News & Updates

An excellent summary of the issues related to CMS’ Emergency Triage, Treatment and Transport (ET3) model in Health Affairs on June 23, 2025.
 
For each patient enrolled in the ET3 mode, the average Net Savings to Medicare (NSM) is shown below. Treatment in Place (TIP) models are patient-centric models that have the potential to save hundreds of millions of dollars to the Medicare program.

A summary of the economic case for EMS TIP programs can be found here.
 
We encourage EMS and stakeholders to support current legislation that changes Medicare’s EMS payment model to reimburse for TIP and MIH.
 
H.R. 2538 - Comprehensive Alternative Response for Emergencies (CARE) Act of 2025 (TIP Bill)
H.R. 4011 – Community Paramedicine Act of 2025

Learning From The Failure Of A CMS Emergency Medical Services Model
Erik Blutinger, Alexander J. Ulintz, Kevin Chason, Nicholas Gavin
June 23, 2025
 
https://www.healthaffairs.org/content/forefront/learning-failure-cms-emergency-medical-services-model
 
Barely one year after the eruption of the global COVID-19 pandemic, the Centers for Medicare and Medicaid Services (CMS) launched an exciting initiative for Medicare fee-for-service beneficiaries. The Emergency Triage, Treat, and Transport (ET3) Model afforded one of three outcomes for every patient encounter: ambulance transport to a covered destination (that is, a hospital emergency department), ambulance transport to an alternative destination (for example, urgent care), or treatment in place (emergency medical service [EMS] on scene with telehealth physician consult). The program—a voluntary, five-year payment model covering prehospital services beyond emergency stabilization and transportation—sought to answer a critical question: Is there a better way to deliver acute, unscheduled care to older adults in the community without defaulting to expensive, intensive care settings?
 
However, CMS abruptly announced the death of ET3 in 2023. Another planned aspect of the model, which would have provided up to $34 million for local emergency communications centers to establish or expand medical triage lines, was canceled prior to implementation after CMS received fewer than 30 applications.
 
The recent publication of CMS’s final report provided insights into the limited participation and other challenges that prevented the model from flourishing, but the current landscape leaves EMS agencies, emergency departments, and other key stakeholders stuck in a current of costly prehospital acute care services while trying to paddle upstream toward value-based care. This article examines the forces that led to an early termination of ET3 but laid the groundwork and set the trajectory for value-based care and EMS-led innovation.
 
What ET3 Was Trying To Solve
Over the past two decades, the EMS community has realized that person-centered, value-based care could look very different than the traditional model of transporting all patients to an emergency department. “Community paramedicine” programs, which emerged in the 1990s, filled critical health care gaps in rural America. This concept gained momentum in the 2010s after passage of the Affordable Care Act spurred an interest in value-based models. Several state Medicaid programs reimburse for community paramedic services, and some EMS systems have launched programs funded by local taxpayers or agreements with providers and payers. In 2019, EMS Agenda 2050 envisioned systems of care, integrated with EMS, that allowed the right level of care in the right setting to be delivered to the patient, with reimbursement for the value of the service provided. This broader concept—extending EMS beyond its transport function and expanding its patient navigation function in coordination with health systems and community services—is increasingly known as “mobile integrated health” (MIH). The dream of MIH, however, was often limited to grant-funded pilot programs, including some supported by the Center for Medicare and Medicaid Innovation.
 
Historically, Medicare primarily has paid emergency ground ambulance services for transporting individuals to expensive facilities such as traditional hospitals, critical access hospitals, dialysis centers, and skilled nursing facilities. As a result, when calling 9-1-1, beneficiaries typically get taken to a hospital emergency department rather than a destination or outcome that, in some cases, may align better with their medical needs and personal preferences for receiving care outside of the emergency department.
 
The misalignment between the services that EMS provides and reimbursement solely for its transportation function leads to inefficiency and potentially unnecessary Medicare spending. The downstream consequences of this model are significant: high costs of care in intensive settings, emergency department overcrowding, longer EMS wait times during an emergency. Moreover, EMS agencies, already running on thin margins, are often not reimbursed for the emergency response, acute care, medications, and supplies used if a patient does not want—or does not need—transportation to a reimbursable destination.
 
Recognizing these inefficiencies, EMS agencies have long advocated for alternative care models, leading to experimental programs such as ET3.
 
ET3, Organization Design And Operational Dynamics
The prehospital community was excited to have a path toward sustainably offering patients a customized care path rather than defaulting to sometimes unnecessary transportation to an intensive and expensive care setting. In March 2021, CMS unveiled a list of 184 public and private ambulance providers and suppliers selected to participate. Enthusiasm grew as the groundwork was laid for a paradigm shift in prehospital medicine.
 
Overall, model participants were afforded generous flexibility for tailoring their own care pathways. New care protocols were built from an early stage. Communities stood up new structures for building novel interventions and new procedures even in places such as New York City, whose Fire Department of New York organized weekly meetings with major health systems to discuss recommended “best practices.”
 
New protocols and procedures also were greeted with overwhelming optimism by the EMS community and patients in parts of the country. Interest in out-of-hospital care is high especially when telehealth becomes a new option for patients to receive care in the comfort of their homes. With ET3’s goals of person-centered care, increased efficiency in the EMS system, and growing technological capabilities in the out-of-hospital environment, systems were willing to invest, build new protocols, and develop new policies for meeting consumer demand.
 
Several barriers, however, impeded overall progress and acceptance of ET3. The lack of cultural acceptance, high administrative costs, and challenging care coordination seemed to limit potential outcomes. Implementation challenges quickly became apparent, as participation rates lagged, and adoption—even among highly motivated participating agencies—was hindered. According to CMS, from January 1, 2021, to December 30, 2023, 147 EMS agencies participated in the model but only 72 (49 percent) submitted a claim for these services. The number of unique Medicare and Medicaid beneficiaries who received an ET3 intervention was 2,964, suggesting an average of 41 patients per provider. There were also many more treatment-in-place interventions (3,144) than transports to alternate destinations (253).
 
ET3 could have demonstrated significant cost savings by diverting preventable emergency department visits through treatment in place with telehealth or transport to alternative destinations such as urgent care. The program, however, was canceled early, partially attributable to delays in implementation and slow uptake of systemwide interventions.
 
 
Why ET3 Failed
Out-of-hospital care is popular yet often associated with costs and limited resources. The final report underscores the administrative, operational, and reimbursement complexity that EMS systems face when implementing innovative programs, even with federal and community support. Significant barriers prevented model participation in most local health care Marketplaces: Many health systems and departments rely upon fee-for-service, volume-driven care models versus programs with value-based care elements such as ET3 that was intended to reduce emergency department volume and inpatient admissions. Value-based care programs have faced their fair share of challenges in health care but still represent an aspirational goal in the United States, to blunt the long-term trajectory of ever-rising health care costs.
 
The post-public health emergency era has introduced changing policy, payment, and coding surrounding virtual health care visits. Major health stakeholders are struggling to predict future health trends especially now that COVID-19-era–related policies are no longer in effect. After COVID-19, many health systems have not experienced healthy operating margins, prompting executives to “think twice” about alternative care models that have yet to prove long-term financial sustainability.
Onward And Upward
 
So, what now?
Despite the premature closure of the ET3 pilot, the national appetite for value-based care beyond the four walls of a clinic or hospital continues to grow, as does innovation in MIH. Future efforts should: Balance local flexibility in program design with clear federal reimbursement structures that are feasible for small MIH programs to participate in; integrate MIH into existing value-based payment infrastructure, including broader insurance participation beyond Medicare; and support rigorous evaluation of similar MIH programs that continue to flourish across the country.
 
Data will require prioritization, too. The collection and comparison of systematic data is indispensable for meeting individualized community needs as it pertains to areas such as billing procedures, EMS payment model structuring, and cultural acceptance of new home-based technologies. Future partnerships with private payers may also help with the acquisition, accessibility, and overall processing of patient-level data. It is difficult to understand care delivery without data—a key pillar to any future program that aims to replicate parts of ET3.
 
There is no innovation and creativity without failure. ET3 failed due to problems with program implementation, resource allocation, financial incentives with ongoing focus on fee-for-service arrangements, and cultural acceptance within both EMS and its health care partners. But the program should be considered a landmark success for its ability to pioneer new ideas with good intentions in EMS. The model’s challenges have provided valuable lessons for policy makers and health care systems to reopen the door for sustainable, value-based EMS care for years to come.

While the headline is a little deceiving (every agency referenced in the report is a governmental agency), this lengthy news report is very well done.
 
Ambulance agencies resort to processes like these to collect owed fees from patients when insurers make surprise under-reimbursements for services in order to reduce public tax burden from communities. 
 
Scenarios like these are why the ambulance industry, being good patient advocates, continues to push for patient protection initiatives that require insurers to appropriately reimburse ambulance agencies.
 
The May 2025 PWW|AG Financial Index Report provides data on the under-reimbursement of ambulance services by commercial insurers.

Special thanks to John (JP) Peterson from MEDIC in Charlotte and Regina Godette-Crawford from EMS|MC for providing insight for this news report, and to Brian LaCroix from Cambridge Consulting Group for finding and sharing this report.

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Ambulance companies collect millions by seizing wages, state tax refunds
Some ambulance patients are surprised to find their wages or tax refunds seized to settle hefty bills. EMS leaders say the measures are needed to cover their costs because insurers often underpay.
by Michelle Crouch and Charlotte Ledger
June 16, 2025
 
https://www.northcarolinahealthnews.org/2025/06/16/ambulance-companies-collect-millions-by-seizing-wages-state-tax-refunds/
 
When Christy Owca’s 17-year-old son flipped his Jeep in a crash in 2019, she was grateful that an ambulance got him to the hospital quickly and that his injuries turned out to be minor. So when the first bill from Gaston County’s ambulance agency came, she didn’t think twice about paying the $61 fee.
 
But more bills kept coming. Then came statements from her health insurance company, each showing a different amount she owed just for the ambulance ride.
 
Confused, Owca began making calls — to Gaston Emergency Medical Services, to her health insurance company, to supervisors at both places. She said she spent hours making calls over several months trying to get the situation sorted out. Each time, a representative assured her the issue would be resolved.
 
The bills and notices kept coming. 
 
Then, one day while she was at work, something mortifying happened: She was notified by her company’s human resources office that her wages were being garnished for an unpaid medical bill — that ambulance ride.
 
“It was a total shocker and extremely embarrassing,” said Owca, who got the garnishment removed after she sent a complaint to the N.C. Attorney General’s Office about the incident. “If you need an ambulance, if you have a car accident or another emergency, you shouldn’t have to worry that they’re going to take your wages if you call 911.”
 
Powerful collection tools
Because most EMS agencies in North Carolina are government entities or government-affiliated, they have access to two powerful debt collection tools:
 
Wage or bank account garnishment: State law allows EMS agencies to take up to 10 percent of a person’s paycheck each month or to garnish an unlimited amount from a bank account in their name.
 
State tax refund seizure: Through the state’s “debt setoff” program, EMS agencies can intercept your state tax refund or lottery winnings. In 2024 alone, Mecklenburg County’s EMS provider, MEDIC, collected $2.5 million through the program — more than any other public agency in the state. (More than 500 N.C. public agencies made these collections last year, here’s a list of how much was collected by each.)
 
For ambulance agencies facing budget gaps and rising costs, these tools offer a crucial source of revenue and a way to recoup unpaid bills when costs are rising. EMS leaders say they’re forced to go after patients because insurance companies deny or underpay emergency transport claims.
 
Patient advocates respond that the practices are out of step with efforts in North Carolina and across the country to reduce the aggressive collection of medical debt. In 2024, the state’s hospitals agreed to a medical debt relief plan that prohibits them from using liens, wage garnishment or tax refund seizure to collect medical debt.
 
“People should not be pushed to suffer financially because they needed help at a critical time,” said Rebecca Cerese, health policy advocate for the NC Justice Center. “These types of punitive policies keep people from calling an ambulance when they need one.”
 
Two steps to take your paycheck
Unlike other states, North Carolina does not require ambulance agencies to get a court order to garnish wages or seize funds from a bank account, said Christopher McLaughlin, a professor at the UNC Chapel Hill School of Government who has studied policies related to government debt collection.
 
Instead, he said, N.C. law requires just two pieces of paper: a letter to the debtor notifying them of the garnishment and a notice to the employer or bank directing them to seize the amount owed.
 
It’s the same process that counties and cities can use if you don’t pay your property taxes, he said.
 
“They don’t need to go to court. They don’t need to get approval from anybody,” McLaughlin said.
 
The debtor can stop the garnishment only if they can prove that the agency has the wrong person or they can prove they already paid, McLaughlin said.
 
It’s not clear how many EMS agencies across the state use wage or bank account garnishment or how much they collect, but McLaughlin said he thinks most do.
 
$21M seized from tax refunds and lottery winnings
As for debt setoff, 469 government entities — including counties, cities and utilities — used it to collect $21.4 million from people’s North Carolina tax refunds and lottery winnings in 2024, according to a clearinghouse that helps agencies use the program.
 
Representatives for Wake County EMS and MEDIC — which serve the state’s two largest counties — told The Charlotte Ledger/NC Health News they use the debt setoff program, but they do not pursue wage garnishment.
 
MEDIC considered using wage garnishment in 2019 to address a budget shortfall but dropped the plan after public outcry.
 
A tactic of last resort
Gaston County spokesman Adam Gaub said he could not comment on a specific patient’s bill, citing privacy laws, and he declined a request for an interview about the county’s ambulance billing policies.
 
In a written response to questions, Gaub said Gaston’s ambulance service, known as GEMS, uses a sliding fee scale and does not garnish wages or seize refunds from patients who cannot afford to pay.
 
He emphasized that the agency uses wage garnishment and debt setoff only “as an absolute last course of action” after working with individuals and offering payment plans.
 
The agency’s policy is to send three bills over 90 days before turning a bill over to collections, which triggers the wage garnishment process. The county also sends certified letters to the patient and their employer notifying them of the garnishment.
 
GEMS collected $31,757 in wage garnishments and $244,168 from the debt setoff program in 2024.
 
The agency is already operating in a deficit, Gaub said. In 2024-25, GEMS brought in $16.6 million and spent $23.1 million, with the difference made up by the county’s general fund revenues, which includes property taxes.
 
“Not collecting for services rendered from those who have the capacity to pay would place an additional burden on Gaston County taxpayers and/or would negatively affect our ability to provide our current level of service,” Gaub wrote.
 
What happened to my tax refund?
In Charlotte, Mae Cynthia Glover was caught off guard in 2020 when the state tax refund she was expecting never arrived. Instead, she said she received a letter saying MEDIC had seized it to cover an unpaid ambulance bill.
 
The letter said her refunds would continue to be garnished every year until her full balance was paid, Glover recalled.
 
“It wasn’t much, but it would have been better than nothing,” she said.
 
The unpaid bill dated back to 2019, when Glover finished a week of double shifts at her job as a catering company dishwasher and began feeling dizzy and nauseous. Her sister urged her to call 911. Moments later, in the back of the ambulance, Glover’s heart stopped. Paramedics revived her with a defibrillator, and doctors later implanted a pacemaker.
 
Glover doesn’t remember the exact amount of the ambulance bill — only that it was in the thousands and she couldn’t pay it.
 
She set up a monthly payment plan with MEDIC, but she said she fell behind after her health forced her to stop working. The unpaid bill was sent to collections, triggering the tax refund seizure.
 
“It’s frustrating because you ain’t got no choice when you call the ambulance,” she said. “It’s usually a life-or-death situation.”
 
She said she was relieved when she turned 65 last year and got on Medicare, so she doesn’t have to worry anymore about a big bill if she calls 911.
 
Ambulance providers say they wish they didn’t have to use collection actions like debt setoff and wage garnishment, but they have little choice because of how insurance companies handle emergency transport bills.
 
Medicare and Medicaid reimbursement rates are so low they don’t even cover the cost to run an ambulance, said Regina Godette-Crawford, a lobbyist for the North Carolina Association of EMS Administrators. And private insurance companies routinely underpay or deny claims because they often treat ambulance transports as out-of-network.
 
That leaves the patient responsible for the balance, sometimes totaling in the thousands of dollars.
 
In addition to low reimbursement rates, ambulance services are also grappling with rising costs, workforce shortages and increasing numbers of calls.
 
John Peterson, executive director of MEDIC, said the agency makes every effort to work with patients, offering financial aid to low-income patients and interest-free payment plans. The agency also sends “multiple letters, multiple correspondences” before taking action, he said.
 
He said MEDIC uses the debt setoff program only when patients don’t respond to repeated billing attempts.
 
“If we don’t hear from anybody, then … we have to do what any good agency or business would do, and try to collect those dollars wherever we can,” he said. “We are a safety-net provider, but we’re also a business. We have to be good stewards of taxpayer and patient dollars.”
 
MEDIC gets an annual subsidy from Mecklenburg County’s general fund, which is supported by property and sales taxes. The subsidy is expected to remain flat for 2025-26 at $22.5 million. The new county budget also includes $7.6 million for one-time capital purchases like new ambulances and equipment.
 
Other states have protections
In North Carolina, legislation unanimously approved by the state house aims to ease some of the financial pressure on ambulance agencies. House Bill 489 would require health insurers to treat emergency ambulance transports as in-network and reimburse providers at local rates. The proposed legislation says patients should pay no more than $100 per ride.
 
Nineteen other states have approved similar “surprise ambulance bill” legislation. In some states, such as Massachusetts and California, those laws include provisions that ban EMS agencies from using aggressive collection actions like wage garnishment, said Mona Shah, senior director of policy and strategy at Community Catalyst, a national nonprofit that advocates for medical debt protections.
 
Other states take different approaches to shield patients from harsh collection practices, Shah said.
 
In Texas, for example, wage garnishment for medical debt is banned entirely. And in New Jersey, a 2024 law says wages can’t be garnished for medical debt if a person’s income is below 600 percent of the federal poverty level — currently $192,900 for a family of four. That law specifically names ambulance services as subject to its provisions.
 
“While there are broader policies around hospitals not being able to garnish wages, there can be loopholes for ambulance companies,” Shah said.
 
It’s particularly troubling for a government ambulance agency to be garnishing wages, she said, because it jeopardizes a person’s economic stability for an emergency they couldn’t control.
 
“You expect your government to be there to help in times of emergency,” she said.
 
She added that the real problem lies with insurers failing to cover emergency ambulance bills in the first place — shifting the financial burden to local governments and, ultimately, patients.
 
“We should really be going after insurance companies for denying coverage,” she said, “not patients who call 911 because they have a medical emergency.”

We are honored to share that AIMHI is now part of the Modern Medicaid Alliance. 

The mission of the Alliance is to educate policymakers and the public about the benefits of Medicaid to the American people in terms of cost savings, health outcomes, and social impact.

The alliance highlights how Medicaid is innovating in the delivery of care – especially for America’s most vulnerable citizens – and accountability of the program.

AIMHI Excellence in EMS Integration Award Winners Announced

 To Be Recognized at the AAA Annual Conference & Trade Show

Mechanicsburg, PA—The Academy of International Mobile Healthcare Integration (AIMHI) is excited to announce the winners of the 2025 AIMHI Excellence in EMS Integration Awards. These prestigious honors celebrate agencies, people and programs that integrate high-performance, high-value EMS into the overall healthcare system.

2025 Award Winners are:

• Excellence in EMS Integration Award: Jackson Care Connect, Oregon
• Advocacy in Integrated Healthcare Award: Nye Strategies Communications Firm, Virginia
• Excellence in Public Information or Education: Riggs Ambulance Service, California
• Excellence in Value Demonstration or Research: Prisma Health Ambulance Service - Mobile Integrated Health
• Leadership in Integrated Healthcare Award: Chip Decker, Richmond Ambulance Authority
• 2025 Legislator of the Year: Rep. Jason Smith, Chairman of the House Ways and Means Committee

2025 Honorable Mentions include:

• Nevada Hospital Association
• St. Charles County Police Department
• Tele911

“The 2025 Excellence in Integration Award winners represent the very best in mobile integrated healthcare. We are proud to honor these exceptional programs and individuals,” said AIMHI President Rob Lawrence.

This year’s winners will be celebrated at the American Ambulance Association Annual Conference & Trade Show in Lexington, KY on June 21, 2025.

Click below for a full description of the award winners, and notable honorable mentions.

2025 Awards Summary.pdf

It is increasingly crucial that EMS agencies, and their stakeholders, pay close attention to legislative initiatives that could impact reimbursement for ambulance services.

We recommend active engagement with professional associations advocating for appropriate reimbursement for vital ambulance services!

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Senate GOP proposes bigger Medicaid cuts than House

By: Michael McAuliff

June 16, 2025 06:03 PM

https://www.modernhealthcare.com/politics-regulation/mh-one-big-beautiful-bill-senate-provider-tax/

Senate Republicans are eying even deeper Medicaid cuts and stricter limits on the provider taxes states use to finance the program under legislation introduced Monday.

The House-passed version of the One Big Beautiful Bill Act of 2025 would establish a moratorium on new provider taxes. The Senate Finance Committee portion of the upper chamber’s bill would go further by ordering the District of Columbia and the 40 states that expanded Medicaid under the Affordable Care Act of 2010 to reduce their provider taxes.

States tax providers to help raise their share of funding for the state-federal health program for low-income people. Providers tend to come out ahead because this financing mechanism enables states to maintain Medicaid benefits and reimbursements.

The catch is states may only pay back up to 6% of a provider’s revenue in what’s known as a “safe harbor.” Rather than freezing provider taxes at 6% and barring new ones, as the House bill would do, the Senate measure would start rolling back the safe harbor in 2027 and cap it at 3.5% in 2031.

The nonpartisan Congressional Budget Office has not evaluated the new legislation. But the nonpartisan health policy research institution KFF previously estimated that restricting the provider tax “safe harbor” to 5% would reduce federal spending by $48 billion over 10 years and that limiting it to 2.5% would cut expenditures $241 billion.

The Finance Committee similarly targets so-called state-directed payments in Medicaid expansion states. States utilize this policy to set minimum provider reimbursements for Medicaid managed care insurers. Under the Senate measure, those payments could not exceed Medicare rates in expansion states, while the remaining 10 states could set payments up to 110% of Medicare.

The Senate bill notably doesn’t include an increase in Medicare payments to physicians.

In a news release, Finance Committee Chair Mike Crapo (R-Idaho) does not address the healthcare provisions but said the legislation could change as Congress strives to deliver it to President Donald Trump by July 4.

“I look forward to continued coordination with our colleagues in the House and the administration to deliver President Trump’s bold economic agenda for the American people as quickly as possible,” Crapo said.

The chief purposes of the bill are to extend tax cuts Trump enacted during his first term and to slash spending across the government, which a particular emphasis on healthcare programs. According to the CBO, the House bill would cut healthcare funding by more than $1 trillion, with more than 80% coming from Medicaid.

Finance Committee ranking member Ron Wyden (D-Ore.) slammed the Senate bill in a news release. “The House Republican version of this bill was already a class war, but Senate Republicans decided to inflict even more devastation on the lives of working Americans to give even larger handouts to the top,” he said.

“The biggest winners here are wealthy corporations who would get hundreds of billions of dollars in additional tax breaks on top of what they got in the House Republican bill,” Wyden said. “Senate Republicans would pay for those new corporate tax breaks by making even deeper cuts to Medicaid, slashing funding for rural hospitals and other essential healthcare providers, and throwing cash-strapped states off a funding cliff.”

There is little Democrats can do impede the GOP majority in Congress, which is using expedited procedures under so-called budget reconciliation rules that allow bills to pass the Senate on simple majority votes and don’t permit filibusters.

However, at least four Republicans have raised concerns about Medicaid cuts in recent weeks. The GOP has a 53-47 majority, meaning Majority Leader John Thune (R-S.C.) can afford to lose three votes and still advance the legislation.

Ambulance agencies should continue to work with national and state advocacy associations to monitor the developments related to the One Big Beautiful Bill Act of 2025, as well as CMS’s May 12, 2025 Preserving Medicaid Funding for Vulnerable Populations - Closing a Health Care-Related Tax Loophole Proposed Rule, and the status of the ongoing CMS OIG audits of Medicaid ambulance supplemental payment programs (GEMT).

These developments could have a significant impact on things like payer mixes, supplemental payment programs, and potential Medicare payment reductions through the Statutory Pay‑As‑You‑Go Act of 2010 (S-PAYGO) sequestration provisions.

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GOP tax bill will cost health sector $1T: CBO
Michael McAuliff 
June 04, 2025
 
https://www.modernhealthcare.com/politics-policy/tax-bill-medicaid-cuts-cbo-gop
 
The Republican tax-and-spending-cuts legislation speeding through Congress would take more than $1 trillion out of the healthcare system over a decade, according to an analysis the Congressional Budget Office published Wednesday.
 
The nonpartisan agency's fullest accounting of the House-passed One Big Beautiful Bill Act of 2025 details how President Donald Trump and the GOP-led Congress intend to slash federal spending to partially offset trillions of dollars in tax cuts. In healthcare, Medicaid would be subject to the lion's share of the cuts and see its federal budget diminish by $864 billion. The work requirement provisions alone would reduce spending by $344 billion.
 
The CBO projects that the Medicaid cuts and other policies would lead to 10.9 million people becoming uninsured, including 7.8 million who would lose Medicaid benefits.
 
The estimated Medicaid cuts and the increase in the uninsured are higher than under previous CBO reports because the House made last-minute changes to the measure before sending it to the Senate last month, such as moving the start date for Medicaid work requirements from 2029 to 2026.
 
Most of the healthcare cuts come from the section of the bill authored in the House Energy and Commerce Committee, which total $1 trillion. The House Ways and Means Committee's part of the bill includes several policies targeted at the Affordable Care Act of 2010 that would crimp premium tax credits for migrants and step up eligibility checks for everyone to save about $230 billion. Those provisions account for about 2.3 million people losing insurance.
 
Democrats were quick to blast the bill based on the new score.
 
“We’ve said from the beginning that the numbers would only get worse," Energy and Commerce Committee ranking member Frank Pallone (D-N.J.) said in a news release.
 
“It’s shocking House Republicans rushed to vote on this bill without an accounting from CBO on the millions of people who will lose their healthcare or the trillions of dollars it would add to the national debt," Pallone said. "The truth is Republican leaders raced to pass this bill under cover of night because they didn’t want the American people or even their own members to know about its catastrophic consequences.”
 
Another 4.2 million people would become uninsured if Congress and Trump don't extend the enhanced health insurance exchange subsidies due to expire at the end of the year, according to a separate analysis the CBO presented to Pallone, Ways and Means Committee ranking member Richard Neal (D-Mass.) and Senate Finance Committee ranking member Ron Wyden (D-Ore.) on Wednesday.
 
An additional 900,000 would lose exchange coverage as a result of a proposed rule the Centers for Medicare and Medicaid Services issued in March, which would shorten the annual enrollment period, require stricter eligibility reviews and make other changes to the marketplaces, the CBO reported to the Democratic lawmakers.
 
The combined effects of those policies and the One Big Beautiful Bill Act would result in 16 million more uninsured people by 2024, the CBO concluded.
 
The Senate is working on the tax bill now, with GOP senators holding meetings on how they would like to modify the bill. While nearly every Republican has embraced cutting waste, fraud and abuse in healthcare, some have raised concerns about how deep the Medicaid cuts will be, and have signaled they will listen to constituents to determine if they go too far.

Republican Sens. Susan Collins (Maine), Lisa Murkowski (Alaska) and Josh Hawley (Mo.) have been the most vocally resistant to the steep Medicaid cuts.
 
On Tuesday, Hawley expressed unease in particular about proposed limits on the provider taxes states levy to help finance their share of Medicaid spending, which he described as essential for rural hospitals. Hawley also said he disliked the provisions that would impose cost-sharing requirements on some Medicaid enrollees, dubbing it a "sick tax."
 
"I don't want to see Medicaid benefit cuts in the state, and I don't want to see rural hospitals close," Hawley said.
 
Yet Republicans including Sens. Mike Lee (Utah), Dr. Rand Paul (Ky.) and Ron Johnson (Wis.) are pushing for bigger cuts.

Senate Majority John Thune (R-S.D.) said Republicans are working through the issues, and may identify other possible cuts while satisfying the senators who want to soften the Medicaid provisions.
 
"We have an agenda that everybody campaigned on, most notably the president of the United States, and we're going to deliver on that agenda. And the legislation that was passed by the House will be approved here, strengthened in the Senate," Thune said Tuesday. "When it's all said and done, we'll send it back to the House and hope that they can pass it and put it on the president's desk." 

EMS agencies should pay close attention to the potential Medicaid and Medicare changes proposed in this bill that will likely impact reimbursements to EMS agencies. Specifically:

Medicaid – 

- Reduces the number of Medicaid beneficiaries through work requirements and other eligibility limitations.
- Bars states from using State Directed Payments to require Medicaid HMOs from reimbursing more than 100% of Medicare reimbursement for similar services, or 110% of Medicare in non-Medicaid expansion states.
- Mandates cost-sharing up to $35 for services provided to Medicaid expansion enrollees with incomes above the federal poverty level, which is $15,650 for a single person.
- Limits retroactive provider reimbursements for newly enrolled Medicaid recipients to one month instead of three.

Medicare – 

- Triggers Medicare cuts under the Statutory Pay As You Go Act of 2010 that could include reductions in provider reimbursements.

Also recall that CMS released a proposed rule last week, that according to the language in CMS' release, "would end states’ ability to exploit a health care-related tax loophole currently used by seven states to generate billions in federal Medicaid payments—without contributing their fair share or expanding care for Medicaid enrollees".

We recommend strong engagement with local and national EMS advocacy organizations and keeping abreast of these potential legislative and regulatory changes.
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What the 'One Big Beautiful Bill' does on healthcare

Michael McAuliff

May 22, 2025

https://www.modernhealthcare.com/politics-policy/big-beautiful-bill-medicaid-medicare-pbms

The House passed a sweeping tax-and-spending cuts bill Thursday that would dramatically reshape the healthcare system by slashing more than $1 trillion from Medicaid and other programs.

The majority Republican lower chamber voted 215-214 to approve the One Big Beautiful Bill Act of 2025 just before 7 a.m. EDT after an all-night floor debate. Attention now shifts the GOP-led Senate, which has not commenced public debate on its tax measure. Congress is scheduled to begin a recess Friday and will return to Washington on June 2.

The legislation was in flux all week as Republican leaders sought to balance the competing demands of hard-line conservatives who wanted deeper spending cuts and swing-district members pushing the other direction. As a consequence, the details changed, the final legislative language didn't emerge until late Wednesday, and the nonpartisan Congressional Budget Office and Joint Committee on Taxation couldn't keep up.

But the thrust of the package remained the same, even as the particulars and the numbers fluctuated. To partially offset about $3.8 trillion in lost federal revenue over 10 years from extending the tax cuts President Donald Trump enacted during his first term, House Republicans seek to reduce federal spending by hundreds of billions of dollars, according to the most recent CBO analyses. The largest source of those savings is Medicaid.

These are the key healthcare provisions from the One Big Beautiful Bill Act:

Medicaid

Establishes work requirements for adult enrollees who don't have disabilities or dependents that would begin no later than Dec. 31, 2026, and directs the Health and Human Services Department to issue guidance to states on this policy by the end of this year. Beneficiaries would have to document at least 80 hours a month of work or other qualifying activity, such as volunteering. The CBO estimated this would reduce spending by $280 billion based on an earlier iteration that wouldn't have taken force until 2029.

Bans new or increased state provider taxes and tightens standards for what provider taxes are legally permissible. The bill also bars most states from using state-directed payments to order Medicaid managed care companies to pay providers more than 100% of Medicare rates, but states that haven't expanded Medicaid under the Affordable Care Act of 2010 would be able to pay up to 110% of Medicare. Combined, these would cut federal spending by $197 billion, although the CBO analysis was based on a previous version of the bill that limited all state-directed payments to 100% of Medicare.

Orders states to maintain updated information on Medicaid enrollees, such as verifying addresses and removing deceased people from the rolls. This would save $17 billion.

Suspends a 2024 Centers for Medicare and Medicaid Services regulation designed to ease enrollment in Medicaid, the Children's Health Insurance Program and the Basic Health Program. Federal spending would be $82 billion lower under this policy.

Requires eligibility redeterminations every six months for adults covered under the ACA Medicaid expansion. This would cut spending by $53 billion.

Mandates cost-sharing up to $35 for services provided to Medicaid expansion enrollees with incomes above the federal poverty level, which is $15,650 for a single person. That is projected to reduce spending by $13 billion.

Limits retroactive provider reimbursements for newly enrolled Medicaid recipients to one month instead of three. That is projected to save $6 billion.

Reduces federal Medicaid funding to states that use their own money to cover undocumented immigrants through Medicaid. This would cut spending by $11 billion.

Cancels a regulation setting staffing minimums for nursing homes. This would reduce spending by $23 billion.

Eliminates extra federal Medicaid funding from the American Rescue Plan Act of 2021 intended to encourage states to expand Medicaid under the ACA. The provision is estimated to save $881 million.

Delays cuts to Medicaid disproportionate share hospital payments for three years. That would increase spending by $16 billion.

Medicare

Increases Medicare physician reimbursements 2% in 2026 and pegs future payment updates to the Medicare Economic Index. In addition, this provision would eliminate extra payments to physicians participating in alternative payment models. These policies would cost $8 billion.

Triggers Medicare cuts under the Statutory Pay‑As‑You‑Go Act of 2010 that could include reductions in provider reimbursements. Because the bill would increase the budget deficit by $2.3 trillion, the CBO projects the White House Office of Management and Budget would have to curtail Medicare spending by $45 billion in 2026 and $490 billion from 2027 to 2034.

Suspends a rule to facilitate enrollment in Medicare Savings Programs that cater to low-income people eligible for Medicare and Medicaid by pushing back the effective date to 2035. Savings are estimated to be $84 billion.

Expands rural emergency hospitals program. There was no cost estimate for this part of the bill.

Ends Medicare eligibility for some lawfully present foreign nationals who currently qualify by limiting the program to permanent residents who are green card holders, from Micronesia, the Marshall Islands or Palau, or, in certain cases, from Cuba. This would save $132 million.

Health insurance exchanges

Institutes stricter eligibility and income verifications for exchange customers and requires new checks for low-income enrollees with zero-premium plans. This would save $101 billion.

Shortens open enrollment period by one month.

Ends permanent special enrollment opportunity for people with incomes up to 150% of poverty and bars federal and state exchanges from establishing special enrollment periods linked to income.

Allows health insurance companies to demand premium payments before beginning coverage and to remove customers who are in arrears, regardless of income.

Ends automatic enrollment into Silver-level plans for low-income exchange customers with Bronze-level plans who qualify for cost-sharing reductions that can only be applied to Silver plans.

Those provisions combined would reduce spending by $101 billion.

Restores cost-sharing reduction payments to health insurance companies covering the lowest-income exchange policyholders, which Trump cut off in 2017. A CBO analysis from 2018 said that would reduce federal spending by $19 billion, in part because it would enable insurers to reduce premiums, which would decrease spending on premium tax credits. The bill also would withhold cost-sharing reduction payments for insurance plans that cover abortion.

Requires full repayment of excess premium tax credits regardless of enrollee income. Savings are projected to be $2.3 billion.

Expands ICHRAs — individual coverage health reimbursement arrangements — by permitting employees offered these plans to buy exchange coverage with pre-tax dollars. Creates tax credit for small employers that offer ICHRAs. This is projected to cut spending by $514 million.

Limits lawful immigrant access to unsubsidized exchange coverage and makes Deferred Action for Childhood Arrivals recipients ineligible for subsidies. This section would save $63 billion.

Bans gender-affirming care as an Essential Health Benefit under the ACA as well as Medicaid and CHIP coverage of these services. This would reduce spending by $830 million.

Pharmacy benefit managers

Requires greater transparency for PBMs in Medicare Advantage and Medicare Part D.

Orders PBMs to "delink" their compensation from the discounts they negotiate with drugmakers and instead charge set fees under Medicare Part D.

Those provisions combined would reduce spending by $402 million.

Bans spread pricing, a practice under which a PBM charges more for a medicine than the price it secured from the drug company. This would save $3 billion.

Health savings accounts

Relaxes rules governing HSAs, such as raising the annual contribution limit, declaring individual market Bronze and Catastrophic plans compatible with HSAs, and making gym memberships and some other sport and fitness costs HSA-eligible. These policies would result in $25 billion in lost tax revenue.

Two actions this week in DC may be signaling the future of GEMT programs.

First, CMS released a proposed rule Monday, that according to the language in CMS' release, "would end states’ ability to exploit a health care-related tax loophole currently used by seven states to generate billions in federal Medicaid payments—without contributing their fair share or expanding care for Medicaid enrollees". 

Second, the House Energy and Commerce Committee released their 160 page heath package for the Budget Reconciliation Act. The legislation would limit states’ ability to levy taxes on providers to finance Medicaid programs and changes Medicaid eligibility to reduce the number of Medicaid enrollees. 

The “Provider Tax” limitation language starts on page 64, line 19 of the document here.

News reports related to these two actions are below.

Recall that the CMS OIG is still auditing GEMT cost reports, and are due to release the results from their audits this year (https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000786.asp),

The OIG initiated these audits following a notice from CMS to state Medicaid offices detailing their concerns about non-allowable costs being included in some GEMT cost reports (https://www.medicaid.gov/federal-policy-guidance/downloads/cib08172022.pdf).

Providers who are currently participating in GEMT programs, or are awaiting State Plan Amendment approvals from CMS, should monitor these development closely.

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CMS proposes crackdown on 'money laundering' provider tax policies
Bridget Early
May 12, 2025
 
https://www.modernhealthcare.com/policy/provider-tax-medicaid-requirements-cms
 
The Centers for Medicare and Medicaid Services is proposing to close what the agency dubs a "loophole" in an obscure form of Medicaid funding.
 
In a proposed rule released Monday, CMS seeks to tighten its oversight of state provider tax policies. The agency said it wants to ensure that states' provider taxes are either broad-based and uniform as required by law, or that states applying for a waiver from that requirement are qualified to receive one.
 
The proposed rule would also ban states from taxing Medicaid dollars higher than other payments and set deadlines for states to wind down existing provider tax policies the agency deems to be noncompliant with federal law.
 
States tax providers and insurers to help fund their share of Medicaid’s federal-state payment structure.
 
The system has garnered heavy criticism from spending hawks, who argue the dollars are returned to providers in the form of Medicaid payments down the line.
 
By law, provider taxes must be broad-based and uniform, meaning they need to apply to a vast swathe of products and services and they need to be applied at the same rate for all healthcare services within a category. States are also prohibited from reimbursing providers more than 6% of their net revenue.
 
In instances where states seek to levy a tax that doesn't meet the parameters, CMS must conduct a series of statistical tests to ensure the payments are permissible under statute. CMS can waive requirements that these taxes be broad-based and uniform in some instances — for instance, when regulators determine that a state’s tax would be generally redistributive, meaning revenue from taxes on non-Medicaid services would be used to fund the state's Medicaid share. 
 
Now, CMS is looking to tighten its oversight.
 
The agency says in its proposed rule that it has found loopholes in the statistical test it uses to determine whether states’ provider tax proposals are generally redistributive. Some waivers have passed the test but are not generally redistributive, particularly for taxes on Medicaid managed care organizations, the rule says.
 
In response, the agency proposes to ban states from effectively taxing provider revenue from Medicaid at higher rates than Medicare or commercial healthcare, even if a state's tax proposal passes the statistical testing required by law.
 
The agency estimates finalizing the rule would save more than $30 billion in the next five years, according to a fact sheet on the proposal, adding that the issues in its statistical tests represent “a Medicaid tax loophole exploited by states to inflate federal payments to states.”

“States are gaming the system — creating complex tax schemes that shift their responsibility to invest in Medicaid and rob federal taxpayers,” said CMS Administrator Dr. Mehmet Oz in a news release on the proposed rule.
 
CMS also proposes to ban “vague language” in states’ proposals that it says conceals taxes focused on Medicaid. The agency says it will closely assess “language that does not specify Medicaid explicitly, but appears to invoke it implicitly,” such as language identifying the providers and services that would be taxed.
 
All states except Alaska have some form of provider tax, according to a March analysis from KFF: 45 states tax hospitals and 46 tax nursing homes, while 20 states have provider taxes on managed care organizations.
 
If finalized, the rule would also set timing requirements depending on when a state’s waiver was last approved. States that have had a waiver approved within the last two years would not be eligible for a transition period, CMS proposes, but any states outside that window would have one year from the date of the final rule to come into compliance.
 
Some hospital groups are criticizing the proposal, which would come as yet another blow to the Medicaid program. Hospitals have been embroiled in a firestorm of lobbying to stave off sweeping funding cuts.
 
“While we are still reviewing the proposal, any effort to reduce provider taxes would harm long-term care facilities and hospitals’ ability to care for Medicaid patients. These taxes are essential to keeping state Medicaid programs afloat and enabling hospitals to continue providing critical health care services to their communities,” said Marie Johnson, senior director of media relations for the Catholic Health Association of the United States, in an email.
 
Republicans on Capitol Hill have set their own sights on provider taxes. Lawmakers are looking to curtail certain provider taxes and eliminate others in a sweeping reconciliation package released Monday as lawmakers look to generate substantial savings from the Medicaid program.
 
The CMS regulation was first listed in a December 2024 Unified Agenda published by the White House Office of Management and Budget in the final weeks of President Joe Biden’s tenure.
 
Comments are due in July.
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House Republicans release Medicaid cuts proposal
By: Jakob Emerson
5/12/25
 
https://www.beckershospitalreview.com/legal-regulatory-issues/house-republicans-release-medicaid-cuts-proposal/
 
House Republicans unveiled legislation May 11 that would introduce Medicaid work requirements nationwide and stricter eligibility requirements.

The 160-page bill, introduced by the House Energy and Commerce Committee as part of a broader budget reconciliation package, aims to reduce federal spending by hundreds of billions of dollars over the next decade, with Medicaid and ACA programs facing the majority of the proposed cuts.
 
The legislation calls for more frequent eligibility redeterminations and strict address verification processes to prevent duplicate enrollment across states, and managed care organizations would be required to relay updated address information to Medicaid programs.
 
A key provision mandates that able-bodied adults aged 19 to 64 without dependents work at least 80 hours per month or participate in community engagement activities to maintain their Medicaid coverage, with exemptions for pregnant individuals and certain other situations. States that fail to verify citizenship or immigration status among enrollees could lose federal funding for those individuals’ benefits. The proposal would also ban the use of Medicaid and CHIP funding for gender transition procedures for individuals under the age of 18.
 
The bill does not propose per capita caps or a complete overhaul of Medicaid expansion funding, but it does include provisions to penalize states financially if they provide Medicaid benefits to noncitizen residents by reducing their ACA expansion matching rate.
 
The GOP proposal would also shorten the retroactive coverage period under Medicaid from three months to one and eliminate federal reimbursement for benefits during the “reasonable opportunity” period in which applicants verify immigration or citizenship status, unless verification is completed.

The legislation would limit states’ ability to levy taxes on providers to finance Medicaid programs, which are typically imposed on hospitals, nursing facilities, and physicians.

The bill also includes provisions aimed at pharmacy benefit managers, requiring that contracts between states and PBMs adopt a transparent pass-through pricing model to limit payments for prescription drugs to the ingredient cost and dispensing fees. Additionally, any payments to PBMs for drugs must be fully passed through to pharmacies or providers. The bill would also ban the use of spread pricing within Medicaid programs.
 
Democratic lawmakers and hospitals have criticized the legislation, pointing to an analysis from the Congressional Budget Office indicating the bill could cut Medicaid and ACA spending by up to $715 billion over the next decade and result in at least 8.6 million people losing insurance coverage by 2034. Hospital and health system leaders have been outspoken about proposed cuts, warning that even without FMAP reductions or per capita caps, the cuts could still deliver a blow to hospitals and their patients.
 
“Congressional Republicans and President Trump rightly pledged to protect Medicaid benefits and coverage – this bill fails that test,” Federation of American Hospitals’ President and CEO Chip Kahn said. “It is imperative Republicans go back to the drawing board; too many lives depend on it.”
 
The bill is scheduled for markup in the Energy and Commerce Committee on May 13 and will need to pass in the narrowly divided House and Senate.

Many EMS agencies across the country are struggling financially, leading to challenges retaining and recruiting staff, resulting in service delivery challenges and even closures of EMS agencies.

PWW Advisory Group (PWW|AG), in partnership with EMS|MC, is launching a new EMS Financial Index: Driving Change Through Data and Best Practices.

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This inaugural report, with a foreword written by the Rob Lawrence, the President of the Academy of International Mobile Healthcare Integration (AIMHI), reveals data broken down by region of the country such as:

• Average Base Fee
• Level of Care Billed
• Dollars Collected
• Average Reimbursement by Payer Classification

The index report will be released quarterly, highlighting various benchmark revenue cycle data from the over 1,500 agencies serviced by EMS|MC across the U.S. and will focus on several consistent themes, as well as specialized content each period.

It is our hope that sharing benchmark data, along with best practice recommendations, will help EMS agencies assess their revenue cycle management (RCM) practices and outcomes to improve their financial health.

Click below to download this free report: 

Stay tuned for the next report in July, which will cover metrics including:

• Emergency call service mix (BLS, ALS ALS2, TIP)
• Commercial insurer claims, payer paid vs. patient paid
• Medicare FFS vs. Managed Medicare Reimbursement
• Payments for Treatment in Place (TIP) services

Is there national and regional data YOU would like to see included in future index reports? If so, click here and send us your request.

Nice to see the progressive leaders of an outstanding EMS agency implementing scientific, evidence-based system design changes to enhance patient care, improve employee morale, and reduce system costs!

An overview of the assessment that led to these changes, and how the KCEAA Team is implementing these them will be presented at the upcoming American Ambulance Association Conference and Trade Show in Lexington, KY June 22 - 24, 2025.

Response Reboot? Implementing Data Driven Decisions for System Sustainability – A Case Study

https://annual.ambulance.org/session/response-reboot/  

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KCEAA implementing changes to cut costs while improving service
by: Blake DeJarnatt
May 5, 2025
 
https://www.wowktv.com/news/west-virginia/kanawha-county-wv/kceaa-implementing-changes-to-cut-costs-while-improving-service/
 
CHARLESTON, WV (WOWK)- Leaders with the Kanawha County Emergency Ambulance Authority met Monday to discuss how they can tackle a $4 million deficit, while improving the quality of their medical care.
 
The way it works now is whichever ambulance is closest to an emergency call is dispatched, even if they aren’t best suited for the job. In partnership with Metro 911, they plan to implement “tiered responses,” a system that would ensure the best ambulance available for the situation would be dispatched, regardless of proximity to the emergency.
 
“Tiered response is basically taking the appropriate ambulance and dispatching it to the appropriate situation. So, if you have a cardiac situation, you need one level of staffing as opposed to, say, you have a sprained ankle, that kind of simplifies it. Taking advances in technology and making sure the appropriate ambulance, the appropriate equipment is being dispatched to the appropriate situation,” said Tom Susman, a spokesperson for KCEAA.
 
This system would ensure that Advanced Life Support (ALS) vehicles would be dispatched to dire emergency situations, like a heart attack or stroke. Basic Life Support (BLS) vehicles would be reserved for what would be considered minor injuries, like a sprained ankle or broken finger.

Susman says that this initiative could save costs when it comes to how to best utilize resources and cut back on overtime pay for paramedics. When a BLS squad is sent to a critical situation, they may take more time at the scene than an ALS squad would.
 
“I think you’d be able to save KCEAA money because you’d be able to do away with some duplication. It would be a more efficient use of resources. It’s also good for paramedics. The staff want to be able to dispatch to their level of training. So, for example, you don’t have a primary care doctor going to the cardiac unit, and conversely, you won’t have a cardiac doctor going to a primary care situation,” said Susman.
 
Susman says the KCEAA is also putting feelers out in having a third-party organization take over their billing operations. He says that they’re still waiting on the board of directors’ approval, but that having a third party take over could lead to a more streamlined and cost-effective billing process.
 
“Billing in medical services is becoming more and more complicated,” said Susman. “You need to keep your equipment up, ’cause insurance companies are tough to bill with. So, if you have somebody who does this for hundreds of thousands of people across the country, or millions of people, they have better systems than a stand-alone EMS agency might have. So, it’s really, it’s just trying to find out if there’s a way to do it that generates more resources and better use of the dollars.”
 
Susman says that some of the main reasons for the $4 million deficit are increased operating costs, offering competitive pay for their paramedics, and low reimbursement rates from insurance companies.
Susman says that they plan on implementing tiered responses in the next 90 days, but they won’t launch the new system until they are certain it will work the way they have planned.