Rule 37.86.2606 - AMBULANCE SERVICES, QUALIFIED RATE ADJUSTMENT, PAYMENT ELIGIBILITY AND COMPUTATION(1) Eligible Montana ambulance providers may receive a qualified rate adjustment (QRA) from the department for ambulance services. Eligible providers are ambulance service providers that are either owned or operated by a local government unit.(2) For an eligible provider to receive a QRA payment, the following conditions must be met: (a) local government funds must be transferred in accordance with the contract required by (2)(d);(b) the funds must be certified by the city or county treasurer, or an authorized local government official, as an intergovernmental transfer of public funds that qualifies as a payment of services eligible for federal financial participation (FFP, the federal government's share of a state's expenditures under the Medicaid program) in accordance with 42 CFR 433.51(2004);(c) the provider must be in compliance with a signed, written contract with the department; and(d) the written contract covering the requirements for the QRA payment must be executed prior to the issuance of the QRA payment. A retroactive effective date on the written agreement will not be allowed.(3) To be eligible for FFP, the local government funds cannot be federal funds unless the federal funds are authorized by federal law to be used to match other federal funds.(4) The QRA payment will be computed separately for all eligible ambulance providers on or before December 31, annually, using the following formula: QRA payment = C x D x FMAP
(a) For the purposes of calculating the QRA payment amount, the following definitions apply: (i) "C" represents the number of the provider's complete set of Medicaid paid claims for dates of service for the most recent state fiscal year filed in accordance with ARM 37.85.406; (ii) "D" represents the difference between the Medicare and Medicaid allowed amount per the Healthcare Common Procedure Coding System (HCPCS); and(iii) "FMAP" represents the Federal Medical Assistance Percentage (FMAP) in effect at the time of department payment. This percentage is the amount of federal participating matching funds for payment of Montana Medicaid program services. The methodology for determining this percentage is set forth in 42 USC 1396 b(a) (2004). The department adopts and incorporates by reference the methodology set out in 42 USC 1396 b(a) (2004). A copy of that statute may be obtained from the Department of Public Health and Human Services, Health Resources Division, P.O. Box 202951, Helena, MT 59620-2951.(5) The QRA is subject to the following conditions:(a) the eligible ambulance provider's local government funds must be received by the department before it will disburse the QRA payment to the provider;(b) information submitted from the eligible ambulance provider, the local Medicare fiscal intermediary, and the Montana Medicaid Paid Claims Database will be used for calculations, utilizing data from the most recent state fiscal year with completed Medicaid paid claims data filed in accordance with ARM 37.85.406;(c) the limited situations where there is no Medicare HCPCS code or fee schedule for the ambulance service, the billed charges from the provider will be used in the computation; and(d) the ambulance provider is not allowed to bill Medicaid more than it bills private payers and other insurers.(6) The QRA payment is subject to the restrictions imposed by federal law and to the availability of sufficient local government, state and federal funding. Mont. Admin. r. 37.86.2606
NEW, 2005 MAR p. 385, Eff. 3/18/05; AMD, 2015 MAR p. 825, Eff. 6/26/2015.AUTH: 53-6-113, MCA; IMP: 53-6-113, MCA