Impact of Partial Government Shutdown on Healthcare
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Tag: Medicaid
2023 Ambulance Fee-for-Service Medicaid Rate Survey
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CMS Medicare, Medicaid, and CHIP Enrollment
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Today, the Centers for Medicare & Medicaid Services (CMS) released the latest enrollment figures for Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP). These programs serve as key connectors to care for more millions of Americans. Medicare As of May 2022, 64,553,288 people are enrolled in Medicare. This is an increase of 103,837 since the last report. 34,893,853 are enrolled in Original Medicare. 29,659,435 enrolled in Medicare Advantage or other health plans. This includes enrollment in Medicare Advantage plans with and without prescription drug coverage. 50,086,253 are enrolled in Medicare Part D. This includes enrollment in stand-alone prescription drug plans as well as Medicare Advantage plans that offer prescription drug coverage. About 12 million individuals are dually eligible for Medicare and Medicaid, so are counted in the enrollment figures for both programs. Detailed enrollment data can be viewed here: https://data.cms.gov/summary- Medicaid and Children’s Health Insurance Program (CHIP) As of May 2022, 88,978,791 of people are enrolled in Medicaid and CHIP. This is an increase of 677,711 since the last report. 81,904,569 are enrolled in Medicaid 7,074,222 are enrolled in CHIP For more information on Medicaid/CHIP enrollment, including enrollment trends, visit https://www.medicaid.gov/ Every day, CMS ensures that people across the U.S. have coverage that works. See the latest coverage totals across all CMS programs at https://www.cms.gov/pillar/ |
HHS Provides More Details on Phase 4 and Rural Provider Relief Fund Distribution
As previously reported by the AAA, the Department of Health and Human Services (HHS) has announced that it will open on September 29, Phase 4 of the Provider Relief Fund (PRF) to allocate $17 billion dollars for COVID-19 relief. In addition, it will provide $8.5 billion specifically for rural providers. On September 15, HHS held a stakeholder call on the PRF in which the agency provided more details on the distribution.
The application process will remain open for 4 weeks. Providers will be able to use the funding through December 31, 2022. The Administration’s goal is to release the rural funds before Thanksgiving and the Phase four funds by mid-December 2021. The agency indicated it has additional funding it is holding back to reimburse for the uncompensated care fund for which providers and suppliers can still apply.
The AAA has been advocating relentlessly for the Administration to open a fourth phase of funding and support rural providers and suppliers. As described below, these phases of funding will rely upon data from Medicare, Medicaid, and the State Children’s Health Insurance Program (CHIP). It is important that all AAA members who qualify not only submit applications, but also make sure that you have appropriately submitted claims to these programs, including when allowed, claims under the ground ambulance treatment in place waiver. We strongly recommend that all AAA members apply for funding.
Phase 4 Funding
The Phase 4 PRF methodology and application will primarily follow the same rules set forth for Phase 3. It will apply for Q2 2020 through Q1 2021. The funding will be available for the same broad set of providers and suppliers that were eligible under Phase 3.
Phase 4 will have two components. The Acting Administrator of HRSA has explained that 75 percent of the funding for Phase 4 will be determined based on a provider’s lost revenues and expenses that the provider submits through the application process. HRSA will calculate the amount awarded based on the number of applications received. However, it will establish a base for all providers and then adjust that base up for medium and small providers who have lower volumes over which to spread their costs. The determination of provider size will be based on patient revenues.
The second component of Phase 4 funding will allocate 25 percent for bonus payments to providers serving Medicare, Medicaid, and CHIP patients. The final amounts awarded will be determined based on the volume of services provided to these patient populations.
The Acting Administrator also noted that once again providers who have higher values compared to their peer group will be flagged and may have the amount they receive capped or may not receive any funding. There will be a reconsideration process for these providers as well.
Rural Funding
In addition to Phase 4, HRSA will provide rural-specific relief to providers and suppliers serving rural patients. The determination of whether a provider qualifies will be based on the patient’s location, not that of the providers. HRSA will use Medicare, Medicaid, and CHIP data to calculate the payment, so the application process will be simplified and providers required to submit less information. The amounts will be determine based on the number of patients served and the number of applicants.
Additional Relief
The Acting Administrator also indicated that HRSA will provide a 60-day grace period for those providers who received funds already and are required to report if they cannot meet the current reporting deadline. She also noted that HRSA is establishing a reconsideration process for Phase 3 as well. Details will be available on the HRSA website.
Additional Information
HRSA will be posting information on its website. It will also host two webinars on September 30 and October 5 to provide more information about how providers can apply to these programs.
CMS | New Medicaid and CHIP Enrollment Snapshot
FOR IMMEDIATE RELEASE
June 21, 2021
Contact: CMS Media Relations
CMS Media Inquiries
New Medicaid and CHIP Enrollment Snapshot Shows Almost 10 million Americans Enrolled in Coverage During the COVID-19 Public Health Emergency
Report Shows Record Medicaid Enrollment and Highlights the Program’s Importance in Preserving Coverage for Millions of Children and Adults Throughout the United States
The Centers for Medicare & Medicaid Services (CMS) released a new Enrollment Trends Snapshot report today showing a record high, over 80 million individuals have health coverage through Medicaid and the Children’s Health Insurance Program (CHIP). Nearly 9.9 million individuals, a 13.9% increase, enrolled in coverage between February 2020, the month before the public health emergency (PHE) was declared, and January 2021.
Among the 50 states and the District of Columbia, a total of 80,543,351 people were enrolled and receiving full benefits from the Medicaid and CHIP programs by the end of January 2021. In the 50 states that reported total Medicaid child and CHIP enrollment data for January 2021, over 38.3 million children were enrolled in Medicaid and CHIP combined, approximately 50% of the total Medicaid and CHIP enrollment. These numbers highlight the essential role the Medicaid and CHIP programs play in providing quality and needed coverage for millions of vulnerable children and adults. In fact, both programs serve as the largest single source of health coverage in the country.
“The Biden-Harris administration is using every lever to ensure any American needing access to quality health coverage receives it. Now more than ever, people need the peace of mind of knowing that they have health coverage,” said HHS Secretary Xavier Becerra. “This report reminds us what a critical program and rock Medicaid continues to be in giving tens of millions of children and adults access to care. This pandemic taught us that now more than ever, we must work to strengthen Medicaid and make it available whenever and wherever it’s needed using the unprecedented investments Congress provided.”
The increase in total Medicaid and CHIP enrollment is largely attributed to the impact of the COVID-19 PHE, in particular, enactment of section 6008 of the Families First Coronavirus Response Act (FFCRA). FFCRA provides states with a temporary 6.2% payment increase in Federal Medical Assistance Percentage (FMAP) funding. States qualify for this enhanced funding by adhering to the Maintenance of Effort requirement, which ensures eligible people enrolled in Medicaid stay enrolled and covered during the PHE.
“Medicaid and CHIP serve as a much-needed lifeline for millions of people throughout this country. The increase we are seeing is exactly how Medicaid works: the program steps in to support people and their families when times are tough,” said CMS Administrator Chiquita Brooks-LaSure. “For the parents that may have lost a job or had another life change during the pandemic, having access to coverage for themselves and their kids is life-changing. CMS is committed to ensuring our nation’s marginalized communities and low-income families have the coverage they need.”
To assist states and territories in their response to the COVID-19 PHE, CMS developed numerous strategies to support Medicaid and CHIP programs in times of crisis, including granting states more flexibility in their Medicaid and CHIP operations. Today’s data release also reflects a range of indicators related to key application, eligibility, and enrollment processes from within state Medicaid and CHIP agencies.
The Snapshot is a product of the Centers for Medicare and Medicaid CHIP Services (CMCS) Medicaid and CHIP Coverage Learning Collaborative (MACLC), which monitors Medicaid and CHIP enrollment trends, primarily using the CMS Performance Indicator (PI) data reported to CMS by state Medicaid and CHIP agencies. PI data reflects key Medicaid and CHIP business processes- including applications, renewals, eligibility determinations, and enrollment.
The Enrollment Trends Snapshot, which is released monthly, is available here: https://www.medicaid.gov/
The complete dataset, including data from January 2021, is available on data.Medicaid.gov.
CMS Releases Update Guidance on Hospital EMTALA Obligations Related to COVID-19
On March 9, 2020, CMS published a memorandum to State Survey Agency Directors that provides updated guidance on the obligations of hospitals and critical access hospitals (CAHs) under the Emergency Medical Treatment and Labor Act (EMTALA). This guidance was issued in response to numerous inquiries regarding the EMTALA obligations of these facilities as they struggle to respond to the COVID-19 pandemic.
Under EMTALA, hospitals and CAHs with emergency departments have an obligation to provide an appropriate medical screening examination to any individual that comes into the emergency department seeking examination or treatment of an emergency medical condition. Hospitals and CAHs are further required to make a determination as to whether the patient actually has an emergency medical condition, and, if so, to provide stabilizing treatment within the hospital’s capabilities, or make appropriate arrangements to transfer the patient to a facility that does have the necessary capabilities.
The hospitals and CAHs had requested guidance on how they can fulfill their basic EMTALA obligations while minimizing the risks of exposure from COVID-19 infected individuals to their staff and other patients in their emergency departments.
Note: in summarizing the CMS guidance document, references to a “hospital” will include both hospitals and CAHs.
Acceptance of Patients Suspected or Confirmed to be Infected with COVID-19
CMS indicated that hospitals with the capacity and the specialized capabilities needed to provide stabilizing treatments are required to accept transfers from hospitals without the necessary capabilities. CMS indicated that it would take into account the recommendations of the Centers for Disease Control (CDC) in assessing a hospital’s capabilities and capacity. CMS further indicated that the presence or absence of negative pressure rooms (Airborne Infection Isolation Room (AIIR)) would not be the sole determining factor related to determining when an EMTALA transfer is required. CMS is advising hospitals to coordinate with their state and local public health officials regarding the appropriate placement of individuals who meet specific COVID-19 assessment criteria, as well as the most current standards for treating patients confirmed to be infected with COVID-19.
CMS is further confirming that hospitals have the ability to set up alternative screening sites on the hospital campus, i.e., the initial medical screening exam does not need to take place in the emergency department. CMS is confirming that individuals may be redirected to an alternative screening site after being logged into the emergency department. This redirection can even take place outside the entrance to the emergency department. Medical screening exams conducted in alternative screening sites must still be conducted by qualifying personnel (i.e., physicians, NPs, Pas, or RNs).
CMS is also indicating that hospitals may set up screening sites at “off-campus, hospital-controlled” sites. Hospitals and community officials may encourage the public to go to these sites instead of the hospital for screening for influenza-like illnesses. However, a hospital cannot tell an individual that has already presented at their emergency department to go to an off-site location for their medical screening exam. Unless the off-campus site is already considered to be a dedicated ED (e.g., a free-standing ED) under EMTALA regulations, the EMTALA regulations would not apply to these off-site screening areas; however, the hospital would be required under its Medicare Conditions of Participation to arrange a referral/transfer to an appropriate hospital if the patient has a need for emergency medical attention.
Finally, communities may set up screening clinics at sites not under the control of a hospital. These sites would not be subject to EMTALA.
EMTALA Obligations when a Screening Suggests Possible COVID-19 Infection
To the extent a hospital determines, following a medical screening exam that a patient may be a possible COVID-19 case, the hospital is expected to isolate the patient immediately. CMS indicated that it expects that all hospitals will be able to provide medical screening exams and initiate stabilizing treatment while maintaining isolation requirements.
Once an individual is admitted to the hospital or the emergency medical condition ends, the hospital has no further obligations under EMTALA.
CMS is further reminding hospitals that the latest screening guidance from the CDC calls for hospitals to contact their State or local public health officials when they have a case of suspected COVID-19.
CMS Grants State of Florida’s 1135 Waiver Request for Coronavirus Response
On March 16, 2020, CMS approved an 1135 Waiver request submitted by the State of Florida. The State had requested the flexibility to waive prior authorization requirements, streamline its Medicaid enrollment process, and allow care to be provided in alternative settings to the extent an existing health care facility needs to be evacuated. The key provisions of the waiver are summarized below:
1. Payments to Out-of-State Providers: Under current CMS coverage guidelines, the Florida Medicaid Program had the authority to reimburse out-of-state providers that were not enrolled in the Florida Medicaid Program provided certain criteria were met. However, this authority was limited to situations involving: (a) a single instance of care furnished over a 180-day period or (b) multiple instances of care furnished to a single Florida Medicaid beneficiary over a 180-day period. Under the waiver, CMS is removing the 180-day restriction for the duration of the emergency.
2. Expedited Enrollments: With respect to providers that are not currently enrolled in the Medicare Program or with another State Medicaid Agency, CMS is waiving the following screening requirements: (a) the payment of the application fee, (b) the fingerprint-based criminal background checks, (c) the required site visits, and (d) the in-state/territorial licensing requirements. Under the waiver, the state would still be required to check enrolling providers against the OIG exclusion list, and confirm that the out-of-state provider is properly licensed in their home state.
3. Cessation of Revalidation Efforts: CMS granted Florida the authority to temporarily cease the revalidation of enrolled in-state Medicaid providers and suppliers who are directly impacted by the emergency.
4. Waiver of Prior Authorization Requirements: CMS has granted Florida the right to waive any prior authorization requirements that are currently part of the State Medicaid Plan. This waiver applies to services provided on or after March 1, 2020, and will continue through the termination of the emergency declaration.
5. Waiver Allowing Evacuating Facilities to Provide Services in Alternative Settings: CMS will allow facilities, including nursing facilities, intermediate care facilities for individuals with intellectual and developmental disabilities, psychiatric residential treatment facilities, and hospitals to be reimbursed for services rendered during an emergency evacuation to an otherwise unlicensed facility. This waiver will extend for the duration of the declared emergency; however, CMS will require the unlicensed facility to seek licensure with the state after 30 days.
Understanding Medicare, Medicaid, and SCHIP Coverage of Ambulance Services under a Declared National State of Emergency
On March 13, 2020, President Donald J. Trump announced a national state of emergency in response to the COVID-19 pandemic. Previously, HHS Secretary Alex Azar had declared a public health emergency under Section 319 of the Public Health Service Act in response to COVID-19.
This has prompted many AAA members to ask what impact, if any, these declarations have on the coverage of ambulance services under federal health care programs?
The short answer is that these declarations give CMS the authority under Section 1135 of the Social Security Act to waive certain Medicare, Medicaid, and SCHIP Program requirements. This waiver authority includes, but is not necessarily limited to:
• Waiving certain conditions of participation and/or certification requirements;
• Waiving certain pre-approval requirements;
• Waiving the requirements that a provider or supplier be licensed in the state in which they are providing services;
• Waiving EMTALA requirements related to medical screening examinations and transfers; and
• Waiving certain limitations on payments for services provided to Medicare Advantage enrollees by out-of-network providers.
One situation where an 1135 waiver may be of use to an ambulance provider or supplier would be where the ambulance provider or supplier is sending vehicles and crews to a state that is outside its normal service area. The ambulance provider or supplier is unlikely to be licensed by the state in which it is responding. As a result, under normal circumstances, it would be ineligible for payment under federal health care program rules. The 1135 waiver would permit it to submit claims for the services it furnishes in the other state.
Of more immediate significance to the current national emergency, an 1135 waiver may permit hospitals and other institutional health care providers to establish an off-site treatment center for initial screenings of patients. For example, hospitals may establish triage sites in parking lots and other open spaces for the initial intake of patients suspected of being infected with the COVID-19 virus. In theory, this waiver could also extend to drive-thru testing sites to the extent they are operated by the hospital or another health care provider. When a hospital has obtained an 1135 waiver to operate an off-site treatment center, the off-site area becomes a part of the hospital for Medicare payment purposes. Therefore, ambulance transports to an approved off-site treatment area should be submitted to Medicare using the “H” modifier for the destination.
CMS Announces New Healthy Adult Opportunity Initiative
On January 30, 2020, the Centers for Medicare and Medicaid Services (CMS) announced the roll-out of its “Healthy Adult Opportunity” (HAO) initiative. Under the initiative, participating states will have a portion of their current federal Medicaid funding converted to block grants. In return, the states will gain greater flexibility in providing for the health care needs of certain portions of their existing Medicaid populations.
In a letter directed to State Medicaid Directors, CMS outlined the details of how the HAO initiative would operate. The initiative will be operated under CMS’ 1115 waiver authority. In order to participate, a state must submit an application setting forth the specific demonstration projects it intends to implement. CMS reiterated that participation in the HAO initiative is voluntary. CMS further indicated that it will review state applications on a case-by-case basis and make an independent decision on whether the proposed policies merit approval. States with existing Section 1115 waivers that cover eligible populations will be permitted to transition existing demonstrations into the HAO initiative.
CMS indicated that HAO demonstrations will generally be approved for an initial 5-year period, and successful demonstrations may be renewed for a period of up to 10 years.
A summary of some of the major provisions of this initiative is provided below.
Federal Funding
The Medicaid Program is a joint federal and state program that provides free or low-cost health coverage to nearly 65 million Americans. The Program is administered by each state, with the federal government reimbursing states for a percentage of their qualifying Medicaid expenditures. The amount of federal matching funds is based on a statutory formula that compares a state’s per capita income to the national average. States with lower per capita incomes receive a higher Federal Medical Assistance Percentage (FMAP). FMAPs range from 50% to a maximum of 83%. In addition, the federal government provides higher matching rate (called an Enhanced FMAP) for certain services or populations. For example, the federal government currently pays 90% of the costs of providing health care to those covered by the Medicaid expansion included in the Affordable Care Act.
Under the HAO initiative, participating states would forego the FMAP for certain Medicaid populations. Instead, these states would receive a fixed amount of federal funding (i.e., a block-grant), which will be calculated based on either a total expenses or per-enrollee basis. To the extent the state spends more than its budgeted amount, it would not be eligible for additional federal matching funds. To the extent the state ends up spending less than its budgeted amount, the state would participate in the cost-savings.
Eligible Medicaid Populations
The HAO initiative is focused on the non-mandatory adult Medicaid populations, i.e., individuals that are under the age of 65, and who are not eligible for Medicaid on the basis of disability, or their need for long term care, and who are not otherwise eligible under a State Medicaid Plan. In other words, this initiative is largely targeted at those individuals that become eligible for Medicaid as a result of the Affordable Care Act.
Benefit Package Design
Under the HAO initiative, states will have the ability to design benefit packages that closely resemble the benefit packages provided by private insurers. At a minimum, this would include benefit packages that cover all of the Essential Health Benefits (EHBs) required for commercial insurances sold on the State ACA Exchanges. States may also design federally qualified health center coverages that facilitate the use of value-based payment design among safety-net providers.
Beneficiaries that are shifted into HAO demonstration projects will retain certain beneficiary protections, including all federal disability and civil rights laws, fair hearing rights, and limits on their mandatory cost-sharing amounts.
Coverage of Prescription Drugs
One major change would be to state’s coverage of prescription drugs. The initiative would give states the flexibility to offer formularies under an HAO demonstration project similar to those provided in commercial health insurance markets. This would remove the current mandate that states provide a so-called “open formulary.” States that elect to establish their own formulary would be required to comply with the EHB requirements regarding prescription drug benefits. States would also be required to cover substantially all drugs used to treat: (1) mental health disorders (i.e., antipsychotics and antidepressants), (2) HIV (i.e., antiretroviral drugs), and (3) opioid use disorders (i.e., all forms, formulations, and delivery mechanisms) where there are rebate agreements in place with the manufacturers.
In theory, this would permit states to cover only a single drug for many pharmaceutical classes.
Cost-Sharing Amounts
States would have the flexibility to impose additional cost-sharing obligations on beneficiaries covered under a demonstration program, subject to two broad limitations:
- Aggregate out-of-pocket costs for beneficiaries covered under an HAO demonstration must not exceed 5% of the beneficiary’s household income, measured on a monthly or quarterly basis; and
- Premiums and cost-sharing charges for tribal beneficiaries, those beneficiaries living with HIV, those beneficiaries needing treatment for substance use disorders, and the cost-sharing charges for prescription drugs used to treat mental health conditions must not exceed amounts permitted under the implementing regulations. States would also not be permitted to suspend enrollment for these individuals if they fail to pay their premiums or cost-sharing amounts.
Wrap-Around Services (Including NEMT)
States would be given the flexibility to discontinue the coverage of Alternative Benefit Plan wrap-around services, including non-emergency medical transportation (NEMT) and early and periodic screening, diagnostic and treatment services (EPSDT) for individuals aged 19-20.
HHS OIG Issues Advisory Opinion on Community Paramedicine
HHS OIG Issues Advisory Opinion Permitting Community Paramedicine Program Designed to Limit Hospital Readmissions
On March 6, 2019, the HHS Office of the Inspector General (OIG) posted OIG Advisory Opinion 19-03. The opinion related to free, in-home follow-up care offered by a hospital to eligible patients for the purpose of reducing hospital admissions or readmissions.
The Requestor was a nonprofit medical center that provides a range of inpatient and outpatient hospital services. The Requestor and an affiliated health care clinic are both part of an integrated health system that operates in three states. The Requestor had previously developed a program to provide free, in-home follow-up care to certain patients with congestive heart failure (CHF) that it has certified to be at higher risk of admission or readmission to a hospital. The Requestor was proposing to expand the program to also include certain patients with chronic obstructive pulmonary disease (COPD). According to the Requestor, the purpose of both its existing program and its proposed expansion was to increase patient compliance with discharge plans, improve patient health, and reduce hospital inpatient admissions and readmissions.
Under the existing program, clinical nurses screen patients to determine if they meet certain eligibility criteria. These include the requirement that the patient have CHF and either: (1) be currently admitted as an inpatient at Requestor’s hospital or (2) be a patient of Requestor’s outpatient cardiology department, and who had been admitted as an inpatient at Requestor’s hospital within the previously 30 days. The clinical nurses would identify those patients at higher risk of hospital admission based on a widely used risk assessment tool. The clinical nurses would also determine whether the patient had arranged to receive follow-up care with Requestor’s outpatient CHF center. Patients that do not intend to seek follow-up care with the CHF center, or who have indicated that they intend to seek follow-up care with another health care provider, would not be informed of the current program. Eligible patients would be informed of the current program, and offered the opportunity to participate. The eligibility criteria for the expanded program for COPD patients would operate in a similar manner.
Eligible patients that elect to participate in the current program or the expanded program would receive in-home follow up care for a thirty (30) day period following enrollment. This follow up care would consist of two visits every week from a community paramedic employed by the Requestor. As part of this in-home care, the community paramedic would provide some or all of the following services:
- A review of the patient’s medications;
- An assessment of the patient’s need for follow-up appointments;
- The monitoring of the patient’s compliance with their discharge plan of care and/or disease management;
- A home safety inspection; and/or
- A physical assessment, which could include checking the patient’s pulse and blood pressure, listening to the patient’s lungs and heart, checking the patient’s cardiac function using an electrocardiogram, checking wounds, drawing blood and running blood tests, and/or administering medications.
The community paramedic would use a clinical protocol to deliver interventions and to assess whether a referral for follow-up care is necessary. To the extent the patient requires care that falls outside the community paramedic’s scope of practice, the community paramedic would direct the patient to follow up with his or her physician. For urgent, but non-life threatening conditions, the community paramedic would initiate contact with the patient’s physician.
The Requestor certified that the community paramedics would be employed by the Requestor on either full-time or part-time basis, and that all costs associated with the community paramedic would be borne by the Requestor or its affiliates. The Requestor further certified that no one involved in the operation of the program would be compensated based on the number of patient’s that enroll in the programs. While one of the states in which the Requestor operates does reimburse for community paramedicine services, Requestor certified that it does not bill Medicaid for services provided under the program.
The question posed to the OIG was whether any aspect of the program violated either the federal anti-kickback statute or the prohibition against the offering of unlawful inducements to beneficiaries.
In analyzing the program, the OIG first determined that the services being offered under the program offer significant benefit to enrolled patients. The OIG specifically cited the fact that one state’s Medicaid program reimbursed for similar services as evidence of this value proposition. For this reason, the OIG concluded that the services constitute “remuneration” to patients. The OIG further concluded that this remuneration could potentially influence a patient’s decision on whether to select Requestor or its affiliates for the provision of federally reimbursable items and services. Therefore, the OIG concluded that the program implicated both the anti-kickback statute and the beneficiary inducement prohibition.
The OIG then analyzed whether the program would qualify for an exception under the so-called “Promoting Access to Care Exception.” This exception applies to remuneration that improves a beneficiary’s ability to access items and services covered by federal health care programs and which otherwise pose a low risk of harm. The OIG determined that while some aspects of the program would likely fall within this exception, other aspects would not. Specifically, the OIG cited the home safety assessment as not materially improving a beneficiary’s access to care.
Having concluded that there was no specific exception that would permit the arrangement, the OIG then analyzed the arrangement under its discretionary authority, ultimately concluding that the program posed little risk of fraud or abuse. In reaching this conclusion, the OIG cited several factors:
- The OIG felt that the potential benefits of the program outweighed the potential risks of an improper inducement to beneficiaries. The OIG cited the fact that beneficiaries must have already selected Requestor or its associated clinic as their provider of services before learning about the program. As the OIG indicated “the risk that the remuneration will induce patients to choose Requestor or the Clinic for CHF- or COPD-related services is negligible because patients already have made this selection.” The OIG also noted that the community paramedic will inform beneficiaries of their right to choose a different provider prior to referring the beneficiary to the Requestor or its clinic for services outside the scope of the program.
- The OIG noted that, to the extent the program works as intended, it would be unlikely to lead to increased costs to federal health care programs. As noted above, Requestor had certified that it would not bill federal health care programs for the services of the community paramedic.
- The program was designed in a way as to minimize the potential for interference with clinical decision-making.
- The Requestor certified that it would not advertise or market the program to the public, thereby minimizing the chances of beneficiaries learning about the program prior to selecting Requestor for their CHF- or COPD-related care.
- The OIG noted that the program appeared to be reasonably tailored to accomplish the goal of reducing future hospital admissions. For example, the OIG cited the fact that the Requestor limited inclusion in the program to patients deemed to be at a higher-than-normal risk of hospital admission or readmission, and that it made these determinations using a widely used risk assessment tool. The OIG noted that these patients would likely benefit from the continuity of care offered under the program. In addition, the OIG noted that the community paramedics would be in a position to keep the patients’ physicians appraised of their health by documenting all of their activities.
Potential Impact on Mobile Integrated Health and/or Community Paramedicine Programs
OIG advisory opinions are issued directly to the requestor of the opinion. The OIG makes a point of noting that these opinions cannot be relied upon by any other entity or individual. Legal technicalities aside, the OIG’s opinion is extremely helpful to the industry, as it lays out the factors the OIG would consider in analyzing similar arrangements. Thus, the opinion is extremely valuable to ambulance providers and suppliers that current operate, or are considering the operation of, similar mobile integrated health and/or community paramedicine programs.
AAA Releases 2019 State Medicaid Ambulance Rate Survey
The AAA is pleased to release its 2019 State Medicaid Rate Survey. This survey sets forth the fee-for-service Medicaid rates for all 50 states. For each state, the Survey lists the rate paid for each of the following procedure codes:
- A0428 – BLS Non-Emergency
- A0429 – BLS Emergency
- A0426 – ALS Non-Emergency
- A0427 – ALS Emergency
- A0433 – ALS-2
- A0434 – SCT
- A0225 – Neonate Transport
- A0998 – Treatment, No Transport
- A0425 – Mileage
- A0422 – Oxygen
- A0382/A0398 – BLS/ALS Routine Disposable Supplies
- A0420 – Wait Time
- A0424 – Extra Attendant
Download the Survey as Spreadsheet
The rates set out in this survey are based on publicly available information provided by the various State Medicaid agencies. While the AAA has taken steps to verify the accuracy of the information on this Survey, it is possible that the rates provided in the Survey may not reflect changes to a state’s reimbursement policies that have not been made publicly available. These rates may not also not reflect any emergency budgetary measures or other temporary reductions imposed by a state.
The AAA’s goal is to make this Survey as accurate as possible. Therefore, if you believe the rates for your state are inaccurate, please contact the AAA at info@ambulance.org or me at bwerfel@aol.com.