2021 Legislative Priorities Highlights & Wrap Up
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Sequestration and PAYGO Update
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Call to Action: Write Your Members of Congress Today!
Our nation’s EMS infrastructure is at risk. Ground ambulance service organizations are facing a financial crisis due to the lack of adequate reimbursement for their services and a crippling shortage of paramedics and EMTs. If Congress does not act soon, the situation will become worse with an additional 4% sequestration cut for all Medicare providers and suppliers including for ground ambulance services. Our nation’s 9-1-1 EMS infrastructure is at risk.
Place follow the link below to contact your members of Congress and ask that they protect ground emergency and non-emergency ambulance services in our communities.
CMS | Data Collection Q&A December 14
From CMS
Medicare Ground Ambulance Data Collection System Webinar: Question and Answer (Q&A) Session Tuesday, December 14, 2021 | 2:00 PM – 3:00 PM ET
To register for this CMS Zoom webinar:
https://cms.zoomgov.com/webinar/register/WN_Jy_wpLZLQnuNu5vv_5Dbyw
After registering, you will receive a confirmation email containing information about joining the webinar.
Do you have questions about the Medicare Ground Ambulance Data Collection System? We are holding a live Q&A session on December 14, 2021 at 2:00 pm. Please send questions in advance to AmbulanceDataCollection@cms.hhs.gov with “December 14 Q&A” in the subject line. We will answer your questions that you submitted in advance during the call or participants may also submit live questions using the “Q&A” button at the bottom of your Zoom screen. In addition, we will update documents on our Ambulances Services Center webpage with answers to common questions from this session.
For more information, including the list of ground ambulance organizations selected to collect and report information starting in 2022, see the Ambulances Services Center webpage, the CY 2022 PFS Final Rule, the CY 2020 PFS final rule, and the Bipartisan Budget Act of 2018.
HHS: Availability of Add’l $25.5 Billion in COVID-19 Provider Funding
HHS Announces the Availability of $25.5 Billion in COVID-19 Provider Funding
This morning the Department of Health and Human Services (HHS) announced that it will be making $25.5 billion in new funding available for healthcare providers affected by the COVID-19 pandemic. The funding, available through the Health Resources and Services Administration (HRSA) will include $8.5 billion in American Rescue Plan Act (ARPA) resources for providers who serve rural Medicaid, Children’s Health Insurance Program (CHIP), or Medicare patients, and an additional $17 billion for Provider Relief Fund (PRF) Phase 4 for a broad range of providers who can document revenue loss and expenses associated with the pandemic.
Getting additional financial relief for ground ambulance service providers who are still struggling from the lost revenue and increased expenditures resulting from being on the frontlines of responding to the pandemic has been a top priority for the AAA. The AAA along with the International Association of Fire Chiefs, International Association of Firefighters, National Associations of EMTs and National Volunteer Fire Association have continually pressed HHS to release the remaining funds. We strongly encourage all AAA members to submit an application regardless of whether you have applied for previous rounds of funding.
Consistent with the requirements included in the Coronavirus Response and Relief Supplemental Appropriations Act of 2020, PRF Phase 4 payments will be based on providers’ lost revenues and expenditures between July 1, 2020, and March 31, 2021 (Q3 – Q4 2020 and Q1 2021). The PRF Phase 4 will reimburse smaller providers, who tend to operate on thin margins and often serve vulnerable or isolated communities, for their lost revenues and COVID-19 expenses at a higher rate compared to larger providers. PRF Phase 4 will also include bonus payments for providers who serve Medicaid, CHIP, and/or Medicare patients, who tend to be lower- income and have greater and more complex medical needs. HRSA will price these bonus payments at the generally higher Medicare rates to ensure equity for those serving low-income children, pregnant women, people with disabilities, and seniors.
Consistent with the focus of the ARPA, HRSA will make ARPA rural payments to providers based on the amount of Medicaid, CHIP, and/or Medicare services they provide to patients who live in rural areas as defined by the HHS Federal Office of Rural Health Policy. As rural providers serve a disproportionate number of Medicaid and CHIP patients who often have disproportionately greater and more complex medical needs, many rural communities have been hit particularly hard by the pandemic. Accordingly, ARP rural payments will also generally be based on Medicare reimbursement rates.
In the announcement, HHS stated that it would “expedite and streamline” the application process and minimize administrative burdens, providers will apply for both programs in a single application. HRSA will use existing Medicaid, CHIP and Medicare claims data in calculating payments. The application portal will open on September 29, 2021. HHS has stated that to ensure that these provider relief funds are used for patient care, PRF recipients will be required to notify the HHS Secretary of any merger with, or acquisition of, another health care provider during the period in which they can use the payments. They have stated that providers who report a merger or acquisition may be more likely to be audited to confirm their funds were used for coronavirus-related costs.
To promote transparency in the PRF program, HHS also released detailed information about the methodology utilized to calculate PRF Phase 3 payments. Providers who believe their PRF Phase 3 payment was not calculated correctly according to this methodology will now have an opportunity to request a reconsideration. HHS announced that additional details on the PRF Phase 3 reconsideration process will be released at a later date.
In addition, many of you attended the PRF Reporting Q&A AAA webinar yesterday with Asbel Montes, Brian Werfel, and Scott Moore. HHS has acknowledged the challenges facing many providers across the country due to recent natural disasters and the Delta variant, HHS announced a final 60-day grace period to help providers come into compliance with their PRF Reporting requirements if they fail to meet the deadline on September 30, 2021. While the deadlines to use funds and the Reporting Time Period will not change, HHS will not initiate collection activities or similar enforcement actions for non-compliant providers during this grace period.
Members can access more information about eligibility requirements, the documents and information providers will need to complete their application, and the application process for PRF Phase 4 and ARP Rural payments by visiting the HRSA website.
The combined application for American Rescue Plan rural funding and Provider Relief Fund Phase 4 will open on September 29, 2021. Like we have done with the previous rounds of HHS funding, we encourage all ambulance service providers to submit an application for this Phase 4 funding. If you have questions regarding this or any COVID-19 related questions, please contact hello@ambulance.org.
EMS Provider Comments Needed on the “Surprise Billing” Interim Final Rule
The Department of Health and Human Services, Department of Labor, and the U.S. Treasury Department (Departments) have issued an Interim Final Rule (IFR) on “surprise billing” that will take effect September 13, 2021. However, the Departments are taking comments on the IFR. While the Congress expressly excluded ground ambulance organizations from the statute that the IFR seeks to implement, the Departments have included a prohibition on balance billing for nonemergency ground ambulance transports that occur after a patient has been stabilized in a facility.
The Congress established an Advisory Committee to consider the best way to address balance billing in the context of ground ambulance services, and the Departments should wait to be advised by that group before subjecting nonemergency ground ambulance transports to the broader balancing billing prohibition.
It is important that the Departments hear from as many stakeholders as possible opposing this expansion of the law. To help you develop a comment letter, we provided the following template that we ask you to tailor to your experience and organization. Tailored letters will be of greater value to the Department as they consider the rules. At a minimum, please customize the templated language to insert information about who you are and where you operate.
The must be submitted by September 7, 2021.
CMS Proposes Modifications to Ambulance Cost Collection System
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Administration Releases First Surprise Billing Interim Final Rule
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EMS Balance Billing Quick Take—July 7, 2021
Webinar July 7, 2021 | 13:00–13:30 ET | Free to AAA Members
Speakers: Kathy Lester, Esq. & Asbel Montes
On July 1, CMS issued a proposed rule on Surprise Billing which applies to those providers and physicians identified in the No Surprises Act. This statute subjected ground ambulance suppliers to an HHS Advisory Committee process prior to any rulemaking addressing these services.
The consultants and staff of the American Ambulance Association are doing a deep dive into the 400+ page rule and evaluating its nuances. We continue to understand from our conversations that ground ambulances are not included and instead are subjected to the Advisory Committee.
The American Ambulance Association will soon provide a summary to members, and will address any confusion with the Administration. Join AAA for a quick take live webinar on July 7 at 13:00 ET to learn more!
HHS Revises Provider Relief Fund Reporting Requirements
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Medicare Ambulance Relief Bill introduced in Senate
Yesterday, Senators Catherine Cortez Masto (D-NV) and Susan Collins (R-ME) introduced the Protecting Access to Ground Ambulance Medical Services Act of 2021 (S. 2037). Senators Cortez Masto and Collins were joined by Senators Debbie Stabenow (D-MI), Bill Cassidy (R-LA), Patrick Leahy (D-VT) and Bernie Sanders (D-VT) as primary cosponsors and leads on the legislation.
S. 2037 is identical to H.R. 2454 by Representatives Terri Sewell (D-AL), Devin Nunes (R-CA), Peter Welch (D-VT) and Markwayne Mullin (R-OK) and 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 due to the COVID-19 public health emergency, an analysis of the data by MedPAC and subsequent action by the Congress to reform the Medicare ambulance fee schedule.
The legislation would also help ensure that rural zip codes in large urban counties remain rural following geographical changes under the fee schedule as a result of the 2020 census data. The current definition using rural urban commuting areas (RUCA) in Goldsmith Modification areas would be modified for zip codes with 1,000 people or less per square mile would also be 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 be 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 International Association of Fire Chiefs, International Association of Fire Fighters, National Association of EMTs, National Rural Health Association and the National Volunteer Fire Council.
The AAA will be launching a Call to Action shortly requesting AAA members to ask their Senators to cosponsor S. 2037, and reach out to their Representatives to cosponsor H.R. 2454 if they have not already done so.
We greatly appreciate the leadership of Senators Cortez Masto, Collins, Stabenow, Cassidy, Leahy, and Sanders on this vitally important legislation.
Thank you @SenCortezMasto, @SenatorCollins, @SenBillCassidy, @SenStabenow, @SenatorLeahy, and @SenSanders for collaborating to support America's #EMS providers in the pandemic and beyond! #SupportEMS #AlwaysOpen #MobileHealthcare #NotJustaRide pic.twitter.com/q7Divtby8z
— AmericanAmbulanceAsc (@amerambassoc) June 10, 2021
CNN | Rural ambulance crews are running out of money and volunteers
From CNN on May 22, 2021
Rural ambulance crews are running out of money and volunteers. In some places, the fallout could be nobody responding to a 911 call
America’s rural ambulance services, often sustained by volunteers, are fighting for their survival — a crisis hastened by the impact of Covid-19.
More than one-third of all rural EMS are in danger of closing, according to Alan Morgan, CEO of the National Rural Health Association. “The pandemic has further stretched the resources of our nation’s rural EMS.”
Update on Provider Relief Funding Phase 3
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AAA Task Force to Address Balance Billing Challenges
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2020 Post-Election Outlook
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America First Healthcare Executive Order on Surprise Coverage
President Trump’s “An America-First Healthcare Plan” Executive Order on Surprise Billing Policy
by Kathy Lester, J.D., M.P.H.
As the American Ambulance Association (AAA) reported yesterday, President Trump issued an Executive Order (EO) “An America-First Healthcare Plan.” The EO includes several provisions, including related to drug importation generally and for insulin specifically. It also includes statements that indicate if the Congress does not act before the end of the year, the President will have the Department of Health and Human Services (HHS) “take administrative action to prevent a patient from receiving a bill for out-of-pocket expenses that the patient could not have reasonably foreseen.” It does not mention ground ambulances.
In addition to suggesting action if the Congress does not pass legislation, the EO also states that within 180 days, the Secretary will update the Medicare.gov Hospital Compare website to inform beneficiaries of hospital billing quality, including:
- Whether the hospital is in compliance with the Hospital Price Transparency Final Rule;
- Whether, upon discharge, the hospital provides patients with a receipt that includes a list of itemized services received during a hospital stay; and
- How often the hospital pursues legal action against patients, including to garnish wages, to place a lien on a patient’s home, or to withdraw money from a patient’s income tax refund.
The narrative related to balance billing (surprise coverage) reads as follows:
My Administration is transforming the black-box hospital and insurance pricing systems to be transparent about price and quality. Regardless of health-insurance coverage, two‑thirds of adults in America still worry about the threat of unexpected medical bills. This fear is the result of a system under which individuals and employers are unable to see how insurance companies, pharmacy benefit managers, insurance brokers, and providers are or will be paid. One major culprit is the practice of “surprise billing,” in which a patient receives unexpected bills at highly inflated prices from providers who are not part of the patient’s insurance network, even if the patient was treated at a hospital that was part of the patient’s network. Patients can receive these bills despite having no opportunity to select around an out-of-network provider in advance.
On May 9, 2019, I announced four principles to guide congressional efforts to prohibit exorbitant bills resulting from patients’ accidentally or unknowingly receiving services from out-of-network physicians. Unfortunately, the Congress has failed to act, and patients remain vulnerable to surprise billing.
In the absence of congressional action, my Administration has already taken strong and decisive action to make healthcare prices more transparent. On June 24, 2019, I signed Executive Order 13877 (Improving Price and Quality Transparency in American Healthcare to Put Patients First), directing certain agencies — for the first time ever — to make sure patients have access to meaningful price and quality information prior to the delivery of care. Beginning January 1, 2021, hospitals will be required to publish their real price for every service, and publicly display in a consumer-friendly, easy-to-understand format the prices of at least 300 different common services that are able to be shopped for in advance.
We have also taken some concrete steps to eliminate surprise out‑of-network bills. For example, on April 10, 2020, my Administration required providers to certify, as a condition of receiving supplemental COVID-19 funding, that they would not seek to collect out-of-pocket expenses from a patient for treatment related to COVID-19 in an amount greater than what the patient would have otherwise been required to pay for care by an in-network provider. These initiatives have made important progress, although additional efforts are necessary.
Not all hospitals allow for surprise bills. But many do. Unfortunately, surprise billing has become sufficiently pervasive that the fear of receiving a surprise bill may dissuade patients from seeking appropriate care. And research suggests a correlation between hospitals that frequently allow surprise billing and increases in hospital admissions and imaging procedures, putting patients at risk of receiving unnecessary services, which can lead to physical harm and threatens the long-term financial sustainability of Medicare.
Efforts to limit surprise billing and increase the number of providers participating in the same insurance network as the hospital in which they work would correspondingly streamline the ability of patients to receive care and reduce time spent on billing disputes.
The AAA will continue to advocate for the resources necessary to sustain life-saving mobile healthcare.
Department of Health and Human Services Extends Deadline to Apply for Provider Relief Funds
The Department of Health and Human Services (HHS) recently announced that it would be extending the deadline for health care providers to apply to receive general distribution funding from the HHS Provider Relief Fund. The deadline to apply for these funds was previously June 3, 2020.
Relevant Background
On March 27, 2020, President Trump signed into law the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). As part of that Act, Congress allocated $100 billion to the creation of a “CARES Act Provider Relief Fund,” which will be used to support hospitals and other healthcare providers on the front lines of the nation’s coronavirus response. An additional $75 billion was allocated as part of the Paycheck Protection Program and Health Care Enhancement Act, bringing the total “Provider Relief Fund” up to $175 billion. This $175 billion will be distributed to health care providers and suppliers to fund healthcare-related expenses or to offset lost revenue attributable to COVID-10.
HHS ultimately elected to allocate these funds through a $50 billion “general allocation,” and multiple smaller “targeted allocations.”
Under its general allocation program, HHS intended to provide health care providers with funds roughly equal to 2% of the provider’s 2018 “net patient revenue,” i.e., the provider’s total revenues from patient care minus provisions for bad debt, contractual write-offs, and certain other adjustments. This general allocation was made in two tranches, with the first tranche being distributed to all providers in mid-April. This first tranche was made based on provider’s 2019 Medicare revenues. As a result, any provider that received payments from the Medicare Fee-for-Service Program in 2019 automatically received an initial relief payment. However, HHS required providers to submit an application to receive relief funding as part of the second tranche. The deadline for applying for the second tranche of relief funding was June 3, 2020.
Scope of New Extension
HHS indicated that the new extension is limited to health care providers that missed the June 3, 2020 deadline to apply for the second tranche of relief funding. The extension also applies to providers that were ineligible for the first tranche of relief funding due to a recent change of ownership. The specific situations that HHS indicated would meet the requirements for the extension include:
- Health care providers who were ineligible for the first tranche of relief funding because: (1) they underwent a change in ownership in calendar year 2019 or 2020 under Medicare Part A and (2) did not have Medicare Fee-for-Service revenues in calendar year 2019;
- Health care providers who received a payment in the first tranche of funding but: (1) missed the June 3, 2020 deadline to submit revenue information or (2) did not receive funds in the first tranche that total approximately 2% of their net patient revenue; or
- Health care providers who received a payment in the first tranche of funding, but who ultimately elected to refund that payment (e.g., because they did not believe they met the eligibility requirements), and who are now interested in reapplying.
Health care providers that meet one of the requirements listed above will have until August 28, 2020 to submit an application for additional relief funds. This deadline aligns with the extended deadline for other eligible Phase 2 providers, such as Medicaid, Medicaid Managed Care, CHIP, and dental providers.
Applications should be submitted through the CARES Provider Relief Fund webpage, which can be found at: https://cares.linkhealth.com/#/.
IRS Guidance on Taxation of HHS Provider Relief Funds
On July 7, 2020, the Internal Revenue Service published a series of Frequently Asked Questions that address the taxation of payments to health care providers under the HHS Provider Relief Fund.
As part of the Coronavirus Aid, Relief and Economic Security Act (CARES Act), Congress appropriated $100 billion to reimburse eligible health care providers for health care-related expenses and/or lost revenue attributable to the COVID-19 pandemic. The Paycheck Protection Program and Health Care Enhancement Act appropriated an additional $75 billion to the Provider Relief Fund.
The first FAQ addressed the issue of taxation for for-profit health care providers. Specifically, the IRS was asked whether a for-profit health care provider is required to include HHS Provider Relief Fund payments in its calculation of “gross income” under Section 61 of the Internal Revenue Code (Code), or whether such payments were excluded from gross income as “qualified disaster relief payments” under Section 139 of the Code.
The IRS indicated that payment from the Provider Relief Fund do not qualify as qualified disaster relief payments under Section 139 of the Code. As a result, these payments are includible in the gross income of the entity. The IRS further indicated that this holds true even for businesses organized as sole proprietorships.
The second FAQ addressed the issue of taxation for tax-exempt organizations. The IRS indicated that health care providers that are exempt from federal income taxation under Section 501(a) would normally not be subject to tax on payments from the Provider Relief Fund. Notwithstanding this general rule, the IRS indicated that the payment may be subject to tax under Section 511 of the Code to the extent the payment is used to reimburse the provider for expenses or lost revenue attributable to an unrelated trade or business as defined in Section 513 of the Code.
The IRS FAQ can be viewed in its entirety by clicking here. Members are advised to discuss the issue of potential taxation of any relief funding they received with their tax professionals.
July 22 | EMS Advocacy Facebook Livestream
July 22, 2020 | 14:00 ET | Register Now for a Reminder!
Join AAA advocacy experts for a fast-paced informal dialogue on Facebook Live! Learn first-hand about EMS advocacy initiatives in the face of COVID-19.
Register to receive a reminder email one hour in advance of the live broadcast on the American Ambulance Association Facebook page!
Panelists
- Randy Strozyk, Secretary, AAA
- Jamie Pafford-Gresham, Chair, AAA Government Affairs Committee
- Asbel Montes, Chair, AAA Payment Reform Committee
- Rob Lawrence, Chair, AAA Communications Committee
- Maria Bianchi, AAA Executive Director
- Tristan North, AAA SVP of Government Affairs
- Mercury Group Public Affairs
CMS Modifies the Cost Data Collection System Year 1 Data Collection
CMS has issued a blanket waiver modifying the data collection period for the ground ambulance services that were selected to report in Year 1. Under the current law, these organizations would have been required to collect data beginning January 1, 2020, and through December 31, 2020. The waiver allows these organizations to select a new continuous 12-month data collection period that begins between January 1, 2021 and ends December 31, 2021. This modification means that such organizations will collect and report data during the same time period as the ground organizations that CMS will select for Year 2 of the cost collection program.
From the summary of the waiver, it appears that organizations will have the choice of submitting data in Year 1 or Year 2. CMS has not moved the timeline for any other data collection year, so there is the potential for a substantial number of organizations to report in Year 2, which would increase the amount of data available.
The AAA has supported the data collection system to make sure that CMS and the Congress have valid and reliable data to support maintaining the geographic add-ons to the Medicare Ambulance Fee Schedule and to support efforts to address the chronic underfunding of the Medicare Ambulance Fee Schedule.
The complete FAQ is below and also available at: https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf (on page 29).
“CMS is modifying the data collection period and data reporting period, as defined at 42 CFR § 414.626(a), for ground ambulance organizations (as defined at 42 CFR § 414.605) that were selected by CMS under 42 CFR § 414.626(c) to collect data beginning between January 1, 2020 and December 31, 2020 (year 1) for purposes of complying with the data reporting requirements described at 42 CFR § 414.626. Under this modification, these ground ambulance organizations can select a new continuous 12-month data collection period that begins between January 1, 2021 and December 31, 2021, collect data necessary to complete the Medicare Ground Ambulance Data Collection Instrument during their selected data collection period, and submit a completed Medicare Ground Ambulance Data Collection Instrument during the data reporting period that corresponds to their selected data collection period. CMS is modifying this data collection and reporting period to increase flexibilities for ground ambulance organizations that would otherwise be required to collect data in 2020- 2021 so that they can focus on their operations and patient care.”
“As a result of this modification, ground ambulance organizations selected for year 1 data collection and reporting will collect and report data during the same period of time that will apply to ground ambulance organizations selected by CMS under 42 CFR § 414.626(c) to collect data beginning between January 1, 2021 and December 31, 2021 (year 2) for purposes of complying with the data reporting requirements described at 42 CFR § 414.626.”