We would like to thank all the AAA members who have worked closely with their elected representatives to get this legislation introduced. In the coming weeks, the AAA will be asking members to contact their Members of Congress to voice their support of this legislation.
The American Ambulance Association has been working hard to accomplish the legislative goals of the membership in the 116th Congress. The AAA would like to take this opportunity to provide an update on what we have accomplished thus far in the 116th Congress.
Balance/surprise billing is a hot button issue that recently came into the spotlight at the start of the 116th Congress. With the President’s announcement calling for Congress to pass legislation that would end surprise billing for patients, there has been an increase in Congressional action on the issue including introduced legislation, discussion drafts and hearings in all committees of jurisdiction. The AAA has been working tirelessly with the Congressional committees of jurisdiction to educate Members and staff on the unique characteristics of EMS systems and that it would be inappropriate to apply the same restrictions on balanced billing to ground ambulance services.
The AAA has formed a working group comprised of AAA member volunteers that have worked on policy and messaging on balance billing. The working group has submitted comments to the Energy and Commerce Committee and Senate HELP committees advocating that the ambulance industry is unique from other stakeholders, and as such, should be looked at differently. Ambulance service providers and suppliers are required by law to treat and transport all patients, regardless of their ability to pay and are heavily regulated at the local level. The AAA has been working to communicate these factors that place the ambulance industry in a different situation than many other stakeholders.
Public Safety Officers Death Benefit (PSOB)
The Public Safety Officers Death Benefit (PSOB), a one-time benefit paid to families of first responders killed in the line of duty, is an issue that the AAA has passionately advocated for over many years. In the 116th Congress, the AAA has secured introduction of legislation in the House of Representatives, H.R. 2887, the Emergency Medical Service Providers Protection Act. H.R. 2887 would extend the PSOB to first responders employed by private for-profit EMS agencies. The AAA was able to secure several commitments from Members of Congress to cosponsor the legislation during Stars of Life meetings in Washington, DC. In addition to taking action to move H.R. 2887 through the legislative process, the AAA will be engaging in an outreach campaign in the next few weeks.
Dialysis Off-Set Restructuring
The AAA has worked toward reintroduction of legislation to restructure the offset that was passed into law in the Bipartisan Budget Act of 2018 (H.R. 1892) in the 115th Congress. This offset included a total cut of 23% to the Medicare reimbursement for basic life support (BLS) non-emergency transports performed by all ambulance service suppliers and providers to and from dialysis centers. This cut served as an offset to the 5-year extension of Medicare add on payments that our industry worked hard to get extended.
The AAA has secured introduction of legislation in both the House and Senate. H.R. 3021 was introduced by Representatives LaHood (R-IL) and Sewell (D-AL) and S. 228 by Senators Cassidy (R-LA) and Jones (D-AL). If passed, this legislation would change the cut that is currently in place so that it applies specifically to companies conducting over 50% ESRD non-emergency transports. Those ambulance services with over 50% ESRD transports would get a cut of 29.5%, while those doing less would receive a 15.5% cut. The AAA will continue to work toward movement and passage of this legislation that would better distribute the reduction to those providers which do almost exclusively non-emergency dialysis transports and thus have a lower cost of providing services.
Medicare Priorities Bill
The AAA has crafted legislation that is specifically aimed at addressing major Medicare ambulance industry issues. The issues that will be included in future legislation include making Medicare ambulance add-ons permanent, implementing a prior-authorization program across the nation, allowing for transportation to alternative destinations, reducing regulatory burdens, and providing relief through maintaining many zip codes as rural following the next census. The AAA is working to get this Medicare priorities legislation introduced in the coming months so that we can get to work on solving these Medicare issues that impact our industry as a whole.
Another priority that that the AAA has been diligently working toward getting introduced is Veterans Affairs (VA) legislation. The Veterans Reimbursement for Emergency Ambulance Services Act (VREASA) introduced by Congressman Tipton (R-CO) would provide veterans with reimbursement for emergency ambulance services when a Prudent Layperson would have a reasonable expectation that a delay in seeking immediate medical attention will jeopardize the life or health of the veteran. This legislation was introduced as a result of the VA consistently requiring all medical records be provided, including the records of treatment after the emergency service has taken place. Should those records show that it was not a life threatening emergency or a false alarm, the claim for reimbursement is being denied. The VA legislation would mandate that the VA apply the “prudent layperson” definition of emergency to determine coverage of ambulance claims.
The AAA is also working toward addressing two other issues with the VA to enforce more prompt payment by the VA and treating the VA as the first payor, similar to Medicare, as it is determined whether there is a different primary payor. The AAA has been working with Senators Collins and Tester on language help solve this ongoing and serious reimbursement issue.
In our next update, we will be reporting on the progress the AAA has made this year on regulatory issues.
Questions? Contact Us
If you have questions about the discussion draft or balance billing initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.
Tristan North – Senior Vice President of Government Affairs
firstname.lastname@example.org | (202) 802-9025
Ruth Hazdovac – AAA Senior Manager of Federal Government Affairs
email@example.com | (202) 802-9027
Aidan Camas – Manager of State & Federal Government Affairs
firstname.lastname@example.org | (202) 802-9026
Thank you for your continued membership and support
The American Ambulance Association is proud to announce the winners of the 2019 AAA Legislative Awards, in recognition of their strong advocacy for emergency medical services. Each legislator was chosen for their ongoing dedication to the ambulance services across the United States.
2019 AAA Legislator of the Year
2019 AAA Legislative Recognition Award Recipients
- Senator Bill Cassidy, M.D.
- Senator Susan M. Collins
- Senator Chuck Grassley
- Senator Doug Jones
- Senator Patrick J. Leahy
- Senator Pat Roberts
- Senator Charles E. Schumer
- Senator Debbie Stabenow
- Senator Jon Tester
- Senator John Thune
- Senator Ron Wyden
- Representative Earl Blumenauer
- Representative Rosa DeLauro
- Representative Debbie Dingell
- Representative Richard Hudson
- Representative Darin LaHood
- Representative Markwayne Mullin
- Representative Richard E. Neal
- Representative Devin Nunes
- Representative Steve Scalise
- Representative Scott Tipton
- Representative Fred Upton
- Representative Greg Walden
- Representative Peter Welch
- Representative Lee Zeldin
House Introduces NEATSA Act Companion Bill (H.R. 3021)
The American Ambulance Association (AAA) is pleased to announce that, Congressman Darin LaHood (R-IL) and Congresswoman Terri Sewell (D-AL) have introduced H.R. 3021 the “Non-Emergency Ambulance Transportation Sustainability and Accountability Act of 2019” or “NEATSA Act.”
Last year, Congress included in the Bipartisan Budget Act of 2018 an offset to cover the cost of the 5 year extension of the add-ons. The offset cuts reimbursement for BLS non-emergency transports to and from dialysis centers by an additional 13%. This is on top of the preexisting 10% reduction. This legislation would restructure the offset so that a majority of the additional reduction would be focused on those ambulance service agencies in which 50% or more of their volume are repetitive BLS non-emergency transports to and from dialysis centers.
H.R. 3021 is the reintroduction of H.R.6269 from last Congress. This legislation serves as a companion bill to the Senate version, S. 228 by Senator Cassidy (R-LA) and Senator Jones (D-AL) which was introduced in January 2019. The additional cut went into effect on October 1, 2018 and has since negatively impacted AAA members. As such, the AAA is grateful for the support of Congressman LaHood and Congresswoman Sewell in working with us to get this important legislation introduced.
The AAA has worked diligently to ensure the timely introduction of this legislation that will ultimately help protect vital ambulance services for end stage renal disease patients. The AAA is working to help pass this bill through the legislative process and we will keep members updated as this legislation moves through Congress.
Last year, Congress included in the Bipartisan Budget Act of 2018 an offset to cover the cost of the 5 year extension of the add-ons. The offset cuts reimbursement for BLS nonemergency transports to and from dialysis centers by an additional 13%. This is on top of the preexisting 10% reduction.
The AAA is pleased to announce that Senators Bill Cassidy (R-LA) and Doug Jones (D-AL) have recently introduced S. 228 which would restructure the offset so that a majority of the additional reduction would be focused on those ambulance service agencies in which 50% or more of their volume are repetitive BLS nonemergency transports to and from dialysis centers.
S. 228 is the reintroduction of S. 3619 from last Congress which served as a companion bill to the House version, the NEATSA Act (H.R.6269), by Congressman LaHood (R-IL) and Congresswoman Sewell (D-AL) which was introduced in June 2018. AAA staff and volunteer leaders are working to get a House version of this legislation reintroduced shortly.
The additional cut went into effect on October 1, 2018 and negatively impacted AAA members. The AAA is working to help pass this legislation and we will keep members updated as this legislation moves through Congress.
Earlier this year, Congress included in the Bipartisan Budget Act of 2018 an offset to go along with the extension of the add-ons that will cut reimbursement for BLS nonemergency transports to and from dialysis centers by an additional 13%. This will be on top of the existing 10% reduction.
Senators Bill Cassidy (R-LA) and Doug Jones (D-AL) just introduced S. 3619 which would restructure the offset so that a majority of the additional reduction would be focused on those ambulance service agencies in which 50% or more of their volume are repetitive BLS nonemergency transports to and from dialysis centers. S. 3619 will serve as a companion Bill to the House version, the NEATSA Act (H.R.6269) by Congressman LaHood (R-IL) and Congresswoman Sewell (D-AL) which was introduced in June 2018.
The additional cut went into effect on October 1 and impacted AAA members and the AAA are working to get this legislation passed. The AAA will be sure to keep members updated as this legislation moves through Congress.
Questions?: Contact Us
If you have questions about the legislation or regulatory initiatives being undertaken by the AAA, please do not hesitate to contact a member of the AAA Government Affairs Team.
Tristan North – Senior Vice President of Government Affairs
email@example.com | (202) 802-9025
Ruth Hazdovac – AAA Senior Manager of Federal Government Affairs
firstname.lastname@example.org | (202) 802-9027
Aidan Camas – Manager of State & Federal Government Affairs
email@example.com | (202) 802-9026
Thank you for your continued membership and support.
Talking Medicare: CMS Implements Further Cuts in Reimbursement for Dialysis Services; Medicare Payment Data Shows Continued Reduction in Overall Spending on Dialysis Transports, but Net Increase in Dialysis Payments in Prior Authorization States
On October 1, 2018, CMS implemented an additional thirteen (13%) cut in reimbursement for non-emergency BLS transports to and from dialysis. This cut in reimbursement was mandated by Section 53108 of the Bipartisan Budget Act of 2018. This on top of a ten (10%) cut in reimbursement for dialysis transports that went into effect on October 1, 2013. As a result, BLS non-emergency ambulance transports to and from dialysis that occur on or after October 1, 2018 will be reimbursed at 77% of the applicable Medicare allowable.
In related news, CMS has released its national payment data for calendar year 2017. This data shows a continued reduction in total Medicare payments for dialysis transports. Medicare paid $477.7 million on dialysis transports in 2017, down from $488.9 million in 2016. This continues a downward trend that has seen total payments decline from a high of more than $750 million in 2013 (see accompanying chart to the right). Not coincidentally, it was in 2013 that our industry saw its first reduction in Medicare’s payments for dialysis transports.
The payment reduction is partially the result of the reduction in the amounts paid for dialysis services. However, it is also reflective of an overall decline in the number of approved dialysis transports. For this, we can look primarily to the impact of a four-year demonstration project that requires prior authorization of dialysis transports in 8 states and the District of Columbia.
As a reminder, the original prior authorization states were selected based on higher-than-average utilization rates and high rates of improper payment for these services. In particular, the Medicare Payment Advisory Commission (MedPAC) had singled out these states as having higher-than-average utilization of dialysis transports in a June 2013 report to Congress. The chart below shows total spending on dialysis in those states in the years immediately preceding the implementation of the prior authorization project up through 2017, the third year of the demonstration project. While the three states had very different trajectories prior to 2015, each showed a significant decrease in total payments for dialysis under the demonstration project.
However, it is the trajectory of these changes that I want to discuss in this month’s blog. In previous blogs, I discussed the impact of the particular Medicare Administrative Contractor on the outcomes under prior authorization. Specifically, I noted that, while dialysis payments dropped in each state, the decline was far more dramatic in the states administered by Novitas Solutions (NJ, PA) than in the South Carolina, which was administered by Palmetto GBA. This trend continued in the second year of the program, which saw prior authorization expanded into five additional states and the District of Columbia. Those states administered by Novitas (DE, MD) saw far greater declines than the states administered by Palmetto (NC, VA, WV).
Given these declines, the data from the third year is somewhat surprising. The states administered by Palmetto continued to see declines in total dialysis payments, with the only exception being West Virginia. However, in the states administered by Novitas, we saw total dialysis payments increase, particularly in New Jersey, which saw nearly a 33% increase in total dialysis payments.
Three years into the prior authorization program, it is starting to become clear that the two MACs have approached the problem of overutilization of dialysis transports using two different approaches. Palmetto appears to have adopted a slow-and-steady approach, with total payments declining in a consistent manner year after year. By contrast, Novitas adopted more of a “shock the system” approach, where it rejected nearly all dialysis transports in the first year, and has adopted a somewhat more lenient approach in subsequent years.
Last year, I wrote that two years of data under the prior authorization program permitted two conclusions: (1) the implementation of a prior authorization process in a state will undoubtedly result in an overall decrease in the total payments for dialysis within that state and (2) the size of that reduction appears to be highly dependent on the Medicare contractor.
With an additional year of data, I think both conclusions remain valid, although I would revise the second to suggest that the initial reduction has more to do with the Medicare contractor. The evidence from the third year of the program suggests that the trends tend to equalize after the first few years. It is also possible that Novitas felt a more aggressive approach was needed in the first few years to address evidence of widespread dialysis overutilization in the Philadelphia metropolitan area.
This has potential implications beyond the demonstration project, as CMS looks towards a possible national expansion of the program. Among other issues, it suggests that the AAA must continue its efforts to work with CMS and its contractors on developing more uniform standards for coverage of this patient population.
What the AAA is Doing
The AAA continues to work on legislation that would restructure this cut to dialysis transport reimbursement. The AAA strongly supports the NEATSA Act (H.R.6269) introduced by Congressman LaHood (R-IL) and Congresswoman Sewell (D-AL) that would restructure the offset so that a majority of the additional reduction would be focused on those ambulance service agencies in which 50% or more of their volume are repetitive BLS nonemergency transports. AAA members and the AAA are working to get a Senate companion bill introduced shortly. The goal of this legislation would be to have the restructured offset go into effect as soon as possible. Thank you to the dozens of AAA members who have already contacted their members of Congress voicing their support for this critical legislation.
Have an issue you would like to see discussed in a future Talking Medicare blog? Please write to me at firstname.lastname@example.org