Government Stop-Gap Measure Extends Add-On Payments
3203
In the eleventh hour, just prior to a looming federal government shutdown, Congress was able to pass the American Relief Act of 2025.
The Act provided funding to keep the federal government afloat through the end of this year and extending through the first quarter of the new year. The numbers 3-2-0-3, as in Section 3203 of the Act, were especially beneficial for the ambulance industry as this section provided for the extension of the Medicare Ambulance Add-On Payments through midnight of March 31, 2025.
April 1st!
The stop-gap measure means that once again leading up to April 1st, Congress will need to come together to act to continue the add-ons.
The add-ons are contained in Section 1834(l) of the Social Security Act (42 U.S.C. 1395m(l) ) and is required to be amended based on a specific date that Congress sets periodically. The add-on payments supplement the national Medicare Ambulance Fee Schedule boosting the reimbursement formula to include an additional…
- 2% reimbursement for transports originating in an urban zip code
- 3% reimbursement for transports originating in a rural zip code
- 22.6% reimbursement for transports originating in a super-rural zip code
Awaiting Revised PUF
Now that this extension has been passed, the industry will await a revised Public Use File (PUF) to be published by CMS. CMS previously provided a PUF on December 2nd, however due to the uncertainty surrounding the extension of the add-on payments, those values were not factored into the expected amounts published in the PUF at that time. As has been past custom, CMS will now release a revised PUF in the coming days to reflect the extended add-ons.
The PUF is important as it details the actual amounts to be paid on Medicare claims for transportation of Medicare beneficiaries by ambulance. It also extends to payment levels reimbursed by Medicare Managed Care Organizations (MCOs) and even extends in many states to insurance reimbursements realized for ambulance transports by auto insurers, workers compensation payers and commercial insurers.
Additionally, we are finding that a growing number of states that are enacting individual state balance billing restrictions are basing mandatory insurance reimbursement amounts as a percentage of the values reimbursed by Medicare.
As such, the trickle-down affects the Medicare Ambulance Fee Schedule, complete with the add-on payment adjustments, deeply affecting funding for EMS agencies across the nation and well beyond the reach of simply traditional Medicare.
Funding Crisis Averted
So, for now, the funding crisis is once again averted for the upcoming ninety-day period.Â
I label this an ongoing funding crisis, as the recently released report from CMS and the RAND Health Care Corporation detailing the results of the Year 1 and Year 2 Cohort analysis from the Ground Ambulance Data Collection System (GADCS) is proving to reveal a sharp underfunding for Medicare patient transports.
While still very freshly published, our initial review of the findings showed a differential of over $1,500 between mean cost and mean revenue received per transport.
Of the over 5,000 ambulance services sampled via the GADCS, it has been determined that the Unadjusted Mean Cost Per Transport across all the reporting ambulance services to provide EMS services nationwide stood at $2,673 per transport. Meanwhile, the respondents reported that the Unadjusted Mean Revenue Per Transport received stands at $1,147 per transport.
Does the funding methodology need to be fixed? Well, you tell me.Â
What other industry or business can continue to stay viable if underfunding at a rate of $1,526 per unit is realized?
Food for thought, for sure!
