CMS Publishes New Rules for Ambulances

PWW’s Summary

On November 16, 2015, the Centers for Medicare & Medicaid Services (CMS) published the Final 2016 Physician Fee Schedule Rule in the Federal Register.  The Final Rule contains several notable ambulance-specific provisions, which PWW excerpted HERE

The Final Rule Does Three Main Things:

1. Updates Medicare Regulations to Account for Bonus Payment Extensions

Starting way back in July of 2008, Congress increased the Medicare ambulance fee schedule amounts for ground ambulance services.  These so-called “ambulance bonus payments” have been extended several times since then, and most recently, they were extended until December 31, 2017 by the Medicare Access and CHIP Reauthorization Act (MACRA).  In this Final Rule, CMS is revising the Medicare regulations to reflect the most recent extension of the bonus payments. 

The Bottom Line:

The regulations will now state that the ambulance fee schedule will be increased until December 31, 2017 as follows:

  • 2% for ground transports originating in urban areas
  • 3% for ground transports originating in rural areas
  • 22.6% for ground transports originating in super-rural areas

These increases will go away for ground transports performed on or after January 1, 2018 unless Congress chooses to extend them beyond that date. 

2. Continues the New Geographic Delineations

CMS is sticking to the geographic changes (the ZIP code changes) that went into effect on January 1, 2015.  These changes stay in place for 2016 and beyond under the Final Rule.   

Quick Refresher

Last year, CMS updated the way that geographic area delineations are made for ambulance fee schedule purposes. This had the effect of changing some ZIP codes from urban to rural and substantially more ZIP codes from rural to urban.  This is significant because for pickups in rural areas, CMS increases the mileage rate by 50 percent for each of the first 17 miles (42 CFR §414.610(c)(5)(i)), and the rural bonus is 3%.  For air ambulance services where the point of pick-up is in a rural area, the total payment (base rate and mileage rate) is increased by 50 percent (42 CFR §414.610(c)(5)(i)).  So, if a point of pickup (POP) ZIP code changed from rural to urban, an ambulance service receives less Medicare reimbursement (and vice-versa if a POP ZIP code changed from urban to rural).

CMS looked at the number of ZIP codes that changed urban/rural statuses after CY 2014 and found that:

  • Geographic designations for approximately 95.22 percent of ZIP codes are unchanged.
  • More ZIP codes have changed from rural to urban (1,600 or 3.73 percent) than from urban to rural (451 or 1.05 percent)
  • The state of Ohio has the most ZIP codes that changed from urban to rural with a total of 54, or 3.63 percent of all ZIP codes in the state.
  • The state of West Virginia has the most ZIP codes that changed from rural to urban (149 or 15.92 percent of all ZIP codes in the state).

For the latest information from CMS, and a state-by-state list of ZIP codes that changed, click HERE (list of ZIP codes are located in the “Downloads” section).  Any future changes to geographic delineations should come through rulemaking.   For now, the changes from 2015 are here to stay. 

3. Revisions to the Ambulance Staffing Regulations

Finally, CMS is revising the ambulance staffing regulations in three ways.  CMS maintains it is trying to promote compliance with all applicable laws and ensure consistency and accuracy in the Medicare regulations through these revisions.   

What’s Driving These Changes?

The OIG recently discussed in a July 24, 2014 Report, Medicare Requirements for Ambulance Crew Certification, its concern that  in some cases the second crew member “(1) possessed a lower level of training than required by state law, or (2) had purchased or falsified documentation to establish their credentials.”  The OIG pointed out that the current Medicare regulations and manual provisions do not outline licensure or certification requirements for the second crew member. So, the OIG recommended that CMS revise the regulations and manual provisions to require that all ambulances be equipped in ways that comply with state and local laws.

Here are the 3 Changes:  

  • State and Local Requirements. CMS is revising the regulations to state that all ambulance transports must be staffed by at least two people who meet the requirements of applicable state and local laws where the services are being furnished, and the current Medicare requirements. CMS believes this would, in effect, require both of the required ambulance vehicle staff to also satisfy any applicable state and local requirements that may be more stringent than those currently set forth in the Medicare regulations. 
  • Regulations Will Expressly Require an “EMT Basic.”  CMS is proposing to revise the regulations to clarify that, for BLS vehicles, at least one of the staff members must be certified at a minimum as an emergency medical technician–basic (EMT-Basic).
  • Revising BLS Definition to Delete an Example.  CMS also revised the definition of Basic Life Support (BLS) at 42 CFR §414.605 to delete the last sentence: “For example, only in some states is an EMT-Basic permitted to operate limited equipment on board the vehicle, assist more qualified personnel in performing assessments and interventions, and establish a peripheral intravenous (IV) line).”  CMS was concerned that this sentence may not accurately reflect the status of the relevant state laws over time.