GAPB Advisory Committee is Seeking Public Comment by September 5, 2023

The Committee seeks public comment on the following issues under consideration:   
Please submit public comment by September 5 to the following email address:  GAPBAdvisoryCommittee@cms.hhs.gov  

1. Should balance bills for ground ambulance services be prohibited (as with services currently under the purview of the No Surprises Act)?  
   
   Balance billing cannot be prohibited under the current No Surprises Act (NSA) without implementing sufficient safeguards for 911/emergency services.  In order to cover their costs, ground ambulance providers must be permitted to bill insurance companies appropriate charges, and in exchange, get the proper DIRECT payment from the insurance companies.  The fact that almost all 911 and interfacility ambulance providers are regarded as being out-of-network by insurance companies contributes to the problem, resulting in reimbursement reductions that often make the patient responsible for the majority of transport costs.  When dialing 911, patients seldom ever have a choice in the Emergency Medical Services (EMS) provider that arrives.  Consequently, insurers must be required to pay the amounts billed by EMS, consistent with the carrier’s insurance coverage documentation (for example, all but X amount or Y percentage).  Insurance companies who choose to underpay ambulance reimbursements by arguing that patients had a choice in who provided their emergency services shouldn't be able to hold patients hostage.
   
   
2. Would it be appropriate to incorporate ground ambulance services into existing NSA protections?  
   
   Ground ambulance services should not be included in the present safeguards stipulated by the NSA.  Local governments oversee emergency/911 services and should also set the fees the selected services can charge.  Insurance company reimbursement must match the fees set by the entity responsible for emergency/911 services.  The insurance industry cannot be allowed to determine what they believe a reasonable reimbursement rate should be as they have a vested interest in minimizing costs rather than focusing on a patient’s needs. The Qualified Payment Amount (QPA) determination outlined in the NSA is also not appropriate for the ground ambulance industry as the costs for EMS suppliers in a geographic area vary widely based on how localities have chosen to structure their EMS system. Additionally, the ground ambulance sector does not fit the Independent Dispute Resolution (IDR) mechanism described in the NSA.  It calls for an arbitration procedure that is wholly inapplicable to a ground ambulance bill.  This covers things like a 90-day waiting period between each arbitration and each billing code being treated as a distinct arbitration (e.g., base rate, mileage, supplies, and services).  Additionally, the existing IDR process fees commonly exceed the amount of the bill in question.
   
   
3. Should any protections apply to non-emergency transports? If so, should those protections differ for emergency transports? 
   
   Non-emergency transports sometimes allow a choice of ambulance transportation providers.  Non-emergency transports which are routine, predicable, and did not originate from a 911 call lend themselves to contracting between insurers and transportation providers that pre-establish rates and terms of payment.  In these situations, some provisions of the NSA could be applied.  However, as previously indicated, the IDR mechanism described in the NSA remains wholly un-useful as a dispute resolution process for ground ambulance services, even for non-emergency transportation given the costs of appeals far exceeding amounts disputed, the waiting periods, and complexity of the process.  Should the NSA apply to non-emergency transports, a separate and unique IDR process would be needed to ensure continued participation of ground ambulance services in this market.
   
   
4. Should any protections apply to assessment, first responder, or other non-covered fees?  
   
   Patients should not be required to cover the costs associated with assessments, treatment on scene, ALS first response, and transportation to destinations other than a landing zone or hospital.  The safeguards must ensure that each insurance provider pays for these essential services and does not exclude them from being considered as necessary or covered services. The Emergency Medical Services (EMS) system in the US offers a comprehensive range of services in addition to providing transportation.  Like the federal Medicare program, many insurance companies only provide reimbursement for transport services.  As a result, the patient becomes responsible for the full costs of other services provided as part of the 911 response. 
   
   EMS is unique in the healthcare system as these agencies deliver healthcare services in a perceived emergency, but are denied reimbursement unless the patient is transported. If a patient is evaluated in a hospital emergency room but not admitted, the NSA still requires their insurers to pay hospitals for these diagnostic services. Under the current system, insurers save significant costs when a patient receives an emergency medical evaluation by EMS crews, but is not transported to a hospital. EMS agencies must not be expected to provide emergency response care without receiving reimbursement. Health insurers must acknowledge these services and reimburse for the costs of patient care – regardless of whether a transport occurs.  
   
   
5. How can meaningful public and /or consumer disclosures be crafted?  
   
   Disclosures should not be required to be given to a patient after they have called for emergency/911 services because of the emergency nature of the event.  However, if disclosures were required, it might be considered posting them on the responding agency's website or at their place of business (for agencies without websites).
   
   
6. Should there be cost-sharing limitations for EMS in Medicare Advantage?  
   
   The Medicare Advantage program's present reimbursement system must be enhanced to cover assessment, treatment on-scene, ALS first response, and transportation to alternative destinations. In terms of cost sharing, the patient's payments must correspond to the amounts stated in their insurance plan documentation. If they are required to pay a 20% co-pay, their maximum liability would be limited to that sum. By paying for the extra services described previously, the patient would not be responsible for full payment of those costs, thereby lowering their out-of-pocket expenses. Because Medicare Advantage plans offer more services than traditional Medicare, these plans should continue to reimburse 911 service providers at higher levels than traditional Medicare program rates.
   
   
7. Should there be a federal, universal EMS benefit?  
   
   Yes, there should be a federal and state-level universal EMS benefit. The services offered as part of the EMS system in the United States (US) must be covered by all insurance policies. The US EMS system encompasses more than just transportation services - it is a comprehensive and complex medical care system. The suppliers of EMS services, in particular 911 EMS service, provide the US public a wide variety of benefits. This includes emergency assessment and treatment on the scene following a 911 call. EMS crews routinely use heart monitors and other sophisticated diagnostic equipment to ascertain whether the patient needs transportation. Insurers, including Medicare and Medicaid, must be expected to cover these costs and not pass them along to patients. 
   
   Furthermore, in providing these coverages, insurers must also recognize the role of all EMS providers, regardless of whether they provide a transportation benefit. As an example, fire departments commonly provide Advanced Life Support (ALS)-level first response services, but not transportation. The EMS systems of many communities depend on this ALS-level first response, which is now entirely unreimbursed. To prevent the patient from bearing this expense, these treatment-on-scene services must also be covered as a general EMS benefit. This universal EMS benefit must also cover transportation to locations other than an emergency department (or a landing zone for an aeromedical transport to a hospital). There are times when patients need to be able to be taken somewhere other than an emergency room, including a high-level urgent care, a sobering center, or a mental health facility. Transportation destinations that are appropriate for the patient need to be covered services.  Transportation to these alternate destinations not only save insurance companies and patients excessive expenses, but it also enables patients to receive the appropriate level of care.
   
   
8. Should EMT’s and Paramedics be classified as providers?  
   
   Individual emergency medical technicians (EMT) and paramedics should not be classified as providers. Regardless of their transport status, organizations that employ EMTs and paramedics must be regarded as covered entities and given a National Provider Identification (NPI) number so they can bill insurance companies directly for the services rendered. At the moment, only organizations that offer transportation services can obtain an NPI. It shouldn't matter if an organization uses an ambulance, fire truck, quick response vehicle, or another vehicle to provide paramedic level services to 911 callers. Insurers must cover the actual care provided to a patient and not base payment solely on whether a patient could theoretically be transported. All agencies delivering emergency/911 services should have access to an NPI, be able to bill insurance companies directly, and be paid directly for their services. 
   
   
9. Should state and local governments specify the out-of-network reimbursements?  
   
   Yes. If a state or local government (including a Fire, EMS District, other local agency and/or authority having jurisdiction) has set a fee or rate for the delivery of EMS services, this fee should be regarded as the allowable payment that the patient's insurance and the patient are permitted to pay (via a co-pay or cost share). Charges established by a state or local government must be considered in-network as there is rarely any opportunity for a patient to select an EMS provider subsequent to a 911 call.  
   
   
10. Should a public utility model be deployed?  
    
    The decision to implement a Public Utility Model (PUM) or any other form of operational or financial management over EMS should be left to the entity who has the responsibility for the management of the EMS system in the area in question.  In almost all cases, this is and should remain a local government responsibility.
    
    
11. Should emergency ambulance services be considered “in-network” since the consumer has no choice when they call 9-1-1?   
    
    Yes.  Anytime a patient calls 911, the services provided (regardless of transportation to a hospital) must be considered an in-network service. This also should apply to interfacility transports from one hospital to another where the patient needs a higher level of care or simply transportation to their in-network facility.  As with 911 responses, these interfacility transports are often times provided by the local provider and the patient does not have the ability to request a specific company. The key item here is that patients rarely can choose the provider of emergency or interfacility transports and should not be penalized by the insurance company and forced to pay a higher portion of the bill because an out-of-network agency provided the services.
    
    
12. We are seeking information related to examples where consumers receive bills from ambulance providers for services not covered by an insurance carrier.  
    
    Agencies should provide examples of these instances where appropriate. 
    
    
13. What communities or areas in the United States are without emergency ambulance service coverage? 
    
    Agencies should provide information on these areas when known.  
    
    
14. Should NSA protections apply to volunteer ambulance service agencies?   
    
    It is essential that volunteer ambulance services are not penalized by any regulations relating to amounts charged, allowable or collected that are not applied to other types of suppliers.  The fact that a volunteer ambulance service may not incur full personnel costs and benefits, they must still be reimbursed for the full costs of providing patient care services. Volunteer ambulance services are historically in areas of low volume and often serve rural or super rural areas.  Generating sufficient reimbursement to cover the cost of facilities, supplies, equipment and ambulance repair and replacement is paramount to the survival of these services.  Therefore, if the charges for the volunteer ambulance services are established by a governmental entity, then they should be considered the allowed charges just like for other types of 911 providers.  Additionally, in the case of volunteer ambulance services, all of their transports, whether emergency, inter-facility or non-emergency, should be considered in network transports.