03.20 Appropriation Emergency Transport Program Fund `�OF...�1t,�
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TO: Honorable Mayor and Members of the City Council
THRU: Rick Otto, City Manager
FROM: Doug Fackiner, Fire Chief �f/�
REVIEW: City Manag r� Finance �/
1 . SUBJECT
Appropriation of $250,000 from the Emergency Transport Program fund (125) for the
California Department of Health Care Services Ground Emergency Medical Transport
Program Quality Assurance Fee.
2. SUMMARY
California Senate Bill 523 enacted a Quality Assurance Fee of $25.23 for every ground
ambulance transport to a hospital. The fee will be used by the California Department of
Health Care Services to increase federal financial participation and raise reimbursements
of Medi-Cal fee-for-service and Medi-Cal managed care ambulance transports. The
quality assurance fee is due for transports performed by Orange City Fire Department
Rescue Ambulances beginning January 1, 2018.
3. RECOMMENDED ACTION
Authorize the appropriation of $250,000.00 from the Emergency Transport Program
unreserved fund balance to expenditure account number 125.3015.52611.20406
Emergency Transport Program — Quality Assurance Transport Fees. `
nc'
4. FISCAL IMPACT
The total expenditure for this program is $250,000 and will be funded through Emergency
Transport Program (125).
5. STRATEGIC PLAN GOALS
Goal 2: Be a Fiscally Healthy Community
a: Expend fiscal resources responsibly.
6. DISCUSSION AND BACKGROUND
The City's Emergency Medical Services (EMS) is mandated to provide hospital transport
to all individuals, regardless of insurance coverage. Because public health providers do
ITEM 3,o� 0 1 05/14/2019
not provide full reimbursement, both public and private transport services continue to
heavily subsidize their transport programs. The City currently participates in two programs
to recoup federal reimbursements for EMS. Ground Emergency Medical Transport
(GEMT) increases the reimbursement for Medi-Cal fee-for-services patients, and the
InterGovernmental Transfer(IGT) does the same for Cal-Optima patients. Both programs
are voluntary and are only available to public providers.
Senate Bill 523, signed into law on October 13, 2017, was designed to recover a higher
percentage of Medi-Cal reimbursements, and is available to both public and private
providers. SB 523 has secured federal approval, federal financial participation, and a
corresponding State Plan Amendment to increase Medi-Cal Reimbursement. The bill was
enacted immediately as an urgency statute and levies a Quality Assurance Fee (QAF) on
all transports, both public and private, to be redistributed based on a provider's
percentage of Medi-Cal transports.
QAFs have been levied by the California Department of Health Care Services (DHCS) to
add supplemental payments to skilled nursing facilities since 2004, intermediate care
facilities for the developmental disabled since 2010, and hospitals since 2013. City staff
have performed the required reporting of quarterly transports and yearly gross receipts
for the quarter beginning January 1, 2018. DHCS used this data to determine the
statewide QAF per transport of $25.23 and the add-on Medi-Cal reimbursement of
$220.80, both of which will be reviewed each fiscal year. Quarterly QAF reporting and
payment is mandatory for both public and private ambulance transport providers.
Penalties will be assessed for late payments, and Medi-Cal payments will be withheld
from providers for non-payment.
Based on the City's current and recent total amount of rescue ambulance transports and
insurance payor mix, the amount collected in add-on reimbursements should exceed the
amount of QAF paid to DHCS. This net-positive effect is dependent on several variables
and is subject to change. In the future, if the QAF amount exceeds the add-on
reimbursement, it may become necessary to pass the fee on to the end user to avoid
subsidy by the City. Based on the payor mix of current and past rescue ambulance
transports, the projected Medi-Cal reimbursements will exceed the total quality assurance
fees paid. For the three reported quarters in 2018 the fiscal impact is as follows:
Increased Medi-Cal Reimbursement $223,008.00
Quality Assurance Transport Fees (129,117.60)
Total: $93,890.40
The appropriation of $250,000 is requested to make payments for ambulance transports
provided between January 1, 2018 and June 30, 2019. Future QAF payments, and the
subsequent Medi-Cal add-on reimbursements, will be included in the Fiscal Year 2019-
2020 budget.
7. ATTACHMENTS
1. Senate Bill 523
2. Calfornia State Plan Amendment 18-004
ITEM 2 05/14/2019
A
�� STATE OF CALIFORNIA
��;,u� AUTHENTICATED
MUPEi; EIFRftdNICIEWLMATEItIAL
Senate Bill No.523
CHAPTER 773
An act to add and repeal Article 3.91 (commencing with Section 14129)
of Chapter 7 of Part 3 of Division 9 of the Welfaze and Institutions Code,
relating to Medi-Cal,making an appropriation therefor, and declaring the
urgency thereof,to take effect unmediately.
[Approved by Govemor October 13,2017.Filed with
Secretary of State October 13,2017.]
LEGISLATIVE COUNSEL'S DIGEST
SB 523,Hernandez.Medi-Cal: emergency medical transport providers:
quality assurance fee.
Existing law establishes the Medi-Cal program, which is administered
by the State Department of Health Caze Services, under which qualified
low-income individuals receive health caze services.The Medi-Cal program
is,in part, governed and funded by federal Medicaid program provisions.
Existing law establishes a quality assurance fee program for skilled nursing
and intermediate caze facilities,as prescribed.
This bill,commencing 7uly 1,2018,and subject to federal approval and
the availability of federal financial participation, would impose a quality
assurance fee for each emergency medical transport provided by an
emergency medical transport provider, as defined, subject to the quality
assurance fee in accordance with a prescribed methodology.The bill would
authorize the Director of Health Care Services to exempt categories of
emergency medical transport providers from the quality assurance fee if
necessary to obtain federal approval.The bill would require the Director of
Health Care Services to deposit the collected quality assurance fee into the
Medi-Cal Emergency Medical Transport Fund,which the bill would create
in the State Treasury, to be continuously appropriated,thereby making an
appropriation,to the department to be used exclusively in a specified order
of priority to enhance federal financial participation for ambulance services
under the Medi-Cal program, and to provide additional reimbursement to,
and to support quality improvement efforts of,emergency medical transport
providers,to pay for state administrative costs, and to provide funding for
health care coverage for Californians.The bill would require each emergency
medical transport provider to report to the department data on the number
of actual emergency medical transports by payer type and on gross receipts,
as defined, in accordance with a specified timeline in a manner and form
prescribed by the department.The bill would authorize the department to
establish an Intemet Web site for the submission of these data reports.The
bill would authorize the department to require a certification by each
emergency medical transport provider,under penalty of perjury,of the truth
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Ch.773 —2—
of these data reports. By expanding the scope of the crime of perjury, the
bill would impose a state-mandated local program.The bill would authorize
the department, upon written notice to the emergency medical transport
provider,to impose a$100 per day penalty,to be deposited into the Medi-Cal
Emergency Medical Transport Fund,against the provider for each day that
the provider fails to make a report within 5 business days of the date upon
which the data report was due.
The bill, commencing July 1, 2018, and subject to federal approval and
the availability of federal financial participation, would increase the
Medi-Cal reimbursement to emergency medical transport providers for
emergency medical transports, including both fee-for-service transports
paid by the department and managed care transports paid by Medi-Cal
managed care health plans,as specified.
The bill would authorize the department to implement,interpret,or make
specific these provisions by means of provider bulletins, plan letters, or
other similaz instructions.
The bill would authorize the director to decide to not implement these
provisions in any state fiscal year if,before June 1 preceding the start of an
applicable state fiscal year,he or she finds that the implementation is likely
no longer a benefit to the General Fund for the applicable state fiscal year.
The bill would provide that the provisions of the bill shall cease to be
operative on the first day of the state fiscal year beginning on or after the
date one or more of certain conditions, including withdrawal of federal
approval,aze satisfied.The bill would authorize the department to conduct
appropriate close-out activities if these provisions become inoperative,and
would repeal these provisions when those activities have been completed
and the director notifies specified state entities.
The California Constitution requires the state to reimburse local agencies
and school districts for certain costs mandated by the state. Statutory
provisions establish procedures for making that reimbursement.
This bill would provide that no reimbursement is required by this act for
a specified reason.
This bill would declaze that it is to take effect immediately as an urgency
statute.
Appropriarion:yes.
The people of the State of California do enact as follows:
SECTION 1. The Legislature finds and declares all of the following:
(a) The Legislature recognizes the essential role that emergency medical
transport providers play in serving the state's Medi-Cal beneficiaries. To
that end, it has been and remains the intent of the Legislature to improve
funding for emergency medical transport providers and obtain all available
federal funds to make supplemental Medi-Cal payments to emergency
medical transport providers.
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(b) It is the intent of the Legislature to impose a quality assurance fee to
be paid by emergency medical transport providers, which will be used to
increase federal financial participation in order to increase Medi-Cal
payments to emergency medical transport providers.
(c) It is the intent of the Legislature to increase the Medi-Cal emergency
medical transport reimbursement in Medi-Cal fee-for-service and Medi-Cal
managed care by increasing the fee-for-service payment schedule for
emergency medical transports to support quality improvement efforts by
emergency medical transport providers, including, but not limited to, the
provision of advanced life support services, as defined in Section 1797.52
of the Health and Safety Code.
(d) It is the further intent of the Legislature that the increased
fee-for-service and Medi-Cal managed care payment schedule amounts
pursuant to Article 3.91 (commencing with Section 14129)of Chapter 7 of
Part 3 of Division 9 of the Welfare and Institutions Code shall not result in
any expenditure from the General Fund.
SEC. 2. Article 3.91 (commencing with Section 14129) is added to
Chapter 7 of Part 3 of Division 9 of the Welfare and Institutions Code, to
read:
Article 3.91. Medi-Cal Emergency Medical Transportation
Reimbursement Act -
14129. For purposes of this article,the following definitions apply:
(a) "Annual quality assurance fee rate"means the quality assurance fee
assessed on each emergency medical transport during each applicable state
fiscal year. .
(b) "Aggregate fee schedule increase amount"means the product of the
quotient described in paragraph(2) of subdivision(a) of Section 14129.3
and the Medi-Cal emergency medical transports, including both
fee-for-service transports paid by the department and managed caze transports
paid by Medi-Cal managed care health plans,utilizing the billing codes for
emergency medical transport for the state fiscal year.
(c) "Available fee amounY'shall be calculated as the sum of the following:
(1) The amount deposited in the Medi-Cal Emergency Medical Transport
Fund established under Section 14129.2 during the applicable state fiscal
year,less the amounts described in subparagraphs(A)and(B)of paragraph
(2)of subdivision(fl of Section 14129.2.
(2) Any federal financial participation obtained as a result of the deposit
of the amount described in pazagraph (1) in the Medi-Cal Emergency
Medical Transport Fund, created pursuant to Section 14129.2, for the
applicable state fiscal year.
(d) "Department"means the State Department of Health Care Services.
(e) "Director"means the D'uector of Health Care Services.
(fl "Effective state medical assistance percentage"means a ratio of the
aggregate expenditures from state-only sources for the Medi-Cal program
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divided by the aggregate expenditures from state and federal sources for
the Medi-Cal program for a state fiscal year.
(g) "Emergency medical transport" means the act of transporting an
individual from any point of origin to the nearest medical facility capable
of ineeting the emergency medical needs of the patient by an ambulance
licensed,operated,and equipped in accordance with applicable state or local
statutes,ordinances,or regulations that are billed with billing codes A0429
BLS Emergency, A0427 ALS Emergency, and A0433 ALS2, and any
equivalent, predecessor, or successor billing codes as may be deterniined
by the director. "Emergency medical transports" shall not include
transportation of beneficiaries by passenger car, taxicabs, litter vans,
wheelchair vans,or other forms of public or private conveyances,nor shall
it include transportation by an air ambulance provider. An "emergency
medical transport"does not occur when,following evaluation of a patient,
a transport is not provided.
(h) "Gross receipts" means gross payments received as patient care
revenue for emergency medical transports, determined on a cash basis of
accounting."Gross receipts"shall include all payments received as patient
care revenue for emergency medical transports, including payments for
billing codes A0429 BLS Emergency,A0427 ALS Emergency,and A0433
ALS2, and any equivalent,predecessor, or successor billing codes as may
be determined by the director, and any other ancillary billing codes
associated with emergency medical transport as may be detertnined by the
director. "Gross receipts"shall not include supplemental amounts received
pursuant to Section 14105.94.
(i) "Emergency medical transport provider" means any provider of
emergency medical transports.
(j) "Emergency medical transport provider subject to the fee"means all
emergency medical transport providers that bill and receive patient care
revenue from the provision of emergency medical transports, except
emergency medical transport providers that are exempt pursuant to
subdivision(c)of Section 14129.6.
(k) "Medi-Cal managed care health plan"means a"managed health care
plan"as that term is defined in subdivision(ab)of Section 14169.51.
14129.1. (a) (1) The depar[ment shall establish the manner and format
for emergency medical transport providers to report the data required
pursuant to this section.
(2) The department may establish an Internet Web site for the submission
of reports required by this section.
(3) The department may require a certification by each emergency medical
transport provider under penalty of perjury of the truth of the reports required
under this section.Upon written notice to an emergency medical transport
provider, the department may impose a penalty of one hundred dollazs
($100)per day against an emergency medical transport provider for every
day that an emergency medical transport provider fails to make a report
required by this section within five days of the date upon which the report
was due. Any funds resulting from a penalty imposed pursuant to this
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paragraph shall be deposited in the Medi-Cal Emergency Medical Transport
Fund created pursuant to subdivision(fl of Section 14129.2.
(b) Each emergency medical transport provider shall report to the
depaztment data on the number of actual emergency medical transports by
payer type, including, without limitation, Medi-Cal fee-for-service
emergency medical transports and Medi-Cal managed care emergency
medical transports per quarter,as follows:
(1) For each quarter beginning on July 1, 2015, through the quarter
beginning on July 1,2017,inclusive,the data shall be submitted on or before
October 15,2017.
(2) For the quarter beginning on October 1, 2017, and continuing each
quarter thereafter,the data shall be submitted on or before the 45th day after
the last day of the applicable quarter.
(c) Each emergency medical transport provider shall report to the
department data on the gross receipts received from the provision of
emergency medical transports per state fiscal yeaz,as follows:
(1) For the state fiscal years beginning on July 1,2015,and July 1,2016,
the data shall be submitted on or before October 15,2017.
(2) For each state fiscal year beginning on July 1,2017, and continuing
each state fiscal year thereafter,the data shall be submitted on or before the
45th day after the last day of the applicable state fiscal year.
14129.2. (a) (1) Commencing with the state fiscal quarter beginning
on July 1,2018,and continuing each state fiscal quarter thereafter for which
this article is implemented,there shall be imposed a quality assurance fee
for each emergency medical transport provided by each emergency medical
transport provider subject to the fee in accordance with this section.
(2) The director shall ensure that the quality assurance fee per emergency
medical transport imposed pursuant to this article is collected.
(b) (1) On or before June 15, 2018, and continuing each June 15
thereafter for which this article is implemented,the director shall calculate
the annual quality assurance fee rate applicable to the following state fiscal
year based on the most recently collected data from emergency medical
transport providers pursuant to Section 14129.1.The director may correct
any identified material or significant errors in the data collected from
emergency medical transport providers pursuant to Section 14129.1 for the
purposes of calculating the annual quality assurance fee rate.The director's
determination whether to exercise his or her discretion to correct any data
pursuant to this paragraph shall not be subject to judicial review, except
that an emergency medical transport provider may bring a writ of mandate
under Section 1085 of the Code of Civil Procedure to rectify an abuse of
discretion by the director in conecting that emergency medical transport
provider's data when that correction results in a greater fee amount for that
provider pursuant to this section.
(A) For the state fiscal year beginning on July 1,2018,the annual quality
assurance fee rate shall be calculated by multiplying the projected total
annual gross receipts for all emergency medical transport providers subject
to the fee by 5.1 percent, which resulting product shall be divided by the
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projected total annual emergency medical transports by all emergency
medical transport providers subject to the fee for the state fiscal year.
(B) For state fiscal yeazs beginning July 1, 2019, and conrinuing each
state fiscal year thereafter, the annual quality assurance fee rate shall be
calculated by a ratio, the numerator of which shall be the sum of: (i) the
product of the projected aggregate fee schedule atnount and the effective
state medical assistance percentage and (u) the amount described in
subparagraph(A)of paragraph(2)of subdivision(fl for the state fiscal year,
and the denominator of which shall be 90 percent of the projected total
, annual emergency medical transports by all emergency medical transport
providers subject to the fee for the state fiscal year.
(2) On or before June 15,2018,and continuing each June 15 thereafter
for which this article is implemented,the director shall publish the annual
quality assurance fee rate on its Intemet Web site.
(3) In no case shall the fees calculated pursuant to this subdivision and
collected pursuant to this article exceed the amounts allowable under federal
law.If,on or before June 15 of each year,the director makes a determination -
that the fees collected pursuant to this subdivision exceed the amounts
allowable under federal law, the d'uector may reduce the add-on increase
to the fee-for-service payment schedule described in Secrion 14129.3 only
to the extent necessary to reflect the amount of fees allowable under federal
law in an applicable state fiscal year.
(4) If, during a state fiscal year for which this article is operative, the
actual or projected available fee amount exceeds or is less than the actual
or projected aggregate fee schedule amount by more than 1 percent, the
director shall adjust the annual quality assurance fee rate so that the available
fee amount for the state fiscal year will approximately equal the aggregate
fee schedule amount for the state fiscal yeaz.The available fee amount for
a state fiscal yeaz shall be considered fo equal the aggregate fee schedule
amount for the state fiscal year if the difference between the available fee
amount for the state fiscal yeaz and the aggregate fee schedule amount for
the state fiscal year constitutes less than 1 percent of the aggregate fee
schedule amount for the state fiscal yeaz.
(c) (1) Each emergency medical transport provider subject to the fee
shall remit to the department an amount equal to the annual quality assurance
fee rate for the 2018-19 state fiscal year multiplied by the number of
transports reported or that should have been reported by the emergency
medical transport provider pursuant to subdivision(b)of Section 14129.1
in the quarter beginning on April 1,2018,based on a schedule established
by the d'uector.The schedule established by the director for the fee payment
described in this paragraph shall require remittance of the fee payment
according to the following guidelines:
(A) The director shall require an emergency medical transport provider
that rendered 35,000 or more Medi-Cal fee-for-service emergency medical
transports during the 2016-17 state fiscal year to remit the fee payment
described in this paragraph on or after July 1,2018.
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(B) The director shall require an emergency medical transport provider
that rendered fewer than 35,000 Medi-Cal fee-for-service emergency medical
transports during the 201Cr17 state fiscal yeaz to remit 50 percent or less
of the fee payment described in this paragraph on or after August 1,2018.
(C) The director shall require an emergency medical transport provider
that rendered fewer than 35,000 Medi-Cal fee-for-service emergency medical
transports during the 2016-17 state fiscal year to remit any remaining fee
payment amount described in this paragraph on or after August 15,2018.
(2) Commencing with the state fiscal quarter beginning on October 1,
2018, and continuing each state fiscal quarter thereafter, on or before the
first day of each state fiscal quarter, each emergency medical transport
provider subject to the fee shall remit to the department an amount equal to
the annual quality assurance fee rate for the applicable state fiscal yeaz
multiplied by the number of transports reported or that should have been
reported by the emergency medical transport provider pursuant to subdivision
(b)of Section 14129.1 in the immediately preceding quarter.
(d) (1) Interest shall be assessed on quality assurance fees not paid on
the date due at the greater of 10 percent per annum or the rate at which the
department assesses interest on Medi-Cal program overpayments pursuant
to subdivision(h)of Section 14171.Interest shall begin to accrue the day
after the date the payment was due and shall be deposited in the Medi-Cal
Emergency Medical Transport Fund established in subdivision(fl.
(2) In the event that any fee payment is more than 60 days overdue,the
department may deduct the unpaid fee and interest owed from any Medi-Cal
reimbursement payments owed to the emergency medical transport provider
until the full amount of the fee, interest, and any penalties assessed under
this article are recovered.Any deduction made pursuant to this subdivision
shall be made only after the department gives the emergency medical
transport provider written notification.Any deduction made pursuant to this
subdivision may be deducted over a period of time that takes into account
the financial condition of the emergency medical transport provider.
(3) In the event that any fee payment is more than 60 days overdue, a
penalty equal to the interest charge described in paragraph (1) shall be
assessed and due for each month for which the payment is not received after
60 days. Any funds resulting from a penalty imposed pursuant to this
paragraph shall be deposited into the Medi-Cal Emergency Medical
Transport Fund created pursuant to subdivision(fl.
(4) The director may waive a portion or all of either the interest or
penalties, or both, assessed under this article in the event the director
determines,in his or her sole discretion,that the emergency medical transport
provider has demonstrated that imposition of the full amount of the quality
assurance fee pursuant to the timelines applicable under this article has a
high likelihood of creating an undue financial hazdship for the provider.
Waiver of some or all of the interest or penalties pursuant to this paragraph
shall be conditioned on the emergency medical transport provider's
agreement to make fee payments on an alternative schedule developed by
the department.
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(e) The department shall accept an emergency medical transport
provider's payment even if the payment is submitted in a rate year
subsequent to the rate year in which the fee was assessed.
(� (1) The director shall deposit the quality assurance fees collected
pursuant to this section in the Medi-Cal Emergency Medical Transport Fund,
which is hereby created in the State Treasury and,notwithstanding Section
13340 of the Government Code,is continuously appropriated without regard
to fiscal years to the department for the purposes specified in this article.
Notwithstanding Section 16305.7 of the Government Code,the fund shall
also include interest and dividends earned on moneys in the fund.
(2) The moneys in the Medi-Cal Emergency Medical Transport Fund,
including any interest and dividends earned on money in the fund,shall be
available exclusively to enhance federal financial participarion for ambulance
services under the Medi-Cal program and to provide additional
reimbursement to,and to support quality improvement efforts of,emergency
medical transport providers, and to pay for the state's administrative costs
and to provide funding for health care coverage for Californians, in the
following order of priority:
(A) To pay for the department's staffing and administrative costs direcfly
attributable to irnplementing this article,not to exceed the following amounts:
(i) For the 2018-19 state fiscal year,one million three thousand dollars
($1,003,000),exclusive of any federal matching funds.
(ii) For the 2019-20 state fiscal year and each state fiscal year thereafter,
three hundred seventy-four thousand dollars ($374,000), exclusive of any
federal matching funds.
(B) To pay for the health care coverage in each applicable state fiscal
year in the amount of 10 percent of the annual quality assurance fee
collection amount,exclusive of any federal matching funds.
(C) To make increased payments to emergency medical transport
providers pursuant to this article.
(g) In the event of a merger,acquisition,or similaz transaction involving
an emergency medical transport provider that has outstanding quality
assurance fee payment obligations pursuant to this article, including any
interest and penalty amounts owed, the resultant or successor emergency
medical transport provider shall be responsible for paying to the department
the full amount of outstanding quality assurance fee payments, including
any applicable interest and penalties,attributable to the emergency medical
transport provider for which it was assessed,upon the effective date of such
transaction. An entity considering a merger, acquisition, or similar
transaction involving an emergency medical transport provider may submit
a request pursuant to Chapter 3.5(commencing with Section 6250)of Title
1 of the Government Code to ascertain the outstanding quality assurance
fee payment obligations of the emergency medical transport provider
pursuant to this article as of the date of the department's response to that
request.
14129.3. (a) Commencing July 1, 2018, and for each state fiscal year
thereafter for which this article is operadve, reimbursement to emergency
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medical transport providers for emergency medical transports shall be
increased by application of an add-on to the associated Medi-Cal
fee-for-service payment schedule.The add-on increase to the fee-for-service
payment schedule under this section shall be calculated on or before June
15, 2018, and shall remain the same for later state fiscal years for which
this article is operative, to the extent the department determines federal
financial participation is available and is not otherwise jeopardized. The
add-on increase to the fee-for-service payment schedule under this section
shall apply only to those billing codes identified in, or any equivalent,
predecessor,or successor billing codes as may be deternuned by the director
pursuant to,subdivision(g)of Section 14129.The department shall calculate
the projections required by this subdivision based on the data submitted
pursuant to Section 14129.1.The fee-for-service add-on shall be equal to
the quotient of the available fee amount projected by the department on or
before June 15,2018,for the 2018-19,state fiscal year,divided by the total
Medi-Cal emergency medical transports, including both fee-for-service
transports paid by the department and managed care transports paid by
Medi-Cal managed care health plans,utilizing these billing codes projected
by the department on or before June 15,2018,for the 2018-19 state fiscal
year. The resulting fee-for-service payment schedule amounts after the
applicarion of this section shall be equal to the sum of the Medi-Cal
fee-for-service payment schedule amount for the 2015-16 state fiscal year
and the add-on increase.
(b) Each applicable Medi-Cal managed care health plan shall sarisfy its
obligation under Section 438.114(c) of Tide 42 of the Code of Federal
Regulations for emergency medical transports and shall provide payment
to noncontract emergency medical transport providers consistent with Section
1396u-2(b)(2)(D) of Title 42 of the United States Code. Effective July 1,
2018, and for each state fiscal year thereafter for which this article is
operarive,the amounts a noncontract emergency medical transport provider
could collect if the beneficiary received medical assistance other than through
enrollment in a Medi-Cal managed caze health plan pursuant to Section
1396u-2(b)(2)(D)of Title 42 of the United States Code shall be the resulting
fee-for-service payment schedule amounts after the application of this
section.
(c) The increased payments required by this section shall be funded solely
from the following:
(1) The quality assurance fee set forth in Section 14129.2, along with
any interest or other investment income earned on those funds.
(2) Federal reunbursement and any other related federal funds.
(d) The proceeds of the quality assurance fee set forth in Section 14129.2,
the matching amount provided by the federal government,and any interest
earned on those proceeds shall be used to supplement existing funding for
emergency medical transports provided by emergency medical transport
providers and not to supplant this funding.
(e) Notwithstanding any provision of tkus article, the department may
seek federal approval to implement any add-on increase to the fee-for-service
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Ch.773 —10—
payment schedule pursuant to this section for any state fiscal yeaz or years,
as applicable, on a time-limited basis for a fixed program period, as
determined by the department.
(fl Notwithstanding any provision of this article,the add-on increase to
the fee-for-service payment schedule pursuant to this section shall only be
required and payable for state fiscal years for which a quality assurance fee
payment obligation exists for emergency medical transport providers.
14129.4. If there is a delay in the implementation of this article for any
reason,including a delay in any required approval of the quality assurance
fee and reimbursement methodology specified by the federal Centers for
Medicaze and Medicaid Services,both of the following shall apply:
(a) An emergency medical transport provider subject to the fee may be
assessed the amount the provider would be required to pay to the department
if the add-on increase to the fee-for-service payment schedule described in
Section 14129.3 were already approved,but shall not be required to pay the
fee until the add-on increase to the fee-for-service payment schedule
described in Section 14129.3 is approved. The director shall establish a
schedule for payment of retroactive fees pursuant to this subdivision in
consultation with emergency medical transport providers to minimize the
disruption to the cashflow of emergency medical transport providers.
(b) The department may retroactively implement the add-on increase to
the fee-for-service payment schedule pursuant to Section 14129.3 to the
extent the department determines that federal financial participation is
available and is not otherwise jeopardized.
14129.5. Notwithstanding Chapter 3.5(commencing with Section 11340)
of Part 1 of Division 3 of Title 2 of the Government Code,the department
may implement,interpret,or make specific this article,in whole or in part,
by means of provider bulletins, plan letters, or other similar instructions,
without taking regulatory action.The department shall provide notification
to the fiscal and appropriate policy committees of the Legislature within 10
business days after the above-described action is taken. The department
shall make use of appropriate processes to ensure that affected stakeholders
are timely informed of, and have access to, applicable guidance issued
pursuant to this authority,and that this guidance remains publicly available
so long as this article remains operative.
14129.6. (a) (1) The department shall request any approval from the
federal Centers for Medicare and Medicaid Services it deems necessary for
the use of fees pursuant to this article and for the purpose of receiving
associated federal matching funds.
(2) In making that request, the department may seek, as it deems
necessary, a request for waiver of the broad-based requirement, waiver of
the uniformity requirement, or both,pursuant to paragraphs (1) and(2)of
subdivision (e) of Section 433.68 of Title 42 of the Code of Federal
Regulations,or a request for waiver of any other provisions of federal law
or regulation necessary to implement this article.
93
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(3) This article shall be implemented only to the extent that any necessary
federal approvals aze obtained and federal financial participation is available
and is not otherwise jeopardized.
(b) The director may modify or make adjustments to any methodology,
fee amount,or other provision specified in this article to the extent necessary
to meet the requirements of federal law or regulations or to obtain federal
approval.If the director,after consulting with affected emergency medical
� transport providers, deternunes that a modification is needed,the d'uector
shall execute a declaration stating that this determination has been made
and that the actual or projected available fee amount for a state fiscal year
remains approximately equal to the actual or projected aggregate fee schedule
amount for each applicable state fiscal yeaz,as defined by paragraph(4)of
subdivision(b)of Section 14129.2.The director shall retain the declaration
and provide a copy, within five working days of the execution of the
declaration, to the fiscal and appropriate policy committees of the
Legislature.
(c) The director may add categories of exempt emergency medical
transport providers or apply a nonuniform fee per transport to emergency
medical transport providers that are subject to the fee in order to meet
requirements of federal law or regulations. The director may exempt
categories of emergency medical transport providers from the fee if necessary
to obtain federal approval.
(d) If,before June 1 preceding the start of an applicable state fiscal year,
the director finds that the implementation of this article is likely no longer
a benefit to the General Fund for the applicable state fiscal year,the director
may decide to not implement this article for that state fiscal year.The director
shall notify the appropriate fiscal and policy committees of the Legislature,
and emergency medical transport providers individually and via the
department's Internet Web site of its finding pursuant to this subdivision.
14129.7. (a) This article shall be implemented only if, as long as, and
to the extent that;all of the following conditions are met:
(1) The federal Centers for Medicaze and Medicaid Services does not
determine that the quality assurance fee revenues may not be used for the
purposes set forth in this article.
(2) The department obtains any necessary federal approvals for the
collecrion of the quality assurance fee pursuant to this article and the add-on
increase to the fee-for-service payment schedule described in subdivision
(a)of Section 14129.3.
(3) The state continues its maintenance of effort for the level of state
funding not derived from the quality assurance fee of emergency medical
transports reimbursement for the 2018-19 rate year,and for each applicable
rate year thereafter, in an amount not less than the amount that the state
would have paid for the same number of emergency medical transports
under the rate methodology that was in effect on July 31,2016.
(4) Federal financial participation is available, and is not otherwise
jeopardized.
93
Ch.773 —12—
(b) This article shall cease to be operative on the first day of the state
fiscal year beginning on or after the date one or more of the following
conditions is satisfied:
(1) The federal Centers for Medicare and Medicaid Services no longer
allows the collection or use of the emergency medical transport provider
assessment provided in this article.
(2) The increase to the Medi-Cal payments described in Section 14129.3
no longer remains in effect.
(3) The quality assurance fee assessed and collected pursuant to this
article is no longer available for the purposes specified in this article.
(4) The director determines that a change in federal law or federal
Medicaid policy results or is likely to result in a reduction of associated
federal financial participation for the Medi-Cal program such that the director
determines the continued'unplementation of this article is no longer a benefit
to the General Fund.
(5) A final judicial deternunation is made by the Califomia Supreme
Court or any California Court of Appeal that the revenues collected pursuant
to this article that aze deposited in the Medi-Cal Emergency Medical
Transport Fund are either of the following:
(A) "General Fund proceeds of taxes appropriated pursuant to Article
XIII B," as used in subdivision (b) of Section 8 of Article XVI of the
California Constitution.
(B) "Allocated local proceeds of taxes," as used in subdivision (b) of
Section 8 of Article XVI of the Califomia Constitution.
(6) A final judicial determination made by any state or federal court that
is not appealed, or by a court of appellate jurisdiction that is not further
appealed, in any action by any parly, or a final determination by the
administrator of the federal Centers for Medicare and Medicaid Services
that is not appealed,that federal financial participation is not available with
respect to any payment made under the methodology implemented pursuant
to this article.
(7) The state does not continue its maintenance of effort for the level of
state funding of emergency medical transports reunbursement for the
2018-19 state fiscal yeaz, or for any subsequent state fiscal year, in an
amount not less than the amount that the state would have paid for the same
number of emergency medical transports under the rate methodology in
effect on July 31,2016.
(c) In the event one or more of the conditions listed in subdivision(b)is
satisfied,the director shall notify,in writing and as soon as practicable,the
Secretary of State, the Secretary of the Senate, the Chief Clerk of the
Assembly, the Legislative Counsel, and the fiscal and appropriate policy
committees of the Legislature of the condition and the approximate date or
dates that it occurred.The d'uector shall post the notice on the department's
Internet Web site.
(d) (1) Notwithstanding any other law,in the event this article becomes
inoperative pursuant to subdivision(b),the department shall be authorized
to conduct all appropriate close-out activities and implement applicable
93
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provisions of this article for prior state fiscal yeazs during which this article
was operative including, but not limited to, the collection of outstanding
quality assurance fees pursuant to Section 14129.2 and payments associated
with any add-on increase to the Medi-Cal fee-for-service payment schedule
pursuant to Section 14129.3.In implementing these close-out activities,the
department shall ensure that the actual or projected available fee amount
for each applicable state fiscal year remains approximately equal to the
aggregate fee schedule amount for the state fiscal year, as defined by
paragraph(4)of subdivision(b) of Section 14129.2.During this close-out
period,the full amount of the quality assurance fee assessed and collected
remains available only for the purposes specified in this article.
(2) Upon a detemunation by the department that all appropriate close-out
and implementation activities pursuant to pazagraph(1)have been completed,
the director shall notify,in writing,the Secretary of State,the Secretary of
the Senate, the Chief Clerk of the Assembly, the Legislative Counsel, and
the fiscal and appropriate policy committees of the Legislature of that
determination.This article shall be repealed as of the effective date of the
notification issued by the director pursuant to this paragraph.
SEC.3. No reimbursement is required by this act pursuant to Section 6
of Article XIII B of the California Constitution because the only costs that
may be incurred by a local agency or school district will be incurred because
this act creates a new crime or infraction,eliminates a crune or infraction,
or changes the penalty for a crime or infraction, within the meaning of
Section 17556 of the Government Code,or changes the definition of a crime
within the meaning of Section 6 of Aiticle XIII B of the California
Constitution. '
SEC. 4. This act is an urgency statute necessary for the immediate
preservation of the public peace, health, or safety within the meaning of
Article IV of the California Constitution and shall go into immediate effect.
The facts constituting the necessity aze:
In order to make the necessary changes to increase Medi-Cal payments
to emergency ambulance providers, at the earliest possible time, and to
allow this act to be operative as soon as approval from the federal Centers
for Medicaze and Medicaid Services is obtained by the State Department
of Health Care Services,it is necessary that this act take effect immediately.
�s
�
93
DEPARTMENT OF HEALTH&HUMAN SERVICES
Centers for Medicare&Medicaid Services
San Francisco Regional Office �
90 Seventh Street,Suite 5-300 (5V�
San Francisco,CA 94103-6706 CENTERS FOR MEDICARE&MEDIGAID SERVICES
DNISION OF MEDICAID &CHILDREN'S HEALTH OPERATIONS
February 7,2019
Mari Cantwell
Chief Deputy Director,Health Care Programs
California Department of Health Care Services
P.O. Box 997413,MS 0000
Sacramento, CA 95899-7413
Dear Ms. Cantwell:
Enclosed is an approved copy of California State Plan Amendment(SPA) 18-004,which was
submitted to the Centers for Medicare &Medicaid Services (CMS) on July 11, 2018. SPA 18-
004 implements a one-year Quality Assurance Fee(QAF)program and reimbursement add-on
for Ground Emergency Medical Transports (GEMT)provided by emergency medical
transportation providers effective for the State Fiscal Year(SFY)2018-19 from July 1,2018 to
June 30, 2019.
The effective date of this SPA is July 1, 2018. Enclosed are the following approved SPA
pages that should be incorporated into your approved state plan:
• Supplement 29 to Attachment 4.19-B,pages 1-2
If you have any questions,please contact Cheryl Young at 415-744-3598 or via email at
Chervl.Young(�a,cros.hhs.gov.
Sincerely,
Richard Allen
Acting Associate Regional Administrator
Division of Medicaid&Children's Health Operations
Enclosures
cc: Lindy Harrington, California Department of Health Care Services(DHCS)
Connie Florez,DHCS
Angel Rodriguez,DHCS
Angeli Lee, DHCS
Amanda Font,DHCS
DEPARTMENT OF HEALTH ANDHUMAN SERVICES FORMaPPRovED
CENTERS FOR MEDICARE 8 MEDICAID SERVICES oMB No.0938-0193
1.TRANSMITTAL NUMBER 2.STATE
TRANSMITTAL AND NOTICE OF APPROVAL OF California
STATE PLAN MATER/AL ' 8 — o o a
FOR: CENTERS FOR MEDICARE&MEDICA/D SERVICES 3.PROGRAM IDENTIFICATION:TITLE XIX OF THE SOCIAL
SECURITY ACT(MEDICAID)
Title XIX of the Social Securi Act Medicaid
TO: REGIONAL ADMINISTRATOR 4. PROPOSED EFFECTIVE DATE
CENTERS FOR MEDICARE&MEDICAID SERVICES July 1, 2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES
5.TYPE OF PLAN MATERIAL(Check One)
❑ NEW STATE PLAN ❑ AMENDMENT TO BE CONSIDERED ASNEW PLAN ❑� AMENDMENT
COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT(Separate fransmiffal foreach amendment)
6. FEDERAL STATUTE/REGULATION CITATION 7. FEDERAL BUDGET IMPACT
Title 42 CFR 447 Subpart F &42 CFR 433.68 a. FFYz�1e $4.461.892
b. FFY 2019 $13,385,675
S. PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT 9.PAGE NUMBER OF THE SUPERSEDED PLAN SECTION
OR ATTACHMENT(IfApplicable)
, � . -
Supplement 29 to Attachment 4.19-B, pages 1-2 None
10.SUBJECT OFAMENDMENT
One-year reimbursement rate add-on for ground emergency medical transport services
11.GOVERNOR'S REVIEW (Check One)
❑ GOVERNOR'S OFFICE REPORTED NO COMMENT 0■ OTHER,AS SPECIFIED
❑ COMMENTS OF GOVERNOR'S OFFICE ENCLOSED The Governor's Office does not wish to
❑ NO REPLY RECEIVED WITHIN 45 DAYS OF SUBMITTAL review the State Plan Amendment.
12.SIGNATURE OF STATE AGENCY OFFICIAL 16.RETURN TO
Department of Health Care Services
Attn: Director's Office
13.TYPED NAME P.O. Box 997413, MS 0000
Mari Cantwell Sacramento, CA 95899-7413
14.TITLE
State Medicaid Director
15. DATE SUBMITfED
�July 11, 2018
FOR REG/DNAL OFF/CE USE ONLY
17. DATE RECEIVED 18. DATE APPROVED
Julv 11,2018 February 7, 2017
PLAN APPROVED-ONE COPY ATTACHED
19.EFFECTIVE DATE OF APPROVED MATERIAL 20.SIGNATURE OF REGIONAL OFFICIAL
July 1, 2018 �S�
21.TYPED NAME 22.TITLE Acting Associate Regional Administrator,
Richard Allen Division of Medicaid &Children's Health Operations
23.REMARKS
Box 6: CMS made a pen and ink change on 9/26/18 to add "42 CFR 433.68,"the regulatory citation for permissible health-care
related taxes. Box 8: CMS made a pen and ink change on 9/21/18 to add page 2, a new page with page 1, and to correct
supplement number to 29. Box 12: DHCS added signature on 1/31/19.
FORM CMS-179(07/92) Instructions on Back �
Supplement 29 To Attachment 4.19-B
Page 1
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
STATE: CALIFORNIA
ONE-YEAR REIMBURSEMENT RATE ADD-ON FOR GROUND EMERGENCY
MEDICAL TRANSPORT SERVICES
Introduction
This program provides increased reimbursement to ground emergency medical transport
providers by application of an add-on to the Medi-Cal fee-for-service(FFS) fee schedule
base rates for eligible emergency medical transportation services. The reimbursement rate
add-on will apply to eligible Current Procedural Terminology(CPT) Codes,between July
1,2018 and June 30,2019. The base rates for emergency medical transportation services
will remain unchanged through this amendment.
"Emergency medical transport"means the act of transporting an individual from any
point of origin to the nearest medical facility capable of ineeting the emergency medical
needs of the patient by an ambulance licensed, operated, and equipped in accordance with
applicable state or local statutes, ordinances, or regulations, excluding transportation by
an air ambulance provider,that are billed with CPT Codes A0429,A0427, and A0433.
Methodology
For State Fiscal Year(SFY)2018-19,the reimbursement rate add-on is fixed for FY
2018-19. The resulting payment amounts are equal to the sum of the FFS fee schedule
base rate for the SFY 2015-16 and the add-on amount for the CPT Code. The resulting
total payment amount for CPT Codes A0429,A0427, and A0433 will be $339.00. The
add-on is paid on a per-claim basis.
Service Code Description Current Add On Resulting
Payment Amount Total Payment
A0429 Basic Life Support $118.20 $220.80 $339.00
� A0427 Advanced Life $118.20 $220.80 $339.00
Support,Level 1
A0433 Advanced Life $118.20 $220.80 $339.00
Support, Leve12
TN 18-004
Supersedes
TN: None Approval Date: February 7,2019 Effective Date: July 1, 2018
Supplement 29 To Attachment 4.19-B
Page 2
STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
STATE: CALIFORNIA
The resulting total payment amount of$339.00 is considered the Rogers rate,which is the
minimum rate that managed care organizations can pay noncontract managed care
emergency medical transport providers, for each state fiscal year the FFS reimbursement
rate add-on is effective.
TN 18-004
Supersedes
TN: None Approval Date: February 7, 2019 Effective Date: July 1, 2018