907 KAR 1:061. Payments for ambulance transportation.

 

      RELATES TO: KRS 205.520, 205.8451, 42 C.F.R. 440.170, 447.200 -447.205, 42 U.S.C. 1396, 2005 Acts ch. 173 Parts I., A.22.(i), I., H.3.b.(19)

      STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3)

      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 any requirement that may be imposed, or opportunity presented, by federal law for the provision of medical assistance to Kentucky's indigent citizenry. This administrative regulation establishes the method for determining amounts payable by the Department for Medicaid Services for ambulance transportation services.

 

      Section 1. Definitions. (1) "Advanced life support (ALS) emergency ambulance transportation" means an ambulance service meeting the standards for advanced life support services established in accordance with 202 KAR 7:501.

      (2) "Advanced Life Support (ALS) Medical First Response Provider" means an emergency medical professional licensed in accordance with 202 KAR 7:501 to provide ALS care.

      (3) "Air ambulance provider" means an air ambulance service licensed in accordance with 202 KAR 7:510.

      (4) "Appropriate medical facility or provider" means a local medical provider other than an emergency room of a hospital who can provide necessary emergency care if a hospital emergency room is not located within a recipient's county of residence or a contiguous county.

      (5) "Basic life support (BLS) emergency ambulance transportation" means an ambulance service which meets the standards for basic life support services established in 202 KAR 7:501.

      (6) "Department" means the Department for Medicaid Services or its designated agent.

      (7) "Membership or subscription fee" means a payment collected from a recipient by a provider which entitles the recipient to free or discounted ambulance transportation services.

      (8) "Recipient" is defined in KRS 205.8451(9).

      (9) "Upper limit" means the maximum reimbursement rate the department shall pay an ambulance transportation provider for the service provided.

 

      Section 2. Reimbursement for Licensed Ambulance Services. (1) The department shall reimburse an ambulance service at the lesser of:

      (a) The provider's usual and customary charge for the service; or

      (b) An upper limit established in this section for the service plus, if applicable, a rate for oxygen and reimbursement for disposable medical supplies utilized during an ambulance transportation service.

      (2) Except for an air ambulance transportation service, the upper limit for an ambulance service shall be calculated by adding a base rate, mileage allowance, and flat rate fees as follows:

      (a) For ALS emergency ambulance transportation to the emergency room of a hospital:

      1. A base rate of 110 dollars;

      2. A mileage allowance of four (4) dollars per mile; and

      3. If transported concurrently, a flat rate of twenty-five (25) dollars for an additional recipient;

      (b) For BLS emergency ambulance transportation to the emergency room of a hospital:

      1. A base rate of eighty-two (82) dollars and fifty (50) cents;

      2. A mileage allowance of three (3) dollars per mile; and

      3. If transported concurrently, a flat rate of twenty (20) dollars for an additional recipient;

      (c) For ALS or BLS emergency ambulance transportation to an appropriate medical facility or provider:

      1. A base rate of sixty (60) dollars;

      2. A mileage allowance of two (2) dollars and fifty (50) cents per mile; and

      3. If transported concurrently, a flat rate of fifteen (15) dollars for an additional recipient;

      (d) For BLS emergency ambulance transportation to the emergency room of a hospital during which the services of an ALS Medical First Response provider is required to stabilize the recipient:

      1. A base rate of 110 dollars;

      2. A mileage allowance of four (4) dollars per mile; and

      3. If transported concurrently, a flat rate of twenty-five (25) dollars for an additional recipient;

      (e) For BLS emergency ambulance transportation to an appropriate medical facility or provider during which the services of an ALS Medical First Response provider are required:

      1. A base rate of sixty (60) dollars;

      2. A mileage allowance of two (2) dollars and fifty (50) cents per mile; and

      3. If transported concurrently, a flat rate of fifteen (15) dollars for an additional recipient; and

      (f) For non emergency ambulance transportation during which the recipient requires no medical care during transport:

      1. A base rate of fifty-five (55) dollars; and

      2. A mileage allowance of two (2) dollars per mile.

      (3) In addition to the rates specified in subsection (2) of this section, the department shall reimburse for:

      (a) The administration of oxygen during an ambulance transportation service at a flat rate of ten (10) dollars per one (1) way trip if medically necessary; and

      (b) The cost of disposable supplies actually utilized during an ambulance transportation service if the provider lists the supplies used during the service on an invoice. The department shall not reimburse for a supply item that is not disposable or is not actually used during the ambulance transportation service.

      (4) Reimbursement for air ambulance transportation shall be an all inclusive rate which shall be the lesser of:

      (a) The provider's usual and customary charge; or

      (b) An upper limit of $3,500 per one (1) way trip.

      (5) Payment for a service identified in subsections (2) through (4) of this section shall be contingent upon a statement of medical necessity which:

      (a) Shall be maintained in accordance with 907 KAR 1:060, Section 5(2); and

      (b) May be requested by the department for post-payment review.

      (6) If a recipient has paid a membership or subscription fee to a transportation provider, the provider shall not be eligible for Medicaid reimbursement for service provided to the recipient.

 

      Section 3. Appeal Rights. (1) An appeal of a negative action regarding a Medicaid recipient shall be in accordance with 907 KAR 1:563.

      (2) An appeal of a negative action regarding Medicaid eligibility of an individual shall be in accordance with 907 KAR 1:560.

                (3) An appeal of a negative action regarding a Medicaid provider shall be in accordance with 907 KAR 1:671. (Recodified from 904 KAR 1:061, 5-6-86; Am. 15 Ky.R. 2190; eff. 5-17-89; 16 Ky.R. 2603; eff. 6-27-90; 17 Ky.R. 576; eff. 9-19-90; 1880; eff. 12-18-90; 18 Ky.R. 544; 1148; eff. 10-16-91; 19 Ky.R. 2150; eff. 4-21-93; 22 Ky.R. 2499; eff. 8-21-96; 26 Ky.R. 659; 1186; 1422; eff. 1-12-2000; 32 Ky.R. 407; 921; 1108; eff. 1-6-06; 34 Ky.R. 1576; eff. 4-4-08.)