AGENDA ITEMS 4&13
May 19,2010
Action
MEMORANDUM
TO:
FROM:
County Council
~Michael
Faden, Senior Legislative Attorney
Minna Davidson, Legislative Analyst
f?j£:(fJ
SUBJECT:
Action:
Expedited Bill 13-10, Emergency Medical Services Transport Fee - Established
Executive Regulation 6-10, Emergency Medical Services Transport Fees
Public Safety Committee recommendation: The Committee recommended against
enacting the bill (2-1, Councilmember Eirich supported the Bill).
Although the Council had not received Regulation 6-10 at the time
of the
Committee
review (the Executive had included a draft regulation with his transmittal of the bill), the
Committee's recommendation against Bill 13-10 would mean that no EMST fee would be
authorized, and the fee regulation should be
disap~roved.
Expedited Bill 13-10, Emergency Medical Services Transport Fee - Established,
sponsored by the Council President at the request of the County Executive, was introduced on
March 23, 2010. A public hearing was held on April 13 and a Public Safety Committee
worksession was held on April 26.
Bill 13-10 would authorize the County to impose and collect a fee to recover costs
generated by providing emergency medical service transports. This bill would also provide for a
schedule of emergency medical services, transport fees, fee waiver criteria, permitted uses of fee
revenues and other procedures to operate the emergency medical services fee program. Bill
13-10 would prohibit a local Fire and Rescue Department from imposing a separate emergency
medical services transport fee. The Executive would be required to issue regulations to
implement the fee; draft regulations were provided when the bill was transmitted to the Council.
On May 13, the Council received Regulation 6-10 which is attached on ©10-12.
Bill 13-10 would treat tax revenues received by the County as payment, on behalf of
County residents, for the balance of each resident's EMST fee that is not covered by insurance.
Thus, County residents who are insured would not be required to pay any co-pays or deductibles,
and uninsured County residents would not be required to pay the fee. Non-County residents
would be required to pay any portion of the fee that is not covered by insurance. A hardship
waiver would be available for individuals whose household income is at or below 300 percent of
the federal poverty guidelines.
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Fiscal analysis
County Executive's Budget Assumptions for FYll
For FYll, the Executive originally assumed $14.7 million in revenues from an EMS fee
as part of the MCFRS budget. He also assumed expenditures of $1.2 million to implement the
fee. The Executive's proposed implementation costs break out as follows.
$
I
Manager III
105,500
i
Information Technology Specialist II
85,250
Training of MCFRS personnel
25,000
I
Third party contractor
800,470
Community Education
200,000
Total
1,216,220
Item
wy
1.0
1.0
0.2
2.2
After the Executive transmitted the FYll budget to the Council, he received updated
EMST fee revenue estimates which reduced the estimated FYll revenue to $14.1 million. On
April 22, the Executive proposed additional adjustments to the FYll operating budget which,
among other things, adjusted for a projected reduction of $557,000 in EMST fee revenues.
On the expenditure side, the Fiscal Impact Statement estimates a reduction of about
$30,000 in implementation costs because third party administrator costs, which are calculated as
a percentage of revenues, will be lower based on the decreased revenue projections.
If
the
Council approves an EMST fee, Council staff recommends reducing the amount budgeted
for the third party contractor by $30,000 to take this revised cost estimate into account.
Fiscal Impact Statement - Revised Revenues
The Fiscal Impact Statement (FIS) which was provided with this bill was based on March
19, 2010 fiscal analysis showing that the EMST fee will result in revenues of $14.1 million in
FYll, $14.7 million in FYI2, $15.2 million in FYI3, and $15.8 million in FYI4. These
revenues were adjusted downward from previous estimates that were provided in November
2008. After the Public Safety Committee worksession, the consultant provided an updated fiscal
analysis (dated April 23, 2010) which corrected a technical error in the spreadsheet calculations
for FYI2-FYI4. With the corrected figures, the total revenue estimate for the first 4-year period
of implementation has been reduced from $62.2 million to $61.6 million.
Comparison of Estimated EMT Fee Revenues (in millions)
Year 1 Year 2 Year 3 Year 4 Total
November 13, 2008 14.55
15.87
16.60
62.21
15.19
April 23, 2010
14.14
16.71
61.59
14.94
15.80
Net Change
-0.41
-0.25
-0.07
+0.11
-0.62
The County requested the new estimates to consider any change in circumstances in
health care billing, as well as in the economic or political climate, which may have impacted
previous projections. In addition, the County began to use the new Electronic Patient Care
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Reporting system (ePCR) in January, providing 2 months of actual data which were used to
replace previous assumptions that were based on informed estimates.
The Executive Summary in the attached
Updated 2010 EMS Transport Revenue
Projections
from Page, Wolfberg
&
Wirth, LLC, (PWW) lists the following major reasons for
the revenue change in order of impact. They are described in more detail under "Methodology
and Assumptions" on ©20-22.
• MCFRS dispatch data show a lower-than-anticipated Advanced Life Support
(ALS) dispatch rate, resulting in fewer transports eligible for ALS reimbursement
under the ALS Assessment rule;
• MCFRS ePCR and dispatch data compelled revising the ALS vs. Basic Life
Support (BLS) transport ratio from 57:43 to 45:55.
• Medicare implemented a 0% Ambulance Inflation Factor (AIF) for 2010. While
future years' AIF are expected to be positive, uncertainty over counterbalancing
Medicare cuts under the federal health reform law conservatively led us to assume
a 0% inflationary adjustment in allowed charges in years 2-4 of these projections.
• The Geographic Practice Cost Index (GPCI) (which is used by Medicare to
calculate ambulance fee schedule reimbursement rates) for Maryland Locality 01
was adjusted from 1.08 to 1.057 in 2009.
In addition, the limited ePCR data made available by the County also showed a higher volume of
Advanced Life Support - Level 2 (ALS2) transports than previously anticipated, though this had
a negligible (but slightly positive) impact on the projections.
Issue: Fewer than anticipated ALS dispatches: PWW noted that previously they
assumed an ALS/BLS ratio of 57% ALS to 43% BLS. In the January and February 2010
MCFRS dispatch data, approximately 60% of all dispatches were categorized as BLS. PWW
noted that these data appeared to under-triage the reporting of ALS conditions at the time of
dispatch, compared with their experience in other jurisdictions. They revised the ratio to 45%
ALS to 55% BLS.
Under the 1+1 ALS deployment model, "Charlie"-level ALS patients are transported to
the hospital by BLS units. (See ©45, footnote #2.) This practice enables ALS providers to
remain available to respond to other more serious ALS calls.
• To what extent is the apparent under-reporting of ALS conditions at the time of
dispatch related to the practice of transporting certain ALS patients by BLS units?
• If
an EMST fee is imposed, would decisions about policies and practices in the field
consider or be driven by the impact on EMST fee revenues?
Self-pay Charges: Because there has been considerable discussion about assumptions
regarding self-pay (uninsured) individuals, Council staff notes that the PWW projection assumes
that 28% of those billed would be self-pay. Of those, PWW assumes that 90% would be County
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residents from whom no fee would be collected. Of the remaining 10% -- non-County residents
who would be billed -- they assume a collection rate of 30%. ' Even though self-payers are
assumed to make up 28% of the billing population, the amount projected to be collected from
this payer category is relatively small. The self-pay calculation for Year One is on ©29.
Medigap Coverage: In the past there have been questions about whether the PWW
calculations assume Medigap coverage of Medicare co-payments. Council staff notes that
Medigap co-payments are included in the Medicare Payer Category, and are estimated at 52% of
the co-payment amount. The Medicare calculation for Year One, including Medigap receipts, is
on ©28.
Legislative issues
Fee structure The FIS assumed the following fee structure for a range of levels of
service. The fee structure would be established by Regulation 6-10 (See © 10-12). The service
levels (but not the fee amounts) are defined by Federal regulation.
Fee
I
Transport mileage
$8.50 per mile*
i
Basic Life Support - Non Emergency
$300.00
I
Basic Life Support Emergency
$400.00
• Advanced Life Support - Levell ­ Non-Emergency $350.00
• Advanced Life Support Level 1 - Emergency
$500.00
Advanced Life Support - Level 2
$700.00
Specialty Care Transport
$800.00
*The PWW analysis assumed $8.00 per mile.
I
T~I!e
of Service
In its fiscal analysis, PWW advised that the County's charges should be a fair amount
higher than the prevailing Medicare-approved rates because, under federal law, Medicare pays
the lesser of the approved Medicare fee schedule amount or the provider's actual charge. If a
provider charges less than the Medicare approved rate, Medicare only pays the provider's
charge, and does not pay the full scheduled amount. The Executive's proposed fee structure
would set the EMST fees above the 2010 approved Medicare charges.
Council staff understands that because the Executive recommended a model in which
County residents would not be billed for any costs beyond those reimbursed by insurance, raising
the fees at this time would not produce much additional revenue. Since the County will cover
with taxes the portion of residents' EMST fees that are not paid by an insurer and will cover the
entire fee for residents who are uninsured, a fee increase would only affect co-payments and
deductibles from non-County residents, and payment in full from the small percentage of
non-County self-payers who would pay the fee.
Waivers As introduced, Bill l3-1O would require the Fire Chief to waive the EMST fee
for any individual whose household income is at or below 300% of the federal poverty
guidelines. Under the current guidelines (©43) a family of 4 would be eligible for a waiver if
their income is at or below $66,150.
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As noted earlier, County residents, whether insured or uninsured, would not have to pay
any EMST fee that is not covered by insurance. Thus, hardship waivers would only be needed
for non-County residents.
Timing of Fee Implementation The revenue projections in the FIS assumed mid-year
implementation of the fee, with retroactive billing to the beginning of the fiscal year. (This
assumes that the Council would enact Bill 13-10 before June 30, 2010.) Federal regulations
allow a health care provider to bill retroactively to the effective date in the authorizing
legislation.
If
the Council agrees with this approach, the bill would have to be amended to
allow retroactive billing during the first year start-up period.
Direct Allocation to the LFRDs When the Executive proposed an EMST fee in the
FYIO budget, he recommended $750,000 for a direct allocation of fee revenues to the Local Fire
and Rescue Departments (LFRDs). Although the Executive had budgeted for a direct allocation,
neither the then proposed bill nor the proposed implementing regulation addressed this issue.
For FYII, the Executive did not recommend funding for a direct allocation to the
LFRDs. Bill 13-10 and Regulation 6-10 do not address this issue. In response to questions on
the budget, MCFRS staff indicated that the Executive is open to discussing options for sharing
revenues with the LFRDs.
If
the Council wishes to include a direct allocation of EMST fee revenues to the
LFRDs, the Council would have to decide the amount of the allocation and the conditions
under which it would be provided. The Council would also have to include funds for the
direct allocation in the FYll operating budget.
Supplement vs. Supplant The proposed implementing legislation for the FYIO EMST
fee (Bill 25-08 as revised) said that, except for the transfer of funds to cover residents' unpaid
EMS transport costs, the revenues from the EMST fee must be used to supplement, and
must not supplant, existing expenditures for EMS and other related fire and rescue services
provided by MCFRS.
Bill 13-10 (see ©3-4, lines 52-58) provides:
(h)
Use of revenue.
Except for the transfer received from the General Fund under
subsection (e) and in the first fiscal year this fee is implemented, the revenues
collected from the emergency medical services transport fee must be used to
supplement, and must not supplant, existing expenditures for emergency medical
services and other related fire and rescue services provided by the Fire and
Rescue Service.
Council staff assumes that the Executive intends that the "supplement not supplant"
requirement would apply in
all but the first year
of implementation, but others have interpreted
this language to mean that
it
applies
only in the first year.
Executive staff clarified that the
non-supplantation clause is not intended to apply in FYll, but is intended to apply in FY12
and beyond.
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The Executive's recommended FYll-16 Fiscal Plan for the Consolidated Fire Tax
District is attached on ©42. EMST fee revenues are included in the "Charges for Services" line
together with some fire code enforcement fees. While the EMST fees are not broken out
separately, it appears that revenue from the EMST fee would supplant fire tax revenues in FYll.
The picture is not as clear for FYI2.
An
increase in 4-person staffing, new ambulances
for Kingsview and Milestone, and an increase for a recruit class are assumed, but the cost of
these new initiatives would total only $7.12 million, less than half of the projected FY12 EMST
fee revenue of $15.19 million.
It
is not clear whether the fiscal situation in FY12 will allow
funding of the new services that are envisioned in the Fiscal Plan. In addition, we would argue
that funding for a recruit class should be treated as an ongoing cost of operating MCFRS and
thus not count as supplementing.
Council staff would pose the following questions regarding this issue:
1) Since the fee was originally proposed to supplement the existing MCFRS budget, should
the law allow an exemption from the "supplement not supplant" requirement even for one
year?
2) If the exemption is intended to apply in the first year only, is
it
realistic to assume that it
will be possible to use fee revenue only to supplement the existing budget in FY12 and
later years?
Fairfax County experience At the public hearing, representatives of the Volunteer Fire
and Rescue Association submitted information (see ©46) arguing that ambulance service calls in
Fairfax County decreased as a percentage of population after that County imposed its similar fee.
However, the EMS Deputy Chief of the Fairfax County Fire and Rescue Department who
testified at the same hearing (see testimony, ©47-48) attributed this decrease to a flawed
reporting system, and concluded that Fairfax County's implementation of the fee was well
planned and successful.
Summary of Public Safety Committee discussion: Councilmember Andrews said that
his position remains the same as in prior reviews of the EMST fee. He feels that
it
is
fundamentally bad policy to charge for ambulance services because there is good evidence that
an EMST fee may discourage people from calling for help. He was concerned that if asked
whether there is a fee, MCFRS personnel would have to ask patients about their residence and
insurance status in order to determine how to respond. He felt that the fee would create division,
rather than strengthen the fire and rescue service, and thought that the County should not resort
to such a fee even under the current fiscal constraints.
Councilmember EIrich thought the fee would provide an opportunity to collect money
from insurance companies which insured individuals have already paid for in their insurance
premiums. His understanding of the implementation was that the hospital, rather than the
County, would collect all of the relevant information for the EMST fee through the hospital's
billing process, the County would not pursue residents without insurance, and would grant
waivers for non-residents who could not afford to pay the fee.
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He stressed the importance of the volunteers in the delivery of fire and rescue service and
wanted to assure that local fire and rescue departments are not harmed by the fee. He also said
that the fee must not supplant fire tax monies, but must support the expansion of the fire service
including staffing for new fire stations, and new apparatus and equipment.
Councilmember EIrich said that while he would support the fee, for the long run he
would prefer a different approach with a separate tax for the fire and rescue service which is not
subject to the Charter limit. This alternative approach would make it possible to increase the fire
tax as much as is needed to adequately support the fire and rescue service.
Councilmember Berliner acknowledged the County's severe fiscal situation at this time
and the amount of money that could be generated by an EMST fee. However he had concluded
during previous fee reviews that implementing the fee would cause a degradation of the
combined fire and rescue service that would cost more than the County would gain through
EMST fee dollars. He said that there was no question that volunteers find the concept of
charging for service which they voluntarily provide to be offensive. In addition, considering that
there is already a fire tax, and the Council is evaluating an increase in the energy tax, he thought
that implementing an EMST fee at the same time would not serve the community welL
Assistant CAO Boucher spoke on behalf of the Executive, discussing his reasons for
supporting the fee, and responding to some of the concerns and points raised by Committee
members. She said that the Executive is concerned that the threat to the fire and rescue service
as a whole if the fee is not implemented outweighs other concerns about the fee. The Executive
continues to value the role of volunteers in the fire and rescue service and would be open to
establishing provisions to protect them from any negative financial consequences resulting from
this bilL She mentioned that there is an imbalance when County residents must pay EMST fees
to other jurisdictions for transports under mutual aid, and when residents from other jurisdictions
who are transported by Montgomery County do not have to pay because the County does not
charge a fee.
The Fire Chief said that he understood that Bill 13-10 would have an impact on the fire
and rescue service whether it passes or not. He supports the fee as recommended by the
Executive. In his view,
Bill 13-10
provides a logical way to implement a fee that is necessary to
provide service improvements which are essential to the fire and rescue service.
Councilmember Berliner said that, while there are many points of view on the EMST fee,
another approach might be the one which Councilmember Eirich touched on. Councilmember
Berliner suggested revisiting the fire tax, which in his view is no longer a dedicated tax, to
explore whether it can be removed from the Charter Limit. He said that he intends to pursue this
option further with the fire and rescue service, the Executive, and the Council to determine
whether there are alternative ways to ensure that the fire and rescue service receives the
resources that it needs to continue its excellent service to the community.
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Executive Regulation 6-10, Emergency Medical Service Transport Fees
On May 13, the Council received proposed Regulation 6-10 to implement the EMST fee.
The Executive's transmittal memorandum says that the regulation was advertised in the
April 2010 Register and no public comments were received.
Regulation 6-10 would: (1) establish the EMST fee schedule; (2) require an individual
who receives an EMS transport to provide health insurance information to the County or the
County's designee; (3) require an individual who applies for a waiver to provide certain financial
information necessary for the Fire Chief to determine eligibility for the waiver; and (4) require
the Fire Chief to increase the amount of the fees in the schedule annually by the Medicare
Ambulance Inflation Factor.
Regulation 6-10 must be processed under method (2) of Section 2A-15 of the County
Code. Under method (2), if the Council does not approve or disapprove a regulation within 60
days after the Council receives it, the regulation automatically takes effect unless the Council, by
resolution, extends the deadline for action.
If
the Council wishes to approve the fee, the Council should approve the regulation
so that the Executive can begin the implementation process.
If
the Council does not wish to
approve the fee, the Council should disapprove the regulation so that it does not
automatically take effect.
Issues
If the Council wishes to implement the EMST fee, Council staff would recommend that
the Council request that the Executive amend the regulation as discussed below. If the Council
agrees with the amendments, the Executive would have to re-issue and re-number the regulation
as 6-1 OAM to indicate that it was amended after transmittal to the Council.
Issue #1
Section 2.a. says:
If requested by the Fire Chief, each individual who receives an emergency
medical services transport must furnish to the County, or its designated agent: (i)
information pertaining to the individual's health insurer (or other applicable
insurer); and (ii) financial information that the Fire Chief determines is necessary
for determination of granting a waiver of the fee.
In Council staffs view, this language is confusing, and does not make it clear that each
individual who receives an emergency medical services transport must furnish health insurance
information to the County or its designated agent. Council staff recommends splitting this
paragraph into two sections as follows:
An
individual who receives an emergency medical services transport must furnish
to the County or its designated agent information pertaining to the individual's
health insurer (or other applicable insurer).
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An individual who requests a hardship waiver must provide to the Fire Chief any
financial information which the Fire Chief determines is necessary for
determining eligibility for a waiver of the fee.
Issue
#2
The proposed regulation would require the Fire Chief to increase the amount of the fees
in the schedule annually by the amount of the Medicare Ambulance Inflation Factor. Council
staff recommends that this provision include a requirement for the Fire Chief to publish the new
fee schedule in the Register when
it
is updated each year. Council staff recommends adding the
following sentence (underlined) to the existing Section 2.c.
The Fire Chief must increase the amount of the fees in the schedule annually by
the amount of the Ambulance Inflation Factor (AIF), as published by the Centers
for Medicare and Medicaid Services (CMS), United States Department of Health
and Human Services. The Fire Chief must publish the new fee schedule in the
Register each vear when the fee schedule is updated.
This packet contains:
Expedited Bill 13-10
Legislative Request Report
Memo from County Executive
Proposed regulation
Fiscal Impact Statement (Updated on April 23, 2010)
FYII-16 Fiscal Plan, Fire Tax District
2009/2010
HHS Poverty Guidelines
Excerpt from
FIR
EMS Master Plan 2009 Update
Materials re Fairfax County experience
Circle
#
1
5
6
9
13
42
43
44
46
F:ILAWIBILLSIIOI3 EMT FeelAction Memo.Doc
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Expedited Bill No.
13-10
Concerning: Emergency Medical Services
Transport Fee - Established
Revised:
3-22-10
Draft No.
_1_
Introduced:
March
23,2010
Expires:
September
23. 2011
Enacted: __________________
Executive: _____________
Effective: ______________
Sunset Date:
_N:...:.o~n..!.::e=__
_ _ _ _ __
Ch. _ _, Laws of Mont. Co. ______
COUNTY COUNCIL
FOR MONTGOMERY COUNTY, MARYLAND
By: Council President at the Request of the County Executive
AN EXPEDITED ACT
to:
(1)
authorize the County to impose and collect a fee to recover costs generated by
providing emergency medical service transports;
(2) provide for a schedule of emergency medical services transport fees, fee waiver
criteria, permitted uses of fee revenues, and other procedures to operate the
emergency medical services fee program;
(3)
prohibit a Local Fire and Rescue Department from imposing a separate emergency
medical services transport fee;
(4) require the Executive to issue certain regulations to implement an emergency
medical services transport fee;
(5) require a certain annual transfer be made as payment of residents' uninsured portion
of the emergency medical services transport fee; and
(6) generally amend County law regarding the provision of emergency medical services;
By adding
Montgomery County Code
Chapter 21, Fire and Rescue Services
Section 21-23A. Emergency Medical Services Transport Fee
Boldface
Underlining
[Single boldface brackets]
Double underlining
[[Double boldface bracketsD
Heading or defined term.
Added to existing law by original bill.
Deletedfrom existing law by original bill.
Added by amendment.
Deletedfrom existing law or the bill by amendment.
Existing law unqffected by bill.
* * *
The County Council for Montgomery County, Maryland approves the following Act:
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EXPEDITED BILL
No.
11-10
1
2
Sec.
1.
Section 21-23A is added as follows:
21-23A.
Emergency Medical Services Transport Fee.
3
4
ill
Definitions.
In this Section the following terms have the meanings indicated:
5
6
ill
Emergency medical services transport
means transportation
Qy
the Fire and Rescue Service of an individual
Qy
ambulance or
other Fire and Rescue Service vehicle used for a similar
purpose.
Emergency medical services transport
does not
7
8
9
10
11
12
13
14
include transportation of an individual under an agreement
between the County and
f!
health care facility.
ill
Federal poverty guidelines
means the applicable health care
poverty guidelines published in the Federal Register or
otherwise issued
Qy
the federal Department of Health and
Human Services.
15
16
17
ill
(Q}
Fire and Rescue Service
includes each local fire and rescue
department.
18
Imposition gffee.
The County must impose
f!
fee for any emergency
medical services transport provided in the County and, unless
prohibited
Qy
other law, outside the County under
f!
mutual aid
agreement.
19
20
21
22
(£}
Liability for fee.
Subject to subsection
(Q1
each individual who
23
receives an emergency medical services transport is responsible for
paying the emergency medical services transport fee.
@
24
25
Hardship waiver.
26
27
ill
The Fire Chief must Waive the emergency medical servIces
transport fee for any individual whose household income is at or
(j)
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EXPEDITED BILL
No. 13-10
28
below 300 percent of the federal poverty guidelines.
An
29
30
31
32
33
34
35
36
37
38
39
40
41
individual must request
~
waiver on
~
form approved
Qy
the Fire
Chief.
ill
The Fire Chief may deny
~
request for
~
waiver if an individual
who claims financial hardship under this Section does not
furnish all information required
Qy
the Fire Chief.
W
Payment
gf
Residents' Uninsured Portion
gf
the Emergency Medical
Services Transport Fee.
ill
Tax revenues received
Qy
the County must be treated as
payment, on behalf of County residents, of the balance of each
resident's portion of the emergency medical services transport
fee that is not covered
Qy
the resident's insurance.
ill
The County Council must annually transfer from the General
Fund to the Consolidated Fire Tax District Fund an amount that
the Council estimates will not be covered
Qy
residents'
insurance as payment of all residents' uninsured portion of the
emergency medical services transport fee.
42
43
44
45
46
ill
Obligation to transport.
The Fire and Rescue Service must provide
emergency medical services transport in accordance with applicable
medical protocols to each individual without regard to the individual's
ability to
IlliY:.
(g)
47
48
49
50
51
52
53
54
Restriction on Local Fire and Rescue Departments.
A local fire and
rescue department must not impose
medical transport.
~
separate fee for an emergency
®
Use
gf
revenue.
Except for the transfer received from the General
Fund under subsection
W
and in the first fiscal year this fee is
implemented, the revenues collected from the emergency medical
CD
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EXPEDITED BILL
No. 13-10
55
56
57
58
59
60
61
servIces transport fee must be used to supplement, and must not
supplant, existing expenditures for emergency medical services and
other related fire and rescue services provided
Qy
the Fire and Rescue
Service.
ill
Regulations; fee schedule.
The County Executive must adopt
!!
regulation under method
ill
to implement the emergency medical
services transport fee program. The regulation must establish
!!
fee
schedule based on the cost of providing emergency medical services
transport.
The fee schedule may include an annual automatic
62
63
64
65
66
67
adjustment based on inflation, as measured
Qy
an index reasonably
related to the cost of providing emergency medical services transports.
The regulation may require each individual who receives an
emergency
medical
services
transport
to
provide
financial
information, including the individual's insurance coverage, and to
assign insurance benefits to the County.
Sec. 2. Expedited Effective Date.
68
69
70
71
The Council declares that this legislation is necessary for the immediate
protection of the public interest. This Act takes effect on the date when it becomes
law.
Approved:
72
73
74
75
76
77
Nancy Floreen, President, County Council
Date
78
Approved:
79
80
81
Isiah Leggett, County Executive
Date
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LEGISLATIVE REQUEST REPORT
Expedited Bill 13-10
Emergency Medical Services Transport Fee - Established
DESCRIPTION:
This Bill would authorize the County to impose and collect a fee to
recover costs generated by providing emergency medical services
transports.
In order to meet current fiscal challenges facing the County, the County
must increase the amount of revenue available to maintain core
Government programs and services.
To enhance the amount of revenue available to support core government
programs and services.
PROBLEM:
GOALS AND
OBJECTIVES:
COORDINATION:
Office of Management and Budget; Department of Finance; Fire and
Rescue Service
FISCAL IMPACT:
To be requested.
ECONOMIC
IMPACT:
EVALUATION:
To be requested.
Subject to the general oversight of the County Executive and the County
Council.
Many jurisdictions in the regions have imposed an emergency
medical services transport fee.
Joseph Beach, Director of Management and Budget
Kathleen Boucher, Assistant Chief Administrative Officer
Richard Bowers, Chief, Fire
&
Rescue Service
Marc Hansen, Acting County Attorney
EXPERIENCE
ELSEWHERE:
SOURCES OF
INFORMATION:
APPLICATION
Yes.
WITHIN
MUNICIPALITIES:
PENALTIES:
To be researched.
F:\LAW\BILLS\1013 EMT Fee\LRR.DOC
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OFFICE OF THE COUNTY EXECUT1VE
ROCKVILLE. MARYLAND 20850
lsiah
Cotll1tv
Executive
MEMORANDUM
,""'.
}
March 18,2010
TO:
FROM:
SUBJECT:
Nancy Floreen, Council President
Isiah
Leggett,
County
EXeCUtiVe~~tfJ
,//)
-- i
FY 2011 Budget Reconciliation and Financing Act
I am attaching for Council's consideration a Budget Reconciliation and Financing
Act (BRF A) which makes changes to the County Code that are necessary to reconcile my
recommended FY 2011 operating budget with projected FY 2011 revenues. This bill will help
the County address its current fiscal challenges by increasing the amount of revenue available to
maintain and enhance core government programs and services. I am also attaching a Legislative
Request Report for the bill. A Fiscal Impact Statement will be transmitted to Council soon.
The BRF A consists of five primary components. First, it increases the energy tax
rates. Second, it temporarily redirects the portion of recordation tax revenues that are currently
reserved for County Government capital projects and rental assistance programs to the general
fund for general purposes. Third, it allows revenues generated by the Water Quality Protection
Charge to be used to pay debt service on bonds that fund stom1water management infrastructure
projects. Fourth, it transfers responsibility for administering equal employment opportunity
programs from the Office of Human Resources to the Office of Human Rights. Fifth, it
authorizes the Fire and Rescue Service to impose an Emergency Medical Services (EMS)
Transport Fee.
As the Council knows, the County's energy tax is actually a tax on fuel oil,
natural gas, and electric utility providers which is passed on to all utility customers. Because the
energy tax is a broad-based tax, its impact on families is reduced by the fact that it is paid by
businesses and households, and all levels of govemment, including federal agencies located in
the County (that currently do not pay any other major County tax). Additionally, the energy tax
is a consumption tax based on energy usage.
It
is not based on the overall size of the utility bill
or the cost per unit of energy used as billed to the consumer. Therefore, the amount of the tax
can be lessened by reduced energy usage. Based on existing usage pattems for the average
homeowner, my recommended FY 2011 budget assumes an average increase in the energy tax of
approximately $2.90 per month. I have also recommended additional funding in the Health and
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Nancy Floreen, Council President
March 18,2010
Page 2
Human Services budget for the County's Energy Assistance Program to minimize the impact to
low-income households.
My recommended FY 11 budget contains several efforts to restructure County
Government to improve responsiveness and efficiency. One of these changes is the transfer of
the Equal Employment Opportunity program from the Office of Human Resources to the Office
of Human Rights. This shift takes advantage of existing staff resources to reduce costs and
leverage the efforts of County staff to produce better outcomes for the community. This bill
modifies the County code provisions relating to the responsibilities of the Office of Human
Resources and Office of Human Rights to reflect this change.
The EMS Transport Fee is needed to fund fire and rescue services in the County.
Without this fee, emergency response to residents will be impaired. EMS Transport Fees are
widely employed throughout the nation and by local governments throughout the Washington
region. These jurisdictions have not experienced any indication that people decline to use
emergency transports as a result of the imposition of an ambulance fee. By creating a prepaid
fund for uninsured County residents, the legislation that I am transmitting imposes a fee only on
County residents with health insurance which covers EMS Transports. This arrangement more
equitably distributes the economic burden of providing EMS transport services in the County
between residents and nonresidents. The legislation provides for a hardship waiver for
nonresidents who fall below 300 percent of federal poverty guidelines.
To provide the Council with a complete picture of the EMS Transport Fee
program created by this bill, I am attaching a copy of the proposed Executive Regulation to
implement the fee. This proposed regulation will be published in the April 2010 County Register
and submitted to Council after the 30-day public comment period ends on April 30.
Finally, I note that the BRFA is consistent with Bill 31-09, Consideration of
Bills - One Subject (enacted on September 29,2009), which requires that a bill "contain only
one subject matter".· As noted in the Council staff packet for Bill 31-09, that bill was intended to
adopt the "one subject rule" of the Maryland Constitution, which requires all laws enacted by the
General Assembly to contain only one subject. The Maryland Attorney General has repeatedly
concluded that budget reconciliation and financing bills do not conflict with the one subject rule.
For example, in 2005, the Attorney General noted that "[fjor the past fourteen years, 15 budget
reconciliation, budget reconciliation and financing acts or variations thereof, have been used to
balance budgets, raise revenue, make fund transfers, redistribute funds, cut mandated
appropriations and authorize or mandate appropriations. ,,) The Attorney General concluded that
all of those bills were consistent with the one subject rule because the provisions of the bills were
"clearly germane to the single subject of financing State and local government".
See Panitz
v.
Comptroller ofthe Treasury,
247 Md. 501 (1967) (Omnibus supplemental appropriation bill
comprised a single subject for purposes of
§
29 of
Art
III of the State Constitution even though
See May 19, 2005 memorandum from Attorney General J. Joseph Curran, Jf. to Governor Robert Ehrlich regarding
House Bill 147 (2005).
J
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Nancy Floreen, Council President
March 18,2010
Page 3
the bill combined such diverse elements as police aid to local government; teacher salaries and
pensions; and general unrestricted grants to local government).
Attachments (3)
cc:
Joseph Adler, Director, Office of Human Resources
Jennifer Barrett, Director, Finance Department
Joseph Beach, Director, OMB
Kathleen Boucher, ACAO
Richard Bowers, Fire Chief, MCFRS
Marc Hansen, Acting County Attorney
Robert Hoyt, Director, DEP
Richard Y. Nelson, Jr., Director, DHCA
James Stowe, Director, Office of Human Rights
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-
LL
rnF
cc.
S13r::­
rno
J~
OFFICE OF THE COUNTY EXECUTIVE
Isiah Leggett
County Executive
ROCKVILLE, MARYLAND 20850
! ..
~
...
MEMORANDUM
May l3, 2010
-
..
;~
-..<
C~
056885
TO:
Nancy Floreen
Council President
County Executive
FROM:
IsiahLeggett~ ~
..,
~
0.
~,,*j
ffien40D
_ __
SUBJECT:
Executive Regulation 6-10 - Emergency Medical Service Transport Fee
r
! .....
With this memorandum, I am transmitting Executive Regulation 6-10,
Emergency Medical Service Transport Fee, for your approval. This Regulation would
implement Expedited Bil113-l0 by: (1) establishing an emergency medical services
(EMS) transport fee schedule; (2) requiring an individual who receives an EMS transport
to provide health insurance information to the County or the County's designee; and (3)
requiring an individual who applies for a waiver ofthe fee to provide financial
information requested by the Fire Chief as necessary to determine eligibility for the
WaIver.
This Method 2 Regulation was advertised in the April 2010 County
Register. No public comments were received. If you have any questions about this
Regulation, please contact Assistant Chief Administrative Officer Kathleen Boucher at
240-777-2593 or Assistant Chief Scott Graham at 240-777-2493.
Attachments
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MONTGOMERY COUNTY
EXECUTIVE REGULATION
Offices ofthe County Executive • 101 Monroe Street • Rockville, Maryland 20850
Subject
Emergency Medical Service Transport Fees
Originating Department
Montgomery County Fire and Rescue Services
Montgomery County Regulation on
EMERGENCY MEDICAL SERVICE TRANSPORT FEES
Issued by: County Executive
Regulation No. 6-10
COMCOR: Chapter 21
Authority: Montgomery County Code Section 21-23 A
Supersedes:
NI
A
Council Review: Method (2) under Code Section 2A-IS
Register Vol. 27, No.4
Effective Date: Date Bill 13-10, Emergency Medical Services Transport Fee­
Established becomes effective
Comment Deadline: April 16, 2010
Summary:
This Regulation establishes:
(1)
An
emergency medical services transport fee schedule;
and (2) a requirement that an individual who receives an emergency medical services
transport provide certain information and execute an assignment of certain health
insurance benefits.
Scott Graham, Assistant Chief, Montgomery County Fire and Rescue Service
(240) 777-2493
Montgomery County Fire and Rescue Service
Executive Office Building
101 Monroe Street, 12th Floor
Rockville, Maryland 20850
Number
6-10
Effective Date
Staff contact:
Address:
Seetien 1.
Fee Schedule.
a.
In
imposing and collecting the emergency medical services transport fee authorized under
Code Section 21M23A. the Fire Chiefmust comply with all applicable provisions of42
CFR Parts 410
and
414,
Fee Schedule for payment ofAmbulance Services and Revisions
to the Physician Certification Requirementsfor Coverage ofNon-emergency Ambulance
Services.
Page 1 of3
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MONTGOMERY COUNTY
EXECUTIVE REGULATION
Offices of the County Executive -101 Monroe Street - Rockville, Maryland 20850
Subject
Emergency Medical Service Transport Fees
Originating Department
Montgomery County Fire and Rescue Services
Number
6-10
Effective Date
b.
The Fire Chief must impose the emergency medical services transport fee according to
the following schedule:
i.
ii.
$8.50 per mile, one way, from point ofpick up to
the health care facility; plus
• Basic Life Support - Non-emergency·
• Basic Life Support - Emergency*
• Advanced Life Support - Levell - Non-emergency*
• Advanced Life Support - Levell - Emergency*
• Advanced Life Support - Level 2*
• Specialty Care Transport*
$300.00
$400.00
$350.00
$500.00
$700.00
$800.00
• The tenns in the schedule are as defined in 42 CFR Parts 410 and 414.
Section 2.
Required Information; Assignment of Benefits.
a.
If requested by the Fire Chief, each individual who receives an emergency medical
services transport must furnish to the County, or its designated agent: (i) infonnation
pertaining to the individual's health insurer (or other applicable insurer); and
(ii)
financial
infonnation that the Fire Chief detennines is necessary for detennination of granting a
waiver of the fee.
Each insured individual who receives an emergency medical services transport must
execute an assignment ofbenefits necessary to pennit the County to submit a claim for
the fee to the applicable third-party payor.
The Fire Chief must increase the amount ofthe fees in the schedule annually by the
amount of the Ambulance Inflation Factor (AIF), as published by the Centers for
Medicare and Medicaid Services (CMS), United States Department of Health and Human
Services.
b.
c.
Section 3.
Severability.
Ifa court of final appeal holds that any part ofthis regulation is invalid, that ruling does not affect the
validity of other parts of the regulation.
Section 4.
Effective Date.
Page 2 00
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MONTGOMERY COUNTY
EXECUTIVE REGULATION
Offices of the County Executive • 101 Monroe Street • Rockville, Maryland 20850
Subject
Number
6-10
Effective Date
Emergency Medical Service Transport Fees
Originating Department
Montgomery County Fire and Rescue Services
This regulation is effective on the date the Bill 13-10, Emergency Medical Services Transport Fee ­
Established becomes effective.
Approved:
Page 3 of3
@
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OFFICE OF MANAGEMENT AND BUDGET
!siah Leggett
County Executive
Joseph F. Beach
Director
MEMORANDUM
May 13,2010
TO:
Joseph F. Beach, Director
Office of Management and Budget
Alex
VIA:
VIA:
EsPin~a,
Management and Budget Manager
.
John Cuff,
~ement
and Budget Specialist
Blaise
FROM:
DeFazit'~1anagement
and Budget Specialist
SUBJECT: Executive Regulation 6-10, Emergency Medical Service
Transport Fees
REGULATION SUMMARY
The proposed regulation establishes: (1)
An
emergency medical services transport fee
schedule; and (2) a requirement that an individual who receives an emergency medical services transport
provide certain information and execute an assignment of certain health insurance benefits.
FISCAL SUMMARY
The projected revenues are based on a mix of four payer types-Medicare, Medicaid,
Commercial/Auto Insurance and SelfPay, average revenue per transport rate of$248 in FYII up to $261
in FY14, and a Montgomery County Fire and Rescue Service estimated transport volwne of 56,977 for
FYII which is expected to increase to 64,091
in
FY14.
The
transport fee is expected to result in revenues
of$14.1 million in FYl1', $14.9 million in FYI2, $15.8 million in FYl3 and $16.7 million
in
FY14. For
additional details on the basis of these estimates please see the attached EMS Transport Revenue
Projections Report prepared for the County by Page, Wolfberg, and Wirth.
Assuming mid-year implementation, with collection of
revenues
beginning retroactively from
the
beginning of the
fiscal year assuming Council passage of the expedited legislation before June 30, 2010.
I
Office of
tile
Director
101 Monroe
Street,
14th Floor' Rockville, Maryland 20850 • 240-777-2800
www.montgomerycountymd.gov
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Expenditures
Personnel Costs
It is expected that in the first year of implementation two additional fun-time personnel
will be needed for implementation: A Manager of BilHng Services and an Office Services Coordinator.
The FYIl salary, wages and benefits total will be $190,750.
Operating Expenses
Operating expenses for FYI 1 is comprised ofthird party contract expenditures of
$770,870 (5.5% ofgross revenues collected), $200,000 for community outreach activities, and $25,000
for training. Total annual operating expenses for full year operation ofthe program are dependent, in
part, on the negotiated fee for the third party contractor who will manage the bi11ing program on behalf of
the County. Also, the costs of community outreach win be reduced after the initial year of
implementation because the need for these outreach activities will not be as significant when the program
is fully operationa1.
Assistant Chief Scott Graham with the Montgomery County Fire and Rescue Service
contributed to and concurred with this analysis.
JFB:bed
cc: Kathleen Boucher, Assistant Chief Administrative Officer
Richard Bowers, Chief, Montgomery County Fire and Rescue Service
Dee Gonzalez, Office of the County Executive
Dominie Del Pozzo, Fire and Rescue Service
Blaise DeFazio, Office ofManagement and Budget
John Cuff, Office of Management and Budget
OMB~
F;sca! Impact Statement approv.d
¥
L
~
OMB Director
Fiscal Impact Statement not approved, OMB will contact department to remedy.
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PRIVILEGED AND CONFIDENTIAL
ATTORNEY-CLIENT COMMUNICATION
MONTGOMERY COUNTY FIRE RESCUE SERVICES
Updated 2010 EMS Transport Revenue Projections
Submitted
By:
Pagel,lIr
Wolfberg
r&'J~l
The National EMS Industry Law Firm'"
&
Wrrth
Ii.
~
U
April 23, 2010
Page, Wolfberg
&
Wirth, LLC
5010 E.
Trindle Road, Suite
202
Mechanicsburg,
PA
17050
(717) 691-0100
(717) 691-1226
(fax)
Web Site: www.pwwemslaw.com
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EXECUTIVE SUMMARY
If EMS insurance billing is implemented in Montgomery County, Maryland, the
County is projected to generate $61,597,110 in new revenue over the initial four years of the
program. Thereafter, the County would be expected to continue to derive in excess of $15
million per year of new revenue under the program. Under the proposed Montgomery
County EMS transport fee model, none of the projected revenues would paid out of the
pockets of County residents.
This report supplements two earlier reports, submitted in January and November of
2008. The County requested this updated report in light of any changed circumstances in
health care billing, as well as the economic and federal political climate, that may have
impacted our earlier projections. In addition, in January, 2010 the Countytransitioned its
EMS operations from paper-based to electronic patient care reporting, so a limited amount
of actual data became available to replace assumptions that could only previously be made
using informed estimates.
The updated 2010 report adjusts the total four-year revenue projections downward
by $634,392 (from $62,231,502 to $61,597,110) as compared to the four-year projections in
the November, 2008 report. The major reasons (none of which were foreseeable at the time
of the 2008 projections) for this change, in order of impact, are:
• MCFRS dispatch data show a lower-than-anticipated Advanced Life
Support (ALS) dispatch rate, resulting in fewer transports being
eligible for
AL~
reimbursement under the ALS Assessment rule;
• MCFRS ePCR and. dispatch data compelled revising the ALS vs.
Basic Life Support (BLS) transport ratio
trom
57:43 to 45:55.
• Medicare implemented a 0% Ambulance Inflation Factor (AIF) for
2010. While future years' AIF are expected to be positive, uncertainty
over counterbalancing Medicare cuts under the pending federal health
care reform legislation have conservatively led us to assume a 0%
inflationary adjustment in allowed charges in years 2-4 of these
projections; and
• The Geographic Practice Cost Index (GPCI) (which is used by
Medicare to calculate ambulance fee schedule reimbursement rates)
for Maryland Locality 01 was adjusted from 1.08 to 1.057 in 2009.
In addition, the limited ePCR data made available by the County also showed a
higher volume of Advanced Life Support - Level 2 (ALS2) transports than previously
anticipated, though this had a negligible (but slightly positive) impact on the projections.
Montgomery County, Maryland
Updated 2010 EMS Transport Revenue Projections (April 23, 2010)
Page 2
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TABLE OF CONTENTS
Executive Summary........................................ ,................................................. 2
L
II.
Overview................................................................................ , . ......... ...... 4
Methodology and Assumptions.................................................................. 5
A.
B.
C.
D.
E.
F.
G.
H.
L
Time Intervals ...............................................
n
..............................
5
Estimated Transport Volume ............................................................ 5
Transport Mix by Payor. .................................................................. 5
Transport Mix by Level of Service..................................................... 6
Payor Type .................................................................................... 7
Self-Pay Transports ....................................................................... 7
Mileage................... : ................................................................... 7
Charges...................................................................................... 7
Approved Charges ........................................................................ 8
"Allowables................................................................................... 9
Patient Care Documentation............................................................ 9
J.
K.
111.
Reve,nue Projections................................................................................. 10
A.
B.
C.
Total Cash Receipts ....................................................................... 10
Average Revenue Per Transport....................... ............................... 10
Gross and Net Collection Percentages.............................................. 10
IV.
V.
Conclusion........................................................................................... 12
Important Notices ................................................................................... 12
Appendix A - Year One Revenue Projections ........................................................ 13
Appendix B - Year Two Revenue Projections ........................................................ 16
Appendix C - Year Three Revenue Projections ...................................................... 19
Appendix D - Year Four Revenue Projections ........................................................ 22 '
Appendix E - EMS Rate Setting Article .................................................................. 25
Montgomery County, Maryland
Updated 2010 EMS Transport Revenue Projections (April 23, 2010)
Page 3
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I.
Overview
Montgomery County Fire Rescue Services (MCFRS) is evaluating the potential
implementation of an EMS Transport Revenue Recovery Program. MCFRS has engaged
Page, Wolfberg
&
Wirth, LLC (PWW), a national EMS industry law and consulting firm, to
assist it in this process. Among the tasks with which PWW is charged is the development of
revenue projections that might be realized in the event that the revenue recovery program is
implemented. PWW was asked to update these projections in March, 2010 and to make
revisions in April, 2010. At that time, some of the first electronic patient care reporting
(ePCR) data became available, with the system having been implemented countywide in
January, 2010. We have stated in this updated report where assumptions were changed
based on these data, though it must be noted that two months of data might not be
representative. of EMS trends in the County. Nevertheless, where actual data are now
available to replace prior assumptions in certain aspects of the projections, the data will be
used instead of the assumptions.
When assessing potential revenues from any proposed health care billing
undertaking,
it
must be remembered that revenue forecasting is both an art and a science;
there is little in the way of published, publicly-accessible data from which meaningful
comparisons to similar jurisdictions can be drawn. Whenever possible, key assumptions
affecting these projections were kept on the "conservative" side, and many such
assumptions are based on our experience in working with EMS systems of all configurations
across the United States. All assumptions made in the generation of these projections will
be stated so that Montgomery County elected officials, policymakers and Fire Rescue
leadership can be guided accordingly.
Our detailed revenue projection spreadsheets for Years One - Four are attached to
this report as Appendices A-D.
Previous revenue projection reports dated January 18, 2008 and November 13, 2008
were also provided to the County.
Montgomery County, Maryland
Updated 2010 EMS Transport Revenue Projections (April 23, 2010)
Page 4
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II. Methodology and Assumptions
A.
Time Intervals
This report provides four (4) years of revenue projections. We utilized 2010
Medicare rates as a starting figure for this updated report. The reports are presented on a
Calendar Year (CY) basis. These projections were made on a CY basis primarily because
Medicare (from which. the single largest portion of revenues is expected to be derived)
typically adjusts its allowed rates on a calendar year basis. CY projections can easily be
converted into Fiscal Year (FY) projections by taking a pro-rata share of the annual
projections and combining them with the corresponding pro-rata portion of the subsequent
calendar year's projections.
B.
Estimated Transport Volume
This
statistic is the key driver
in
any EMS transport fee revenue projection mode\. We note that
MCFRS previously utilized a paper patient care reporting approach, which limits both the
accuracy and the quantity of available data from which these projections can be made.
Starting in January, 2010, the County transitioned to an electronic patient care
reporting system (ePCR). For the purpose of preparing this updated 2010 report, two
months of 2010 data was made available to PWW for review (January and February 2010).
Although caution should be taken in generalizing a mere two months of ePCR data
(particularly in months where two of the worst weather-related events. of the past 25 years hit
the region). the data generally confirm the transport volume estimations made by
PWW
in
the 2008 reports. For instance, the estimated ALS1-Emergency transport volume in Year
two of the November 2008 PWW report was 12,535, or an average of 1044.58 transports
per month. According to the MCFRS ePCR data for January, 2010, the reported number of
ALS transports in January, 2010 was 1029, a variation of less than 1.5%. Therefore, the
total transport volume estimates have not been modified in this report.
Modest annual increases in call volume, which can be expected as population grows,
continue to be assumed in these updated 2010 projections, as they were in the 2008
reports.
C.
Transport Mix by Payor
All
estimated transport volumes utilized in this report were provided by MCFRS.
Transport mix estimates are found on the top of each spreadsheet (Exhibits A-D).
The "transport
mix~
is the number and percentage of transports by applicable payor type.
Because MCFRS has not previously billed for EMS transport, these payor mix
percentages are estimates which are, if anything, designed to conservatively underestimate
revenues. It is possible that in actual experience, the "Self Pay" category (which includes
uninsured patients and patients for whom insurance cannot be identified) will be lower than
the estimated 28%. In addition, the possible enactment of federal health care reform
legislation might ultimately reduce the Self Pay category by moving more of the uninsured
into an insured category. Lowering the Self Pay category would move more people into
either the Commercial Insured, Medicare or Medicaid categories, which would have
a
resulting increase on revenues. However, we believe it is best to continue to estimate the
Montgomery County, Maryland
Updated 2010 EMS
Transport
Revenue Projections
(April
23, 2010)
Page 5
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payor mix more conservatively and therefore will continue to use the previous payor mix
estimates.
D.
Transport Mix by Level of Service
Within each payor category, we utilized a consistently estimated approach to the
level of service mix (Le., BLS vs. ALS). In our 2008 report, we utilized an ALS-BLS ratio of
57143
(Le., 57% ALS, 43% BLS). In the two months of 2010 dispatch data provided by the
County, we note that approximately 60% of all dispatches were categorized as BLS (59.3%
in January, 2010 and 60.3% in February. 2010). These data appear to under-triage the
reporting of ALS conditions at the time of dispatch when compared to our experience in
other jurisdictions. The
57143
projections used in the 2008 report were conservative based
on our experience in other jurisdictions, and frankly we were surprised to see such a low
percentage of ALS dispatches in the January and February 2010 data.
Medicare rules reimburse ambulance services at the ALS1-Emergency level for
medically necessary. covered transports when the provider furnishes a qualifying "ALS
Assessment," even if no ALS interventions are provided. However, a prerequisite to billing
for ALS Assessments is a qualifying ALS-Ievel dispatch. Because MCFRS data suggest
under-triage of ALS dispatch conditions, we are revising the ALS/BLS ratio to
45155.
We
are selecting 45/55 because, even though the reported percentage of ALS-Ievel dispatches
are only 40%, there will undoubtedly be a number of calls where the reported dispatch is
condition is BLS but the patient is found to require an ALS intervention. The revision of
these service mix estimates will have a negative effect on the revenue projections, though
that will of course make the projections even more conservative.
Certainly as more ePCR and CAD data become available, these service mix
estimates can be revisited.
It is also important to note that we assigned a small (almost negligible) percentage
(1 %) of transports to "non-emergency"'evels of service. We recognize that MCFRS is solely
a 911, emergency provider. However, until dispatch protocols are fully integrated with billing
systems, there is a chance that on a small percentage of calls, billers will not have the
requisite emergency dispatch information available to them and, acting out of an abundance
of compliance, will code the claims as "non-emergencies." That is why non-emergency
levels of service are included in the model.
We also included the "Specialty Care Transport" (SCT) level of service on the
spreadsheet model, though we did not assign any transports to this category. SCTs are
interfacility transports, which we presume would not
be
handled by MCFRS, though the SCT
category is included in case MCFRS would like to investigate the financial impact of
providing this type of service in the future.
In our 2008 reports we also assumed a relatively conservative 1% for "ALS2" level
transports. This is a more intensive (and higher-reimbursed) level of service that applies
when a patient receives invasive interventions such as endotracheal intubation. We note
that the January/February 2010 ePCR data reported by MCFRS suggest that the actual
ALS2 percentage might be as high as 2.1 %. Accordingly, we have adjusted our ALS2
service mix from 1% to 2%. A small positive impact on revenues will result from this
change.
Montgomery County, Maryland
Updated 2010
EMS
Transport Revenue Projections (April 23, 2010)
PageS
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E.
Payor Type
There are four payor types utilized in these projections: Medicare, Medicaid,
Commercial/Auto Insurance and Self-Pay.
As
a provider of emergency, 911 services only,
we assumed that MCFRS will not enter into contracts with Medicare managed care
rMedicare Advantage") organizations or other commercial payors. Therefore, because non­
contracted providers are paid by Medicare Advantage plans for emergency transports at the
Medicare fee-for-service rates, all transports of Medicare Advantage patients are included in
the "Medicare" category. "Medigap" copayments are also included in the Medicare
category, with an estimate of 52% of copayments being paid by these Medicare
supplemental insurance poliCies ("Medigap"). Similarly, the "Commercial/Auto Insurance"
category includes commercial managed care plans, traditional indemnity "fee-for-service"
plans. automobile liability insurance policies, workers compensation payments, and similar
types of commercial or self-insurance.
F.
.
Self-Pay Transports
In this model, we assumed that the County would implement an "jnsurance only"
billing policy, under which County residents would
be
billed only to the extent of available
insurance. County residents would not be billed for co payments, deductibles or other
charges unmet by their insurance coverage (in addition, no payment would be collected
from uninsured residents). We assume that 90% of patients in the Self Pay category will be
County residents, and. therefore that only 10% of the Self Pay category are non-residents.
We further also assume a collection rate of 30% from the non-resident, self-pay population
in this model.
G.
Mileage
Medicare and most commercial payors reimburse ambulance services for "loaded"
miles, Le., for those miles which the patient is on board the ambulance, from the point of
pickup to the closest appropriate destination. We made the assumption,. given the
geography, population centers and population density of the County, that the average
transport would include five (5) loaded miles. As with all assumptions in this model, this
particular assumption can be modified to determine the resulting impact on revenues if
desired.
H.
Charges
We included a proposed schedule of charges for each level of service.
Of
course,
the selection of a rate schedule is entirely up to County policymakers and is typically a factor
of many economic and political considerations. However, the County's charges should,
without question, be a fair amount higher than the prevailing Medicare-approved rates,
because, under Federal law, Medicare pays the
lesser
of the approved Medicare fee
schedule amount
or
the provider's actual charges .. In other words, if a provider charges
less
than the applicable Medicare fee schedule payment, Medicare does not "make up the
difference." It becomes legitimate revenue that is irretrievably lost and cannot be recovered
from any other source. Establishing rates that are comfortably above the approved
Medicare fee schedule amounts is a paramount consideration in the establishment of any
ambulance rate schedule.
Montgomery County, Maryland
Updated 2010 EMS Transport Revenue Projections (April 23, 2010)
Page 7
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We assumed an annual increase of
5%
in the County's ambulance rate schedule
(Le., charges) in years
2-4.
An article dealing with ambulance rate-setting that the County might find helpful is
attached to this report as Appendix
E.
I.
Approved Charges,
For each payor category (except, of course, for self-pay), we estimated an "approved
charge." This is the amount that Medicare, Medicaid or commercial insurers will approve for
the particular level of service. Medicare rates are established annually according to a
national fee schedule and vary slightly based on geography {due to the incorporation of the
"Geographic Practice Cost Indicator" (GPCI) from the Medicare physician fee schedule into
the Medicare ambulance fee schedule. The
2008
projections assumed a GPCI of
1.08,
which was at that time the applicable GPCI for Maryland Locality
01.
For purposes of this
2010
updated report, we note that the Medicare approved charges reflect a GPCI for
Maryland Locality
01
that was slightly adjusted in
2009
by Medicare to
1.057.
This will have
a negligible, though slightly negative effect on the projections.
We also note that in our
2008
report, we used
2008
approved Medicare charges as
the "starting point" upon which all subsequent years' projections were based. For purposes
of.this updated
2010
report, we are using
2010
approved Medicare charges as the starting
point, which are approximately
3.4%
higher than they were in
2008.
With regard to the GPCI, a portion of the Medicare Ambulance Fee Schedule is
adjusted to reflect geographic cost differences in providing ambulance services in different
parts of the country. Because Medicare found it inefficient to develop a national cost index
specific to measure the different costs of providing ambulance services across the United
States, it simply "borrowed" a geographic cost formula it had already developed for the
Physician Fee Schedule and incorporated into the Ambulance Fee Schedule. That formula
is the "Practice Expense" portion of the Geographic Practice Cost Index (GPCI) from the
Physician Fee Schedule.
Medicare rates have historically increased annually by a modest inflation factor. In
2007,
Medicare announced an Ambulance Inflation Factor (AI F) of
2.7%
for dates of service
in CY
2008.
A
5%
AIF was adopted for dates of service in CY
2009.
Since the adoption of
the Medicare ambulance fee schedule
in
2002,
there has consistently been a positive AIF.
Therefore, we conservatively assumed a
2.5%
Medicare AIF for years
2-4
of the projections
in our
2008
report. However, since the AIF is based on
a
consumer price index, and
because of deterioration in the overall economy, Medicare adopted a
0%
AIF for
2010.
In
addition, as of December
31,2010,
some temporary Medicare ambulance increases expired
and were not legislatively renewed. Finally, the pending health care reform legislation
WOUld, if enacted, result in Medicare cuts over the next several years, though ambulance
reductions are not specifically targeted. Nevertheless, we are modifying our projections to
presume a
0%
AIF in years
2-4.
We do not believe it to be likely that there will be continued
0%
growth in approved charges, but In order to keep these projections as conservative as
possible, we are assuming
0%
inflation in the
2010
base rates for years
2-4
for the Medicare
and Commercial categories. As in our
2008
reports, we assumed no annual increase in
Maryland Medicaid rates, which are a flat
$100
(ALS or BLS) with no allowance for loaded
mileage.
Montgomery County, Maryland
Updated 2010 EMS Transport Revenue Projections (April 23, 2010)
Page 8
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For commercial insurers, we assumed an overall percentage of approved charges of
67%. It is very difficult to predict with certainty how this payor class will respond to the
implementation of an EMS billing program. Some commercial insurers pay 100% of billed
charges for emergencies without question; others take aggressive stands against paying full
charges and often will pay some arbitrary amount that they deem to be "reasonable." We
believe that an overall figure of 67% of charges takes these variables into account.
The difference between MCFRS's charges and the payor-"approved charges" are
ordinarily not collectible. With regard to Medicare, this is considered to be "balance billing"
and is prohibited by Medicare law. These mandatory "write offs" are referred to as
"contractual allowances."
J.
"Allowables"
For each payor category, we included an estimated
"aHowable~
percentage. This
can be confusing, but an "allowable" percentage is the percentage of the payor-approved
charges that MCFRS can expect to be paid. In other words, once Medicare applies the
"contractual allowance" referenced above and determines the "approved charge," Medicare
only pays the provider 80% of that approved charge. The remaining 20% is a copayment,
which is the responsibility of the patient. As state above, in this model, we assume a
Medicare copayment collection rate of 52% from "Medigap" insurers, which generally pay
these copayment amounts, without regard to residency status, automatically after Medicare
makes the primary payment.
We utilized a 100% "allowable" figure for Medicaid and commercial payors, but,
again, remember that this is
not
the same as assuming a 100% "collection rate" from these
payors. This merely means, to use Medicaid as an example, that Medicaid can be expected
to pay 100% of
its approved charge
for ambulance services (currently. $100) and
not 100%
of MCFRS's actual charges.
We utilized a collection rate of 30% for self-pay accounts (i.e., the estimated 10% of
the self-pay category that are non-residents), again reflecting the likely adoption of an
"insurance only" billing policy for residents.
K.
Patient Care Documentation
One key variable not reflected in these projections is that EMS billing is only as good
as the field documentation that supports it. For instance, EMS providers must thoroughly
and accurately document information necessary to support proper billing decisions,
including patient condition, treatment and other clinical factors, and must collect signatures
of patients (when possible) or other authorized signers at the time of service. The County
should provide periodic documentation training for all EMS personnel in the County to
ensure that legally defensible and compliant documentation is completed in all cases.
Inadequate or inaccurate completion of patient care reports can negatively impact projected
revenues. The County's January, 2010 implementation of an electronic patient care
reporting (ePCR) system will undoubtedly be
a
significant benefit in producing quality EMS
documentation as well as reliable EMS data.
Montgomery County, Maryland
Updated 2010 EMS Transport Revenue Projections (April 23, 2010)
Page 9
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m.
Revenue Projections
A.
Total Cash Receipts
We have broken down projected cash receipts by each payor, and then calculated
an overall total. Year One revenues are projected at approximately
$14.1
million. Years
Two - Four projections are approximately
$14.9
million,
$15.7
million and
$16.7
million,
respectively. Again, County policymakers and budget officials must take into account the
assumptions and limitations discussed above when budgeting anticipated revenues from the
EMS transport fee program.
B.
Average Revenue Per Transport
For each year, we project an Overall Projected Average Revenue Per Transport.
This is a simple calculation of gross cash receipts divided by total transport volume in a
given year. This takes into consideration all revenues from aI/ payor sources and aJllevels
of transport, but it is a helpful "global perspective" of billing performance.
It could be argued that the Average Revenue Per Transport estimates, which range
from approximately
$248 - $262,
are optimistic. Of course, this is directly related to the rate
structure that the County's policymakers ultimately decide to put into place. Nevertheless,
we have compared Montgomery County to other jUrisdictions and believe there are some
compelling reasons why these Average Revenue Per Transport estimates are reasonable.
First, Montgomery County has a comparatively high median household income.
According to U.S. Census bureau statistics, Montgomery County median household income
in
2004
was
$76,957,
compared with
$57.019
for all of Maryland. This puts Montgomery
County in the highest median household incomes in the United States. Given this statistic
alone, some could argue that our Average Revenue Per Transport estimates are
too
conservative.
Second. we compared these Average Revenue Per Transport Estimates with other
jurisdictions in the U.S. (using data available to us in
2008).
While these data do not always
take into account the same factors, and thus creates a potential problem of comparing
"apples and oranges," these data can be informative. For instance, in Dayton, Ohio
(according to data obtained from that City's ambulance billing contractor), a city with a
median household income of
$34,978
and approximately
16,000 EMS
transports per year.
the average revenue per transport was
$217.
On the other side of the spectrum, in Nassau
County, New York, with a median household income
($80,647)
comparable to Montgomery
County's, and
42,106
annual transports, the average revenue per transport reported by their
billing contractor is
$380.
We therefore believe that the Average Revenue Per Transport
estimates in this revenue projection are realistic, again, depending upon the rate structure
implemented by Montgomery County.
C.
Gross and Net Collection Percentages
One common EMS billing measurement is the "collection percentage."
Understanding your projected collection percentage
is
vital when evaluating the ongoing
effectiveness of an outside billing contractor.
Montgomery County. Maryland
Updated 2010 EMS
Transport
Revenue Projections
(April
23. 2010)
Page 10
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When measuring collection percentages, it is critical to distinguish the concepts of
"gross" versus "net" collection percentages. Gross collections look at actual cash receipts
divided by total charges. Net collections, on the other hand, look at actual cash receipts
divided by the amount the provider is allowed to collect for the particular service, after the
mandatory contractual allowances required by law are deducted. While both of these .
measurements of billing performance have their weaknesses, the use of a gross collections
percentage as a measurement of billing performance is highly artificial.
Consider the following example. Say that an agency
charges
$600 for a BLS
emergency call. Now, say that Medicare only
approves
$250 for a BLS emergency. Under
the law, as discussed above, your agency must write off the difference between its charge
and the Medicare approved amount In this example, that "contractual allowance" would be
$350. Under a gross collections approach, assuming you were fully paid by Medicare, and
succeeded in collecting the 20% patient copayment (which likely would not be the case with
Montgomery County residents), you would only have collected
41.7% -
or
$250/$600.
However, under a net collections approach, your agency collected everything it was allowed
to coliect under the law. so your net collection percentage on this claim was
100%.
The gross vs. net collections approach - as shown in this example illustrates how
relatively easy it is to "manipulate"your "collection percentage" merely by adjusting your
actual charges. For instance, say the ambulance service in our example above decides to
increase its BLS emergency charge from $600 to $800. Now, its gross collection
percentage on the sample claim drops to 31%; or
$250/$800.
The amount approved by
Medicare doesn't increase merely because your charges increased, so the result is a drop in
your gross collection percentage. However, the amount of cash you actually received
stayed the same. So, on paper, your billing operation, when measured by a gross collection
percentage, looks like its performance is getting worse. when actually
it
may be unchanged,
or even better when you look at actual cash received. The reverse of this example is also a
potential pitfall: lowering your charges would have the result of artificially
increasing
your net
collection percentage, while not necessarily improving your cash receipts, thus perhaps
making billing performance seem better than it is.
We prOjected both gross and net billing percentages for purposes of this report. The
estimated gross collection rates are, conservatively, lower than reported national averages.
For instance, the Jems
200
City Survey in
2007
reported that the average gross collection
percentage for public-sector EMS agencies was 55.9%. Our gross collection percentage
estimates for Montgomery County run in the
50-51
% range.
It is likely that lower gross collection percentage estimates do result in higher
net
collection percentage estimates. This is because a lower
gross
percentage means that
more of the "unallowed" charges have already been written off, leaving more "pure" and
collectible revenue on the table. Therefore, one would expect that the
net
collection
percentages would be higher. There are no meaningful. national net collection data
reported of which we are aware. Nevertheless, again, because the net collection percentage
represents income to which the County is legally and legitimately entitled, and already
factors in the allowed
~mounts.
contractual write offs and very low estimated self-pay
percentage, we believe that the net collection percentages represent realistic expectations
for a billing contractor to achieve for a county as affluent as Montgomery County, Maryland.
Montgomery County,
Maryland
Updated 2010
EMS Transport
Revenue
Projections (April 23, 2010)
Page
11
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IV. Conclusion
Though based on many variables that are subject to change, these EMS billing
revenue projections demonstrate that there are substantial revenues that could be realized.
were Montgomery County to implement an EMS transport fee. Of course, the decision on
whether or not to do so, and on how any realized revenues would be allocated, is up to the
sound discretion of the County's policymakers.
V. Important Notices
These projections are estimates only and not a guarantee of financial performance.
All projections are based in large part upon data supplied by the client. Estimating revenues
from the provision of any health care services involves many variables that cannot be
accounted for in a revenue estimate and that are beyond the control of the estimator. The
consultants have stated all key assumptions and have provided a relational spreadsheet
that allows the client to modify any assumptions that it finds necessary. The client is
responsible to verify a/l assumptions that affect these projections and to modify them when
necessary. This estimate does not constitute the rendering of professional accounting
advice, and does not take any expenses into account. Revenue projections can also be
impacted by changes in applicable reimbursement laws and regulations. The consultants
are not responsible to update this analysis unless asked to do so by the client. Finally, the
decision to undertake EMS billing rests entirely with the client, and the client bears all
responsibility for appropriate and compliant billing operations.
Montgomery County, Maryland
Updated 2010 EMS Transport Revenue Projections (April 23, 2010)
Page 12
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Appendix A
Year One Revenue Projections
Updated
04/23/10
Montgomery County, Maryland
Updated 2010 EMS Transport Revenue Projections (April 23. 2010)
Page 13
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Montgomery County, MD
EMS Transport Fee·
Reve"-~~£,r()jectlo~
Year One
Total
Est.
Est.
Est.
Commercial!
Auto
-----
Medicare
_
Payor: Medicare (40%)
_
f:.l':§~_N_E
(A0428)
f:.lI.S:~_~()<I29L
__
Al~l-NE (A0426)_~_"
ALS1-E
ALS2
seT
(A043j2_
Loaded Miles JA0425)
~ve~!lge,!rip)
Est.
%
of
P_ay~r:
Medicaid
BLS~NE~04~8)
B,:§~UA0429)_
ALS1-NE
JA04~~L
ALS1-E (A0427l ___
loaded Miles (A0425) (Averageffrip)
BLS:IIl§JA0428) "________
BLS-E~=-:::"~
_ _ _ _ _ _ _ _ _
~
~~l:!'lE
(A0426) ____
AL~:E
(A0427)
_
ALS2Jt-04~_
@
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I
J\LS1:§ (A0427) ____
~~
_ _ _ _
~~~.~+--
_ _
---,.:::.c:.-;-=-_--".-'..C~+
AlS2
SC;!J}\0434_)
_~~
~~
_ __
!Cl.ad~}~"~es
(A042..5) (j\yerCigeffrip) _
GRAND TOTALS ­
CHARGESIAPPROV~E~~_D-,C_H_A_R_G_E_S_~~~--;-
_ _ _ _ _
-+__
~~~
--~----
~~~--"--'l..:..c..:..~v:.olume
is
basedonE!~~imates
provided by Montgomery County Fire Rescue
----1­
I
·=r~~n
2 Estimated number of Medicare
t~I1!1JlOJ:!s
perlevel of servic:eestifll_ated based on comparable M[)f'./Ajurisdictions
3 2010 Medicare rates taken from 2010 Ambulance Public
-------
File from the Centers for Medicare and Medicaid Services
--------
4 Medigap estimate is 52% of total Medicare copayments: Medicare copayments are 20% of Medicare approved charges
~iIIing
for any health care service involves many variables that
cannot~
be accounted for in
a
revf1nue estimate an,d that are beyond our
con~rol.
This is an estimate only and doeS not constitute
a
~,.antee.
i
.~..
I
I
i i i
5~on-resident
self-pay
ChargeS~s.t'fllated!Cl.COmprise1o~<Ji~to~Ge~f~£~i<:ha~geS
I
'
.'
®
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Appendix B
Year Two Revenue Projections
Updated
04/23/10
Montgomery County, Maryland
Updated 2010 EMS Transport Revenue Projections (April 23, 2010)
Page 16
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Est.
1-····------­
Montgomery County MD
,
EMS Transport Fee ­
Revenue Projections
Year Two
Total
Medicare
E~t.
Est.
Commercial!
Auto
- - - + - - - - - - , - - -......... .
Est.
%
of
Est.
%
of
Payor: Medicaid
Est. Medicaid
Transport
Volume
24 $
1.280
$
100
Payor: Commercial/Auto (28%)
BLS-NE
BLS-E
ALS1·NE (A0426)
I·····
----.........
ALS1-E
~~§~
(A0433L__
SCT (A0434)
Loa~.ed
Miles(A0425)
Est.
%
of
Transports
Charges
Est. Ins.
Approved
Charge
Est.
Total Insurance
Commerclal/A
Approved
uto Volume Total Charges
Charges
1%
$
315
$
210.11
280.14
245.46
350.18
490.25
166
$
52.290
$
34.877
2.510,054
40.746
I
---54~i
$
8,960$}.76i2001'.!..
166
..... - - - ­
$
61.088
$
2,510,054
40,746
2,440.370
t - - - - - + - - - - ­
162,761'+--_ _ _
+ ___
--1
-U-"T
6,969
$ 2.440.370
332
$ .
162,7~1
-
$
I~~,no
$
(Av~ra~:e.'!rip)
'sT-
i
0%
$
840
8
$
560.28
5.60
I
I
-
i
$=--------+-----'--1-...._.____
-+_ _
670,068
~u$
446,935
I
I
5.635,744
I
!
®
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I
Est. Self-Pay
I
I
'~!:~~~:t)'
t
....
~~~~~~1~~;:)8)
Payor: Self.Pay (28%)
. .-
_n . .
.
Est.
%
of
!
I
Transport
Transports: Charges
I
Volume
SCT'(A0434)I'
L~~d;dMil~~A0425)
(AveragelTriP)-r----5 i,_$-n
"1
,
I'
.•
1·-~~i~I~~ff---6!~-
r--···-=t
oo~h--840
1--
.
. .
~~I:
__
n~~~1
8,~:H
I
N/A
!
Total Non-
Est. Non-
I
Total Self-Pay Resident Self-.
Resident
I
Total Self-Pay
5
Charges
i
Pay Charges
!
Collection%
I
Cash Receipts!
I
I
SI
I ' · ..__..
I
I.
I
­
$--
$-"';~~~---=3?:~-!Eli: 10::!:~ !_T~-"
-=-1- -- -
... -_.
--3'7!i~~~+~- 37~~~~~u-~ ~~~H
-
··~-:-~~!~---···=r
670~~--n
67,007+
.
·-30%L$----[­
30%. $
.
79
.77()l
I
I
I
...
-_. !u----,=oTALI
$
I
I
,
1
_ ...
253,482-1-­
. _ -..
20.102~!
'
I
I
~-'I
GRAND TOTALS -
CHJ\RGES/AflF~HOVED
CHARGES
I,
. . . . ._ _ _. .
__
I
GRANDTOTAL • PROJECTED dASH
RECEI~TS
-
YEA~TWO
OVERALL PROJECTED AVERAGE REVENUE PER TRANSPORT
Gf~OSS C()LI..~CTIONPE~~ENTAGE
.
I
!
I
:
, i
i.!
30,174,850
I
, i
I
I
I
$ 26,225,923
I
...
n"1
. . ._ . . .. . . . _ :
_
.._
.•...
1___
-----:
I.
r--
r
-IT14;94U5oT
NE~_COLL~~CENTAr~j..
I
...
]l ___
n
II,'
--
I
[~2.010 Medicarer~tes
taken from 2010 Ambulance. Public Use File from the cente.r.s for.
Medic.~re.and
M
..edicaid s.erv.ic. es
.
14
Medigap estimate is 52% of total Medicare copayments; Medicare copayments are 20% of Medicare approved charges
5-Non-resident
estimated to
com~e1Q%
of
tota,-self~p~ycharges- !~~~L---
Footnotes:
1_Transport volume is based on
estim~;ided
by
Mo~tg-;;~~Co;;ty
Fire
Res(;lJl:l_~
2 Estimated number of Medicare transports per level of service estimated based on comparable MONA jurisdictions
I
570/0~
I
.
iJ-'__
.
i
:
l~f~
_____
-5-::0-c-%:-+i-~--'
11-"
252:
.-­
. . .
t=
f
---'-i'__
--L
un.
f-----
nT
!
___
_-+-____.
l--.l
I
:
B.ll!!ng for any health care service involves many
varlables!l'I~t
Cimnot
b~ac:counted
for In
a~~yenue
estimate and that are beyond our control.
This is
an
estimate onlv and does not constitute a...ID!.arantee.
I !
1
®
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Appendix C
Year Three Revenue Projections
Updated 04/2311 0
Montgomery County, Maryland
Updated 2010 EMS Transport Revenue Projections (April 23, 2010)
Page 19
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Montgomery County, MD
EMS Transport Fee -
Revenue Projections
___
Total
Medicare
E~t.
,
Est
Est.! Commerciall
Medicaid
i
Auto
Transports
i
Transports
(4%)
__
:
_ _ _ _ _
__
(28%)
_~~
L~~
Year Three
---- r
I
I
2,465
!
17,255
---i------'­
!
~Esi-·-t
Medicare
Transport
Volume
1
!
-\-._.
i
Total
J47J
$
Loaded
~~(ACl4?~)
J.>.VI"r"nPI
--
Est. Medicaid
-I
Est.
%
of
Payor: Medicaid (4%)
BLS-N~421!>_______
_ __ . _
ALS
1-N~(~..Cl42!1)
AL~1-E
(A0427_)____
ALS2 (A0433)
SCT_~A0434)
---~----
Pa~r: C~lllmerciall
Au_to----'-_--'-+­
BLS~~~(A042~)
._ _ _ _ _ _ _
.--+_ _ _ _ _
__'+_
B.LS-EJAQ42.!:j)
~LS1-NE (A04~)
$
. _.
-
~
$
79,770-1$
I
44,541
177.41.9.
-
100%
$
100%.1
$
100%1
$
100%1$
TOTAL
I
$
ALS2
(A04.3~_)
__
$
265,995.
$
- ,$
I
2,663,396
177
469, 282
~f~
.41~_-==
_. _
._~_.___
!
:
1
_____ ..._______ ..__
70~57'4$_
I
469,-282.!1___
.i
­
_
6.133.578
I
®
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Est Self-Pay
Est.
%
of
Transport
Total Non-
Est
Non.
~_ P~Jor:
BLS- Ni::(AQ428)
BLS-_E_~~_~_,~
__
Transports
~,
_______
~
______
~~
____ _
Volume
___
N_~/~A
_
~f---
_____
~_-l-
_ _ _
~~--+~"
___________
+--__
_
----t-$'------~-'--~+_--~-'------i-------,+-::-----
ALS?~A~~33)
SCT (A0434)
Loaded
Mile~ (A04~veragE!'!l"ip)
GRAND TOTALS ­
CHARGES/APPROVED CHARGES
-------+------+----f-------f-------~~~-,..
!t=()()tnote!i:_
_
________
~
___
_ L_ _
1 !ransport volume is based
011
estimates (l!ovided by
MontgoITlElry_~ounly
Fire
~Elscu_e
,_____
____
~
__ _
2 Estimated number of Medicare
level of service estimated based on
p~~~M~D~N':!:A~~~~~~__.l
___
3 2010 Medicare rates taken from 2010 Ambulance Public Use File from the Centers for Medicare and Medicaid Services
4
estimale is 52% of lotal Medicare
Non-r!!!)idenl!)elf-payc:~l"ges
estimated to
Medicare
10% of total
l'f",,,vm,,nt,,
-~~---~----_r~---~----------~--'
Billina for an" health care service involves man" variables that cannot be accounted for in
a
revenue ....
'ClHI,'. . . .
This is
an
estimate onlv and does not constitute
a
auarantee.
I
®
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Appendix D
Year Four Revenue Projections
Updated
04/23/10
Montgomery County. Maryland
Updated 2010 EMS Transport Revenue Projections (April 23, 2010)
Page 22
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Montgomery County MD
'
EMS T
ranspo
rt
Fee-
Revenue Projections
~~~~--
Total
Est.
Est.
Medicaid
Est.
Commercial!
Auto
--,---­
Year Four
Medicare
Total
Medicare
~r:
l\IIedicare
{4-0cyot
___
:
Medicare
Total Medicare
BLS-NE
(A04~~)
_ _ _ _......
Loaded Miles (A0425) (Average/Trip)
Est. % of
Payor:
----------
Medicaid
--
(4%)
-----~~--
---------t--~---
i
Loa..<l.ed Miles (1\0425) (Average/Trip)
-------
Totallnsur
Approved
Insurance
payo._. :Coml!'ercial/Auto
r
BLS-NE (A0428)
Cha.'"!Jes
41,310
_~~~
.....
_"---'-_t--'-_2~,9_92,~~5
I
Total Insurance
Allowa.b._.h~
c
a.
.S..
hFteC~iP.::-:-:-t-.
...
..
ts
100%$
1
OO%~_
~,31Q..L
2,9_9_2,_47_5
------­
290.431
926
5
$
9.26
$
738,670
$
492,693
100%
$
492,693 :
I
TOTAd
$
6,674,260T
®
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Total Non-
Resident Self-
Est. Non-
Resident
1;)~()!=_§'~lf-f'~y~~)
--=c'-'-'-l-"'-----j
""---1
ALS1-E
AL~2j,l\043..31
SCT (A0434)
Loadedtv1i~~(M425)(A\leragelTrip2
---
,_ _
16Q~
_ _ ,
22,
300,192
GRAND TOTALS­
CHARGES/APPROVED CHARGES
I
I
1 Transp0.r!volume is
bas~don
estimates provided by
Mon~ome'1'.C:ounty£ire
Re:..:s..:::c.::.ue-=----_ _,_ _
"J,' _ _ _ _ _,
+ - - - - - - 1 - - -
+______:----___
- j
COClaVlrnellts:
Medicare
cmlavmenls
5
Non-resi~ent
self-pay,
estilllated to compriSi'l10% of total
Billing for any health care service involves many variables thatcannot be accounted for in
a
revenue estimate and that are beyond our control.
I
-~""
I
"i
'
11
This Is an estimate onlv and does not constitute
a
!luarantee.
®
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AppendixE
EMS Rate Setting Article
Montgomery County, Maryland
Updated 2010 EMS Transport Revenue Projections (April 23, 2010)
Page 25
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How
SHOULD YOUR AMBULANCE
SET
ITS RATES?
If
your EMS organization charges for Its serv­
SERVICE
LEGAL
CONSULT
INCISIVE ANALYSIS OF
EMS LEGAL TOPICS
above that approved amount (except for his
('~'\\
ices, you probably spend days, weeks or or her deductible-iI applicable-or co-pay·
.'
months learning
all
the complex: rules about ment). So you must write off the dHference
b!lling. But if you ask administrators how between your rates and the Medicare fee­
they set their rates, many will provIde an schedule rates.
answer that is only slightly more advanced
Knowing these c.ontractual allowance
than "We pull them out of thin air." However, amounts will prove critical In measuring,
whether your service is public, private or your billing performance. Many
EMS
organi.
not-for-profit, proper rates are crudal to your zations focus on ca1cwating collection per­
organization's overall success, and a rate-set­ centages, but be sure you measure
perform~
ting strategy that complies with the law
Is
ance consistently. Gross collection percent­
fundamental.
ages measure the amount collected versus
First and foremost, start by taking accurate the total amounts blUed. Net collection,
measure of your organization's costs. This percentages-which generally provide
a
includes an assessment not only of such blg­ more meaningful measurement of
billing
ticket line items as personnel, vehicles, performance-evaluate the total
amount'col~
eqUipment and insurance, but also an assess­ lected versus the total amounts billed,
ment of
fuel,
maintenance, heat, electricity . minus the contractual allowances that the
and all other overhead elements. Don't forget law requires you to write off.
depreciation; part of your revenues must go
Another fundamental decision your organ­
toward replacing capital assets
in
th~
future ization must make with regard to rates
is
as
well as to support current operations. whether It will
bill
for services on a bundled
These costs must be amortized-or spread or an unbundled. basis.
A
service using bun­
over your expected call volume-and must dled billing rolls all charges for supplies,
allow for the possibility of bad debt or uncol­ . services, etc., into one base rate charge
(typ­
lectible accounts, so your rates ret1ect the
ically
billing only mileage separately).
A ('
true costs of doing business.
service that uses unbundled billing may
~.
Next, consider whether your organization charge separately for such things as oxygen,
operates in a rate-regulated environment. disposable supplies, wait time and extra
While only a small handful of states (e.g., attendants.
Arizona, Utah and Connecticut) regulate
Though Medicare no longer pays on an
rates at the state level, some local govern­ . unbundled basis
and
considers all these
ments may establish ordinances or laws that ancinary charges to be part of the provider's
set ambulance rates or establish maximum base rate, other payers may still recognize
fee
schedules. Even
if
your locality has no these separate charges:: So ,your service
such local law or ordinance, some contracts should consider the ramifications of charging
between ambulance services and the areas those payers on a bundled versus unbundled
they serve include rate stipulations, so be basis before decidiqg how to
bill
them.
sure to consult your municipal contracts for
Important:
Remember when setting your
any
applicable rate restrictions.
rates that Medicare will pay only the lesser
An ambulance service that is not rate­ of either the approved fee schedule amount
regulated generally has a significant degree or the amount. you bHI.
In
other words,
if
you
of flexibility
in
setting its rates.
In
fact, charge less than the Medicare-approved
your organization can price its services as it amount, Medicare will pay only up to the
sees fit and can generaUy raise those rates at amount of your bill.
For
that reason, and
anytime.
because Medicare is the single largest payer
Of course, not every payer wlU reimburse for most ambulance services, you should
you for 100% of your bill, so you must ensure that your rates are higher than the
also factor these mandatory write-ofts Medicare-approved amounts for your vari­
(called contractual allowances) hlto your ous levels of service; otherwise,your agency
rate-setting. Medicare, for instance, will only leaves legitimate revenue on the table.
Many EMS administraj.Prs mistakenly
pay amounts approved under the
Ambulance Fee Schedule, and the patient believe that an' ambulance service must
cannot be "balance bllled" [or anything ,charge all payers the exa'ct same rates. This
This column i$ not
int~nd.d
as legal advice or leg.1 counsel in the confi"es of an attorney­
cii"",
relationsnip.
Consule
an
artorocy for spedftt legal advice conceming your
situation.
2
FEBRUARY 2007
\liB
EMS INSIOER
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generally is not the case, howeve\.
Ambulance services often charge different
rates
in
different circumstances.
l~
For
instance,
if
your organization partici­
I
~pates
In a
managed care network
as a.
con­
tracted. provider, you might have
a
rate
schedule
In
ypur agreement with
a
particular
HMO or health plan that is lower than your
.retail rate schedule. In some cases, ril-tes
charged. to
a
facUity, such
as a
hospital or
: nursin.g home, also may
differ
from your
. agency's retail rates.
Another important reminder:·. AIthougb·
providers generally may charge different rates
under various
cir­
cumstances,
remember that
your rates must
comply
with
such
laws
as
the feder­
al anti-kickback
. statute.
For
example,
If
you discount the
rates'You charge
a facility. it could
appear that those discounts were
given
in
exchange for the facility's referral of
~
Medicare patients to your servIce, which
( )could constitute
an
illegal inducement and
~.
give
rise to
a
violation of the
AKS.
(Much bas
been written about the AKS and
its
applica­
tion to ambulance services in the pages of
the
EMS insider
in recent years.)
A final caveat: "Setting your rates shoUld
not be a group exercise.
In
other words, to
avoid raising issues under state 'or federal
antitrust laws, your organization must not
establish its rates based
on
discusslons or
agreements with your competitors .or
with
other ser.vlces In your area. This kind of con­
duct could be seen as price
fixing
and
can
have serious legal consequences.
Although. you
will
need to cqnsidez:
other issues when setting rates, these are
the, primary conslderatiqns. Within .the.
. broad parameters of state and federaUaws,
Although
providers
generally
may'charge
different rates under various circumstances,
remember
th~t
your rates must comply with
such
laws as the federal
anti-kickbad<
.statute..
most ambUlance serviCes have great flexibil­
ity in establishing rates and charges for their
services.
Your organization wlll be best served
If.
you give your rates the thought and atten­
tion they deserve Instead of merely pulllng
them out of thin aIr.
Help OSHA Revise Its Emergency-Response Regulations
The Occupational Safety and Health Administration currently covers emer­
gency
responder safety as
part
ofseveral standards. some ofwhich are decades
old and out ofdate. Consequently, OSHA is working to develop
a
single, uni­
fied
.set of
revised
regulations,
and is soliciting
input
from
the
emergency­
response community
by
May
1
on what the revised regulations should include.
For more information and/or to contribute
agendaf2127.htm.
to
thi!l effort. vi!lit www.dol.gov/oshafregs/unmed
Wait to Respond to AMR, IAFC Advises Fire Departments
The International A$ociaoon of Fire' Chiefs on Jan.
4
asked
fire
departments
to
hold off on responding
to an American Medical Response sdlidtadon to EMS providers nationwide
to
agree to provide ambu­
lance services during large-scale disascers "until
the
IAFC and the Federal Emergency'ManagementAgency
can
identifY
if
the
fire
service can
fill
the potential need." According to IAFC, FEMA
"has
placed a hold on
this initiative until it
can
review the
worl<
and recommendations ofthe I/AFC] Mutual Aid System
Task
force." fAFC predicted that the association and FEMA would be able to "resolve this issue and provIde
additional guidance
by
February 2007."
For more information, visit www.iafi:. org
mental relations at Ideaton@iafc..org.
01'
contact lucian
Deaton,
fAFC
EMS manager/govern
,I
_<1'0
1
>1
EMS INSIDER
1m
FEBRUARY 2007
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FYll-16 PUBLIC SERVICES PROGRAM: FISCAL PLAN
CONSOLIDATED FIRE TAX DISTRICT
fY1t
RIC
0.100
ma
FISCAL
PROJECTIONS
ASSUMPTIONS
Properly Tm< Rale: Raoll'topt>!1y
""'.....,bl..
SQ...:
Real Properly (OOQ)
Pmperly
Tax
Colledion Fador: Reel Propt>!1y
PToP"'"Y Tei><
Itm&:
P"rsonQI
P....perly
""'e.."bl",lIa.,,: Person"l
Property
(0001
Properly Tw< Collection Fae!or.
Pmonai
Properly
Indlrecl Cost Rale
CP1 {Fiscal
Year)
Inv.stmont Incom ..
Yi.I.
ESTIMATil
0.105
1611,616,00O
99.1%
0.262
4,102,0.46
FY12
PROJl!cnON
0.103
174.9n,(l()O
99.1%
0.258
4,210,792
97.5%
0.00%
2.3%1
1.8%1
1,561,1201
189,073,920
1,944,240
16.967,980
0
1.322.100
680,000
209,9118,240
(10,681,610)
(10,810,8601
(6,040,1
SO)
\311,2001
(4..459,48 01
(120,750)
0
(1:20,750)
250.000
250.000
200,867,750
0
!
rna
PROJICTION
0.100
183.888,000
99.1'lE.
0.250
.4,265,971
97.5%
0.00%
"14
PROJECTION
0.097
193,027,000
99.1'lE.,
0. 243
i
4,328,
ml
PROJECTION
0.092
206,851.000
9!U'lE.
0.230
4.415,360
97.5%
0.01l'lL
2.S%
FY16
PROJEC.TlOl't
0.08
222,759,000
99.1%
0.215
4ABO,8611
97.5%
0.00%
3.0%
4.8%
170,479,000
99.1%
0.250
4,144.385
97.5%
0.00%
97.5%
0.00%
9
0
1.0'llo
0.3%
13,783,610
185,994,490
1,901,460
1,89.4,610
0
2,058,720
470,000
192,319,2110
(1 4 ,832,750)
(8.349,5'701
(3,B07.~701
2.1%
0.9%
0
179,046,630
1,901,460
16,594,610
0
1,293,000
310,000
199,145,700
(9,616,610)
(9.745,860)
(5,236,630)
0
(4,509,230)
(120,750)
0
(120,150)
250,000
250.000
1 B9,529,0<t0
2.5'lIo
3.3%,
4.5%
6~4
BEGINNING fUND BAlANCE
1lt:V£NUU
Ta"""
Licen....
&
Cnorg...
FarSOI"Iiceo
Fin....
&
Forfejru .....
Intergcvernmantal
5,310,,260
6,418,73ll
198,4'1,650
2.100,880
18,335,060
01
1,42B,610
1,920,000
22:2,276,200
(12,923,050)
(13.052,300)
(8,742,450)
(S68,2~O)
5)124.$00
1'19,241,610
2,163,910
18,885,120
0
1,471,470
2,110.000
223,872,118
(12,052,408)
(12,181,650)
(7,890,200)
(5611,250)
(3,n3,200)
(120,750)
0
(l20,7S0)
2$),000
250.000
217,644,210
0
(187.967.970)
312,6BO
(335,3801
1,061,000
(3,028,0001
(309,5101
(17,460,0001
11,350,0001
(401,520)
(2.2
8O,OOO)
(839,210)
(2U,597,910)
(212,597,910)
5,046,;'00
1'......,,'"
M..
SUb_I .......n
.."s
IHTI!III'UND TRANSfUS (Net
Non-ClPj
Tronofan To Dab! Service
Fund
G08ando
Fins and Rescue
Fue.
Manas_ Sy>tem
Pi.... and Rescue Equipment
Mgml.)
Tran.fan To Th.
Genen>l
Fund
FY10 Fund
Ilolance
...aon."".
192,631,310
1,991.870
17,383,700
0
1,35-4,490
1.2110,000
214,641,370
(11,710,200)
{l1,839,450}
{6,85:2,8501
(568,2~Of
191,714,990
2,043,660
11,835,670
a
1,389,700
1,640.000
218,694,020
(12,121,770)
[12,251,020
1
(7,902,170)
(!l68,250)
[3.780,6(0)
(120,750)
(I
lAPpa"'''''
oeM
Tram"'... From Tho Geln"""i Fvnd
EMSl
Fee
Payment
lor
Uninsured
Resident,
0
[4,5-42,OOOl
(6.483,180)
(6,362,430)
1120,750)
0
0
191,270,140
j4,418,350)
(120,750)
0
120,750)
1
250,000
250,000
208,041,430
0
1120,750)
2$),000
250,000
212,918,580
0
13.741,600)
(120,750)
0
(120,750)
250,000
250,000
215,771,880
0
TOTAl RESOURCES
CJI' CURItINT REVENUE APPROP.
PIP OP!R. BUDGE'!' Al'PROI'/EXP'S.
OperaUng Bud!!"1
Labor Agroemenl
(35,000)
(191,235,140)
0
1187,967,970)
0
n/a
n/tl
M"""II:<IIllons
und OM-lime
AppO"'M Replacemonl
Capilol
Operating
Budg"llmpQcIs
Eledronic Patient
Care
It''l'''rting
Pour
PDrsan Stalling
Mi...t..
mI .....
d King:svi_ Amh",lancos
Mator
Pool
Rate
Adj...
tmonl
Recruit
Class
Staffing
Cost
"/a
n/a
n/a
n/a
../a
.. /a
tVa
n/a
n/a
n/..
fila
../a
n/o
n/a
(191,2:15,140)
(191,210,140)
0
n/a
lila
n/a
(187,967,970)
(187,967,970l
1,561,120
SAFER Gm,,1 Co...
Sub_IPSP 0".......dget ApproI'
IExp's
11&7,967,970} (187,967,970)
312,6eO I
312,680
(335,380)
(335,3a0)
148,060
148,060
(6-4,000)
(1,974,000)
a
(279,760)
13,492,000]
{IS,9S4,ooO]
11,350,000)
(1,350,000)
(401,520)
(0101.520)
(2,280,000)
(2,280,0001
(327,360)
(583,210)
[195,757.490)
(195,757,490}
5.110,260
t201,'95,1~
i187,967,970) [187.967,970)
312,680
312,680
(335,380)
(33MeO)
216,530
148,060
3
1
,025,0001
(3.001,000)
(309,5101
(309,510)
{l3,96B,OOOI
{lO,476,1)OOI
(1,350,0001
(1,350,0001
(401,520)
{401,52O
I
(2,280,000)
{2,280,Oool
(839,210
1
{939;21 0
1
[206,499,1150)
{206,49'1,B50)
6,418,730
1209,947.380)
(209,947,380)
5,824,500
TOTAL USE OF RESOURCES
YEAR END FUND BALANCE
END-Of-YEAR WE11VE5 Ali A
PERCENT OF RESOURCES
(201,695,100)
6,346,330
!
0.0%
O.B'lI
2.5%
3.1%
3,0%
2.7%j
2.3~
Assumptions:
1. Th.l1:Ix rates for the Consolidated Fire Tax District are adjw:ted to mainl1:lin a fund balance
of
approl(imately2.5 percent
of
resources.
2. The Labor contract with the International
Asso~ialion
of Fire Fighters, Local 1664 expires at the end of FYl1.
3.
The
labor contract with the Municipal and Counly Government Employees Organization, lotal
191M
expires at the end
of
FY11.
4. These projections are based on the ExecutivlI's Recommended Budget and include negotiated labor agreements,
tne
operating costs
of
eapikd ftJ;::ilities, th. lisco I impact of approved legislation or regulations, and other programmatic commitments. They do not include inflation
or unapproved service improvements. The
proie~tlld
future expenditures, revenues, and fund balance may vary based on changes
to
fee
or
tax
ra1es, usage, inflcrtion, future labor agreements, and other factors not assumed here.
S. The
costs
of capital ftJcilities will be included in futur. budgets as projects are completed and their costs defined. Implementation of
additional phases of the Four-Person SfClffing initiative and ather staffing improvements are presented here for iIIustrativlI purposes. Stafling
Qeci$ions
will
be reviewed and determined on an annual basis.
12
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FY
2009/2010
Federal Poverty Guidelines - LIHEAP Clearinghouse
Page 1 of 1
2009/2010 HHS Poverty Guidelines
SEARCH
For all states (except Alaska and Hawaii) and for the District of Columbia
St~te
Programs
o Plans/Manuals
o Administration
o LIHEAP
components
o Client eligibility
o Benefits
o Self-sufficiency
o Leveraging
• Tribal LIHEAP
o Manual
o Funding
o Agreements
o Applications
o Benefits
o Leveraging
o REACH
• LIHEAP Funding
• Public
Benefit~
o State summaries
o Studies/reports
• Disconnect Policies
• State Supplements
o Recent year
o Previous years
• LIHEAP Directors
o States/websites
o Tribal
o Insular areas
• Publications
o REACH
o Leveraging
o Benefits/eligibility
o Other LIHEAP
• Related Links
o Community action
• State/regional
• Local
o Low income/energy
o Federal government
Size of
family
unit
100
Percent
of
Poverty
110
Percent
of
Poverty
125
Percent
of
Poverty
150
Percent
of
Poverty
175
Percent
of
Poverty
185
Percent
of
Poverty
200
Percent
of
Poverty
I
2
3
4
5
6
7
$10,830
$14,570
$18,310
$22,050
$25,790
$29,530
$33,270
$37,010
$11,913
$16,027
$20,141
$24,255
$28,369
$32,483
$36,597
$40,711
$13,538
$18,213
$22,888
$27,563
$32,238
$36,913
$41,588
$46,263
$16,245
$21,855
$27,465
$33,075
$38,685
$44,295
$49,905
$55,515
$18,953
$20,036
$21,660
$29,140
$36,620
$44,100
$51,580
$59,060
$66,540
$74,020
$25,498 $26,955
$32,043
$33,874
$38,588 $40,793
$45,133 $47,712
$51,678 $54,631
$58,223 $61,550
$64,768 $68,469
For family units with more than 8 members, add $3,740 for each additional person at
100% of poverty; $4,114 at 110 %; $4,675 at 125%; $5,610 at 150%; $6,545 at 175%;
$6,919 at 185% and $7,480 at 200% of poverty.
Note: For optional use in FFY 2009 and mandatory use in FFY 2010
Page Last Updated: April 5, 2010
http://liheap.ncat.orgiprofiles/povertytablesIFY20
1O/popstate.htm
4/22/2010
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2009 UPDATE OF THE
FIRE, RESCUE, EMERGENCY MEDICAL SERVICES, AND
COMMUNITY RISK REDUCTION MASTER PLAN
responsibility for ALSIBLS quality assurance for a designated area although permitted to
respond elsewhere in the County as needed. \Vhile progress in achieving the existing
recommendation has occurred, five additional EMS Officer positions are needed,
including two that had been funded with overtime monies and one for the recommended
6
th
Battalion (reference: Master Plan Recommendation #33).
Recommendation 41
Revise Recommendation #41 to indicate MCFRS' new ALS service delivery model
involving the use of alternatively-staffed medic units and increased use of ALS first­
responder apparatus (AFRA). The department's intent is to implement the "1 and
I"
ALS deployment model incrementally, whereby minimum staffing composition ofmedic
units is changed from two paramedics to one paramedic and one Emergency Medical
Technician (EMT) - typically a firefighter. The second paramedic position on existing
medic units would be reassigned to serve as the fourth position (Le., firefighter­
paramedic) on an engine (or in one case on an aerial unit) at the same station as the medic
unit,
thus
creating an AFRA in addition to the medic unit. The AFRA would typically
respond along with that station's medic unit, or another available medic unit, to ALS
incidents. This ALS delivery model would provide for ¢.e collective response oftwo
paramedics and four EMTs (between the AFRA and medic unit), thus increasing the
effectiveness ofALS patient care while also meeting NFPA Standard 1710 staffing
requirements for engines with regard to fire suppression.
The "1 and
I"
ALS deployment model, which has been implemented successfully at
several MCFRS stations to date, accomplishes the following objectives:
• Increases ALS senrice delivery to the public: The 1 and 1 ALS deployment
model greatly increases the number of MCFRS units capable of providing ALS
services to the public; although only medic units have ALS transport capability.
By placing a paramedic (firefighter or officer) on designated engines as the fourth
person, these engines can provide ALS service, with transport being provided by
an EMS Unit. With a greater number of ALS units (Le., AFRAs and medic units)
in service, ALS response time has improved county-wide.
• Provides for a more effective utilization of available paramedics: MCFRS
data
indicates that on only about 7% of ALS incidents are two paramedics needed for
providing patient care during transport. On over 90% of ALS incidents, therefore,
the AFRA is able to return immediately to service with four personnel on board,
including the firefighter-paramedic or officer-paramedic (Le., fourth person on
AFRA), ready for the next ALS, fire, or other type ofincident. On less
than
10%
of ALS incidents does the AFRA paramedic join the EMS transport unit's
11
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2009 UPDATE OF THE
FIRE, RESCUE, EMERGENCY MEDICAL SERVICES, AND
COMMUNITY RISK REDUCTION MASTER PLAN
paramedic or EMT2 in transporting patients to the hospital, while the engine
returns to service as a three-person unit, minus the paramedic until that individual
returns to the station from the hospital.
• Provides paramedics with an enhanced opportunity to integrate into fire
suppression activity:
This broadens career development opportunities for current
paramedics and serves as incentive for more ftreftghters to become ftreftghter­
paramedics, with the knowledge that they can remain in suppression services
while serving as paramedics.
The new model is tied directly to the revised phases of fourth-person stafftng of
suppression units as described
in
Recommendation
#32
above.
Recommendation 68
Replace the matrix of ftre-rescue response time goals on page
5-54
with the attached
revised matrix (Figure 5.6). Changes are shown in boldface font. The primary change
involves EMS response time goals to reflect the ftve categories of EMS calls - "Alpha,
Bravo, Charlie, Delta, Echo" - used in the Emergency Medical Dispatch (EMD) protocol.
Other changes include the addition of response time goals for
5
th
due engine on box
alarms, 3
rd
due aerial unit on high-rise box alarms, and command offtcers on major fire­
rescue incidents. Another revision involves the perfonnance levels (i.e., percentages)
associated with the three density zones, where all urban goals have been changed to the
90% perfonnance level, all suburban goals to the 75% level. and all rural goals to the
50% level for consistency purposes.
3
In
addition, a column showing corresponding
NFPA 1710 response time guidelines has been added for comparison purposes.
One change requiring explanation is the response time associated with the basic life
support (BLS) response goal- from 6 to 12 minutes. The increase is due to a
philosophical premise: BLS incidents involve non-life threatening occurrences (e.g.,
sprains, fractures, contusions, unspecifted sicknesses, etc.). so a longer response time is
acceptable. Because of this, units responding to BLS incidents may,
in
some cases, not
require use of emergency lights and sirens (i.e., travel
in
routine mode)4 which would
have the added benefit of a reduction
in~
the number of collisions involving MCFRS
apparatus. The increase
in
BLS response time will also allow for greater emphasis on
advanced life support-"ALS" response (e.g., life threatening emergencies such as heart
2
Ifthe ALS incident is ofthe "Charlie"-level, then a BLS transport unit (staffed by EMTs) would transport
the patient. lfthe ALS incident is of the "Delta" or "Echo"-level, then a medic unit (staffed by one
paramedic and an EMT driver) would transport the patient
3
The lone exception is the goal for BLS response where the urban goal is 98%, suburban goal is 95%, and
rural goal
is
90% due to the increased time associated with BLS response.
4
A decision on allowing response ofBLS units in the routine mode for certain Alpha and Bravo-level
incidents will be determined at a later date by the Fire Chief.
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Review and Analysis of Fairfax County EMS Responses
2002
to
2007
Ambulance fee supporters claim that imposing a charge of
$300-$800/transport
will not
deter people from calling 911, often citing to the experiences of other jurisdictions. For
example, the EMS Transport Fee section of the County's website currently says:
"There is no evidence that those in need of transport will be dissuaded
from calling 911 because their insurance is going to be billed or
because they are uninsured. In the jurisdictions that have been
collecting this fee, there is no evidence of that happening." (1)
Fairfax County began billing for ambulance service in 2005. While total EMS calls in
Fairfax County have increased steadily in the past several years, the number of calls when
corrected for population increases actually decreased from 2004 to 2005. Since that time,
EMS calls (when corrected for population growth) have remained below the 2004 level.
While the reasons for call volume changes are not clear, the statistics raise the question:
Why did EMS call volume drop from 2004 to 2005? And why has EMS call volume
remained below the 2004 level?
Before any ambulance fee is imposed, credible stUdies or analyses should be performed
(e.g., through surveys of impacted populations) to determine whether, in fact, ambulance
fees have deterred some Fairfax County residents from calling 911.
Fiscal Year
2002
2003
2004
2005
2006
2007
Sources:
Population
964712
984366
1007800
1041200
1049333
1077000
Call Volume
89,246
87,621
91,373
88,591
90,086
92,087
EMS
Calls
60,685
60,306
62,420
61,636
62,036
64,088
EMS Calls %
of Pop
6.29%
6.13%
6.19%
5.92%
5.91%
5.95%
Change in
EMS Calls %
of Pop
- 0.16
+
0.06
- 0.27
- 0.01
+
0.04
(1) http://www. montgomerycountymd.g ov/mcgtmpl.asp?url=/contentlpio/ems/facts.asp