| (a) Authority. Payments are made to private and governmental
providers of ground and air ambulance services as specified in the
ambulance program rules in Chapter 354, Subchapter A, Division 9 of
this title (relating to Ambulance Services). The reimbursement determination
authority is specified in §355.101 of this chapter (relating
to Introduction).
(b) Definitions. The following words and terms, when
used in this section, have the following meanings unless the context
clearly indicates otherwise.
(1) Allowable costs--Expenses that are reasonable and
necessary for the normal conduct of operations relating to the provision
of ground and air ambulance services.
(2) Average Commercial Rate--The average amount payable
by commercial payers for the same service.
(3) Centers for Medicare and Medicaid Services (CMS)--The
federal agency within the United States Department of Health and Human
Services responsible for overseeing and directing Medicare and Medicaid,
or its successor.
(4) Governmental ambulance provider--An ambulance provider
that uses paid government employees to provide ambulance services.
The ambulance services must be directly funded by a unit of government
that has taxing authority or has direct access to tax revenues, such
as a local government, hospital authority, hospital district, city,
county, or state. A private ambulance provider under contract with
a governmental entity to provide ambulance services is not considered
a governmental ambulance provider for the purposes of this section.
(5) Medicaid shortfall--The unreimbursed cost to an
ambulance provider of providing Medicaid ambulance services to Medicaid
clients.
(6) Private ambulance provider--An ambulance provider
that uses paid employees associated and financed through a private
entity to provide ambulance services and may be under contract with
a local, state, or federal government.
(7) Uncompensated care costs--The sum of the Medicaid
shortfall and the uninsured costs.
(8) Uninsured costs--The unreimbursed cost to an ambulance
provider of providing ambulance services that meet the definition
of "medical assistance" in Social Security Act §1905(a) to uninsured
patients as defined by CMS.
(9) Unit of service--A unit of service based on one
or more allowable ambulance services provided to a client by all modes
of approved transportation.
(c) Reimbursement methodologies.
(1) Fee-for-service ambulance fee. Fee-for-service
reimbursement is based on the lesser of a provider's billed charges
or the maximum fee established by the Texas Health and Human Services
Commission (HHSC). HHSC establishes fees by reviewing the Medicare
fee schedule and analyzing any other available ambulance-related data.
Fee-for-service rates apply to both private and governmental ambulance
providers.
(2) Supplemental payment and enhanced supplemental
payment for governmental ambulance providers. For services provided
through September 30, 2019, a governmental ambulance provider may
be eligible to receive a supplemental payment in addition to the fee-for-service
payment described in paragraph (1) of this subsection. For services
provided beginning October 1, 2019, eligibility for governmental ambulance
providers to receive a supplemental payment, and the methodology for
calculating the payment amount, are described in §355.8210 of
this subchapter (relating to Waiver Payments to Governmental Ambulance
Providers for Uncompensated Charity Care).
(A) Eligibility for supplemental payments. A governmental
ambulance provider must submit a written request for determination
of eligibility for supplemental payment in a manner designated by
HHSC. If eligible, a governmental ambulance provider may begin to
claim uncompensated care costs related to services provided on or
after the first day of the month after the request for determination
of eligibility is approved. HHSC only considers requests for determination
of eligibility from governmental ambulance providers as defined in
subsection (b) of this section. HHSC will respond to all written requests
for consideration, indicating the requestor's eligibility to receive
supplemental payments. An acceptable request must include:
(i) an overview of the governmental agency;
(ii) a complete organizational chart of the governmental
agency;
(iii) a complete organizational chart of the ambulance
department within the governmental agency providing ambulance services;
(iv) an identification of the specific geographic service
area covered by the ambulance department, by ZIP code;
(v) copies of all job descriptions for staff types
or job categories of staff who work for the ambulance department and
an estimated percentage of time spent working for the ambulance department
and other departments of the governmental agency;
(vi) a primary contact person for the governmental
agency who can respond to questions about the ambulance department;
and
(vii) a signed letter documenting the governmental
ambulance provider's voluntary contribution of non-federal funds.
(B) Eligibility for enhanced supplemental payments.
A governmental ambulance provider must submit an application for enhanced
supplemental payments to HHSC using a form designated by HHSC that
includes the cost and payment data for paid Medicaid and commercial
claims for all procedure codes specified in the application. If HHSC
approves the application, a governmental ambulance provider may begin
to claim enhanced supplemental payments based on the average commercial
rate related only to ground ambulance services reimbursed by Texas
Medicaid on a fee-for-service basis provided on or after the first
day of the month after the application is approved. HHSC will respond
to all applications, indicating approval or disapproval of the applicant's
eligibility to receive enhanced supplemental payments. An acceptable
application must include:
(i) proof of enrollment as a Medicaid provider in the
State of Texas at the beginning of the current demonstration year
as defined in §355.8210 of this subchapter;
(ii) a primary contact person for the government agency
who can respond to questions about the ambulance department;
(iii) a statement from the provider expressing its
intent to participate in the program; and
(iv) a cost report that includes the cost and payment
data for paid Medicaid and commercial claims for all procedure codes
specified by HHSC.
(C) Cost reports. Governmental ambulance providers
that are eligible for supplemental or enhanced supplemental payments
must submit an annual cost report for ground and air ambulance services
delivered to Medicaid and, effective March 1, 2012, uninsured clients
on a cost report form specified by HHSC. Providers certify through
the cost report process their total actual federal and non-federal
costs and expenditures for the cost reporting period. Cost reports
must be completed for a full year based on the federal fiscal year.
HHSC may require newly eligible providers to submit a partial-year
cost report for their first year of eligibility. The beginning date
for the partial-year cost report is the provider's first day of eligibility
for supplemental or enhanced supplemental payments as determined by
HHSC. The ending date of the partial-year cost report is the last
day of the federal fiscal year that encompasses the cost report beginning
date.
(i) Due date. The cost report is due on or before March
31 of the year following the cost reporting period ending date, September
30, and must be certified in a manner specified by HHSC. If March
31 falls on a federal or state holiday or weekend, the due date is
the first business day after March 31. A provider may request in writing,
by regular mail or special mail delivery, an extension of up to 30
days after the due date to submit a cost report. HHSC will respond
to all written requests for extensions, indicating whether the extension
is granted. HHSC must receive a request for extension before the cost
report due date. A request for extension received after the due date
is considered denied. A provider whose cost report is not received
by the due date or the extended due date is ineligible for supplemental
or enhanced supplemental payments for the federal fiscal year.
(ii) Purpose. A cost report documents the provider's
actual allowable Medicaid and uncompensated care costs for delivering
ambulance services in accordance with the applicable state and federal
regulations. Because the cost report is used to determine supplemental
and enhanced supplemental payments, a provider must submit a complete
and acceptable cost report to be eligible for a supplemental or enhanced
supplemental payment.
Cont'd... |
