Comment on CMS-2026-1916-0001

Comment on CMS-2026-1916-0001 Re: CMS-2449-P Docket ID: CMS-2026-1916 On behalf of the Fremont Fire Department, I am writing to express our strong opposition to the provisions in CMS Proposed Rule 2449-P that would cap Ground Emergency Medical Transportation (GEMT) supplemental payments at the Medicare Ambulance Fee Schedule (AFS) rates. Fremont is the southernmost city in Alameda County, positioned along major regional transportation corridors and bordered by jurisdictions whose ambulance resources are already stretched thin. This geography creates a natural bottleneck: when County resources experience high system demand or long hospital offload times, the southern end of the county—Fremont—feels those impacts first and longest. Ambulances must travel farther, traverse more congested corridors, and have fewer adjacent cities that can provide rapid mutual aid. Every year, Fremont Fire responds to more than 19,000 emergency incidents, the majority of which are EMS calls. That volume continues to rise as our population grows and the needs of medically fragile residents increase. Already, we encounter frequent delays in private-ambulance response, often leaving our fire crews on-scene far longer than medically ideal, waiting for a transport unit. This extended “ambulance lag time” ties up advanced life support fire companies who should be available for the next cardiac arrest, stroke, or trauma. These delays are not hypothetical: they affect patient outcomes daily. GEMT supplemental funding allows fire-based EMS systems like ours to maintain 24/7 readiness, staff our paramedic units, purchase and maintain modern medical equipment, and sustain an ambulance system that is already under extraordinary pressure. Medicare AFS rates do not come close to covering the true cost of operating an ALS response system, much less one needed to remain fully staffed and ready for high-acuity emergencies at any moment. Capping GEMT reimbursements at Medicare levels effectively removes the financial foundation that keeps ambulances available in Fremont. If CMS implements this reimbursement cap, Fremont will face extremely difficult operational decisions. We would be adversely impacted by reduced ambulance availability, delay equipment replacement, limited paramedic staffing, and scale back essential EMS readiness capabilities. In a city already experiencing ambulance delays, this would have a direct, measurable impact on survival rates, transport times, and the overall safety of our residents. The people most affected would be those least able to absorb the consequences: the medically underserved, Medicaid patients, children, older adults, and those with chronic conditions whose emergencies cannot wait. It is important to emphasize that GEMT programs are not an area of waste or fraud. Unlike many other reimbursement programs, GEMT programs are uniquely structured and rigorously governed. They rely on CMS-approved cost reports, are subject to annual independent audits, and undergo strict state and federal reconciliation to ensure that payments do not exceed the documented allowable costs of providing care. Furthermore, fire-based EMS agencies have been at the forefront of essential clinical innovation. Many of our agencies are currently developing programs to treat patients in place to avoid unnecessary hospital visits, while others are implementing advanced clinical interventions, such as prehospital blood transfusions. These initiatives reduce overall healthcare costs and improve patient outcomes. Capping reimbursements will stifle this innovation, ultimately proving counterproductive to CMS’s efficiency goals. We respectfully request that CMS modify this proposal to explicitly exempt governmental, volunteer, and 501(c)(3) fire-based EMS agencies that operate under approved, cost-reconciled GEMT programs. Additionally, we request further clarity on the proposed exception for payments that are reconciled to actual incurred costs under §447.381(d)(2). CMS should explicitly state that current, approved cost-reconciled GEMT programs satisfy this exception. Such clarification is necessary to reduce uncertainty and preserve access to emergency services for the communities we serve. Emergency medical services are a fundamental component of our nation’s public safety infrastructure. We urge CMS to withdraw the proposed limitation or provide a broad exemption that protects the essential readiness functions of the fire service. Thank you for your consideration. Sincerely, Zoraida Diaz Fire Chief Fremont Fire Department