Author: Matt Zavadsky

The Centers for Medicare and Medicaid Services has issued a proposed rule that could have major long-term implications for Ground Emergency Medical Transportation (GEMT) reimbursement programs nationwide.

For the first time, CMS is proposing a formal provider-specific payment limit on certain targeted Medicaid supplemental payments made to transportation providers, specifically identifying GEMT providers, air ambulance providers, and NEMT providers within the rule language.

Under the proposal, targeted Medicaid supplemental payments for GEMT providers would be limited to the equivalent Medicare Ambulance Fee Schedule (AFS) payment rates for comparable services.

CMS specifically states that Medicaid supplemental payments tied to GEMT arrangements could not exceed the applicable Medicare AFS payment amounts, including the associated base rates, mileage, geographic adjustments, and rural/super-rural add-on calculations.

This proposal represents a potentially significant policy shift because many current GEMT supplemental payment methodologies nationally are based on cost reconciliation models or Average Commercial Rate (ACR)-style calculations that can exceed traditional Medicare ambulance reimbursement levels.

CMS specifically noted concerns that some targeted supplemental payment arrangements are financed through intergovernmental transfers (IGTs) and “provider-funded mechanisms” (Provider Tax) that, in CMS’ view, may reward providers based more on their ability to finance the non-federal share than on improving Medicaid access or quality outcomes.

CMS also specifically identifies GEMT supplemental payments among the targeted practitioner/provider payment arrangements it believes require additional fiscal oversight and Medicare-based payment limits moving forward.

If finalized as written, this rule could substantially alter future GEMT financing structures, supplemental payment ceilings, SPA methodologies, and the long-term sustainability of Medicaid supplemental reimbursement programs for ambulance agencies across the country.

The payment limits would be effective with the first rating period beginning on or after January 1, 2029.

PWW Advisory Group is actively reviewing the proposed rule and will continue providing updates and strategic analysis to the EMS industry as additional guidance emerges.

Click here to see a highlighted version of the proposed rule identifying the ambulance provisions.

Click here for the release from CMS.

This is a very well-done news report, with logical options articulated by the Rapid City Fire Chief.
 
The issues in South Dakota highlight the plight of agencies trying to provide the service levels desired by the community, in the face of rising costs and stagnant fee-for-service reimbursement; especially in the absence of state legislation for essential service designation, Medicare and Medicaid reimbursement levels, and effective patient protection from balance billing legislation that requires state regulated health plans to provide adequate reimbursement for ambulance service.

An analysis of the average charges and reimbursements for ambulance agencies in South Dakota derived from the PWW|AG Q1 2026 EMS Financial Index reveals the following:

Rapid City (SD) FD may need to reduce ambulance coverage area without funding solutions
SDPB | By Delainey LaHood-Burns
Published May 4, 2026
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https://www.sdpb.org/healthcare/2026-05-04/rcfd-may-need-to-reduce-ambulance-coverage-area-without-funding-solutions
 
Emergency medical service providers across the nation say they are on the brink of collapse, and many ambulance providers in South Dakota are struggling to keep their doors open. While rural services have been hit hard, even the state’s urban EMS organizations are facing difficult choices.
 
Currently, the Rapid City Fire Department is fighting to maintain its coverage of areas outside of city limits. Since its inception in 2003, the department has served a roughly 3,200 square mile area, including Rapid City, Box Elder, New Underwood, Summerset and portions of Pennington, Custer and Meade County.
 
In December 2025, Rapid City Fire Chief Jason Culberson sent letters to the city’s neighboring jurisdictions indicating that the ambulance service can no longer sustainably cover areas outside city limits without funding support. An example of one of these letters, sent to the Meade County Commission, can be found online.
 
According to Culberson, this comes as the costs to operate an ambulance service have skyrocketed, while insurance reimbursement rates are stagnating. Additionally, Rapid City and the surrounding communities are growing substantially, leading to increased call volumes. According to population estimates, Rapid City has grown by nearly 12,000 people since 2020.
 
“We’ve stretched our folks to the max. We’ve asked them more and more and more all along,” said Culberson. “In 2010, we were doing about 10,000 to 12,000 calls, and now we’re doing 22,000 calls.”
Culberson said the department handled 2,655 medical calls outside of Rapid City last year. In order to continue the level of coverage they’ve operated at, more units and staff are needed.
 
The Rapid City Fire Department’s ambulance service is an enterprise fund, with the vast majority of its revenue generated through the transportation of patients. However, reimbursement rates for those patient transports are significantly less than the actual cost of an ambulance run.
 
“Ultimately, the insurance providers are determining what it cost to provide the service,” Culberson explained in a Meade County Commission meeting in March. For example, the base rate of a Basic Life Support call outside of Rapid City limits costs $1,080. In contrast, Culberson said Medicaid only reimburses $255.71 for that same call.
 
About 72 percent of the Rapid City Fire Department’s ambulance payer mix comes from government health insurance programs, including Medicare, Medicaid, Veterans Affairs and Indian Health Services.
 
Over the last five years, Culberson said reimbursement rates for those payers have generally plateaued.
 
“So you see this leveling off of reimbursement, the costs that have shot up since 2020,” said Culberson. “We used to be able to buy an ambulance for about $150,000, and now they are $250,000 to $300,000.
So those two have just diverged from each other. We’re at a point that we need to ask for help.”
 
In his letter, Culberson stated that the Rapid City Fire Department will need to stop its ambulance response coverage to some of its surrounding jurisdictions if formal funding agreements aren’t reached by the end of December 2026. However, he said the department will do everything it can to not leave people without ambulance services in an emergency.
 
“I want to be clear that as long as progress is being made going forward, that we’re not going to stop just because there isn’t a contract totally inked and penned,” said Culberson.

“We’ve gone down this path before it got to this point where it’s an emergency, where we were trying to work on it and nothing ever happened,” he continued. “It just stagnated, stalled and stopped. So that’s why I put a deadline on it. My whole goal is to move forward. But I also want to be clear, if no progress is getting moved forward, we may have to make the hard decision not to respond to those areas.”
 
According to Culberson, he’s had positive conversations with the surrounding communities that could lose their coverage. He says those areas have several options in terms of funding, including setting up contractual service agreements, forming ambulance taxing districts or trying to get coverage from other ambulance providers outside of the Rapid City Fire Department.
 
“The county could just put it in their line item as a budget line item and be able to fund it, which I think is an option – a very easy one,” said Culberson. “Another option is the tax district route, which not always is popular for obvious reasons. When you’re starting to talk about adding onto our property taxes, which are already high. So those are really the two main options. Or the last option is that the areas [decide] they don’t want to have ambulance services, period. I don’t like that option. I don’t think it’s a great option, especially if I lived in that area.”
 
In South Dakota, there’s no statutory requirement for counties or cities to provide ambulance services to their residents. Therefore, if an existing ambulance provider closes or must reduce its coverage area, impacted communities can be left with no ambulance service in an emergency.
 
State lawmakers are working to address this issue with the Emergency Medical Services Funding Task Force, which meets this summer. The task force will study funding mechanisms to support EMS as an essential service, similar to fire and law enforcement.
 
“My hope is they find a realistic funding source to get a baseline of EMS throughout the state of South Dakota,” said Culberson. “Relying on volunteers and other municipalities just to cover the entire state on hopes that they will continue to provide services, those days are done.”
 
While the issue with Rapid City Fire Department’s ambulance service affects multiple counties and municipalities, Culberson believes there are simple and achievable solutions that will ensure citizens have continued coverage. He also said those solutions don’t need to be costly, especially if each area can contribute its portion so the RCFD can continue the broader level of service it’s provided for decades.
 
Currently, the Rapid City Fire Department has several small contracts with entities like Summerset and Conata Basin to provide coverage.
 
Although he feels positive about the progress made so far, Culberson says it’s been hard to face the breaking point that EMS has reached.
 
“This one’s a big one for me,” said Culberson. “The first half of my leadership career was EMS, and this was always something I worked on. Try to make it sustainable and make it appropriate and make sure everybody was cared for. And so when we get to this point where we’re having to ask for funding in order to just provide a basic level of service, that’s a tough spot.”

Interesting editorial and perspective from an EMS clinician in a well-respected healthcare publication.
 
State balance billing laws have been all over the map (literally and figuratively) and only apply to state-regulated plans.
 
The EMS profession should be paying closer attention to the continued call for federal action on surprise payments, and the status of the GAPB committee recommendations to Congress.
 
We should be advocating for our patients by encouraging Congress to adopt the GAPB committee recommendations, which can be found here: https://www.cms.gov/files/document/report-advisory-committee-ground-ambulance-and-patient-billing.pdf

Your Patients Are Getting Surprise Ambulance Bills. Federal Law Still Allows It.

— Excluding ground ambulances from the No Surprises Act has clinical consequences

by Emily James

April 19, 2026 

https://www.medpagetoday.com/opinion/second-opinions/120845

Your patient called 911. They had no say in which ambulance responded. The dispatcher chose, the system routed them, and a crew arrived. Care was delivered. Transport was completed, and weeks later, a bill arrived for $900, $1,500, $2,400, or some other absurd amount. Sure, their insurance covered part of it, but the rest landed on them. And under current federal law, every part of that scenario was entirely legal.

The No Surprises Act, which took effect in January 2022, was a landmark patient protection measure that eliminated surprise billing across most emergency and out-of-network settings. It covered air ambulances. It covered out-of-network emergency physicians, anesthesiologists, and radiologists. It explicitly did not cover ground ambulances, which are the most common form of emergency medical transport, leaving an estimated 1.5 million privately insured patients exposed to surprise bills each year.

As a paramedic who has worked within private emergency medical services (EMS) for nearly a decade, I have watched this gap widen in real time. Patients are stabilized and transported, and then they’re left to navigate a billing system that they don’t understand and that federal law has declined to regulate. This is a gap with direct clinical consequences that emergency and acute care providers should understand.

The Numbers

Approximately 85% of emergency ground ambulance rides are out-of-network. A 2020 Health Affairs analysis found that roughly half of emergency ground ambulance rides resulted in an out-of-network charge for privately insured patients, with a median surprise bill of $450. High-end cases routinely reach into the thousands.

The clinical consequence that tends to receive the least attention is that some patients are delaying or forgoing 911 calls because they fear the bill. This is not a hypothetical. It is a documented pattern of care avoidance driven by financial calculation rather than medical judgment, and it means that some of the patients not arriving in the emergency department are making that decision at home, alone, weighing the cost of the ambulance against the severity of their symptoms.

That calculation will not always go the right way.

Why the Gap Exists and Persists

The exclusion of ground ambulances from the No Surprises Act was deliberate. Congress cited the complexity of ambulance regulation, referring to the mix of private companies, municipal fire departments, hospital-based services, and volunteer squads, as a reason to defer action. The American Ambulance Association lobbied successfully for the carve-out, arguing that the No Surprises Act’s arbitration framework would be unworkable for ambulance providers. In its place, Congress created the Advisory Committee on Ground Ambulance and Patient Billing (GAPB committee) to study the issue and return with its recommendations.

The committee delivered its report in August 2024. Its recommendations were specific and actionable: prohibit balance billing for out-of-network ground ambulance services; cap patient cost-sharing at the lesser of $100 or 10% of the bill; require insurers to process payments within 30 days; and mandate billing transparency. On reimbursement rates, the committee recommended deferring to state and locally set rates with federal guardrails, which is a framework designed to protect rural and smaller agencies from rate compression while still shielding patients.

Congress has not acted on those recommendations.

Why State Solutions Aren’t Enough

Twenty-two states have enacted some form of ground ambulance billing protection. It sounds like meaningful progress, and in some cases it is. But state laws cannot reach self-funded employer-sponsored health plans, which are governed by the Employee Retirement Income Security Act of 1974 (ERISA) and explicitly preempted from state regulation. Approximately 63% of workers with employer-sponsored insurance are in self-funded plans. That means the majority of working Americans with job-based coverage remain unprotected regardless of what their state has done. A patient in a state with strong ambulance billing laws may still receive a surprise bill if their employer uses a self-funded plan, which is something that the largest employers almost uniformly do.

This is not a gap that more state legislation can close. It requires federal action.

What the Clinical Community Can Do

Physicians and other acute care providers are positioned to move this issue in ways that EMS providers alone cannot. Emergency medicine, hospital medicine, and primary care organizations carry legislative influence that individual paramedics do not. When professional societies weigh in on patient safety issues — and care avoidance driven by billing fear is a patient safety issue — Congress listens differently than when it hears only from industry stakeholders and patient advocates.

The GAPB committee has done the analytical work. The report is on Congress’s desk. What has been missing is urgency from the clinical community. This refers to the providers who see the patients who waited too long, or the family members who explain that their loved one didn’t call because they were worried about the bill.

Every month without federal action is another cycle of patients absorbing costs they had no power to prevent, for a service they had no power to choose. The No Surprises Act was a genuine achievement with one significant exception baked into it.

That exception was always meant to be temporary.

It has not been.

Related:

Expanding the No Surprises Act to Protect Consumers from Surprise Ambulance Bills: Map of State Laws

February 5, 2026https://www.commonwealthfund.org/publications/maps-and-interactives/expanding-no-surprises-act-protect-consumers-surprise-ambulance

Ambulance theft is no longer a rare or isolated event—it is a predictable and growing operational risk.  Industry data suggests that an ambulance is stolen approximately every two weeks in the United States, most often from hospital ambulance bays, but increasingly from active scenes. What was once considered an anomaly is now presenting serious and escalating consequences—including police pursuits, spike strip deployments, vehicle crashes, and situations where patients and crews are placed in harm’s way.

The uncomfortable truth is this: many of these incidents are preventable.  This timely and practical webinar brings together operational leadership, regulatory insight, and legal expertise to examine ambulance security from every angle—what’s happening, why it matters, and what you can do about it now.  The Academy of International Mobile Healthcare Integration (AIMHI), Pro EMS and Page Wolfberg & Wirth Advisory Group (PWWAG) are teaming up to help you address this issue.

When:  Tuesday, April 28, 2026, 12n ET

Panel

Rob Lawrence – Pro EMS/AIMHI
President of the Academy of International Mobile Healthcare Integration (AIMHI) and Executive Director of the California Ambulance Association, bringing national perspective and frontline insight into EMS operations and risk.

Bill Mergendahl, Pro EMS
President of ProEMS, offering real-world operational experience on balancing rapid response with vehicle and crew security.

Mark Postma, SVP, Government Relations, Patient Care EMS Solutions
Experienced EMS leader offering insight into standards, compliance expectations, and the evolving role of vehicle security in modern EMS systems.

Doug Wolfberg, Esq. – PWWAG
Nationally-recognized EMS attorney with Page, Wolfberg & Wirth, providing clarity on liability, foreseeability, and the legal consequences of preventable ambulance theft.

Matt Zavadsky – PWWAG, Moderator
A nationally recognized EMS leader and strategist, guiding the discussion and drawing out practical insights across operations, regulation, and law.

Register Here: https://prodigyems.zoom.us/webinar/register/5417760399888/WN_kWrSTW3GTQWoYZRUKUlH6g

The go-to data base for conducting analysis of EMS trends ranging from finance and reimbursement to crashes and thefts – EMSIntel has now passed 4,000 news items and continues to grow.

What began as a simple weekly spreadsheet collated during the pandemic, tracking news reports about EMS, has grown into one of the most influential intelligence resources in Emergency Medical Services. EMSIntel, publicly accessible at www.emsintel.org, has surpassed 4,000 curated profession wide news stories, marking a significant milestone in its evolution from informal briefing tool to a nationally recognized platform for insight, analysis, and understanding.

The origins of EMSIntel are deliberately modest. Developed by Rob Lawrence (Pro EMS), while serving as the American Ambulance Association’s (AAA) Communications Chair, as a weekly compilation of notable EMS developments, the early version was shared with a small network of colleagues seeking clarity in an increasingly noisy information environment.

Recognizing both the value of the content and the opportunity to scale its impact, the AAA provided generous funding and support to transform EMSIntel from a static, spreadsheet-based product into the interactive and searchable platform it is today. This transition marked a pivotal moment, enabling not just collection, but structured collation and accessible analysis at scale.

As the platform matured, the Academy of International Mobile Healthcare Integration joined the collaboration, reinforcing EMSIntel’s role as a shared industry asset and ensuring its continued growth through coordinated collection, curation, and collaboration. Together, these partnerships have anchored EMSIntel firmly within the EMS ecosystem, both reflective of and responsive to its evolving needs.

From its earliest days, EMSIntel has been guided by a disciplined approach to curation and interpretation. Rodney Dyche (Patient Care EMS Solutions) serves as Chief Curator, overseeing the identification and classification of developments from across the United States and internationally. Matt Zavadsky (PWW|AG / Executive Director AIMHI) provides analytical leadership, translating thousands of individual entries into thematic insights that reveal the pressures, trends, and opportunities shaping EMS systems. Rob Lawrence shapes the input into briefings and articles to inform of issues, concerns and alerts.

An analytical summary of EMSIntel and a downloadable Excel file of the EMSIntel log, complete with source references, is updated each month on AIMHI’s News site.
 

This structure and support allows EMSIntel to move decisively beyond aggregation. With more than 4,000 curated entries, the platform now supports meaningful thematic analysis across workforce challenges, reimbursement reform, ambulance patient offload times (APOT), mobile integrated healthcare, and system resilience. It offers not just a snapshot of events, but a longitudinal understanding of how the EMS landscape is changing.

That insight is increasingly being put to use. EMSIntel analysis has supported briefings for policymakers at both state and federal levels, providing evidence and context to inform legislative and regulatory discussions. It has also been cited in journalistic reporting, helping frame EMS issues within a broader, data-informed narrative.
“EMS has no shortage of information, but it often lacks shared understanding,” said Rob Lawrence. “EMSIntel was created to bridge that gap, turning noise into insight, and insight into something that can inform decisions, policy, and public awareness.”

As EMSIntel enters its next phase, the focus will remain on expanding its analytical capability while maintaining the disciplined curation that underpins its value. The milestone of 4,000 entries is not simply a measure of scale, but a signal that EMS now has a growing intelligence function, one capable of tracking, interpreting, and communicating the realities of a complex and evolving system.

About www.EMSIntel.org
EMSIntel is a curated intelligence platform focused on tracking and analyzing developments across the Emergency Medical Services sector. Created by Rob Lawrence and supported by Chief Curator Rodney Dyche and Analyst Matt Zavadsky. EMSIntel provides thematic insight into emerging trends and issues affecting EMS systems, policy, and practice. Learn more at www.emsintel.org

Published analysis derived from EMS Intel
Leading into 2026: The four actions every EMS leader must take: Leading into 2026: The four actions every EMS leader must take
EMS at the edge: Inside a year of reckoning and redesign: EMS at the edge: Inside a year of reckoning and redesign
Funding on fire: Communities are saying the quiet part out loud: Rethinking EMS funding: New models for ambulance service sustainability
Fast & spurious: America keeps losing ambulances and the fix is cheap: Prevent ambulance thefts: Keep paramedics, patients and the public safe

Two news reports last week that could impact EMS reimbursement should catch the attention of EMS leaders.
 
The first report signals that Medicare is considering making enrollment in Medicare Advantage (MA) the ‘default’ enrollment option.
 
As reported in the August 2025 PWW|AG EMS Financial Index Report, MA claims represent 56.9% of all ambulance claims, with Medicare Part B representing 43.1% of claims. The average reimbursement from MA plans is $25 lower than Medicare Part B. Additional enrollees in MA plans could have a negative impact on EMS reimbursement.

The second report reveals that the average out-of-pocket premiums for Affordable Care Act (ACA) enrollees rose 58% this year after the expiration of enhanced subsidies. Also, 1.2 million fewer people enrolled in ACA plans in 2026 compared to 2025. 
 
This possibility was discussed in our summer Pulse of EMS Finance webinar series, explaining that reduced ACA enrollment due to provisions contained in the OBBBA could shift commercially insured patients to uninsured, or Medicaid programs.
 
We strong encourage EMS leaders to closely monitor these types of developments, and consider modeling what these changes may mean for their revenue cycle.

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CMS considering automatic enrollment in a Medicare Advantage plan

The idea is part of the conservative Project 2025 policy.

By Susan Morse

March 24, 2026

https://www.healthcarefinancenews.com/news/cms-considering-automatic-enrollment-medicare-advantage-plan

The Centers for Medicare & Medicaid Services is considering a policy to automatically enroll seniors in a Medicare Advantage plan, according to STAT.

Chris Klomp, director of Medicare and deputy administrator for CMS, told STAT his team is mulling the feasibility of models that would either automatically enroll beneficiaries into a private Medicare Advantage plan or an accountable care organization that participates in the Medicare Shared Savings Program or similar program. 

Klomp said either choice would be better than enrolling beneficiaries in a fee-for-service arrangement, which is Medicare. Individuals could still opt into a different insurance arrangement, he said. 

Klomp is senior advisor to Health and Human Services Secretary Robert F. Kennedy, Jr. 

In February, Kennedy announced in an email to staff that he was remaking his leadership team, putting Klomp in charge of overseeing all HHS operations, according to Politico.

Currently, original Medicare is the default option for seniors who don’t make a choice. Over half of seniors enrolled in a Medicare plan choose a Medicare Advantage plan.

Moving to MA as the default option is part of the conservative Project 2025 policy blueprint, which has made other recommendations that HHS has initiated such as Medicaid work requirements. 

Medicare Advantage (MA), a system of competing private health plans, is the major alternative to traditional Medicare for America’s large and growing cohort of seniors. The program provides beneficiaries with a wide range of competitive health plan choices—a richer set of benefits than traditional Medicare provides and at a reasonable cost. Equally as important, the MA program has been registering consistently high marks for superior performance in delivering high-quality care. Critical reforms are still needed to strengthen and improve the program for the future.”

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ACA premium costs up after subsidies expire

By Peter Sullivan

March 30, 2026

https://www.axios.com/newsletters/axios-vitals-f319f390-2b23-11f1-8489-774d2aecabb5.html

Average out-of-pocket premiums for Obamacare enrollees rose 58%, or $65 per month, this year after the expiration of enhanced subsidies, new federal data shows.

Why it matters: The data helps quantify the effects of the fierce partisan battle in Congress over whether to extend the subsidies, which ended in no action.

By the numbers: The average Affordable Care Act out-of-pocket premium rose from $113 per month in 2025 to $178 per month in 2026, according to the CMS report.

• There are also more enrollees in “bronze” plans with higher deductibles this year: 40% of enrollees compared with 30% last year.
• Larry Levitt, executive vice president of health policy at KFF, wrote on X that the average premium increase would have been higher if some people had not switched into bronze plans with higher deductibles to try to keep their premiums down.

The big picture: 23.1 million people signed up for 2026 coverage, down 1.2 million from 2025.

• CMS touted its enforcement actions, which it said removed coverage or subsidies from nearly 1.5 million people found to be ineligible.