You asked a series of questions about emergency medical service (EMS) rates and how EMS providers are assigned to a geographic location. Specifically, you wanted to know if rates are the same for (1) emergency and nonemergency transport, (2) for-profit and nonprofit services, and (3) different forms of public and private insurance coverage and uninsured people. You also asked whether people using an EMS service for a nonemergency purpose (e. g. , transferring from a hospital to a nursing home) can choose among EMS providers or learn of the charge in advance.

SUMMARY

The Department of Public Health (DPH) annually sets the maximum rate each EMS provider can charge for eight levels of service ranging from nonemergency transport to helicopter-assisted emergency service. A provider's rates are based on its baseline rate plus a cost-of-living adjustment (COLA). Most providers accept the COLA, but they can ask for larger increases. To receive one, the provider must prove the COLA is insufficient for it to remain solvent.

Since different providers started with different baseline rates and many have received different rate increases over time, rate schedules

1. vary substantially among both nonprofit and for-profit providers,

2. differ between for-profit and nonprofit providers, and

3. differ between emergency and nonemergency service (as well as among various types of emergency service).

The DPH rates are the maximum an EMS provider can charge; the amounts each actually charges may be lower. And the amount a provider receives depends on who is paying. The federal government sets payment rates for Medicare patients, and the Department of Social Services sets them for Medicaid and State Administered General Assistance patients. Each provider either negotiates contract rates with private health insurers or accepts their payments and bills the patient for the balance of the charge. State law requires group insurance policies to cover medically necessary ambulance service and allows them to limit their rates to the DPH maximum (CGS § 38a-525). Potentially, the only people who pay the EMS provider's actual charge are those without public or private insurance. DPH's Office of Emergency Medical Services director Len Guercia suggests that most providers negotiate payment amounts with people in this situation.

Guercia says that patients who need nonemergency transport can choose among any of the licensed or certified providers that offers such service in their area. If asked, providers will quote a rate, but if the patient's insurance covers nonemergency transport, the insurer's rate will determine the amount the patient ultimately pays.

Before a provider can begin operating in an area, DPH must determine its services are needed by issuing a certificate of need (CON). DPH must consider (1) the area to be served, its population, and call volume; (2) the proposal's effect on the area's existing EMS; (3) potential improvement in response times and cost effectiveness; and (4) the regional EMS advisory council's recommendation.

Providers apply to DPH to be assigned as the primary service area responder (PSAR) for each of five response services in a primary service area. In making a decision, DPH must consider the size of the population to be served; the proposed PSAR's locations, response and activation times, and level of licensure or certification; the effects of its assignment on other EMS providers in the area; and recommendations from municipal officials and the regional advisory council.

EMS RATE SETTING AND CHARGES

Rate Setting

DPH annually sets the maximum rate each certified (i. e. , municipal and volunteer) and licensed (commercial) ambulance service can charge for eight service levels:

1. basic life saving (BLS),

2. advanced life saving (ALS) I,

3. ALS II,

4. ALS assessment (payment to an ALS service that is dispatched to a scene and then determines the patient needs only BLS service),

5. paramedic intercept (a paramedic service takes over from an ALS service or a paramedic goes with the patient on an ALS transport),

6. specialty care transport (a medical professional with training above the paramedic level (e. g. , physician or nurse) accompanies a patient),

7. helicopter assist (payment to an ambulance service that prepares a patient before he or she is transported on a helicopter), and

8. invalid coach (nonemergency transport).

A provider's annual rates are based on its previous year's rate for each service level plus a uniform, medically based COLA. Annually in May DPH sends providers notice of the COLA for the following calendar year (the 2008 COLA will be 3. 9%). A provider can agree to accept the COLA or it can ask for a larger increase.

A provider that agrees to the COLA simply fills in a short rate application form and returns it to DPH. But a provider that asks for a rate increase above the COLA must provide DPH with detailed financial data for the prior year, projections for the coming year, and the rate it is looking for. The provider must show that the COLA is insufficient for it to remain solvent during the coming fiscal year. A DPH accountant reviews the data to determine if the insolvency claim is accurate. If it is, DPH and the provider negotiate a rate increase.

By law, a provider's allowable rates can be no lower than the rates Medicare allows. Anytime a provider's rates fall below that threshold, DPH must adjust the provider's schedule to bring the rates to or above the Medicare rate.

DPH can also permit EMS providers to apply special charges to each of these rates for (1) mileage, (2) waiting time (when a service waits at a hospital or other facility after transporting a patient because he or she will be transferred someplace else in the near future), (3) night (7 p. m. to 7 a. m. ) transport, and (4) special attendants (when a patient requests someone with special characteristics) (CGS § 19a-177 (9) (A) to (C) and Conn Agency Regs. , 19a-179-21).

ASSIGNING PROVIDERS TO GEOGRAPHIC AREAS

EMS Certificate of Need Process

Any for-profit ambulance service that seeks to provide a new or expand an existing EMS service must first obtain a CON from DPH. In applying for the CON, the provider must submit, among other items, information on:

1. the geographic area and population it proposes to serve;

2. the location of other ambulance providers in that area;

3. the source and volume of calls the current ambulance provider[s] received in the previous 12 months, the average response time, and the number of calls the provider refused and why; and

4. how the proposed service would integrate with the current EMS system.

DPH must send a copy of the application to the EMS advisory council for the region in which the proposed service would operate. The council can recommend to DPH its approval or disapproval, including its reasons. If it fails to make a recommendation at least five days before the required hearing on the application, it is deemed to have approved the application.

Before holding the hearing, DPH must notify other providers in the area. The PSAR for the town in which the service is proposed can ask for intervener status at the hearing, which permits it to cross-examine witnesses.

In making its decision on the CON, DPH must consider (1) the regional council's recommendation, (2) the area to be served and its population and call volume, (3) the proposal's effect on the area's existing EMS, and (4) potential improvement in response times and cost effectiveness. Before granting a CON, DPH must determine that the proposed service is necessary to satisfy the area's emergency medical, ambulance, or invalid coach needs (Conn. Agency Regs. , 19a-180-1 to -10).

Assigning Primary Service Areas and Responders

The law requires the DPH commissioner to establish primary service areas (PSAs) covering all municipalities and assign a PSAR for each of five response services in a PSA—first responder, basic ambulance, mobile intensive care intermediate and paramedic, and aeromedical. The PSAR normally receives the first call when the particular service is needed.

An EMS provider must apply to DPH to be assigned as the PSAR for a particular service(s) in a PSA. In its application, the provider must describe (1) the area it will cover and its population, (2) the need for the level of service for which it is applying, (3) how it will interact with existing providers in the area, and (4) how its designation will improve patient care in the PSA. It must also submit information on its activation and response times (the time it takes, respectively, from a receiving call to begin responding and to arrive at the patient's side), the communications and transport equipment it uses, and its staff and staffing plan. The application includes a check off by the chief administrative official(s) of the municipality or municipalities the PSA covers recommending the application's approval or disapproval.

In making a decision, DPH must consider, the size of the population to be served; the proposed PSAR's locations, response and activation times, and level of licensure or certification; the effects of its assignment on other EMS providers in the area; and any other factors it deems relevant. DPH must also review the municipal officials' recommendations and seek recommendations from the regional advisory council (Conn Agency Regs. , 19a-179-4).

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