EMS professionals have survived a lot. Pandemics. Staffing shortages. Hospital offload delays. Supply chain disruptions. More versions of the phrase “do more with less” than any profession should reasonably tolerate.
We’ve mastered electronic patient care reports that require 17 clicks to document that a patient had a pulse. We’ve attended mandatory training on mandatory training. And we’ve patiently explained to well-meaning elected officials that ambulance billing revenue doesn’t actually cover the cost of operating an ambulance service. Again.
And just when many EMS leaders thought they had finally learned the alphabet soup of Medicaid financing (IGTs, CPEs, UPLs, QAFs, ACRs, ASPPs and GEMT) CMS introduced a new proposed rule that has many EMS finance professionals simultaneously reaching for their calculators and antacids.
Welcome to the latest episode of As the Ambulance Wheels Turn.
| MORE: Medicare & Medicaid Services rule could limit ground emergency transport reimbursements
First, let’s translate this into normal human language
In May 2026, CMS released a proposed rule that could significantly affect Ground Emergency Medical Transportation (GEMT) programs and other ambulance supplemental payment arrangements.
The proposal would establish provider-specific payment limits for certain Medicaid supplemental payments and, for many ambulance programs, could effectively cap supplemental reimbursement at amounts equivalent to the Medicare Ambulance Fee Schedule. If finalized, the earliest implementation date would be Jan. 1, 2029.
An initial review of the proposed rule suggests that certain traditional GEMT programs funded through Certified Public Expenditure (CPE) methodologies may be less vulnerable to the proposed limitations. However, CMS has not provided definitive guidance on how all existing program structures would be treated if the rule is finalized. The proposed rule could affect programs that rely on financing arrangements CMS ultimately determines fall within the scope of the proposed targeted payment limitations, including some provider assessment and Intergovernmental Transfer (IGT)-based models. Similarly, programs that use a payment “directed” by the state (state-directed payments, or SDPs, that exclude certain provider types from participating (public vs. private agencies) in the supplemental payment could also be impacted.
It’s important to restate that this is a proposed rule. Nothing changes tomorrow. No one needs to immediately park ambulances in protest or begin hoarding cardiac monitors. But ignoring it would be a mistake. Because if the proposal moves forward substantially unchanged, the financial implications for many EMS systems could be significant.
Wait ... I thought GEMT was already limited?
Sort of. One of the most common misconceptions about GEMT is that it is some sort of “bonus payment.” It isn’t. GEMT was originally developed because Medicaid historically reimburses ambulance agencies at rates that often fall well below the actual cost of providing service.
In the traditional GEMT models, participating governmental EMS agencies must document their allowable Medicaid costs through extensive cost reporting. The purpose is straightforward: to help public providers recover a portion of documented unreimbursed Medicaid costs. Since those early days, numerous variations of GEMT programs have emerged, many that require financial contributions from pubic and even private ambulance agencies to participate in the supplemental Medicaid payment program. This isn’t Monopoly money. No one is swimming through vaults of Medicaid gold coins like Scrooge McDuck. Most public EMS agencies use these dollars to keep the lights on. Sometimes literally.
The Medicare Ambulance Fee Schedule problem
CMS’s proposal effectively says: “Perhaps Medicare rates should be the benchmark.” At first glance, that might sound reasonable. After all, Medicare is a major payer. It has a fee schedule. There are spreadsheets. Government agencies love spreadsheets. The problem is that the Medicare Ambulance Fee Schedule is not designed to fund the true cost of maintaining an emergency medical response system. It pays for transport. EMS exists to provide readiness. Those are not the same thing. A transport-based reimbursement methodology doesn’t fully account for the fact that ambulance services maintain:
- Personnel 24 hours a day
- Ambulances that may sit ready for hours between calls
- Communications infrastructure
- Medical oversight
- Clinical quality programs
- Disaster preparedness capabilities
- Ongoing education and competency programs
- Fleet replacement cycles
- Surge capacity for the next bad day
Ambulance services incur substantial fixed costs regardless of whether a transport occurs.
In EMS, we don’t get to tell the community: “We’ve hit our reimbursement cap for the month. Please schedule your emergencies for next Tuesday.” Readiness is the product; transport is merely one output.
| MORE: Treatment-in-place billing
The “But we don’t have GEMT” crowd
If you’re reading as an agency that does not participate in some form of CPE GEMT program, you may be tempted to move on to the next article — not so fast! One of the fascinating, and concerning, aspects of this proposal is how many different supplemental payment structures could potentially be affected. The PWW|AG state-by-state GEMT guide documents a remarkably diverse landscape that includes traditional GEMT programs, provider assessment models, managed care directed payments, upper payment limit methodologies, hybrid structures and other state-specific approaches.
Translation? This isn’t just a “California problem.” Or a “government EMS problem.” Or a “someone else will figure it out” problem. Depending on how CMS ultimately interprets and finalizes the proposal, agencies across numerous states could experience varying degrees of exposure. Some programs may be minimally affected, while others could face meaningful reductions. Many agencies are still trying to figure out exactly where they fall on that spectrum, which, admittedly, is not how most EMS leaders hoped to spend their summer.
What the proposed GEMT Rule could mean for local EMS
Let’s avoid the temptation toward apocalypse. The sky is not falling — yet. But local potential impacts deserve honest discussion. Many EMS agencies currently rely on supplemental Medicaid payments to support:
- Recruitment and retention efforts
- Ambulance replacement
- Equipment purchases
- Clinical quality initiatives
- Technology investments
- Community paramedicine programs
- Disaster preparedness activities
- Maintaining adequate response capacity
If future supplemental reimbursement opportunities diminish, local leaders could face difficult choices.
Do you delay replacing aging ambulances? Freeze vacant positions? Reevaluate station locations? Scale back mobile integrated healthcare programs? Increase local subsidies? Ask taxpayers for more support? In some communities, the conversation could become even more fundamental: What level of EMS service can we realistically sustain?
None of those options are particularly attractive. They’re the EMS equivalent of being asked whether you’d rather have your coffee served cold or spilled hot directly into your lap.
This isn’t about profit
This point matters, a lot. The narrative around supplemental payments occasionally drifts toward the suggestion that EMS providers somehow discovered an obscure federal loophole to generate windfall profits. That characterization misses reality.
Supplemental funding helps support staffing, training, equipment, fleet replacement, communications systems and response capacity, not profit maximization. Nobody enters EMS hoping to become a Warren Buffett of ambulance reimbursement. The economic model has never supported that ambition.
So ... what should EMS leaders do?
- First, breathe. Again, this is a proposed rule.
- Second, understand your exposure. If your agency participates in a GEMT or supplemental payment arrangement, work with your state Medicaid agency, state and national associations, and finance teams to understand what the proposal could mean locally. Work with economic modeling in an attempt to evaluate scenarios that may play out if the CMS proposed rule becomes a final rule with little-to-no changes.
- Third, educate policymakers. Most elected officials genuinely have no idea how EMS is funded. They assume ambulances operate like Uber with sirens and a cardiac monitor. Explaining the distinction between transport reimbursement and readiness funding is critical. Fourth, submit comments. CMS accepts and reviews stakeholder feedback, and your agency’s specific data matter. Operational realities matter. If you believe the proposal could adversely affect access to emergency care in your community, say so. Respectfully, preferably without using ALL CAPS!
- Finally, remember that advocacy is not a spectator sport. EMS has historically struggled to tell its own financial story. We often assume policymakers understand our economics simply because we understand them.
They don’t. And frankly, why would they? Most people don’t spend their evenings debating the nuances of CPEs vs. IGTs vs. provider assessments (provider tax) vs. directed payment (DP) models. EMS people do. Which may explain why we don’t get invited to more parties. Or why, when we are invited, people suddenly remember they need to refresh their drinks when we start talking about FMAP calculations.
There is also an opportunity buried within this proposal. It provides EMS leaders with another chance to educate policymakers about a reality our profession has struggled to explain for decades: emergency medical services are not a transportation business that occasionally provides healthcare. We are a readiness-based healthcare and public safety system that happens to transport patients. Until reimbursement models recognize that distinction, these conversations will continue.
The bigger question
Perhaps the most important issue raised by this proposal has nothing to do with GEMT. It forces us to confront a larger question: How should America fund emergency medical services? Should we continue relying on transport-based reimbursement models to sustain a readiness-based public service? Should communities recognize EMS as essential infrastructure deserving stable funding? Can a reimbursement methodology designed decades ago adequately support modern EMS expectations?
These questions aren’t going away. Whether this proposal is finalized, revised, delayed or withdrawn, the underlying issue remains. Communities expect ambulances to arrive. Immediately. Competently. Equitably. Twenty-four hours a day. Three hundred sixty-five days a year. Ready for whatever happens next. That readiness has value. It has cost. And sooner or later, our reimbursement systems need to acknowledge both.
Until then, EMS leaders will continue doing what they’ve always done: adapting, advocating, innovating and somehow figuring out how to provide exceptional care while navigating increasingly complicated financial terrain.
Because if there’s one thing EMS professionals know how to do, it’s making miracles happen with limited resources. We’ve been doing it for decades.
Still, it would be nice if, just once, the spreadsheet helped instead of asking us to do more with less.
Additional resources
PWW|AG has put together a GEMT CMS Proposed Rule Toolkit, including explanations of various types of GEMT programs, a summary of state GEMT program structures with source links, and example agency and association comment letters, with links to where to submit comment on the CMS Proposed Rule.
You can access the Toolkit here.
For EMS leaders who want to learn more or submit comments, the following resources may be helpful:
- CMS Proposed Rule Announcement
- CMS Proposed Rule (with relevant EMS highlights)
- CMS Medicaid Program
- State Plan Amendment (SPA) Resource Center
- Medicaid Managed Care Resource Center
- CMS Ground Emergency Medical Transportation Guidance
- Medicaid financing overview. CMS overview of Medicaid financing, federal matching funds, and state financing mechanisms.
- Medicaid upper payment limit (UPL) information. CMS information regarding Upper Payment Limits and supplemental payment methodologies.
- FMAP information. CMS explanation of Federal Medical Assistance Percentages and state matching rates
- Annual FMAP tables
- CMS managed care directed payments. Federal guidance regarding state directed payments and managed care payment arrangements
- Approved State Directed Payment Preprints
- CMS Ambulance Fee Schedule. Official Medicare Ambulance Fee Schedule information, including payment rates, geographic adjustments, and rural add-ons
- Medicare Ambulance Fee Schedule Public Use Files
- CMS Ground Ambulance Data Collection System (GADCS). Information regarding the Medicare Ground Ambulance Data Collection System
- Medicaid and CHIP Payment and Access Commission (MACPAC). MACPAC provides independent policy analysis regarding Medicaid financing, payment policy and access to care
- Medicaid Financing and Supplemental Payments
