Tag: Seema Verma

Release: CMMI Announces Ambulance Innovative Payment Pilot Program

February 14, 2019

For Immediate Release
Contact Maria Bianchi
American Ambulance Association

CMMI Announces Ambulance Innovative Payment Pilot Program

Washington, DC – Today, the Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (CMMI) announced the launch of the Emergency Triage, Treat and Transport (ET3) Model.  During the next five years, this model will test paying ambulance providers and suppliers when they transport beneficiaries to locations other than an emergency department, if the alternative location is more appropriate medically for the patient.  It will also test paying for health care services provided by qualified health care professionals or through telehealth at the scene even if the ambulance does not transport the patient.

While there are several important details yet to be released, this model appears to track the recommendations the American Ambulance Association, our members, and other industry partners have been working with CMS to implement.

“Over the last 7 years, the AAA and our members have been working to develop an innovative payment framework to modernize the Medicare ambulance benefit,” said AAA President Aarron Reinert. “We are pleased that CMS is taking this important step and look forward to working closely with Administrator Verma, Director Boehler and their teams on the details of the ideas announced today to ensure the appropriate implementation.”

Representatives of the American Ambulance Association also participated in the CMS announcement of this model today in DC.  Senior Department of Health and Human Services (HHS) officials including Secretary Alex Azar, CMS Administrator Seema Verma and CMMI Director Adam Boehler spoke at the event. AAA President-Elect Shawn Baird represented the AAA at the announcement.

While the details of the program are still under development and will be communicated through program guidance, a few general details were provided at the event.

The Emergency Triage, Treat and Transport (ET3) Model, would test two new ambulance payment methods. Under ET3, participating ambulance service providers or suppliers would be able to receive payment for:

  • treatment in place with a qualified health care practitioner, either on-the-scene or connected using telehealth; and
  • for unscheduled, emergency transport of Medicare beneficiaries to alternative destinations (such as 24-hour care clinics) other than destinations covered under current regulations (such as hospital EDs).

The program will be national in scope and thus open to all ambulance service suppliers and providers who meet the program requirements, which are still being finalized. The program will be voluntary so providers and suppliers who chose not to participate can continue to be paid under current policy. CMS anticipates releasing applications for the program this summer and an anticipated start date for the program in early 2020.

While seeing the specific details of the program will be crucial, we are very pleased that CMMI is announcing its commitment today to test multiple innovative payment models for ambulance service providers and suppliers. The AAA and our volunteer leaders and members have been working in a collaborative manner with other EMS organizations for the last 5 years to develop an evidence-based, data-driven structural framework to support the adoption of innovative payment models for ambulance emergency and non-emergency services. In 2016, the AAA issued a joint statement with NAEMSP, NAEMSO, and NAEMT outlining this framework. During the last two year, the AAA has worked closely with the Congress, CMS and the CMMI to seek the implementation of this framework. To encourage as broad an adoption as possible, we have focused on achieving these goals through the regulatory process.

The AAA is committed to the development and implementation of innovative payment models.  It is critical that they be designed in a manner that will ensure their success. Adoption of the framework along with having the necessary data to establish reimbursement rates that reflect the cost of providing ambulance services will usher in a new era of ambulance services for not only Medicare beneficiaries, but also for all Americans. As part of the effort to modernize the ambulance benefit, ambulance service suppliers should be recognized as providers of health care services and not merely a transportation benefit. The days of merely driving patients to and from other providers are long gone.

We believe that our efforts and those of the Administration will help us achieve this exciting goal. The AAA supports expanding the destination site for 9-1-1 and similar calls, which is currently limited to hospital emergency departments. For some patients, it is more appropriate to take them to other types of facilities, such as rural health clinics, substance or behavioral health facilities, and inpatient psychiatric hospitals. Allowing ambulance services to use state and local protocols to help triage patients to the most appropriate setting will help address the opioid epidemic and better care for patients with behavioral health issues, as well as urgent low acuity medical conditions.

We want to thank the Congress and the groups at CMS and CMMI who began to lay the ground work for the next phase of innovative payment models last winter as well. We also greatly appreciate the efforts of other EMS representatives who worked with the CMMI to help push for the pilot program.

The AAA will continue to advocate for data and evidence-based changes to the Medicare ambulance fee schedule which allow ambulance service providers and suppliers to provide even better medical services to patients.


About the American Ambulance Association
The American Ambulance Association, formed in 1979, represents 500 ambulance services across the United States that serve their communities with emergency medical services, interfacility mobile healthcare, and community paramedicine 24/7/365. The Association serves as a voice and clearinghouse for mobile healthcare, and views prehospital care as an essential part of the total public health care system.

Federal District Court Judge Strikes Down the ACA

On December 14, 2018, a federal district court judge for the Northern District of Texas issued a ruling striking down the Affordable Care Act (ACA) on the grounds that the Individual Mandate was unconstitutional, and that the rest of the law cannot withstand constitutional scrutiny without the Individual Mandate.

District Court Judge Reed O’Connor’s decision relates to a lawsuit filed earlier this year by 20 states and two individuals. The plaintiffs argued that the Tax Cuts and Jobs Act of 2017 — which amended the Individual Mandate to eliminate the penalty on individuals that failed to purchase qualifying insurance effect January 1, 2019 — rendered the Individual Mandate unconstitutional. The plaintiffs further argued that the Individual Mandate was inseverable from the rest of the ACA, and, therefore, that the entire ACA should be struck down.

The defendants in this case were the United States of America, the U.S. Department of Health and Human Services (HHS), Alex Azar, in his capacity as the Secretary of HHS, and David J. Kautter, in his capacity as the Acting Commissioner of the Internal Revenue Service (IRS). 16 states and the District of Columbia intervened as additional defendants.

In order to properly understand the district court’s ruling, it is necessary to revisit the Supreme Court’s 2012 decision on the constitutionality of the ACA, National Federal of Independent Business v. Sebelius (NFIB). In that case, 26 states, along with several individuals and a business organization challenged the ACA’s Individual Mandate and Medicaid expansion provisions as exceeding Congress’ enumerated powers. In a complicated decision, the majority of Justices ruled that the Individual Mandate was unconstitutional under Congress’ authority to regulate interstate commerce, but that the provision could be salvaged under Congress’ authority to lay and collect taxes. In reaching this conclusion, the majority of Justices focused on the “shared responsibility payment” aspect of the Individual Mandate, which imposed a tax on those individuals that failed to purchase or otherwise obtain qualifying health insurance. The majority of Justices concluded that the shared responsibility payment was a “tax.” It was therefore constitutional under the Congress’ general taxing authority.

In sum, the Supreme Court ruled that Congress lacked the power to compel individuals to buy qualifying health insurance, but that it could constitutionally impose a tax on those that failed to purchase or otherwise obtain qualifying health insurance.

In the current case, the court was asked to reconsider the Individual Mandate in light of the TCJA, which “zeroed” out of the shared responsibility payment, effective January 1, 2019. The plaintiffs argued that the Individual Mandate could no longer be justified as a valid exercise of Congress’ taxing authority. The federal government and its agents did not necessarily contest the plaintiffs’ argument with respect to the Individual Mandate. By contrast, the intervening states and the District of Columbia argued that the Individual Mandate could continue to be construed as a tax because it continues to satisfy the factors set forth by the Supreme Court in NFIB.

Judge O’Connor sided with the plaintiffs, holding that, because the Individual Mandate would no longer trigger a tax beginning in 2019, the Supreme Court’s ruling on this point in NFIB was no longer applicable. He therefore concluded that the Individual Mandate could no longer be upheld under Congress’ taxing authority. Judge O’Connor then fell back on the Supreme Court’s previous holding that the Individual Mandate, as a stand-alone command, remained unconstitutional under the Interstate Commerce Clause. Judge O’Connor then ruled that the Individual Mandate could not be severed from the rest of the ACA. On this point, the judge cited the express provisions of the ACA, as well as the Supreme Court’s decisions in NFIB and King v. Burwell.

What this decision means

On its face, the decision strikes down the Affordable Care Act in its entirety. However, the ruling is likely to be appealed to the Fifth Circuit Court of Appeals. Most legal experts expect that, regardless of the decision at the Circuit Court, the case is likely to make its way up to the Supreme Court.

Pending the resolution of these appeals, the Administration has adopted a “business as usual” approach. The White House has already indicated that it will not attempt to enforce the ruling during the appeals process. CMS Administrator Seema Verma recently tweeted that the decision will have “no impact to current coverage or coverage in a 2019 plan.”

The American Ambulance Association will continue to monitor this case as it makes its way through the appeals process, and we will notify our members of any new developments.