乌鸦传媒

WASHINGTON -- Rep. Buddy Carter (R-Ga.) will introduce a bill in the House on Thursday that is aimed at fixing problems with Medicare's program for non-emergency ambulance transport for certain low-income beneficiaries, 乌鸦传媒 has learned.

The started in 2014 as a project of the Centers for Medicare & Medicaid Services (CMS) to institute a system of prior authorization for three states -- New Jersey, Pennsylvania, and South Carolina -- with high non-emergency ambulance improper payments and usage. It was further expanded in 2016 to include five more states plus the District of Columbia.

In September 2020, CMS , but expansion was delayed because of the COVID-19 pandemic. The nationwide expansion was eventually completed at the end of July 2022.

On the whole, the model was found to be a success, according to a written for CMS by consulting firm Mathematica. "Overall, our results suggest that the model had no adverse effects on quality of care or access to care," the report said. "We found no increase in emergency department use, hospitalization, or death among model state beneficiaries relative to comparison state beneficiaries."

On the other hand, the authors also found that the prior authorization model reduced RSNAT use and expenditures by 72% for beneficiaries with end-stage renal disease (ESRD) and/or pressure ulcers in the states in which it was implemented, "representing approximately $746 million in RSNAT-related savings ... Stakeholders perceived that prior authorization successfully reduced some transportation providers' fraudulent and questionable practices, and that enforcing the existing RSNAT medical necessity guidelines has resulted in significantly fewer RSNAT services being provided and fewer inappropriate prior authorization requests."

"While we saw some small changes in dialysis use among beneficiaries with ESRD, we found no evidence of reduced access to care resulting in increased hospitalization for complications of ESRD," the authors wrote. "However, in focus groups, online surveys, and interviews, key stakeholders expressed some concerns about the model's potential effects on quality and access, including beneficiaries experiencing delayed or missed treatments and emotional distress."

Patients with ESRD and those needing wound care treatment comprise 85% of all RSNAT claims. In addition, 40% of the Medicare beneficiaries impacted by the RSNAT demonstration are "dual eligibles" who are eligible for both Medicare and Medicaid. If Medicare denies their claim for scheduled non-emergency transport, those who are fully dual eligible can seek the same benefit from Medicaid. And the results of that have been evident -- spending rose under Medicaid for stretcher and wheelchair transportation after the prior authorization program was implemented.

But that Medicaid-funded transport option isn't available to "partial" dual eligibles -- those who have slightly higher incomes than the fully dual-eligible patients and who make up about 30% of all dual eligibles. Many of those ineligible beneficiaries are low-income, frail, disabled, or elderly, and some beneficiaries reported needing to choose between medical transportation and rent or food.

Carter's bill, the Access to Critical Non-Emergency Transportation Services Act, would require states to "assist such individual[s] in enrolling in Medicaid, provided that in addition to Medicare cost-sharing, such individual[s] shall qualify for, and be assisted in accessing, transportation benefits." The bill -- which has two Democratic cosponsors, Rep. Tony Cárdenas of California and Rep. Sanford Bishop of Georgia -- also requires the HHS secretary to issue guidance to states on how to assist dual-eligible beneficiaries with getting the transportation benefit under the program.

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