EMS policy and legislative services

Why the billing category matters to your community

The phrase “Emergency Medical Services” describes how paramedics get paid, not what they do. The category was established in 1966 around a single use case: stabilize and transport to a hospital. Every statute, regulation, reimbursement code, and scope-of-practice definition built since then has organized itself around that category.

The practical consequence is that activities outside that category are either uncompensated or underreimbursed. This includes treat-in-place, transport to alternate destinations, and referral to community services. None of these currently sustain operations on their own.

TPF navigates that landscape for clients, working alongside partner organizations including the 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 succeeded — and which have failed.

Essential service designation

Essential service designation is a governance decision with significant practical consequences. The TPF team has supported essential service designation efforts in multiple states. States that designate EMS as essential create a legal foundation for sustained public funding. This also enables collective bargaining rights and mutual aid obligations that do not exist where EMS is classified as discretionary.

Unlike fire protection and law enforcement, which developed within state police powers frameworks, ambulance services originated in healthcare delivery. They inherited reimbursement logic rather than readiness logic. Agencies are paid for events, not for capacity. In rural and frontier counties where call volume is low but coverage geography is large, that mismatch produces fragility.

TPF provides legislative drafting, testimony support, stakeholder strategy, and bill analysis for essential service designation efforts — including the rural EMS system sustainability challenges that drive many of these legislative needs. The Paramedic Foundation has worked with state EMS offices and legislative staff on this question in multiple states and can draw on that experience directly.

TIP/TAD reimbursement reform

The federal ET3 model demonstrated that Treatment in Place and Transport to Alternate Destination are clinically safe, cost-effective, and patient-preferred. TPF’s innovative care program design work builds on that evidence base. CMS ended the program without a permanent replacement. The gap that created is a payment mechanism problem, not a clinical one — and it is being addressed state by state.

New York enacted EMS reimbursement expansion in October 2024. California’s AB 1544 has produced measurable reductions in transport rates and ED utilization. Illinois’s Public Act 103-1024 requires insurance coverage for Mobile Integrated Healthcare beginning January 2026. At the federal level, several 119th Congress bills address these gaps — including the CARE Act (S. 3145 / H.R. 2538), the EMS ROCs Act (S. 3730), and the Community Paramedicine Act (H.R. 4011). See the federal landscape table below for current status and links.

TPF produces model statutory language for TIP/TAD programs and Medicaid State Plan Amendment frameworks. It also provides medical director guidance and engagement support for state legislative processes.

Community paramedicine Medicaid coverage

Minnesota was the first state to reimburse community paramedicine through Medicaid. Oregon, Maryland, Indiana, and Montana have followed. Each developed its own legislative and regulatory model adapted to its specific payer environment.

TPF assists state EMS offices and legislative partners in developing Medicaid SPA language, actuarial justifications, and stakeholder engagement strategies. The Paramedic Foundation has direct experience with this process in multiple states.

Governance design

A well-designed governance structure is what determines whether a good piece of legislation produces lasting change or generates a new set of workarounds. Advisory council design, regional coordination frameworks, medical oversight structures, and performance accountability systems all shape implementation quality.

TPF produces governance assessments, advisory council bylaws and committee charters, policy and procedure frameworks, and financial governance structures for regional EMS advisory bodies. These are implementation-ready documents, not conceptual frameworks.

Current federal landscape

TPF monitors federal legislation relevant to rural EMS sustainability, treatment in place, and community paramedicine, and analyzes how it intersects with state-level strategy for the agencies and offices it advises. The summary below reflects the 119th Congress; bill statuses are drawn 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.