Changes in VA Emergency Care Authorities

VETERANS HEALTH ADMINISTRATION VETERANS HEALTH ADMINISTRATION Update to VSOs on Final Rule: Changes in Rates VA Pays for Special Modes of Transportation , RIN 2900-AP89 Presented by: Kathleen Metzger, Deputy Director, Veterans Transportation Program (VHA) Darcy Horvat, Executive Director, Procurement (VHA) Joe Duran, Director, Policy and Planning, Office of Integrated Veteran Care (VHA) Date of Briefing: September 21, 2023 1 1

Purpose & Agenda 3 3 5 5 Emergency Care Authorities 6 6 Implementation Timeline 7 7 8 8 Air Ambulance National Broker 9 9 10 10 Current Issue: Non-VA Initiated 911 Calls AP89 Dashboard Demo 11 11 Questions 2

Emergency Care Authority: 72-hour Notification Authority: 38 CFR 17.4020(c) - Authorized non-VA care Criteria: Requires72-hour notification by the Veteran, family member or community provider covers any enrolled Veteran. Allows in-network emergency care visits to be considered authorized ED care, as long as VA was notified within 72 hours. Emergency Travel Authority: Beneficiary Travel (BT) authority: 38 U.S.C 111/38 C.F.R. Part 70, Subpart A If Veteran not eligible for BT, then reviewed for eligibility under 38 U.S.C. 1725/38 C.F.R. 17.1003 Payment Rate: BT Eligible Paid in accordance with AP89 at lesser of 100% of CMS or billed charges. Non-BT eligible but eligible for emergency transportation under 38 CFR 17.1003, paid at 70% of Medicare Ambulance Fee Schedule Example: A Veteran with a 10% disability rating was in a car accident and transported by ambulance to a CCN hospital. The ambulance claim is reviewed for eligibility under BT authority; this Veteran is found not eligible for BT. The ambulance claim is then reviewed for eligibility under 38 USC 1725/38 CFR 17.1003 for reimbursement. 3

Emergency Care Authority - 38 U.S.C 1728 Authority: 38 U.S.C 1728 - Reimbursement of certain medical expenses Type: Unauthorized Care for Service-Connected Conditions Criteria: Care must be (a prudent layperson definition of) an emergency. Veteran has an adjudicated service-connected disability, or a non-service- connected disability associated with and held to be aggravating a service- connected disability. Any disability of a veteran if the veteran has a total disability permanent in nature from a service-connected disability. Emergency Travel Authority: Beneficiary Travel (BT) authority: 38 U.S.C 111/38 C.F.R. Part 70, Subpart A Payment Rate: Paid in accordance with AP89 at lesser of 100% CMS rates or billed charges. Example: Claim reviewed under BT criteria and A Veteran with a service-connected heart condition suffers a heart attack and is transported via ambulance a non- CCN hospital. Claim reviewed under BT criteria and reimbursed in accordance with AP89 4

Emergency Care Authority - 38 U.S.C 1725 Authority: 38 U.S.C 1725 - Reimbursement for emergency treatment Type: Unauthorized Care for Non-Service-Connected Veterans Criteria: Veteran must be VHA enrolled at time of service. Veteran must have received care from the VHA within the last 24 months. Veteran must be personally liable (no entitlement to care from health plan contract) No contractual or legal recourse against a third party that would extinguish veteran liability to provider Veteran not eligible for reimbursement under 38 U.S.C. 1728 Care must be (a prudent layperson definition of) an emergency Emergency Travel Authority: 38 C.F.R. 17.1003 Payment rates for the travel: 70% of Medicare Ambulance Fee Schedule Example: A Veteran with a 10% rating was in a car accident and is transported by ambulance to a non-CCN hospital. VA processes and pays the hospital claim under 1725. The ambulance claim is processed by in accordance with 38 CFR 17.1003 eligibility and paid at in accordance with 38 CFR 17.1005 (generally 70% of Medicare Ambulance Fee Schedule. Can vary if 3rdparty liability exists and Veteran has remaining personal liability). 5

AP89 Implementation Timeline Rulemaking Congressional Authority Final rule (RIN 2900 AP89) published in Federal Register (2/16/2023) 1 year implementation period provided Discretionary authority provided to VA to pay CMS for non- contract ambulance (PL 112-56) (11/21/2011) Rulemaking package submitted to OMB (7/30/2019) VHA published updates to Regulatory Impact Analysis (RIA) (10/28/2020) Continue Industry Collaboration Industry Day #2 (7/20/2023) Industry Day #1 (6/25/2023) Industry Day #3 (8/30/2023) 2011 2019 2020 2021 2022 2023 2024 2018 VA OIG Recommendation VA OIG recommended VA implement congressional authority to implement CMS rates (VA OIG 15-00022-139) (05/07/2018) RFI due from Vendors (7/27/2022) Public Comment Period (11/5/2020 1/4/2021) 6 Comments rec d (5 substantive) Begin CMS Repricing (2/16/2024) VHA IPT Formalized (3/1/2023) VA OALC and VHA VTP began researching contracting options for ambulance services Begin solicitations (9/2023) VHA Stakeholder Training began (4/30/2023) Acquisition Strategy/Implementation Discussion Discussion Most Recent Industry Engagement: Industry Day 3 (Aug 30; Sam.gov Announcement) provided Vendors status of: Contract solicitation timeline/s Review of key components in standardized acquisition packages Conducting market research for Air Ambulance via one national air broker contract (VA-initiated air ambulance transports) 6

Air Ambulance National Broker Mechanics of Air Broker (NAICS 481211) Rates are by aircraft per hour with separate rates for ancillary services such as Flight nurse or doctors that are typically priced per day The Air Broker is responsible for ensuring they have qualified aircraft operators; insurance and safety certificates of all of their sub-contractors Authorized Medical Center employees will call the broker when the need arises Broker will have 30 minutes (emergent) or one hour (non-emergent) to arrange the flight Invoices will be submitted via VetRide and Veteran Transportation staff will verify correct contract pricing was billed Examples of current GSA FSS vendors: Aircraft Transport Services, Inc; CSI Aviation Inc, and Zephyr Aviation, LLC. 7

Air Ambulance National Broker VHA AP89 IPT has determined VHA should utilize National Air Broker contract* for all VA-initiated air ambulance What is an Air Ambulance Broker? How does it work? A non-asset-based company that coordinates with its subcontractor carrier operators to provide air charter services Requirements will include but not limited to reporting, safety, and insurance apply to the brokers and the Government expects that all requirements will flow down accordingly to the subcontractor carrier operators. Performance work statement will include at a minimum line items for nurse or medic per day; ground transportation (origin and destinations) to/from point of departure/arrival; aircraft type per hour etc. Pros Ensures coverage of all VAMC's and their catchment/service areas Provides greater visibility/tracking of pre-authorized air ambulance needs Streamlines procurement process (VHA and Vendors) Meets Category Management goals to eliminate redundant contracts for same services with same vendor in different regions Cons Issue resolution will require three parties: VA; Air Ambulance Broker and Air Ambulance Sub- Contractor *in lieu of individual solicitation at VAMCs; Either an open market contract solicitation will be released, or GSA FSS schedule has contracts with Air Ambulance Brokers 8

Current Issue: Non-VA Initiated 911 Calls Issue: Industry Providers continue to urge Congress to influence VHA to apply contracted rates for non-VA initiated ambulance trips Federal Acquisition Regulations (FAR) require an authorized individual to acquire goods/services prior to the receipt of the goods/services. 38 CFR 70.4 provides regulatory authority to make payment to eligible Veteran after the emergency has occurred Action: OGC and PLO are currently reviewing FAR/VAAR, financial, and other regulations/policies to determine if 911 air ambulance calls are permissible to be added to contracts. VHA can legally enter into contracts for emergency (911), non-preauthorized ambulance transportation services under 38 USC 111. Implementation challenges exist to executing this authority in a contract. Performance work statements will include a section for emergency (911) services that places requirements on the contractor in order for them to bill at the pre-negotiated rate for emergency services. VHA is still developing requirements which would require notification of the transport within 72 hours of it taking place as well as ensuring the rate will only apply when eligible veteran under 38 USC 111 are transported. 9

AP89 Monitoring: How can we monitor? A Power BI Dashboard has been created to monitor required actions. Assessment Findings 44 ground ambulance contracts targeted to enhance geographic coverage 147 modifications necessary to implement VetRide and ordering officers 1 National Contract for Air Ambulance Broker services Existing air ambulance contracts will remain as determined necessary 10

Questions? 11