Through 5 p.m, April 29, 2002, the Secretary will receive comments on portions of the regulation relating to sections of the Medicare, Medicaid, and State Child Health Insurance Program Benefits Improvement and Protection Act (BIPA), Pub. L. 106-554: provisions implementing the portion of §205 of BIPA relating to cost reimbursement for ambulance services furnished by certain critical access hospitals (CAHs) (42 C.F.R. §§414.601 and 414.610(a)); provisions implementing §221 of BIPA, establishing the rate for rural ambulance mileage greater than 17 miles and up to 50 miles (§ 414.610(c)(5)); provisions implementing §423 of BIPA with regard to immediate payment of the full ambulance services fee schedule amount for in-county ground mileage under certain circumstances (§414.615(g)). Comments should be sent to CMS, DHHS, Attention: CMS-1002-FC, P.O. Box 8013, Baltimore, MD 21244-8013. The CMS contact person is Glenn McGuirk (410)786-5723. The Federal Register document containing the ambulance regulations is available on the internet at http://www.access.gpo.gov/nara/index.html.

Regulatory Amendment Highlights

§410.40 - Coverage of Ambulance Services

Types of transport. Medicare covers the following levels of ambulance service as defined in 42 C.F.R. §414.605: Basic Life Support (BLS)(emergency and non-emergency); Advanced Life support, level 1 (ALS1) (emergency and non-emergency); Advance Life support, level 2 (ALS2); Paramedic ALS Intercept (PI); Specialty Care Transport (SCT); Fixed Wing Transport (FW); and Rotary Wing Transport (RWT).

Medical necessity. As a general rule, Medicare covers medically necessary ambulance services only if the services are furnished to a beneficiary whose medical condition is such that other means of transportation are contraindicated. The beneficiary’s condition must require both the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary.

Non-emergency transportation by ambulance is appropriate if either the beneficiary is bed-confined and it is documented that the beneficiary’s condition is such that other methods of transportation are contraindicated; or if his or her medical condition, regardless of bed confinement, is such that transportation by ambulance is medically required. Thus, bed confinement is not the sole criterion in determining the medical necessity of ambulance transportation. It is one factor that is considered in medical necessity determinations.

Definition of bed-confined. For a beneficiary to be considered bed-confined, the following criteria must be met: (i) the beneficiary is unable to get up from bed without assistance; (ii) the beneficiary is unable to ambulate; (iii) the beneficiary is unable to sit in a chair or wheelchair.

Special rule for non-emergency, scheduled, repetitive ambulance services. Medicare covers medically necessary non-emergency, scheduled, repetitive ambulance services if the ambulance provider or supplier, before furnishing the service to the beneficiary, obtains a written order from the beneficiary’s attending physician certifying that the medical necessity requirements of the regulations are met. The physician’s order must be dated no earlier than 60 days before the date the service is furnished.

Special rules for non-emergency ambulance services that are either unscheduled or that are scheduled on a non-repetitive basis. Medicare covers medically necessary non-emergency ambulance services that are either un-scheduled or that are scheduled on a non-repetitive basis: (i) for a resident of a facility who is under the care of a physician if the ambulance provider or supplier obtains a written order from the beneficiary’s attending physician within 48 hours after the transport, certifying that the medical necessity requirements described above have been met.

If the ambulance provider or supplier is unable to obtain a signed physician certification statement from the beneficiary’s attending physician, a signed certification must be obtained from either the physician assistant, nurse practitioner, clinical nurse specialist, registered nurse, or discharge planner, who has personal knowledge of the beneficiary’s condition at the time ambulance transport is ordered or the service is furnished. This individual must be employed by the beneficiary’s attending physician or by the hospital or facility where the beneficiary is being treated and from which the beneficiary is being transported. The individual must also meet Medicare requirements defining physician assistants, nurses, etc., and all applicable state laws.

If the ambulance provider or supplier is unable to obtain the required certification within 21 calendar days following the date of the service, the ambulance supplier must document its attempts to obtain the requested certification and may then submit the claim. In all cases, the provider or supplier must keep appropriate documentation on file and, upon request, present it to the Medicare contractor. Note, the presence of a signed certification statement or signed return receipt does not alone demonstrate that the ambulance transport was medically necessary. All other program criteria must be met in order for payment to be made.

Part 414 - Payment for Part B Medical and Other Health Services

Fee schedule for ambulance services. §414.601 establishes a fee schedule for the payment of ambulance services, requiring that, except for services furnished by certain CAH hospitals (§413.70(b)(5), payment for all ambulance services, otherwise previously payable on a reasonable charge basis or retrospective reasonable cost basis, be made under a fee schedule.

Basis of payment. §414.610(a) provides that Medicare payment for ambulance services is based on the lesser of the actual charge or the applicable fee schedule amount. The fee schedule payment for ambulance services equals a base rate for the level of service plus payment for mileage and applicable adjustment factors. The provision applies to all ambulance services except for certain CAH ambulance services or entities owned and operated by CAHs as described in §413.70(b).

Mandatory assignment. Effective with implementation of the ambulance fee schedule described in §414.601, for services furnished on or after April 1, 2002, all payments made for ambulance services are made only on an assignment-related basis. Ambulance suppliers must accept the Medicare allowed charge as payment in full and may not bill or collect from the beneficiary any amount other than the unmet Part B deductible and part B coinsurance amounts.

Transition to the ambulance fee schedule. §414.615 provides for the fee schedule for ambulance services to be phased in over 5 years beginning April 1, 2002. Payment for services furnished during the transition period will be made based on a combination of the fee schedule payment for ambulance services and the amount he program would have paid absent the fee schedule for ambulance services as set out in §414.615(a)-(f).