RELATES TO:
KRS
45.229,
142.301,
142.318,
142.343,
142.359,
194A.030(2),
205.5601, 205.5602, 205.5603, 42 C.F.R. 413,
42 U.S.C.
1396a
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services, Department for Medicaid Services has responsibility to
administer the Medicaid Program.
KRS
205.520(3) authorizes the
cabinet, by administrative regulation, to comply with a requirement that may be
imposed, or opportunity presented, by federal law to qualify for federal funds.
KRS 205.5602(2) requires the department to promulgate an administrative
regulation to implement the Ambulance Provider Assessment Program, as
established pursuant to KRS 205.5601 and 205.5603. This administrative
regulation establishes the requirements for implementing the Ambulance Provider
Assessment Program for ground ambulance providers.
Section 1. Definitions.
(1) "Assessment" is defined by KRS
205.5602(1)(b).
(2) "Department" is
defined by KRS 205.5602(1)(e).
(3)
"Federal financial participation" is defined by
42 C.F.R.
400.203.
(4) "Ground ambulance provider" is defined by
KRS 205.5602(1)(a).
(5) "Medicaid"
is defined by
KRS
142.301(14).
(6) "MMIS" means the Medicaid Management
Information System or its successor program.
(7) "Program year" means the calendar year
during which supplemental payments and tax assessments are made.
Section 2. Ambulance Provider
Assessment Program.
(1) Prior to the program
year, the department shall calculate for eligible ground ambulance providers an
interim uniform add-on amount for:
(a)
Emergent transports that the ground ambulance provider is eligible to receive
as a supplemental payment for the program year for Medicaid fee-for-service
transports; and
(b) Non-emergent
transports that the ground ambulance provider is eligible to receive as a
supplemental payment for the program year for Medicaid managed care
transports.
(2) On an
annual basis, the department shall calculate a lump sum periodic, of at least
once per quarter, interim supplemental payment for each eligible ground
ambulance provider by:
(a) Utilizing the
uniform add-on amounts referenced in subsection (1)(a) and (1)(b) of this
section;
(b) Utilizing MMIS
fee-for-service data, MMIS managed care encounter data, and ground ambulance
survey data to calculate the transport volume; and
(c) Reducing the payment volume by a five (5)
percent reserve in order to avoid overpayment to ambulance providers.
(3) At least once per quarter in a
program year, the department shall make a Medicaid:
(a) Fee-for-service interim payment to each
qualifying ground ambulance provider in accordance with the methodology
established by KRS 205.5602; and
(b) Managed care interim payment to each
qualifying ground ambulance provider in accordance with the methodology
established by KRS 205.5602.
(4) Payment of the Medicaid managed care
interim payment shall be made at least once per quarter by distribution to each
Medicaid managed care organization through a supplemental capitation
payment.
(5) At least once per
quarter, the department shall submit to each Medicaid managed care organization
a listing of the Medicaid managed care supplemental payments that the Medicaid
managed care organization shall make to each eligible ground ambulance
providers.
(6) Each Medicaid
managed care organization shall remit to each ground ambulance provider, as
directed by the department, the Medicaid managed care supplemental payment
within ten (10) business days of receipt of the supplemental payment.
(7) On an annual basis, the department shall
calculate the monthly tax assessment for each ground ambulance provider in
accordance with KRS 142.318 and KRS 205.5602.
(8) If a ground ambulance provider tax
assessment is not received in a timely manner, the requirements of this
subsection shall be met.
(a) The department
may deny or withhold future supplemental payments until the assessment is
submitted.
(b) The department shall
refer a provider to the Kentucky Board of Emergency Medical Services (KBEMS)
for potential action related to licensure.
(c) Additional penalties and interest may be
assessed in accordance with
KRS
142.343 and
KRS
142.359.
Section 3. Annual Reconciliation.
(1) On an annual basis following the program
year, the department shall make final reconciled payments to ground ambulance
providers based on:
(a) A review of the
interim emergent and non-emergent transport add-ons from Section 2(1)(a) and
(b) of this administrative regulation;
(b) Any interim add-ons that may be adjusted
to account for differences between:
1.
Expected utilization known at the time of the interim add-ons; and
2. Actual utilization following the program
year; and
(c) Final
add-ons that shall be applied to actual transport utilization, based on MMIS
data, to determine the final supplemental payment amount owed to each
provider.
(2) Interim
payments shall be subtracted from the final supplemental payment owed.
(a) A positive balance shall be paid to the
provider.
(b) A negative balance
shall be paid to the department.
(3) When a survey is not received, the
department may use a statewide average of revenue per transport multiplied by
provider transport count data, collected by KBEMS, as a proxy for calculating
taxable revenues for the following program year.
Section 4. Reporting Requirements.
(1) By April 1 of each program year, a ground
ambulance provider shall submit a completed revenue survey. An extension may be
granted on a temporary and case-by-case basis, not to exceed thirty (30) days,
following a written request detailing the exigent circumstances that prevented
timely filing of the completed revenue survey.
(2) If a complete revenue survey is not
received in a timely manner the department may deny or withhold future
supplemental payments until a complete survey is submitted.
(3) A ground ambulance provider, licensed in
Kentucky, operating outside of the state of Kentucky shall report only revenues
for transports originating in Kentucky on the revenue survey.
Section 5. Access to Supporting
Records. Pursuant to
907
KAR 1:672, Section 2(6)(b), a ground ambulance
provider shall maintain and make available, upon request of the department or
any other auditing or investigating entity, any records and data necessary to
justify and document:
(1) Revenue survey
amounts, submitted in accordance with Section 4, of this administrative
regulation;
(2) Resolution of a
supplemental payment that the ground ambulance provider suspects is in error;
or
(3) Quality metrics necessary
for program reporting to the Centers for Medicare and Medicaid
Services.
Section 6.
Appeal Rights. An appeal of a department decision regarding final reconciled
payments shall be in accordance with
907
KAR 1:671.
Section
7. Federal Approval and Federal Financial Participation. The
department's coverage of services pursuant to this administrative regulation
shall be contingent upon:
(1) Receipt of
federal financial participation for the coverage; and
(2) Centers for Medicare and Medicaid
Services' approval for the coverage.