101 CMR, § 327.05

Current through Register 1536, December 6, 2024

Section 327.05 - Nonpublic Ambulance Supplemental Payment Provisions

(1)Provider Eligibility. To be eligible to receive supplemental payments from the Trust Fund, a nonpublic ambulance provider must be

(a) licensed under M.G.L. c. 111C, § 6, as defined by the Department of Public Health (DPH);

(b) a MassHealth enrolled ambulance provider; and

(c) in compliance with the payment conditions set forth in 101 CMR 327.05(2).

(2)Payment Conditions.

(a) Nonpublic ambulance service expenditures will be made only under federally approved payment methods and consistent with federal funding requirements and all federal payment limits as determined by the Secretary of Health and Human Services.

(b) Payments under the Trust Fund will only be made to eligible nonpublic ambulance providers that

1. provide service to MassHealth members without limitations or restrictions based on origin point or diagnosis code, so long as the origin point is consistent with the locality requirements under 130 CMR 407.411(C): Locality Restriction;

2. meet service quality standards as defined by EOHHS via administrative bulletin or other written issuance, including quality standards related to timely service and waiting times;

3. demonstrate compliance with other conditions of payment as described by EOHHS via administrative bulletin or other written issuance, including compliance with applicable requirements under 42 CFR § 433.68; and

4. comply with all applicable requirements of 130 CMR 407.000: Transportation Services.

(3)Compliance with Conditions of Payment.

(a) EOHHS may audit compliance with conditions of payment.

(b) EOHHS may, via administrative bulletin or other written issuance, establish standards governing various conditions of payment including, but not limited to, attestations, reporting requirements, compliance with payment conditions, penalties for noncompliance, and recovery.

(4)Timing of Payments.

(a) EOHHS will direct payments to eligible nonpublic ambulance providers from the Trust Fund each state fiscal year in which funding is available in the Trust Fund. Within 45 days of the end of each quarter, starting with the quarter beginning July 1, 2021, EOHHS will calculate and distribute payments to eligible nonpublic ambulance providers consistent with the payment methodology described in 101 CMR 327.05(5).

(b) Notwithstanding 101 CMR 327.05(4)(a), EOHHS will not make final supplemental payments to nonpublic ambulance providers, unless and until EOHHS receives notice of approval from the Centers for Medicare & Medicaid Services (CMS) for federal financial participation for expenditures related to the assessment described in 101 CMR 324.00: Nonpublic Ambulance Service Reimbursement Trust Fund Assessment and Funding. Upon receiving such approval, EOHHS will make supplemental payments for dates of service on or after July 1, 2021, within 180 days of such approval or the end of the relevant quarter, whichever is later.

(c) EOHHS may elect to make interim supplemental payments to nonpublic ambulance providers prior to receiving notice of approval from CMS for federal financial participation for expenditures related to the assessment. Any interim supplemental payment made to a provider is subject to adjustment to conform final supplement payments to the payment methodology ultimately approved by CMS. In the event CMS does not approve federal financial participation for such expenditures, EOHHS may recover any portion of the interim supplemental payment made to a provider. The adjustment or recovery may include, without limitation, the denial, reduction, or withholding of future payment to that provider or its successor in interest or any provider under common interest.

(5)Payment Methodology. Each quarter starting with the quarter beginning July 1, 2023, and subject to available state and federal funding and allowable under federal law, EOHHS will allocate payments to eligible nonpublic ambulance providers in the following amounts, subject to the limitations describes in 101 CMR 327.05(5)(c):

(a) To calculate the supplemental payments, EOHHS will assign eligible nonpublic ambulance providers to one of the following classifications and set the distribution factor percentage to be applied to the supplemental payments determined in 101 CMR 327.05(5)(b) as follows, provided that EOHHS may prospectively update the distribution factor percentage for a given quarterly payment by not more than plus or minus 5% via administrative bulletin or other written issuance.

1. Not-for-profit nonpublic ambulance providers, 4.00%

2. Not-for-profit hospital nonpublic ambulance providers, 11.50%

3. For-profit nonpublic ambulance providers in region 1 as defined by DPH Office of Emergency Medical Services (OEMS), 3.60%;

4. For-profit nonpublic ambulance providers in region 2 as defined by DPH OEMS, 1.45%;

5. For-profit nonpublic ambulance providers in region 3 as defined by DPH OEMS, 11.55%;

6. For-profit nonpublic ambulance providers in region 4 as defined by DPH OEMS, 43.30%;

7. For-profit nonpublic ambulance providers in region 5 as defined by DPH OEMS, 3.60%; and

8. For-profit nonpublic ambulance providers assigned to multiple regions or no region as defined by DPH OEMS, 21.00%.

EOHHS will assign affiliated for-profit nonpublic ambulance providers located in multiple regions as defined by DPH OEMS to classification 8.

(b) EOHHS will distribute 100 % of the payment to eligible nonpublic ambulance providers as follows, with the amount paid to each nonpublic ambulance provider equaling the product of

1. the ratio of the amount of ground ambulance services billed to MassHealth by that nonpublic ambulance provider to the amount of all nonpublic ambulance providers' in that nonpublic ambulance providers' classification as defined in 101 CMR 327.05(5)(a) billing to MassHealth for ground ambulance services;

2. 100% of the amount calculated to be payable from the Trust Fund; and

3. the applicable distribution factor percentage of the nonpublic ambulance provider's classification set forth in 101 CMR 327.05(5)(a).

(c) The payments to eligible nonpublic ambulance providers described in 101 CMR 327.05(5)(b) may not exceed the sum of the difference between the Medicaid payments otherwise made to these providers for the provision of ground ambulance services and the amount that would have been paid at the equivalent average commercial rate (ACR) in aggregate, as determined by EOHHS, as follows:

1. For all eligible nonpublic ambulance providers, EOHHS will identify the emergency and non-emergency ground ambulance services for which the provider is eligible to receive supplemental payment.

2. The supplemental payment amount will be calculated by first determining the equivalent ACR for all eligible emergency and non-emergency ground ambulance services identified under 101 CMR 327.05(5)(c)1.

3. EOHHS will then subtract an amount equal to the base Medicaid reimbursement amount for all of the emergency and non-emergency ground ambulance services from the ACR calculated in 101 CMR 327.05(5)(c)2. and divide that by the base Medicaid reimbursement amount to determine the percentage increase for each emergency and non-emergency ground ambulance service provided by eligible nonpublic ambulance providers.

4. The supplemental payment due to eligible nonpublic ambulance providers will be subject to available funding and will not exceed the product of