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HHS Announces Groundbreaking EMS Payment Reform

Feb 14, 2019

Dear Members,

We are very pleased to report on an exciting breakthrough for EMS that was announced today by HHS Secretary Alex Azar. Beginning in early 2020, the Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (CMMI) will offer a new payment model for EMS to allow Medicare Fee-For-Service (FFS) beneficiaries to receive the most appropriate level of care at the right time and place with the potential for lower out-of-pocket costs.

The new model – Emergency Triage, Treat and Transport (ET3) Model – will make it possible for participating ambulance suppliers and providers to partner with qualified healthcare practitioners to deliver treatment in place (either on-the-scene or through telehealth) and with alternative destination sites (such as primary care doctors’ offices or urgent-care clinics) to provide care for Medicare beneficiaries following a medical emergency for which they have accessed 911 services. In doing so, the model seeks to engage healthcare providers across the care continuum to more appropriately and effectively meet beneficiaries’ needs. Additionally, the model will encourage development of medical triage lines for low-acuity 911 calls in regions where participating ambulance suppliers and providers operate. The ET3 Model will have a five-year performance period, extending through 2025.

Currently, Medicare primarily pays for unscheduled, emergency ground ambulance services when beneficiaries are transported to a hospital emergency department (ED), creating an incentive to transport all beneficiaries to the hospital even when an alternative treatment option may be more appropriate. To counter this incentive, the ET3 Model will test two new ambulance payments, while continuing to pay for emergency transport for a Medicare beneficiary to a hospital ED or other destination covered under current regulations:

  • Payment for treatment in place with a qualified healthcare practitioner, either on-the-scene or connected using telehealth; and
  • Payment for unscheduled, emergency transport of Medicare beneficiaries to alternative destinations (such as 24-hour care clinics) other than destinations covered under current regulations (such as hospital EDs). 

The ET3 Model encourages high-quality provision of care by enabling participating ambulance suppliers and providers to earn up to a five percent payment adjustment in later years of the model based on their achievement of key quality measures. The quality measurement strategy will aim to avoid adding more burden to participants, including minimizing any new reporting requirements. Qualified healthcare practitioners or alternative destination sites that partner with participating ambulance suppliers and providers would receive payment as usual under Medicare for any services rendered. 

The model will use a phased approach through multiple application rounds to maximize participation in regions across the country. In an effort to ensure access to model interventions across all individuals in a region, CMS will encourage ET3 Model participants to partner with other payers, including state Medicaid agencies.

CMS anticipates releasing a Request for Applications in Summer 2019 to solicit Medicare-enrolled ambulance suppliers and providers. In Fall 2019, to implement the triage lines for low-acuity 911 calls, CMS anticipates issuing a Notice of Funding Opportunity for a limited number of two-year cooperative agreements, available to local governments, their designees, or other entities that operate or have authority over one or more 911 dispatches in geographic locations where ambulance suppliers and providers have been selected to participate.

ET3 Model Fact Sheet:

For more information on the ET3 Model, please visit:

I was honored to represent NAEMT at this groundbreaking announcement.  As our members know, NAEMT has been strongly advocating for this payment change for over five years. We have been in discussions with leaders of CMS and CMMI and with congressional leaders to help them understand the value of EMS to achieving our nation’s healthcare goals. In June 2018, CMS representatives reached out to NAEMT, and other industry associations including the International Association of Fire Chiefs (IAFC), the National Association of EMS Physicians (NAEMSP), and the American Ambulance Association (AAA), seeking input on the design, implementation and quality assurance mechanisms that would be necessary to allow ambulance agencies to voluntarily participate in a new payment model. At CMS’ request, NAEMT facilitated direct communication for CMS officials with organizations that were paying EMS under alternative payment models, allowing CMS officials to hear first-hand from the payers about the benefits and patient outcomes.

This is a transformative day for the EMS profession. This announcement demonstrates recognition of the additional value that EMS practitioners and agencies can bring to America’s healthcare system through the effective response, assessment, treatment and referral of patients to the most appropriate level of care for their medical needs. It is also confirmation that by working together with other EMS associations, we can truly affect major federal policy changes that enhance the services we provide to the patients and communities who rely on local EMS agencies.

There is still much work to be done as CMS develops the guidelines, eligibility, and patient safety and outcome measures for this new payment model. NAEMT has already been requested to assist with that process. We will also be hosting a series of educational sessions on how EMS agencies can implement ET3, and we will have a special session at our EMS 3.0 Workshop in Arlington, VA on April 9, just prior to EMS On The Hill Day.

We thank CMS for their continued work with NAEMT, and other EMS associations, on this EMS economic transformation which we are confident will be of value to our patients, our practitioners, and our healthcare stakeholders.


Matt Zavadsky, MS-HSA, NREMT
President, NAEMT