Ambulances: CMS Flexibilities to Fight COVID-19
Summary
A CMS fact sheet, Ambulances: CMS Flexibilities to Fight COVID-19, with page footers dated 05/10/2023. It states that the fact sheet focuses on Medicare and Medicaid flexibilities only, and covers COVID-19 vaccine payment, including approximately $40 per dose for administration and a total of approximately $76 per dose for in-home administration through calendar year 2023. Under ambulance topics, it says transports during the COVID-19 PHE may go to any destination equipped to treat the patient's condition, describes treatment in place under section 9832 of the American Rescue Plan Act of 2021, and notes that RSNAT Prior Authorization Model processing requirements were paused effective March 29, 2020 and full operations resumed on August 3, 2020. It also lists provider enrollment flexibilities, such as waived site visits and application fees.
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Cite this document
“Ambulances: CMS Flexibilities to Fight COVID-19.”
Original at www.cms.gov. Archived at Pandemic Darlings, https://pandemicdarlings.com/source-documents/ppr-int-7fe2cfa2e41e646b-ambulances-pdf-4153d5576d/
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Ambulances: CMS Flexibilities to Fight COVID-19
At the beginning of the COVID-19 Public Health Emergency (PHE), CMS used emergency waiver
authorities and various regulatory authorities to enable flexibilities so providers could rapidly
respond to people impacted by COVID-19. CMS developed a cross-cutting initiative to use a
comprehensive, streamlined approach to reestablish certain health and safety standards and
other financial and program requirements at the eventual end of the COVID-19 public health
emergency.
This CMS cross-cutting initiative focused on evaluating CMS-issued PHE waivers and flexibilities
to prepare the health care system for operation after the PHE. This review happened in three
concurrent phases:
1. CMS assessed the need for continuing certain waivers based on the current phase of the
PHE. Since the beginning of the PHE, CMS has both added and terminated flexibilities and
waivers as needed. In doing so, CMS considered the impacts on communities — including
underserved communities — and the potential barriers and opportunities that the
flexibilities may address.
2. CMS assessed which flexibilities would be most useful in a future PHE, such as natural and
man-made disasters and other emergencies, to ensure a rapid response to future
emergencies, both locally and nationally, or to address the unique needs of communities
that may experience barriers to accessing health care.
3. CMS is continuing to collaborate with federal partners and the health care industry to
ensure that the health care system is holistically prepared for addressing future
emergencies.
As CMS identified barriers and opportunities for improvement, the needs of each person and
community served were considered and assessed with a health equity lens to ensure our
analysis, stakeholder engagement, and policy decisions account for health equity impacts on
members of underserved communities and health care professionals disproportionately serving
these communities.
Please note: This fact sheet focuses on Medicare and Medicaid flexibilities only.
COVID-19 Vaccines
On October 28, 2020, CMS released an Interim Final Rule with comment period (IFC)
announcing that Medicare Part B would establish coding and payment rates for COVID-19
vaccines and their administration as preventive vaccines, without cost-sharing, as soon as the
Food and Drug Administration (FDA) authorized or approved the product through an
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Emergency Use Authorization (EUA) or Biologics License Application (BLA). The IFC also
implemented provisions of the CARES Act to ensure swift coverage of COVID-19 vaccines by
private health insurance plans participating in the Health Insurance Marketplace, without cost
sharing, from both in- and out-of-network providers, during the course of the COVID-19 public
health emergency (PHE).
Payment After the End of the PHE
CMS will continue to pay approximately $40 per dose for administering COVID-19 vaccines in
most outpatient settings for Medicare beneficiaries through the end of the calendar year in
which the Secretary ends the EUA declaration for drugs and biologicals with respect to COVID-
19. The EUA declaration is distinct from, and not dependent on, the PHE for COVID-19.
Effective January 1 of the year following the year in which the EUA declaration ends, CMS will
set the payment rate for administering COVID-19 vaccines to align with the payment rate for
administering other Part B preventive vaccines, that is, approximately $30 per dose.
Additional Payment for Administering the Vaccine in the Patient’s Home
In calendar year 2023, CMS will pay approximately $36 in addition to the standard
administration amount (approximately $40) per dose to administer COVID-19 vaccines in the
home for certain Medicare patients. For vaccines requiring multiple doses, this payment applies
for each dose in the series, including any additional or booster doses. We also geographically
adjust the additional amount and administration rate based on where you administer the
vaccine. Starting January 1, 2023, we’ll also annually update the additional in-home payment
rate for administering the COVID-19 vaccine to reflect changes in costs related to administering
preventive vaccines.
Additional Payment for Administering the Vaccine in the Patient’s Home After the End of the
PHE
We’ll continue to pay a total payment of approximately $76 per dose to administer COVID-19
vaccines in the home for certain Medicare patients through calendar year 2023. The additional
payment is not affected by the end of the PHE.
More information: COVID-19 vaccine toolkits
• Providers
o Payment
o Billing
o Coding
• Health & Drug Plans
• State Medicaid programs
CMS Hospital Without Walls (Temporary Expansion Sites)
• During the Public Health Emergency (PHE) for the COVID-19 pandemic, we have
temporarily expanded the list of allowable destinations for ground ambulance
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transports (interim final rule with comment period (85 FR 19276)). During the COVID- 19
PHE, ambulance transports may include any destination that is equipped to treat the
condition of the patient in a manner consistent with state and/or local Emergency
Medical Services (EMS) protocols in use where the services are being furnished. These
destinations may include, but are not limited to: any location that is an
alternative site determined to be part of a hospital, CAH or SNF, community mental
health center, federally qualified health center (FQHC), physician’s office, urgent care
facility, ambulatory surgery center (ASC), or any other location furnishing dialysis
services outside of the ESRD facility, and the beneficiary’s home. This interim final
policy was finalized in the CY 2023 Physician Fee Schedule final rule (87 FR 70130) that
the expanded list of covered destinations for ground ambulance transports was for the
duration of the PHE for COVID-19 only.
Ambulance Treat in Place
• Pursuant to authority granted under section 9832 of the American Rescue Plan Act of
2021, CMS could pay for treatment in place under this waiver, by waiving the
requirements under section 1861(s)(7) and section 1834(l) of the Social Security Act, in
cases where the individual who would have been transported would have met the
Medicare criteria for a medically necessary ground ambulance transport to the nearest
appropriate facility that could have treated the patient’s condition, but such transport
did not occur as a result of community-wide emergency medical service protocols due
to the COVID-19 public health emergency. This waiver will end with the end of the
PHE.
Reducing Administrative Burden
• Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior
Authorization Model: Effective March 29, 2020, certain claims processing
requirements for the RSNAT Prior Authorization Model were paused in the model
states of Delaware, the District of Columbia, Maryland, New Jersey, North Carolina,
Pennsylvania, South Carolina, Virginia, and West Virginia because of the COVID-19
pandemic. During the pause, RSNAT claims were not stopped for pre-payment review
if prior authorization had not been requested by the fourth-round trip in a 30-day
period. CMS (through the MACs) continued to review any prior authorization requests
that were submitted.
Given the importance of prior authorization activities to CMS’ program integrity
efforts, CMS discontinued exercising enforcement discretion on August 3, 2020, and
resumed full model operations. Following resumption of the model, the MACs
conducted post payment review on RSNAT claims that were paid during the pause
without prior authorization. CMS worked with affected providers to develop a schedule
for post payment reviews that did not significantly increase provider burden. Claims
that receive a provisional affirmation prior authorization review decision and are
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submitted with an affirmed Unique Tracking Number (UTN) continue to be excluded
from most future medical reviews.
• Medicare Ground Ambulance Data Collection System: Under a section 1135 waiver, CMS
modified the data collection period and data reporting period for ground ambulance
organizations that were selected by CMS to collect data beginning between January 1,
2020, and December 31, 2020, (year one) and January 1, 2021, and December 31, 2021,
(year two) for purposes of complying with the statutory data reporting effort. Under this
modification, these ground ambulance organizations selected a new continuous 12-
month data collection period that begins between January 1, 2022 and December 31,
2022, to collect data necessary to complete the Medicare Ground Ambulance Data
Collection Instrument. CMS modified this data collection and reporting period to
increase flexibilities for ground ambulance organizations that would otherwise be
required to collect data in 2020-2021 so that they could focus on their operations and
patient care.
• Signature Requirements: With respect to ambulance transports where CMS’ regulations
otherwise require a physician or, in lieu of that, certain non-physician personnel to sign
and certify that the need for the non-emergency ambulance transport is medically
necessary, for claims with dates of service during the COVID-19 PHE (January 27, 2020,
until expiration), absent indications of potential fraud or abuse, CMS is not reviewing for
compliance with such signature requirements. Suppliers and providers document in the
medical record that a signature is not able to be obtained because of COVID-19. At the
end of the PHE, reviewers will resume their normal activities to verify compliance.
• COVID-19 Accelerated and Advance Payments (CAAP): For the most up to date
information related to the CAAP Program, please visit
https://www.cms.gov/medicare/covid-19-accelerated-and-advance-payments
• Provider Enrollment: During the PHE, CMS has established toll-free hotlines for
physicians, non-physician practitioners, and Part A certified providers and suppliers who
have established isolation facilities to enroll and receive temporary Medicare billing
privileges. When the PHE ends, the hotlines will be shut down. Additionally, CMS has
provided the following flexibilities for provider enrollment:
o Screening requirements:
• Site Visits: CMS waived provider enrollment site visits for moderate and high-
risk providers/suppliers. (This waiver terminated on 07-06-2020, and CMS,
in accordance with 42 CFR §§ 424.517 and 424.518, resumed all provider
enrollment site visits.)
• Fingerprint-based criminal background checks: CMS waived the requirement
for fingerprint-based criminal background checks for 5% or greater owners of
newly enrolling high-risk categories of providers and suppliers (e.g., newly-
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enrolling Home Health Agencies, DMEPOS suppliers, Medicare Diabetes
Prevention Programs, Opioid Treatment Programs). (This waiver terminated
on 10/31/2021 and CMS, in accordance with 42 CFR § 424.518, resumed
requesting fingerprints for all newly enrolling high-risk providers and
suppliers.)
o Application Fees: CMS waived the collection of application fees for institutional
providers who are initially enrolling, revalidating, or adding a new practice location.
(This waiver terminated on 10/31/2021, and CMS, in accordance with 42 CFR §
424.514, resumed collecting application fees.)
o Revalidation: CMS postponed all revalidation actions. This did not prevent a provider
who wanted to submit a revalidation application from doing so; MACs processed
revalidation applications. (This waiver terminated on 10/31/2021 and CMS
resumed a phased-in approach to revalidation activities; revalidation letters began
being mailed again in November 2021 with due dates in early 2022.)
o Expedited Enrollment: CMS expedited any pending or new applications from
providers and suppliers, including physicians and non-physician practitioners
received on or after March 1, 2020. When the PHE ends, CMS will resume normal
application processing times.
Medicare appeals in Traditional Medicare, Medicare Advantage (MA), and Part D
• During the PHE, CMS has been allowing Medicare Administrative Contractors (MACs)
and Qualified Independent Contractors (QICs) in the FFS program (42 CFR 405.942 and
42 CFR 405.962) and MA and Part D plans, as well as the Part C and Part D Independent
Review Entity (IREs) (42 CFR 422.582 and 42 CFR 423.582), to allow extensions to file an
appeal. Specifically, 42 CFR 422.582(c) and 42 CFR 423.582(c) allow a Part C or Part D
plan to extend the timeframe for filing a request if there is good cause for the late filing.
In addition, the Part D IRE may find good cause for late filing of a request for
reconsideration. When the COVID-19 PHE ends, these flexibilities will continue to apply
consistent with existing authority and requests for appeals must meet the existing
regulatory requirements.
• During the PHE, CMS has been allowing MACs and QICs in the FFS program (42 CFR 405.
950 and 42 CFR 405.966), and the Part C and Part D IREs to waive requirements for
timeliness for requests for additional information to adjudicate appeals. In addition,
under applicable regulations, MA plans may extend the timeframe to adjudicate
organization determinations and reconsiderations for medical items and services (but
not Part B drugs) by up to 14 calendar days if: the enrollee requests the extension; the
extension is justified and in the enrollee's interest due to the need for additional
medical evidence from a noncontract provider that may change an MA organization's
decision to deny an item or service; or, the extension is justified due to extraordinary,
exigent, or other non-routine circumstances and is in the enrollee's interest (42 CFR
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422.568(b)(1)(i), 42 CFR 422.572(b)(1) and 42 CFR 422.590(f)(1)). When the COVID-19
PHE ends, these flexibilities will continue to apply consistent with existing authority
and requests for appeals must meet the existing regulatory requirements.
• During the PHE, CMS has been allowing MACs and QICs in the FFS program (42 CFR
405.910) and MA and Part D plans, as well as the Part C and Part D IREs, to process an
appeal even, with incomplete Appointment of Representation forms (see 42 CFR
422.561 and 42 CFR 423.560 for definitions of “representative”). However, any
communication was sent only to the beneficiary. When the COVID-19 PHE ends, this
flexibility will continue to apply, consistent with existing guidance for the MACs and QIC
in the FFS program. For MA and Part D plans, as well as the Part C and Part D IREs, this
flexibility will no longer apply. The MA and Part D plans, as well as the Part C and D IREs,
must process the appeals based on regulatory requirements (42 CFR 422.582(f)-(g), 42
CFR 423.582(e)-(f), 42 CFR 422.592(d)-(e), and 42 CFR 423.600(g)-(h)).
• During the PHE, CMS has been allowing MACs and QICs in the FFS program (42 CFR 405.
950 and 42 CFR 405.966) and MA and Part D plans, as well as the Part C and Part D IREs,
to process requests for appeal that don’t meet the required elements, but instead use
information that is available (42 CFR 422.562 and 42 CFR 423.562). When the COVID-19
PHE ends, requests for appeals must meet the existing regulatory requirements.
• During the PHE, CMS has been allowing MACs and QICs in the FFS program (42 CFR 405.
950 and 42 CFR 405.966) and MA and Part D plans, as well as the Part C and Part D IREs,
to utilize all flexibilities available in the appeal process as if good cause requirements are
satisfied. When the PHE ends, these flexibilities may only be provided consistent with
existing regulatory authority.
Additional Guidance
• The Interim Final Rules and waivers can be found at https://www.cms.gov/about-
cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-
waivers.
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