EMS policy, payment and legislative support for states

Why EMS payment follows the ambulance trip

The term “Emergency Medical Services” describes how paramedics get paid rather than what they do. The category was set up in 1966 around a single task: stabilize the patient and take them to a hospital. Every law, rule, payment code and scope-of-practice definition written since then has been built around that category.

As a result, work outside that category is paid poorly or not at all. That includes treatment in place, transport to alternate destinations and referral to community services. None of these can yet pay for an EMS operation on its own.

TPF helps clients work through these rules alongside partner organizations, including the International Roundtable on Community Paramedicine (IRCP) and the American College of Paramedics. TPF knows which states have moved and what statutory language has held up. It also knows which Medicaid State Plan Amendment strategies have worked and which have failed.

Essential service designation

Naming EMS an essential service is a governance decision with real practical effects. The TPF team has supported essential service designation efforts in several states. A state that designates EMS as essential creates a legal basis for steady public funding. The designation also enables collective bargaining rights and mutual aid duties that do not exist where EMS is optional.

Fire protection and law enforcement grew up under the state’s police powers. Ambulance services grew up in health care. So they inherited health care’s way of paying, built around each visit, instead of a way of paying for being ready. Agencies are paid for each call rather than for the capacity they keep. In rural and frontier counties, calls are few and the area to cover is large. That mismatch leaves services fragile.

TPF supports efforts to name EMS an essential service. It drafts bills, supports testimony, leads stakeholder engagement and analyzes bills. That work includes the rural EMS system sustainability problems behind many of these bills. The Paramedic Foundation has worked with state EMS offices and legislative staff on this question in several states.

Paying for treatment in place and alternate destinations

The federal Emergency Triage, Treat, and Transport (ET3) model showed that treatment in place and transport to an alternate destination (TAD) are clinically safe, cost-effective and preferred by patients. TPF’s innovative care program design work builds on that evidence. The Centers for Medicare & Medicaid Services (CMS) ended the program with no permanent replacement. The gap that left is a payment problem rather than a clinical one. States are closing it one at a time.

New York passed a law expanding EMS reimbursement in October 2024. California’s AB 1544 has produced measurable drops in transport rates and emergency department use. Illinois’s Public Act 103-1024 requires insurance to cover Mobile Integrated Healthcare starting in January 2026. In Congress, several 119th Congress bills address these gaps. They include the CARE Act (S. 3145 / H.R. 2538), the EMS ROCs Act (S. 3730) and the Community Paramedicine Act (H.R. 4011). The federal table below gives current status and links.

TPF writes model language for state laws on TIP and TAD programs. It also writes frameworks for Medicaid State Plan Amendments. It gives guidance to medical directors and supports stakeholder engagement when a state legislature takes up a bill.

Community paramedicine Medicaid coverage

Minnesota was the first state to pay for community paramedicine through Medicaid. Oregon, Maryland, Indiana and Montana have followed. Each built its own legislative and regulatory model to fit its own mix of payers.

TPF helps state EMS offices and legislative partners write Medicaid State Plan Amendment (SPA) language. It also prepares the actuarial justifications and the plans for stakeholder engagement. The Paramedic Foundation has direct experience with this process in several states.

Governance design

Good governance decides whether a good law brings lasting change or just a new set of workarounds. How advisory councils, regional coordination, medical oversight and performance tracking are set up shapes how well a law is carried out.

TPF reviews governance and writes advisory council bylaws, committee charters, and policy and procedure frameworks. It also designs financial governance for regional EMS advisory bodies. Each document is ready to put to use.

Current federal landscape

TPF tracks federal legislation on rural EMS sustainability, treatment in place and community paramedicine. It analyzes how those bills affect state strategy for the agencies and offices it advises. The summary below covers the 119th Congress. Bill statuses come from the national EMS legislative tracker and are current as of the dates shown. TPF is not a lobbying organization and takes no position on these measures.