Background: Medicaid-Funded Emergency Medical Transportation. The Health Care Authority (HCA) currently reimburses providers for emergency medical transportation on a fee-for-service basis. Providers are reimbursed for emergency medical transportation for ambulance transportation, during which the client receives needed emergency medical services en route to an appropriate medical facility. This includes ambulance transportation between medical facilities. Services rendered may include either basic or advanced life support. Providers are also reimbursed for mileage and tolls or fees, such as parking, incurred during transporting the client. Nonemergency transportation is reimbursed when the client must be transported by stretcher or gurney for medical safety reasons, or must have medical attention from trained medical personnel available en route.

In 2015, the Legislature established the Ground Emergency Medical Transportation Program (GEMT) to provide supplemental payments to qualified publicly owned or operated ground emergency medical transportation providers. The supplemental payments are used to cover the funding gap between a provider’s actual costs per transport and the allowable amount received from Washington Apple Health (Medicaid) and any other sources of reimbursement.

Provider Assessments. Health care provider-related charges, such as assessments, fees, or taxes, have been used in some states to help fund the costs of the Medicaid program. Under federal rules, these provider-related charges include any mandatory payment where at least 85 percent of the burden falls on health care providers. States collect funds from health care providers and pay them back as Medicaid payments. States use these provider-related payments to claim federal matching funds. Federal laws requires health care provider-related assessments, fees, and taxes be broad-based, uniform, and in compliance with hold harmless provisions. To be broad-based and uniform, they must be applied to all providers of the same class and be imposed at the same rate to each provider in that class. If a provider-related assessment, fee, or tax is not broad-based or uniform, these provisions may be waived if the assessment, fee, or tax is generally redistributive. The hold harmless provision may not be waived.

Summary: Quality Assurance Fee Program. The program only applies to private ambulance transport providers (providers). Each provider is required to submit certain data to HCA. HCA must calculate the quality assurance fee based on transport and gross receipts data they receive from providers. Providers are required to pay the fee for each emergency ambulance transport. In return, HCA uses two-thirds of the fees collected to draw down federal match and apply an add-on to Medicaid rates for providers of emergency ambulance transports. The program is conditional upon a number of items, including approval from the Centers for Medicare and Medicaid Services (CMS). HCA is authorized to adopt rules to implement the program. The program expires July 1, 2024.

Data Collection. HCA must establish the form and schedule for providers to report the required data to HCA. On or after August 15, 2020, the provider must report the number of emergency ambulance transports by payer type and the annual gross receipts for the state fiscal year ending June 30, 2020. On or after the 45th day of each state fiscal quarter, beginning with the quarter ending September 30, 2020, the provider must report the number of emergency ambulance transports by payer type for each state fiscal quarter. On or after the 45th day after the end of each state fiscal year, the provider must report the annual gross receipts for the state fiscal year. HCA may impose a civil penalty of $100 per day against a provider that fails to report the data within the required timeframes. HCA must deposit any collected civil penalties into the program's fund.

Fee Assessment. Beginning July 1, 2021, HCA must annually calculate the fee rate. Each provider must pay the fee quarterly, based on the provider's number of emergency ambulance transports in the second quarter preceding the state fiscal quarter for which the fee is assessed. The fee rate is calculated by multiplying the projected total annual gross receipts of all providers by 5.5 percent and dividing its product by the projected total annual ambulance transports by all providers for the state fiscal year. One-third of the fees collected must be used in lieu of state general fund payments for Medicaid emergency ambulance services.

HCA must send each provider an assessment notice quarterly, no later than 30 days prior to the beginning of the applicable state fiscal quarter, and no later than 30 days before the payment is due. HCA must establish the fee payment due dates, but it must not be earlier than 15 days after the beginning of the applicable state fiscal quarter. HCA must assess interest on fees not paid on the due date and deposit the interest into the program's fund. If the fee payment is more than 60 days overdue, HCA may deduct the unpaid fee and interest owed from any Medicaid reimbursements owed to the provider.

The program's fund is known as the ambulance transport fund and is in the custody of the state treasury. The fund must retain its interest and must only be used to receive and disburse funds in accordance with the program.

Add-on. Beginning July 1, 2021, Medicaid reimbursement for provider's emergency ambulance transports must be increased by applying an add-on. The total reimbursement with the add-on must result in a total reimbursement for each emergency ambulance transport that is at least 60 percent of the statewide Medicare rate for an emergency ambulance transport or similar service. The add-on must only be funded from the fees and interest earned on the fees, and federal reimbursement or other related federal funds.

Centers for Medicare and Medicaid Services Approval. HCA must request CMS approval to implement the program and is authorized to modify the program as necessary to obtain CMS approval. The fee must only be assessed and collected for quarters in which the add-on is paid. If CMS approval is delayed, HCA may assess the amount the provider would be required to pay if the program was approved, but the provider is not required to pay the fee until the program is approved.

Conditions. Implementation of the program is conditional upon:

CMS program approval and providing federal match;
the state not reducing its fee-for-service reimbursement for ambulance transport providers;
the state not delegating responsibility to pay for ambulance transports to managed care organizations, prepaid inpatient, or ambulatory health plans; and
the program not prohibiting, diminishing, or harming the GEMT reimbursement program.

Senate	49	0
House	87	10	(House amended)
Senate	44	4	(Senate concurred)