11-26-12 Council Agenda & Packet

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Centers for Medicare&Medicaid Services, HHS §414.610 necessary when a beneficiary's condi- July 1, 2004 through December 31, 2006, tion requires ongoing care that must ambulance services originating in be furnished by one or more health pro- urban areas (both base rate and mile- fessionals in an appropriate specialty age) are paid based on a rate that is area for example, nursing, emergency one percent higher than otherwise is medicine, respiratory care, cardio- applicable under this section, and am- vascular care, or a paramedic with ad- bulance services originating in rural ditional training. areas (both base rate and mileage) are Urban area means a Metropolitan paid based on a rate that is two percent Statistical Area, as defined by the Ex- higher than otherwise is applicable ecutive Office of Management and Budget. under this section. For services fur- nished during the period July 1, 2008 [67 FR 9132, Feb. 27, 2002, as amended at 68 through December 31, 2009, ambulance FR 67693, Dec. 5, 2003; 71 FR 69787, Dec. 1, services originating in urban areas 2006) (both base rate and mileage) are paid §414.610 Basis of payment based on a rate that is 2 percent higher (a) Method of payment. Medicare pay- than otherwise is applicable under this merit for ambulance services is based section, and ambulance services origi- nating the lesser of the actual charge or nating in rural areas (both base rate the applicable fee schedule amount, and mileage) are paid based on a rate The fee schedule payment for ambu- that is three percent higher than oth- lance services equals a base rate for the erwise is applicable under this section. level of service plus payment for mile- (ii)The service-level base rate is then age and applicable adjustment factors. adjusted by the GAF. Compare this Except for services furnished by cer- amount to the actual charge. The less- tain critical access hospitals or enti- er Of the actual charge or the GAF ad- ties owned and operated by them, as justed base rate amount is added to the described in §413.70(b) of this chapter, lesser of the actual mileage charges or all ambulance services are paid under the payment rate per mile, multiplied the fee schedule specified in this sub- by the number of miles that the bene- part (regardless of the vehicle fur- ficiary was transported. When applica- nishing the service). ble, the appropriate RAF is applied to (b) Mandatory assignment. Effective the ground mileage rate to determine with implementation of the ambulance the appropriate payment rates. The fee schedule described in §414.601 (that RVU scale for the ambulance fee sched- is, for services furnished on or after ule is as follows: April 1, 2002), all payments made for ambulance services are made only on RelatiUs) ve an assignment-related basis. Ambu- service level value (RV units (RV lance suppliers must accept the Medi- care allowed charge as payment in full BLS 160. and may not bill or collect from the BLS-Emergency 120 beneficiary any amount other than the ALS1-Emer 120 unmet Part B deductible and Part B ALS2 g enc 9 1.75 2.25 coinsurance amounts. Violations of SCT 3.25 this requirement may subject the pro- PI 1.75 vider or supplier to sanctions, as pro- vided by law (part 402 of this chapter). (2) Air ambulance service levels. The (c)Formula for computation of payment base payment rate for the applicable amounts. The fee schedule payment type of air ambulance service is ad- amount for ambulance services is corn- justed by the GAF and, when applica- puted according to the following provi- ble, by the appropriate RAF to deter- sions: mine the amount of payment. Air am- (1) Ground ambulance service levels. (i) bulance services have no CF or RVUs. The CF is multiplied by the applicable This amount is compared to the actual RVUs for each level of service to charge. The lesser of the charge or the produce a service-level base rate. For adjusted GAF rate amount is added to services furnished during the period the payment rate per mile, multiplied 65