City of Sacramento
City Council - 5PM Report
915 I Street Sacramento, CA 95814
www.cityofsacramento.org
File ID: 2023-00431 5/16/2023 Consent Item 2.
Amended Policy for Emergency Medical Services (EMS) Revenue Recovery and Fee Waiver File ID: 2023-00431
Location: Citywide
Recommendation: Adopt a Resolution 1) repealing section 7 of Resolution No. 2017-0468, and 2) approving the Amended Emergency Medical Services (EMS) Revenue Recovery and Fee Waiver Policy.
Contact: Allison Narramore, Administrative Officer, 916-808-8065, [email protected], Fire Department
Presenter: None
Attachments:
1-Description/Analysis
2-Resolution
3- Emergency Medical Services (EMS) Revenue Recovery and Fee Waiver (Redlined version) 4- Amended Emergency Medical Services (EMS) Revenue Recovery and Fee Waiver Additional Description/Analysis
Issue Detail: On March 18, 2011, the City Council adopted Motion Order 2014-0053 approving the Advanced life support (ALS) Revenue Recovery Policy. On December 5, 2017, the City Council adopted the second amendment to the Emergency Medical Services (EMS) revenue recovery and fee waiver policy. This amendment addressed the provision to waive fees for persons with financial hardship and recommended policy be renamed and amended to support the City's budget sustainability and fiscal responsibility goals.
Over the last three (3) years, the Department of Health Care Services (DHCS) has been developing a new Ground Emergency Medical Transport (GEMT) program to replace the current GEMT cost reporting program. DHCS Plan Provider Ground Emergency Medical Transport (PP-GEMT) program's intent is to provide increased reimbursements to eligible public GEMT providers by applying an add-on fee to emergency medical transport reimbursement.
On December 31, 2022, prior to the established AB 678, the Ground Emergency Medical Transport
File ID: 2023-00431 5/16/2023 Consent Item 2.
(GEMT) program was disbanded. This change no longer requires EMS public agencies to submit an annual GEMT cost report to DHCS.
On January 1, 2023, AB 1705, the Department of Health Care Services (DHCS) Plan-Provider GEMT (PP-GEMT) program commenced.
Policy Considerations: The changes are consistent with the City's budget sustainability and fiscal responsibility goals. Amending the EMS Revenue Recovery and Fee Waiver policy will provide the guidelines and processes to waive all or a portion of the EMS fees due to financial hardships.
Economic Impacts: Not Applicable
Environmental Considerations: This report concerns administrative activities that do not constitute a "project" as defined by section 15378 of the California Environmental Quality Act (CEQA) Guidelines and is otherwise exempt pursuant to sections 15061(b)(3); 15378(b)(2).
Sustainability: Not Applicable
Commission/Committee Action: Not Applicable
Rationale for Recommendation: The Department is requesting to amend the EMS Fee recovery portion of the policy to include the new PP-GEMT program revenues. Any new PP-GEMT revenues that are in excess of the Fire Department's approved General Fund revenue budget during the fiscal year, shall be committed for future appropriations for the Fire Department.
Financial Considerations: Approving this amendment to include PP-GEMT program revenues will allow the Department, through policy adjustment during the fiscal year, to move any excess of the Fire Department's approved General Fund revenue budget to the IGT/GEMT/PP-GEMT Carry forward schedule. The IGT/GEMT/PP-GEMT carry forward schedule has allowed the City Manager and the Department to fund essential needs of the Department over the last five plus (5+) years. With the PP-GEMT Program change the Department along with City Finance, would like to keep the Cary forward schedule funded for future needs.
Local Business Enterprise (LBE): Not Applicable.
RESOLUTION NO.
Adopted by the Sacramento City Council
THIRD ADMENDMENT TO THE EMS REVENUE RECOVERY AND FEE
WAIVER POLICY
BACKGROUND
A. The Fire Department Emergency Medical Services (EMS) is responsible for providing Advanced Life Support (ALS) services and Basic Life Support (BLS) services and transporting patients by ambulance throughout the City. These services are General Fund activities supported by fees charged for services.
B. On March 18, 2014, the City Council adopted Motion Order 2014-0053 approving the Advanced Life Support (ALS) Revenue Recovery Policy.
C. On December 5, 2017, through section 7 of Resolution No. 2017 -0468, the City Council adopted the Second Amendment to the existing Emergency Medical Services Revenue Recovery Policy , which neither addressed fees for basic life support services nor included provisions for waiving or reducing fees for persons with financial hardships.
D. The existing Emergency Medical Services Re venue Recovery Policy does not address the programmatic change related to the discontinuation of the Ground Emergency Medical Transportation (GEMT) program in favor of the now Plan Provider Ground Emergency Medical Transportation (PP-GEMT) program.
BASED ON THE FACTS SET FORTH IN THE BACKGROUND, THE CITY COUNCIL RESOLVES AS FOLLOWS:
Section 1. Repeal section 7 of Resolution No. 2017-0468 in regard to the Emergency Medical Services Revenue Recovery and Fee Waiver Policy.
Section 2. Adopt the Amended Emergency Medical Services Revenue Recovery and Fee Waiver Policy.
Emergency Medical Services (EMS) Revenue Recovery and
Fee Waiver Policy
Scope: CITYWIDE
Administrative Entity
EMS Division
Fire Department
(916) 808-5352
[email protected]
Table of Contents
Purpose
Background
Policy
Related Regulatory References
July 27, 1993 Resolution 1993-0434
October 2011 AB 678-Ground Emergency Medical Transport June 26, 2012 Resolution 2012-0214
March 18, 2014 Motion 2014-0053
December 5, 2017 Resolution 2017-0468
December 31, 2022 AB 678- Ground Emergency Medical Transport – Disbanded January 1, 2023 AB 1705- Plan Provide Ground Emergency Medical Transport
Effective Date: May 16, 2023
EMS Revenue Recovery and Fee Waiver Policy
1) PURPOSE
a) To establish a policy for revenue recovery and fee waiver or reduction of costs associated with providing the City of Sacramento’s (City) EMS program. 2) DEFINITIONS
a) Advanced Life Support (ALS): This term is defined in Health and Safety Code section 1797.52.
b) Basic Life Support (BLS): This term is defined in Health and Safety Code section 1797.60.
c) Electronic Patient Care Report (ePCR ): A patient care report, as defined in Sacramento County Emergency Medical Agency Policy No. 2305.22, in an electronic format. An ePCR is an electronic health record, within the meaning of Health and Safety Code section 1797.227, created for each patient by Fire Department staff at the time of service. The report is used to relay information between the responding unit and the receiving hospital staff. The report serves as documentation of the treatment provided.
d) Emergency: This term is defined in Health and Safety Code section 1797.70. e) Emergency Medical Services (EMS): This term is defined in Health and Safety Code section 1797.72. EMS includes Fire Department responses to provide ALS, BLS, and treat-not-transport patient care.
f) Fee Waiver: the forgiveness of all of a patient’s owed City Council approved EMS user fees, based on a formalized criteria and processes as outlined in this policy.
g) Fee Reduction: the forgiveness of a portion of a patient’s owed City Council approved EMS user fees, based on a formali zed criteria and processes as outlined in this policy.
3) BACKGROUND
a) On July 27, 1993 (Resolution 93-434), the City established the ALS program.
As costs for ALS services continue to increase, the revenues generated by fees for service have not grown proportionally. The City is challenged to recover fee for service revenues due to several different reasons, one of them being payer mix. The City’s payer mix is currently 40 percent Medicare, 40 percent Medicaid, and 15 percent private insurance with the remainder being from self- insured and uninsured. In addition, there are federally mandated write -offs, which allow the City to collect only a small percentage of the actual billed amount from Medicare and Medicaid. In an effort to maximize reimbursements and cover direct costs the City has pursued additional recovery options. b) In October 2011, AB 678 enacted the Ground Emergency Medical Transport (GEMT) program. It provided for the reimbursement of transports of Medi -Cal patients who were not in managed care. On March 18, 2014, the Council authorized an agreement with Sacramento Metropolitan Fire District (Motion No. 2014-0053) to pursue reimbursements through the GEMT program. c) On June 26, 2012, the Council approved increases to the ALS fees for service (Resolution 2012-214) to increase cost recovery to address a portion of the structural variance between the cost of providing services and the revenue collected for those services.
d) On December 16, 2014, Council authorized the participation in the Rate Range Intergovernmental Transfer (IGT) program. IGT allows local governments to receive a federal reimbursement for transporting Medi-Cal patients who are in managed care.
e) On December 5, 2017, Council approved increases to the ALS fees for service (Resolution 2017-0468) to increase cost recovery to address a portion of the structural variance between the cost of providing services and the revenues collected for those services. The resolution allowed staff yearly to adjust the fees based on a medical Consumer Price Index (CPI).
f) On December 31, 2022, the Ground Emergency Medical Transport (GEMT) program ended.
g) On January 1, 2023, the Department of Health Care Services (DHCS) developed the P ublic Provider Ground Emergency Medical Transport (PP - GEMT) Intergovernmental Transfer Program (IGT) , pursuant to AB 1705, to provide increased reimbursements to emergency medic al transports provided by eligible public GEMT Providers through application of an add-on increase. h) While the City can assure the continuation of fee for service revenues, revenue recovery programs such as GEMT, IGT, and PP -GEMT are subject to the availability of state and federal funding.
4) EMS FEE RECOVERY POLICY
a) The EMS Program shall be fully offset by fees generated by services provided.
All revenues recovered for the provision of EMS services shall be used to cover direct and indirect costs to reduce the General Fund subsidy for this program. b) GEMT, IGT, and PP-GEMT revenues received in excess of the Fire Department’s approved General Fund revenue budget, during the fiscal year, shall be committed for future appropriations for the Fire Department. 5) EMS FEE WAIVER POLICY
a) The City Manager or their designee may waive all or a portion of the EMS fees established by City Council as provided herein.
b) In no event shall any person be denied EMS services because of their inability or failure to pay the charges incurred for services provided. c) Procedures:
i. Fee Waiver Application:
1. An applicant or applicant’s legal representative may submit a completed Fee Waiver A pplication with adequate s upporting documentation to the Fire Department for re view and
consideration. The Fee Waiver Application shall be on a form prescribed by the City Manager or their designee.
2. Fire Department staff, through assistance from a contracted billing company, will use reasonable research methods to confirm the validity of the information provided.
3. Upon completion of the application review process above, the contracted billing company will notify all applicants as instructed by the Fire Chief or their designee.
4. Fee waiver applications and supporting documentation will be retained in accordance with the City’s Record Retention Policy. d) Fee Waiver Conditions and Options:
i. Financial Hardship. A fee waiver may be granted in circumstances where a financial hardship is demonstrated. The determination of a financial hardship shall be based on the most recent Federal Poverty Level (FPL) chart provided by the Department of Health and Human Services (HHS). The Fire Chief may grant a waiver, reducti on, or payment plan to applicants that demonstrate a financial hardship.
The current poverty information is available at: https://aspe.hhs.gov/poverty- guidelines.
1. Waiver or Reduction: The Fire Chief may approve a full waiver or partial reduction of the remaining balance after all insurance payments have been posted based on the applicant’s ability to pay the remaining balance. Reductions may range from 25% to 50% based on the applicant’s financi al hardship as reflected above.
2. Payment Plan: The Fire Chief may offer a low -cost monthly payment plan in lieu of, or in addition to, a reduction for applicants that have a verified financial hardship.
ii. Services Provided. A waiver may be granted in circumstances where the level of response or services provided do not justify application of the charges incurred. Such determination shall be based on the contents of the applicable ePCR or one or more of the following circumstances:
1. The call for service did not require response by Fire Department apparatus including an ambulance, engine co mpany, or truck company;
2. Treatment or care provided to the applicant was at a lower level than the defined levels of ALS and BLS service;
iii. The applicant did not initiate the c all for ser vice, and the applicant refused care.
Emergency Medical Services (EMS) Revenue Recovery and
Fee Waiver Policy
Scope: CITYWIDE
Administrative Entity
EMS Division
Fire Department
(916) 808-5352
[email protected]
Table of Contents
Purpose
Background
Policy
Related Regulatory References
July 27, 1993 Resolution 1993-0434
October 2011 AB 678-Ground Emergency Medical Transport June 26, 2012 Resolution 2012-0214
March 18, 2014 Motion 2014-0053
December 5, 2017 Resolution 2017-0468
December 31, 2022 AB 678- Ground Emergency Medical Transport – Disbanded January 1, 2023 AB 1705- Plan Provide Ground Emergency Medical Transport
Effective Date: May 16, 2023
EMS Revenue Recovery and Fee Waiver Policy
1) PURPOSE
a) To establish a policy for revenue recovery and fee waiver or reduction of costs associated with providing the City of Sacramento’s (City) EMS program. 2) DEFINITIONS
a) Advanced Life Support (ALS): This term is defined in Health and Safety Code section 1797.52.
b) Basic Life Support (BLS): This term is defined in Health and Safety Code section 1797.60.
c) Electronic Patient C are Report (ePCR): A patient care report, as defined in Sacramento County Emergency Medical Agency Policy No. 2305.22, in an electronic format. An ePCR is an electronic health record, within the meaning of Health and Safety Code section 1797.227, created f or each patient by Fire Department staff at the time of service. The report is used to relay information between the responding unit and the receiving hospital staff. The report serves as documentation of the treatment provided.
d) Emergency: This term is defined in Health and Safety Code section 1797.70. e) Emergency Medical Services (EMS): This term is defined in Health and Safety Code section 1797.72. EMS includes Fire Department responses to provide ALS, BLS, and treat-not-transport patient care.
f) Fee Waiver: the forgiveness of all of a patient’s owed City Council approved EMS user fees, based on a formalized criteria and processes as outlined in this policy.
g) Fee Reduction: the forgiveness of a portion of a patient’s owed City Council approved EMS user fees, ba sed on a formalized criteria and processes as outlined in this policy.
3) BACKGROUND
a) On July 27, 1993 (Resolution 93-434), the City established the ALS program.
As costs for ALS services continue to increase, the revenues generated by fees for service have not grown proportionally. The City is challenged to recover fee for service revenues due to several different reasons, one of them being payer mix. The City’s payer mix is currently 40 percent Medicare, 40 percent Medicaid, and 15 percent private insurance with the remainder being from self- insured and uninsured. In addition, there are federally mandated write -offs, which allow the City to collect only a small percentage of the actual billed amount from Medicare and Medicaid. In an effort to maximize reimbursements and cover direct costs the City has pursued additional recovery options. b) In October 2011, AB 678 enacted the Ground Emergency Medical Transport (GEMT) program. It provided for the reimbursement of transports of Medi -Cal patients who were not in managed care. On March 18, 2014, the Council authorized an agreement with Sacramento Metropolitan Fire District (Motion No. 2014-0053) to pursue reimbursements through the GEMT program. c) On June 26, 2012, the Council approved increases to the ALS fees for service (Resolution 2012-214) to increase cost recovery to address a portion of the structural variance between the cost of providing services and the revenue collected for those services.
d) On December 16, 2014, Council authorized the participation in the Rate Range Intergovernmental Transfer (IGT) program. IGT allows local governments to receive a federal reimbursement for transporting Medi-Cal patients who are in managed care.
e) On December 5, 2017, Council approved increases to the ALS fees for service (Resolution 2017-0468) to increase cost recovery to address a portion of the structural variance between the cost of providing services and the revenues collected for those services. The resolution allowed staff yearly to adjust the fees based on a medical Consumer Price Index (CPI).
f) On December 31, 2022, the Ground Emergency Medical Transport (GEMT) program ended.
g) On January 1, 2023, the Department of Health Care Services (DHCS) developed the Public Provider Ground Emergency Medical Transport (PP - GEMT) Intergovernmental Transfer Program (IGT) , pursuant to AB 1705, to provide increased reimbursements to emergency medical transports provided by eligible public GEMT Providers through application of an add-on increase. h) While the City can assure the continuation of fee for service revenues, revenue recovery programs such as GEMT, IGT, and PP -GEMT are subject to the availability of state and federal funding.
4) EMS FEE RECOVERY POLICY
a) The EMS Program shall be fully offset by fees generated by services provided.
All revenues recovered for the provision of EMS services shall be used to cover direct and indirect costs to reduce the General Fund subsidy for this program. b) GEMT, IGT, and PP-GEMT revenues received in excess of the Fire Department’s approved General Fund revenue budget, during the fiscal year, shall be committed for future appropriations for the Fire Department. 5) EMS FEE WAIVER POLICY
a) The City Manager or their designee may waive all or a portion of the EMS fees established by City Council as provided herein.
b) In no event shall any person be denied EMS services because of their inability or failure to pay the charges incurred for services provided. c) Procedures:
i. Fee Waiver Application:
1. An applicant or applicant’s legal representative may submit a completed Fee Waiver A pplication with adequate s upporting documentation to the Fire Department for re view and
consideration. The Fee Waiver Application shall be on a form prescribed by the City Manager or their designee.
2. Fire Department staff, through assistance from a contracted billing company, will use reasonable research methods to confirm the validity of the information provided.
3. Upon completion of the application review process above, the contracted billing company will notify all applicants as instructed by the Fire Chief or their designee.
4. Fee waiver applications and supporting documentation will be retained in accordance with the City’s Record Retention Policy. d) Fee Waiver Conditions and Options:
i. Financial Hardship. A fee waiver may be granted in circumstan ces where a financial hardship is demonstrated. The determination of a financial hardship shall be based on the most recent Federal Poverty Level (FPL) chart provided by the Department of Health and Human Services (HHS). The Fire Chief may grant a waiver, reduction, or payment plan to applicants that demonstrate a financial hardship.
The current poverty information is available at: https://aspe.hhs.gov/poverty- guidelines.
1. Waiver or Reduction: The Fire Chief may approve a full waiver or partial reduction of the remaining balance after all insurance payments have been posted based on the applicant’s ability to pay the remaining balance. Reductions may range from 25% to 50% based on the applicant’s fi nancial hardship as reflected above.
2. Payment Plan: The Fire Chief may offer a low -cost monthly payment plan in lieu of, or in addition to, a reduction for applicants that have a verified financial hardship.
ii. Services Provided. A waiver may be granted in circumstances where the level of response or services provided do not justify application of the charges incurred. Such determination shall be based on the contents of the applicable ePCR or one or more of the following circumstances:
1. The call for service did not require response by Fire Department apparatus including an ambulance, engine co mpany, or truck company;
2. Treatment or care provided to the applicant was at a lower level than the defined levels of ALS and BLS service;
iii. The applicant did not initiate the call for ser vice, and the applicant refused care.