Comment on CMS-2026-1916-0001

*Please see attached letter for full comment* Governmental EMS Operates Under a Fundamentally Different Financial Model One of the most consistent findings across our consulting engagements is that emergency medical services are frequently misunderstood as merely transportation providers. In reality, ambulance agencies function as essential community medical response systems that happen to transport patients. The overwhelming majority of EMS costs are associated with maintaining immediate readiness, not individual transports. Communities invest in ambulances, paramedics, communications systems, emergency preparedness, clinical oversight, quality improvement, training, and disaster response capability so that help is immediately available whenever a resident calls 911. Those costs exist whether an ambulance transports two patients or twenty. The Ambulance MFS does not adequately reimburse ambulance agencies for 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%. Ambulance Service Is Evolving Beyond Transportation One of the most significant trends we observe nationally is the transformation of ambulance delivery from a transportation service into a mobile healthcare provider. Communities increasingly rely on ambulance agencies to: •Navigate appropriate patients away from overcrowded emergency departments; •Provide behavioral health response; •Deliver community paramedicine services; •Support telehealth initiatives; •Reduce avoidable hospital admissions; •Improve care coordination for vulnerable populations. Many of these initiatives are specifically designed to improve healthcare quality while reducing overall Medicaid expenditures. Stable funding through ASPP programs has allowed many communities to invest in these innovations. Policies that reduce financial stability may unintentionally slow adoption of programs that align closely with CMS's long-standing goals of improving quality, expanding access, and reducing total healthcare costs. Consider an Alternative Approach Rather than applying a transport-based Medicare benchmark to governmental EMS systems, CMS should consider preserving the existing cost-based GEMT methodology while strengthening transparency and accountability requirements where appropriate. This approach would accomplish CMS's stated objectives without undermining the financial sustainability of local emergency medical response systems. The Financial Impact Extends Beyond Ambulance Services Our work evaluating ambulance systems consistently demonstrates that reductions in reimbursement do not simply affect ambulance agencies - they affect local communities. When ambulance revenue declines, communities generally have only four available options: •Increase local tax support; •Modify service levels; •Delay capital investments; •Postpone workforce investments. None of these outcomes improve access to care or advance CMS's objectives. Indeed, many ambulance services already face unprecedented financial pressures resulting from workforce shortages, inflation, rising labor costs, hospital emergency department overcrowding, and increasing demand for service. Reducing Medicaid supplemental funding would add another layer of financial instability to systems that are already operating with limited financial flexibility. Ambulance services represent one of the nation's most essential public safety and healthcare resources. Our experience evaluating EMS systems across the country demonstrates that financial sustainability depends upon recognizing the unique readiness costs associated with providing emergency medical services. ASPP programs were created to partially address those costs through carefully regulated, cost-based reimbursement mechanisms. Applying the proposed Medicare AFS limitation would fundamentally alter that framework and could shift millions of dollars in unreimbursed costs to local governments while limiting communities' ability to invest in workforce, innovation, quality improvement, and emergency preparedness. We respectfully encourage CMS to exempt ambulance services from the proposed payment limitation and preserve the principles that have guided ASPP programs since their inception. PWW|AG appreciates the opportunity to provide these comments and would welcome the opportunity to work collaboratively with CMS to develop policies that preserve fiscal accountability while ensuring communities continue to have access to sustainable, high-quality ambulance services.