OAR 410-136-3374: Ground Emergency Medical Transportation – Emergency Medical Services Transportation Private Provider Program - Coordinated Care Organizations Requirements and Payment Processing

(1) Definitions: (a) “Coordinated Care Organization” has the meaning defined in OAR 410-141-3500; (b) “Eligible Emergency Medical Services Provider” means an EMS provider that meets all the eligibility requirements described in (section B) below. A nonfederal or nonpublic entity that: (A) Employs individuals who are licensed by the Oregon Health 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. (c) “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 individual, as well as provide advanced, limited-advanced, and basic life support services provided by Eligible Emergency Medical Services Provider before or during the act of transportation. This includes to assess, treat, and stabilize the individual’s medical condition; or prepare and transport the individual to a medical facility; (d) “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; (e) “Managed Care Entity” has the meaning defined in OAR 410-141-3500; (f) "Supplemental Payment" means a payment amount set by the Authority for each approved procedure code to supplement allowable costs for EMST services; (g) "§438.6(c) Preprint" means a 42 CFR §438.6(c) Preprint approved by U.S. Department of Health and Human Services CMS for Qualified Directed Payments to GEMT Providers for GEMT Services rendered during the applicable CCO contract rating period. (2) GEMT EMST Private Provider Eligibility Requirements. To be eligible for supplemental payments, GEMT EMST private providers shall meet 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/or not participating in the GEMT supplemental program; (d) Be a participating provider having a contractual agreement with a CCO on the date of GEMT EMST services. (3) Supplemental Payment Process: (a) GEMTEMST private providers may participate in the GEMT EMST private provider program described in this rule if the GEMT EMST provider is a participating provider in accordance with OAR 410-141-3500 on the date of service during the approved service period. OHA will apply the supplemental payment only to GEMT EMST private provider services rendered to CCO Medicaid members by eligible GEMT EMST Private Providers on or after January 1, 2024; (b) The GEMT EMST Private Provider Program is for supplemental payments made by the Authority to CCOs for GEMT EMST private providers’ qualifying services when rendered by GEMT EMST private providers for the approved service period; (c) In accordance with 42 CFR §438.6(c)(2)(i)(A), the supplemental payments are based on the federal match of the GEMT EMST private providers Quality Assurance Fee (QAF) defined in OAR 410-136-3373; (d) The Authority shall pay any federal financial participation received from CMS, for qualifying GEMT EMST services, to the CCO; (e) The CCO shall increase, by the same amount, the amount of reimbursement paid to the appropriate GEMT EMST private provider; (f) The non-federal share portion of the supplemental payment is contributed by GEMT EMST private providers only; (g) The GEMT EMST private provider shall agree to pay a fee to reimburse the Authority for the costs of administering the program; (h) The Authority may adjust the amount of add on payments based on the costs to administer the program or any penalties or interest owed. (4) Reporting and Billing Processes: (a) The Authority shall provide the CCO with the calculation of the federal match determined by the Data Request Template described in OAR 410-136-3373; (b) Payment by the CCO to participating providers for qualifying GEMT EMST services shall be at least annually. (5) Quality Measurement: (a) In accordance with 42 CFR §438.6(c)(2)(i)(C), this payment arrangement must advance at least one of the goals and objectives in Oregon's Medicaid quality strategy required per 42 CFR §438.340; and the Authority shall review progress on the advancement of the state's goal(s) and objective(s) in the quality strategy identified in this section; (b) GEMT EMST private providers shall submit the quality measurement data specified in the §438.6(c) Preprint. (6) Authority Responsibilities: (a) The Authority shall apply for program authorization through a §438.6(c) Preprint for each calendar year; (b) The Authority shall make a supplemental payment only if the GEMT EMST private provider meets criteria established by the Authority for the GEMT EMST CCO supplemental payment program in accordance with applicable federal requirements approved by CMS for the applicable program year; (c) The Authority shall make a supplemental payment consistent with §438.6(c) Preprint approved with CMS for qualified transports described in OAR 410-136-3372; (d) Upon receipt of an acceptable funds transfer from GEMT EMST private provider, the Authority shall verify data received and draw the federal funds in an amount determined to match the state portion.