Comment on CMS-2026-1916-0001

*Please see attached letter for full text.* Excerpts below. On behalf of the Academy of International Mobile Healthcare Integration (AIMHI), thank you for the opportunity to comment on CMS Proposed Rule CMS-2449-P. AIMHI represents many of the nation's leading high-performance, high-value public, private and public utility model ambulance delivery systems. Collectively, our members respond to millions of 911 requests annually and have pioneered many of the innovations now recognized nationally as best practices in emergency medical care, including Mobile Integrated Healthcare, community paramedicine, nurse navigation, alternative destination programs, telehealth, and evidence-based system design. We appreciate CMS's commitment to ensuring fiscal integrity within the Medicaid program and support appropriate oversight of supplemental payment methodologies. However, we respectfully urge CMS to exempt ambulance Medicaid supplemental payment programs, such as Ground Emergency Medical Transportation (GEMT) programs from the proposed limitation that would effectively cap supplemental Medicaid payments at the Medicare Ambulance Fee Schedule. Ambulance Service Is Fundamentally Different Ambulance services occupy a unique position within America’s healthcare system. Unlike virtually every other healthcare provider, ambulance services cannot limit patient volume, control demand, schedule appointments, or decline services based on insurance coverage or ability to pay. Ambulance agencies must maintain continuous readiness to respond immediately to heart attacks, strokes, traumatic injuries, overdoses, pediatric emergencies, natural disasters, and public health crises, 24 hours a day, 365 days a year. This readiness is the defining characteristic of ambulance agencies. It is also the principal reason why ambulance reimbursement has historically failed to cover the actual cost of providing emergency medical services. The Medicare Ambulance Fee Schedule was designed to reimburse individual ambulance transports, not to fund the infrastructure required to maintain a continuously available ambulance response system. As such, it is not an appropriate benchmark for determining Medicaid supplemental payments intended to recognize the documented cost of maintaining emergency medical readiness. In fact, the recent CMS Ground Ambulance Data Collection System revealed that Medicare under reimburses the cost of providing ambulance service by 75%. The Proposal Risks Weakening EMS Systems Rather Than Improving Medicaid Efficiency Many ambulance agencies rely on Medicaid supplemental payment funding to offset chronic Medicaid underpayment and preserve emergency response capabilities. These dollars support far more than ambulance transports. They fund: •Twenty-four-hour ambulance and paramedic readiness; •Recruitment and retention of EMTs and paramedics; •Clinical quality improvement programs; •Medical oversight and physician leadership; •Continuing education and workforce development; •Ambulance and life-saving medical equipment replacement; •Communications infrastructure; •Disaster preparedness and surge capacity; •Community paramedicine and Mobile Integrated Healthcare programs; •Telehealth and innovative alternative response models. Ironically, many of these investments advance CMS's own long-standing goals of improving care quality, reducing avoidable emergency department utilization, expanding value-based care, and improving healthcare access for Medicaid beneficiaries. Ambulance systems are unlike any other provider within Medicaid. They cannot schedule demand, limit service, or select patients. They must simply be ready - every minute of every day. Medicaid supplemental payment programs such as GEMT were created to recognize this unique mission by allowing ambulance providers to recover a portion of their under-reimbursed Medicaid costs. Replacing this cost-based methodology with a transport-based Medicare payment benchmark would fundamentally alter the purpose of the program and could jeopardize ambulance services in communities across the nation. AIMHI respectfully urges CMS to exempt ambulance agencies from the proposed payment limitation and preserve the cost-based principles upon which Medicaid supplemental payment programs such as GEMT were created. Thank you for your consideration of our comments. We welcome the opportunity to work collaboratively with CMS to develop policies that strengthen fiscal accountability while preserving access to high-quality emergency medical services for the millions of Americans who depend upon them.