Medicare Program; National Expansion Implementation for All Remaining States and Territories of the Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transports |
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Lynette Wilson
Department of Health and Human Services
27 August 2021
[Federal Register Volume 86, Number 164 (Friday, August 27, 2021)]
[Notices]
[Pages 48149-48151]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2021-18543]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-6063-N7]
Medicare Program; National Expansion Implementation for All
Remaining States and Territories of the Prior Authorization Model for
Repetitive, Scheduled Non-Emergent Ambulance Transports
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Notice.
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SUMMARY: This notice announces the implementation dates for all
remaining states and territories for the national expansion of the
Prior Authorization Model for Repetitive, Scheduled Non-Emergent
Ambulance Transports.
DATES: This expansion of the Prior Authorization Model for Repetitive,
Scheduled Non-Emergent Ambulance Transports will begin on December 1,
2021 for independent ambulance suppliers garaged in Arkansas, Colorado,
Louisiana, Mississippi, New Mexico, Oklahoma, and Texas; and no earlier
than: February 1, 2022 for independent ambulance suppliers garaged in
Alabama, American Samoa, California, Georgia, Guam, Hawaii, Nevada,
Northern Mariana Islands and Tennessee; April 1, 2022 for independent
ambulance suppliers garaged in Florida, Illinois, Iowa, Kansas,
Minnesota, Missouri, Nebraska, Puerto Rico, Wisconsin, and U.S. Virgin
Islands; June 1, 2022 for independent ambulance suppliers garaged in
Connecticut, Indiana, Maine, Massachusetts, Michigan, New Hampshire,
New York, Rhode Island, and Vermont; and August 1, 2022 for independent
ambulance suppliers garaged in Alaska, Arizona, Idaho, Kentucky,
Montana, North Dakota, Ohio, Oregon, South Dakota, Utah, Washington,
and Wyoming.
FOR FURTHER INFORMATION CONTACT: Angela Gaston, (410) 786-7409.
Questions regarding the national expansion of the Prior
Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance
Transports should be sent to AmbulancePA@cms.hhs.gov.
SUPPLEMENTARY INFORMATION:
I. Background
In the November 23, 2020 Federal Register (85 FR 74725), we
published a notice titled ``Medicare Program; National Expansion of the
Prior Authorization Model for Repetitive, Scheduled Non-Emergent
Ambulance Transport,'' which announced the national expansion of the
Prior Authorization Model for Repetitive, Scheduled Non-Emergent
Ambulance Transports under section 1834(l)(16) of the Act, as added by
section 515(b) of the Medicare Access and CHIP Reauthorization Act of
2015 (MACRA) (Pub. L. 114-10). The states that participated in the
model under section 1115A of the Social Security Act (the Act), which
included Delaware, the District of Columbia, Maryland, New Jersey,
North Carolina, Pennsylvania, South Carolina, Virginia, and West
Virginia, previously transitioned to the national model on December 2,
2020. Due to the COVID-19 Public Health Emergency, we delayed the
implementation of the expansion to any additional states.
[[Page 48150]]
II. Provisions of the Notice
This notice announces the implementation dates for all remaining
states and territories for the national expansion of the Prior
Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance
Transports under section 1834(l)(16) of the Act, as added by section
515(b) of MACRA (Pub. L. 114-10). This expansion of the model will
begin on December 1, 2021 for independent ambulance suppliers garaged
in Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma,
and Texas; and no earlier than--
February 1, 2022 for independent ambulance suppliers
garaged in Alabama, American Samoa, California, Georgia, Guam, Hawaii,
Nevada, Northern Mariana Islands and Tennessee;
April 1, 2022 for independent ambulance suppliers garaged
in Florida, Illinois, Iowa, Kansas, Minnesota, Missouri, Nebraska,
Puerto Rico, Wisconsin, and U.S. Virgin Islands;
June 1, 2022 for independent ambulance suppliers garaged
in Connecticut, Indiana, Maine, Massachusetts, Michigan, New Hampshire,
New York, Rhode Island, and Vermont; and
August 1, 2022 for independent ambulance suppliers garaged
in Alaska, Arizona, Idaho, Kentucky, Montana, North Dakota, Ohio,
Oregon, South Dakota, Utah, Washington, and Wyoming.
We will continue to test in the remaining states and territories
whether prior authorization helps reduce expenditures, while
maintaining or improving quality of care, by using the prior
authorization process described in the November 23, 2020 Federal
Register (85 FR 74725) to reduce utilization of services that do not
comply with Medicare policy. Prior authorization helps ensure that all
relevant clinical or medical documentation requirements are met before
services are furnished to beneficiaries and before claims are submitted
for payment. It further helps to ensure that payment complies with
Medicare documentation, coverage, payment, and coding rules. Prior
authorization also allows ambulance suppliers to address coverage
issues prior to furnishing services.
The model establishes a process for requesting prior authorization
for repetitive, scheduled non-emergent ambulance transports. The use of
prior authorization does not create new clinical documentation
requirements. Instead, it requires the same information that is already
required to support Medicare payment, just earlier in the process.
Submitting a prior authorization request for repetitive, scheduled
non-emergent ambulance transports is voluntary. However, an ambulance
supplier or beneficiary is encouraged to submit to the Medicare
Administrative Contractor (MAC) a request for prior authorization along
with all relevant documentation to support Medicare coverage of the
transports. If prior authorization has not been requested by the fourth
round trip in a 30-day period, the subsequent claims will be stopped
for prepayment review. Please see the November 23, 2020 Federal
Register (85 FR 74725) for additional details on the prior
authorization model and process.
We will expand outreach and education efforts on this model to
affected ambulance suppliers in all states and territories, through
such methods as an operational guide, frequently asked questions (FAQs)
on our website, a physician letter explaining the ambulance suppliers'
need for the proper documentation, open door forums, and educational
events and materials issued by the MACs. We will work to limit any
adverse impact on beneficiaries and to educate affected beneficiaries
about the model process. Beneficiaries will continue to have all
applicable administrative appeal rights for denied claims associated
with a non-affirmed prior authorization decision.
Additional information is available on the CMS website at http://go.cms.gov/PAAmbulance.
III. Collection of Information Requirements
As required by chapter 35 of title 44, United States Code (the
Paperwork Reduction Act of 1995), the information collection burden
associated with this national model (Form CMS-10708--Ambulance Prior
Authorization) is currently approved under OMB control number 0938-1380
which expires on August 31, 2023.
IV. Regulatory Impact Statement
We have examined the impact of this rule as required by Executive
Order 12866 on Regulatory Planning and Review (September 30, 1993),
Executive Order 13563 on Improving Regulation and Regulatory Review
(January 18, 2011), the Regulatory Flexibility Act (RFA) (September 19,
1980, Pub. L. 96-354), section 1102(b) of the Act, section 202 of the
Unfunded Mandates Reform Act of 1995 (March 22, 1995; Pub. L. 104-4),
Executive Order 13132 on Federalism (August 4, 1999), and the
Congressional Review Act (5 U.S.C. 804(2)).
Executive Orders 12866 and 13563 direct agencies to assess all
costs and benefits of available regulatory alternatives and, if
regulation is necessary, to select regulatory approaches that maximize
net benefits (including potential economic, environmental, public
health and safety effects, distributive impacts, and equity). A
Regulatory Impact Analysis (RIA) must be prepared for major rules with
economically significant effects ($100 million or more in any 1 year).
This rule does not reach the economic threshold and thus is not
considered a major rule.
The RFA requires agencies to analyze options for regulatory relief
of small entities. For purposes of the RFA, small entities include
small businesses, nonprofit organizations, and small governmental
jurisdictions. Most hospitals and most other providers and suppliers
are small entities, either by nonprofit status or by having revenues of
less than $8.0 million to $41.5 million in any 1 year. Individuals and
states are not included in the definition of a small entity. We are not
preparing an analysis for the RFA because we have determined, and the
Secretary certifies, that this notice will not have a significant
economic impact on a substantial number of small entities.
In addition, section 1102(b) of the Act requires us to prepare an
RIA if a rule may have a significant impact on the operations of a
substantial number of small rural hospitals. This analysis must conform
to the provisions of section 604 of the RFA. For purposes of section
1102(b) of the Act, we define a small rural hospital as a hospital that
is located outside of a Metropolitan Statistical Area for Medicare
payment regulations and has fewer than 100 beds. We are not preparing
an analysis for section 1102(b) of the Act because we have determined,
and the Secretary certifies, that this notice will not have a
significant impact on the operations of a substantial number of small
rural hospitals.
Section 202 of the Unfunded Mandates Reform Act of 1995 also
requires that agencies assess anticipated costs and benefits before
issuing any rule whose mandates require spending in any 1 year of $100
million in 1995 dollars, updated annually for inflation. In 2021, that
threshold is approximately $158 million. This rule will have no
consequential effect on state, local, or tribal governments or on the
private sector.
Executive Order 13132 establishes certain requirements that an
agency
[[Page 48151]]
must meet when it promulgates a proposed rule (and subsequent final
rule) that imposes substantial direct requirement costs on state and
local governments, preempts state law, or otherwise has Federalism
implications. Since this regulation does not impose any costs on state
or local governments, the requirements of Executive Order 13132 are not
applicable.
In accordance with the provisions of Executive Order 12866, this
notice was not reviewed by the Office of Management and Budget.
The Administrator of the Centers for Medicare & Medicaid Services
(CMS), Chiquita Brooks-LaSure, having reviewed and approved this
document, authorizes Lynette Wilson, who is the Federal Register
Liaison, to electronically sign this document for purposes of
publication in the Federal Register.
Dated: August 24, 2021.
Lynette Wilson,
Federal Register Liaison, Centers for Medicare & Medicaid Services.
[FR Doc. 2021-18543 Filed 8-26-21; 8:45 am]
BILLING CODE 4120-01-P