In an effort to simplify this report, we’ve included explanations for the acronyms assigned by the entities involved and their respective programs:
CPE: Certified Public Expenditure. The sources of funds certified as actual expenditures by a local or public governmental entity and used as the State share in order to receive federal matching Medicaid funds.
CMS: Centers for Medicare and Medicaid Services. The Centers for Medicare and Medicaid Services is a division of the Dept. of Health and Human Services, and provides health coverage to more than 100 million people through Medicare, Medicaid, the Children's Health Insurance Program, and the Health Insurance Marketplace.
DHCS: Department of Healthcare Services. A department within the California Health and Human Services Agency that finances and administers a number of individual health care service delivery programs, including Medi-Cal, which provides health care services to low-income people.
FFS: Fee-For-Service. A significant proportion of total Medi-Cal expenditures is generated through the Fee-for-Service (FFS) health care delivery system. FFS providers render services and then submit claims for payment that are adjudicated, processed, and paid (or denied) by the Medi-Cal program's fiscal intermediary GEMT: Ground Emergency Medical Transportation-. A voluntary supplemental reimbursement program open to public providers of ambulance transport services.
MC: MANAGED CARE. Contracts for health care services through established networks of organized systems of care, which emphasize primary and preventive care.
MEDI-CAL: California's Medicaid health care program
MEDI-MEDI: A combination of subscriptions to both Medi-Cal and Medicare.
PP-GEMT IGT: Public Provider Ground Emergency Medical Transport Intergovernmental Transfer Program. Replaces GEMT and QAF reimbursement programs.
QAF: Quality Assurance Fee. A mandatory program required of all transport providers in California to level the field between cities, counties and districts with fewer Medi-Cal patients and those with higher amounts of Medi-Cal patients.
W&I: California Welfare and Institutions. One of 29 Codes that contain state statutes, the Code establishes programs and public social services for promoting public welfare.
Within this report, we will periodically refer to GEMT and QAF as the “old programs” and PP-GEMT IGT as the “new program.”
BACKGROUND:
California Welfare and Institutions (W&I) Code § 14105.94, enacted October 2, 2011, authorized the Ground Emergency Medi-Cal Transportation Services (GEMT) supplemental reimbursement program. This voluntary Certified Public Expenditure (CPE) based program provides additional funding to eligible governmental entities that provide GEMT services to Medi-Cal beneficiaries. The Centers for Medicare and Medicaid Services (CMS) approved State Plan Amendment (SPA) 09-024 on September 4, 2013, authorizing the federal share of the supplemental reimbursement payments based on uncompensated costs for Medi-Cal fee-for-service transports provided by public entities, effective January 30, 2010.
In 2013, the California Department of Healthcare Services (DHCS) rolled out the GEMT CPE program retroactive to FY2009/2010.
In 2017, in accordance with Senate Bill 523 (SB 523) DHCS established the GEMT QAF to provide supplemental payments to all Medi-Cal transport providers. Using data collected, the DHCS would impose a fee per transport to all EMS transport providers, and use the funds collected to reimburse a $220 add on for all Medi-Cal Fee-for-Service (FFS) transports. The GEMT QAF program was a mandatory program for all EMS transport providers.
DISCUSSION:
WHAT IS PP-GEMT IGT?
In 2019, California Assembly Bill (AB) 1705 was passed, allowing the DHCS to develop the PP-GEMT IGT program to provide increased reimbursements, by application of an add-on increase, to emergency Medi-Cal transports provided by eligible public GEMT providers. The non-federal share collected will be used to provide an add-on increase to the FFS fee schedule rate for the affected emergency Medi-Cal transport billing codes and a rating increment that will be applied to primary capitation rates for contracted Medi-Cal plans.
As a result of AB 1705, the old programs will transition to the new program. This new program will take effect on January 1, 2023. The old programs sunset on December 31, 2022. The new program is implemented for public providers, as they will no longer be eligible to participate in old programs after December 31, 2022. The CY 2022 QAF rates have not been established, and therefore, invoices have yet to be provided by DHCS.
These payments will be required once the invoices are complete.
We have been provided an estimated upfront non-federal share of costs in the amount of $665,103.64. In order to have DHCS administer the program, the non-federal share of implementing the new program will be supported by the IGT contributions from participating providers to DHCS, such as Cathedral City Fire Department. There is a 10% administrative fee that will be retained by DHCS to cover the costs associated with administering the program.
There was no such provision in Assembly Bill 1705 for the state to front any costs of this program, and it was clearly stated there would be no cost to the state. DHCS has agreed to administer the new program with the understanding there can be no cost to the California taxpayers and because of this DHCS is requiring the up-front buy-in payment is required from participating transporting agencies.
BENEFITS OF THE NEW PROGRAM
Based on FY 2021/2022, the net total revenue was $1,887,494.31, for an average of $475.80 per transport. For calendar year 2023, the Fire Department projects ambulance revenues will be $2,491,353.10, for an average revenue of $626.78 per transport (based on two ambulances and three ambulances after medic 2 is placed into service later this year).
Per the federal government, the per-transport or total reimbursement under the new program is expected to be higher than the amount received from the federal government. Under the old program, the proposed cost recovery with the new add-on for calendar year 2023 is expected to be $946.92 per MC and FFS transports, and $531.80 for Medi-Medi eligible transports. Those three categories accounted for approximately 36.5% of our total transports in FY2021/2022.
To participate in the program, DHCS is requesting the Cathedral City Fire Dept. provide an up-front one-time payment of $665,103.64. At this point, this amount is estimated and DHCS has stated that if they determine the total projected amount of the total voluntary contributions by participating agencies is not sufficient to support the implementation of the program, it is unknown if any of the following scenarios would take place. The first scenario would be to supplementally bill participating agencies to cover the shortfall. The second scenario would be to end the new program altogether.
Should the second scenario come into play, the new program would cease to operate on the first day of the Medi-Cal managed care rating beginning on or after the date of such determination. The public providers may revert to reimbursement under the old programs. One thing to keep in mind, DHCS has stated that after January 1, 2023, the old programs would no longer exist, and they would then be required to re-implement the old programs. In summary:
FY 2021/2022 actual transport cost recovery $475.80/transport CY 2023 projected transport cost recovery $626.78/transport CY 2023 projected additional cost recovery with the new program add-on:
MC & FFS is $946.92/transport
Medi-Medi is $531.80/transport
CY 2023 up-front PP-GEMT IGT participation payment $665,103.64 CY 2023 total estimated new program additional cost recovery will be $866,123.24 The increased cost recovery will recur in future years as well.
FISCAL IMPACT:
To participate in the PP-GEMT IGT program, the General Fund (100) impact in FY 2022/2023 is estimated to be $665,103.64.