Vermont EMS leaders warn reimbursement, workforce shortfalls threaten local ambulance coverage

Drew Hazleton, chief operations at Rescue Inc. and chair of the Vermont EMS Advisory Committee, told the House Health Care Committee on Feb. 4 that the committee is collecting statewide cost and workforce data and drafting a five-year plan for emergency medical services, and that current payment rules are reducing revenue for ambulance providers.

The committee contracted a consultant to assemble scattered local data because “EMS is done different in almost every community in Vermont,” Hazleton said, and the consultant’s report is due April 15. Hazleton said the advisory committee will begin a planning phase to produce a statewide EMS plan that is due to the legislature in December 2026.

Why it matters: Ambulance services operate on thin margins and rely on a mix of Medicare, Medicaid and private payments. Hazleton said a recent change in how Medicaid pays for “treatment without transport” — care provided on scene when no patient is moved — has resulted in payments at the lower hospital-to-hospital nonemergency transport rate rather than the higher emergency BLS rate, reducing expected reimbursement and leaving services short on revenue.

Hazleton described how ambulance billing works and why the distinction matters. ‘‘If we really don’t know what the total cost of EMS is, we don’t know what the total workforce need is,’’ he said, explaining the advisory committee’s decision to gather cost and staffing data before finalizing recommendations. He said ambulance billing typically includes a base rate and mileage and that insurers pay different mileage amounts; emergency calls billed at the basic life support (BLS) emergency rate bring substantially more revenue than nonemergency hospital-to-hospital transfers.

On the Medicaid issue, Hazleton said, “The legislation last year has Medicaid paying us for the treatment that was provided at the scene, but it’s being paid not at that BLS base rate, the emergency base rate, [but] at the hospital-to-hospital transportation rate.” He added that the nonemergency rate is “about half of what the emergency rate is.”

Hazleton gave examples of how tight margins and supply costs can wipe out reimbursement. He said an interosseous infusion needle used when an IV cannot be placed costs $379, while a total reimbursement for an ALS call’s base rate is roughly $600. Those supply costs, he said, can quickly consume payments.

Committee members asked for clarifying legislative language. One member suggested explicitly adding the word “emergency” before “BLS” in the statute governing payment for treatment without transport; Hazleton said that omission likely led to the interpretation by Medicaid that produced a lower rate. The advisory committee will include that clarification and explore fiscal impact as part of its recommendations.

Hazleton also described broader system pressures: an uneven payer mix with high Medicare share in some regions, the looming possible loss of a Medicare rural add-on in Congress, and ongoing workforce shortfalls. He said some services are responding only 60% of the time and that ambulance closures occurred last year with neighboring services filling gaps by mutual aid. "There will likely be more ambulance service closures and reliance on mutual aid in the near future," Hazleton said.

The committee has increased the EMS special fund from $150,000 to $450,000 to help with the study and other uses, Hazleton said, but added that one-time infusions of money have not solved the underlying structural funding and workforce problems. He told lawmakers the advisory committee plans to return with its assessment in April and the five-year plan later in the 2026 cycle.

The committee did not take a formal vote during the session; members asked staff to pursue clarifying statutory language and to include fiscal analysis of paying emergency BLS rates for treatment without transport.

Hazleton and committee members also flagged federal policy: several percent of Medicare revenue for rural ambulance services comes from a rural add-on that may not survive the upcoming federal continuing resolution, which Hazleton said would reduce some Vermont services’ Medicare revenue by an estimated range of about 3%–22% depending on rural designation. He said the advisory committee will engage the congressional delegation and federal partners about that issue.

The session closed with committee members thanking Hazleton and asking the advisory committee to share data and recommendations as they become available. Hazleton said the committee expects the consultant’s data product on April 15 and will seek funding and statutory clarifications as it finalizes the statewide plan due Dec. 2026.