OAR 410-136-3372: General Requirements for Ground Emergency Medical Transportation Emergency Medical Services Transport Private Provider Program

(1) The Ground Emergency Medical Transportation (GEMT) Emergency Medical Services Transport (EMST) private provider program makes supplemental payments to eligible GEMT EMST private providers who furnish qualifying emergency ambulance services to Oregon Health Authority (Authority) Medicaid recipients: (a) The supplemental payment is for an add-on reimbursement fee to the base rates for eligible emergency medical transportation services. The supplemental payment is an add on to the base rates for eligible emergency medical transportation services, excludes Emergency Medical Services (EMS) air transports. The calculation is based on the gross receipts reported on the Centers for Medicare and Medicaid Services (CMS) approved data request template; (b) The Authority makes supplemental payments only up to the amount calculated by the gross receipts. Total reimbursements from Medicaid including the supplemental payment may not exceed one hundred percent of actual costs; (c) The supplemental payment shall cover GEMT EMST private providers and shall be applied in lump sum payment at least annually to eligible providers using the Healthcare Common Procedure Coding System (HCPCS) emergency transport codes. OHA will apply the supplemental payment only to GEMT EMST private provider services rendered to FFS Medicaid members by eligible GEMT EMST Private Providers on or after April 1, 2023; (d) The supplemental payments shall be made at least annually; (e) The base rates for GEMT EMST private providers shall not change with this amendment to Oregon’s Medicaid’s State Plan that authorizes federal participation in this program. (2) Definitions: (a) “Authority” means the Oregon Health Authority; (b) “Advanced Life Support” means special services designed to provide definitive prehospital emergency medical care, including but not limited to, cardiopulmonary resuscitation, cardiac monitoring, cardiac defibrillation, advanced airway management, intravenous therapy, administration with drugs and other medicinal preparations, and other specified techniques and procedures; (c) “Basic Life Support” means emergency first aid and cardiopulmonary resuscitation procedures to maintain life without invasive techniques; (d) “Eligible Emergency Medical Services Transport Private Provider” means an EMS private provider that meets all the eligibility requirements described in (Section 2e) below. A nonfederal or nonpublic entity that: (A) Employs individuals who are licensed by the Authority under ORS chapter 682 to provide emergency medical services; and (B) Contracts with a local government pursuant to a plan described in ORS 682.062. (e) “Emergency Medical Services” means the act of transporting an individual by ground from any point of origin to the nearest medical facility capable of meeting the emergency medical needs of the patient, as well as the advanced, limited-advanced, and basic life support services provided to an individual by Eligible Emergency Medical Services Provider before or during the act of transportation. (A) This includes to assess, treat, and stabilize the individual’s medical condition; or (B) Prepare and transport the individual to a medical facility. (f) “Emergency Medical Services Transport” means an emergency medical services provider’s evaluation of an individual experiencing a medical emergency and the transportation of the individual to the nearest medical facility capable of meeting the needs of the individual. For the purposes of this state plan, EMS air transports are excluded; (g) “Emergency Medical Services Fund” is a fund established in the state treasury, separate and distinct from the General Fund. The Emergency Medical Services Fund consist of moneys collected by the Authority as a quality assurance fee; (h) “Federal Financial Participation (FFP)” means the portion of medical assistance expenditures for emergency medical services that are paid or reimbursed by the Centers for Medicare and Medicaid Services in accordance with the State Plan for medical assistance. Clients under Title XIX are eligible for FFP; (i) “Gross Receipts” means gross payments received as patient care revenue for emergency medical services transports, determined on a cash basis of accounting. Gross receipts do not include Medicaid Supplemental Reimbursement pursuant to Attachment 4.19-B, pages 31-39 of Oregon’s Medicaid State Plan; (j) “Local Government” means all cities, counties and local service districts located in this state, and all administrative subdivisions of those cities, counties and local service districts as defined in ORS 174.116; (k) “Limited Advanced Life Support” means special services to provide prehospital emergency medical care limited to techniques and procedures that exceed basic life support but are less than advanced life support services; (l) “Treatment in Place” means EMT services (basic, limited-advanced, and advanced life support services) provided by a Medicaid-enrolled EMS professional to an individual who is released on the scene without transportation by ambulance to a medical facility; (m) “Usual Charge” means the lesser of the following unless prohibited by federal statute or regulation: (A) The providers charge per unit of service for the majority of non-medical assistance users of the same service based on the preceding months charges; (B) The providers lowest charge per unit of service on the same date that is advertised, quoted, or posted. The lesser of these applies regardless of the payment source or means of payment; (C) Where the provider has established a written sliding fee scale based upon income for individuals and families with income equal to or less than 200 percent of the federal poverty level, the fees paid by these individuals and families are not considered in determining the usual charge. Any amounts charged to third party resources are to be considered. (3) GEMT EMST Private Provider Eligibility Requirements. To be eligible for the supplemental payment, GEMT EMST private providers must meet all the following requirements: (a) Be enrolled as an Oregon Health Plan Medicaid provider; (b) Provide ground emergency medical transport services to Medicaid recipients; (c) The organization is not a publicly owned or operated, and not participating in the GEMT supplemental program. (4) Enhanced Reimbursement Methodology: (a) A uniform supplemental payment rate per emergency transport shall be determined at least annually and shall not exceed one hundred percent (100%) of the difference between Medicaid payments otherwise made to each GEMT EMST private provider for EMS services (base rates) and the usual charge for the service; (b) Medicaid base rate to the GEMT EMST private providers for providing EMS services are derived from the ambulance FFS fee schedule established for reimbursements payable by the Medicaid program by procedure code: (A) The primary source of paid claims data, managed care encounter data, and other Medicaid reimbursements is the Oregon Medicaid Management Information System (MMIS); (B) The number of paid Medicaid EMS transports is derived from and supported by the MMIS reports and the data from the Data Request Report for services during the applicable twelve-month period. (c) The ambulance add-on payments shall not exceed the funding collected by OHA as a quality assurance fee specified in OAR 410-136-3373 in the Emergency Medical Services Fund established in ORS 413.234. Reimbursement may not exceed the costs for the emergency medical service transport, less the amount of reimbursement that the emergency medical services provider is eligible to receive from all public and private sources; (d) Supplemental payments for each GEMT EMST private provider shall be calculated for each provider at least annually by multiplying the uniform add-on rate by the provider’s volume of Medicaid transports billed with Healthcare Common Procedure Coding System (HCPCS) codes A0429 BLS Emergency, A0427 ALS Emergency (Level 1). A0998 Ambulance Treatment in place will be paid at least annually as determined through the Medicaid Management Information System if federally approved for this program supplemental payments. (e) GEMT EMST private providers not licensed within the State of Oregon shall not receive the enhanced supplemental payment. (5) Eligible GEMT EMST Private Provider Reporting Requirements: (a) Submit CMS approved data request template to the Authority; (b) Provide any supporting documentation to serve as evidence supporting information on the data request template, if specifically requested by the Authority. Any supporting documentation provided to the Authority is protected and not subjected to a public records release; (c) Keep, maintain, and have readily retrievable such records to fully disclose reimbursements amounts that the eligible GEMT EMST private provider is entitled to, and any other records required by CMS for seven years. (6) Agency Responsibilities: (a) The Authority shall submit any necessary materials to the federal government to provide assurances that all gross receipts are allowable under federal law; (b) The Authority shall complete an annual audit and reconciliation process within a nine-month period.