Code of Massachusetts Regulations
101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES
Title 101 CMR 327.00 - Rates of Payment for Ambulance and Wheelchair Van Services
Section 327.05 - Nonpublic Ambulance Supplemental Payment Provisions
Universal Citation: 101 MA Code of Regs 101.327
Current through Register 1518, March 29, 2024
(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 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, eligible nonpublic ambulance providers will be assigned
to one of the following classifications, as determined by EOHHS, with the
specified percentage multiplier applied to the eligible nonpublic ambulance
providers' supplemental payments as follows, provided that EOHHS may
prospectively update the percentage multipliers 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, 126.33%;
2. Not-for-profit hospital nonpublic
ambulance providers, 100.79%;
3.
For-profit nonpublic ambulance providers in region 1 as defined by DPH Office
of Emergency Medical Services (OEMS), 128.46%;
4. For-profit nonpublic ambulance providers
in region 2 as defined by DPH OEMS, 111.33%;
5. For-profit nonpublic ambulance providers
in region 3 as defined by DPH OEMS, 91.59%;
6. For-profit nonpublic ambulance providers
in region 4 as defined by DPH OEMS, 106.57%;
7. For-profit nonpublic ambulance providers
in region 5 as defined by DPH OEMS, 84.58%; and
8. For-profit nonpublic ambulance providers
assigned to multiple regions or no region as defined by DPH OEMS, 86.27%.
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' billing to
MassHealth for ground ambulance services;
2. 100% of the amount calculated to be
payable from the Trust Fund; and
3.
the applicable percentage multiplier described 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 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
a. the percentage increase calculated in 101
CMR 327.05(5)(c)3.;
b. multiplied by
the base Medicaid reimbursement amount; and
c. multiplied by the total number of units
for each service.
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