317:30-5-344. Ground Emergency Medical Transportation (GEMT) supplemental payment program
(a) Definitions. The following words and terms, when used in this Section, shall have the following meaning, unless the context clearly indicates otherwise:
(1) "Advanced life support" means emergency medical care and services which are provided by a licensed ground ambulance services provider in accordance with Oklahoma Administrative Code (OAC) 310:641, to include, but not limited to, advanced airway management, intravenous therapy, administration of drugs and other medicinal preparations, and other invasive medical procedures and specified techniques that are limited to the Intermediate, Advanced EMT, and Paramedic scope of practice in accordance with OAC 310:641, Subchapter 5.
(2) "Allowable costs" means an expenditure that complies with the regulatory principles as listed in Title 2 of the Code of Federal Regulations (C.F.R.), Section 200.
(3) "Basic life support" means emergency medical care and services which are provided by a licensed ground ambulance service in accordance with OAC 310:641 to include, but not limited to, cardiopulmonary resuscitation procedures (CPR), hemorrhage control, stabilization of actual or possible skeletal injuries, spinal immobilization, extrication, transportation, and other non-invasive medical care.
(4) "Contracts with a local government" means contracts pursuant to a county plan for ambulance and emergency medical services with a:
(A) City, county, or an Indian tribe as defined in Section 4 of the Indian Self-Determination and Education Assistance Act; or
(B) Local service district, including, but not limited to, a rural fire protection district, or all administrative subdivisions of such city, county, or local service district.
(5) "Eligible GEMT provider" means a GEMT provider that meets all eligibility requirements in OAC 317:30-5-344 and the Oklahoma Medicaid State Plan (State Plan).
(6) "Federal financial participation (FFP)" means the portion of medical assistance expenditures for emergency medical services that are paid or reimbursed by the Centers for Medicare and Medicaid Services (CMS) in accordance with the State Plan.
(7) "GEMT services" means the act of transporting an individual by ground from any point of origin to the nearest medical facility capable of meeting the emergency medical needs of the patient, as well as the advanced, limited-advanced, and basic life support services provided to an individual by eligible GEMT providers before or during the act of transportation.
(8) "Governmental unit" means the entire state, local, or federally-recognized Indian tribal government, including any component thereof.
(9) "Publically owned or operated" means a unit of government that is a state, a city, a county, a special purpose district, or other governmental unit in a state that has taxing authority, has direct access to tax revenues, or is an Indian tribe as defined in Section 4 of the Indian Self-Determination and Education Assistance Act.
(b) Purpose. In accordance with 63 Oklahoma Statutes (O.S.) ' 3242, the GEMT Supplemental Payment Program is a voluntary program which makes supplemental payments above the Medicaid fee schedule reimbursement rate to eligible GEMT providers for specific allowable, certified, and uncompensated costs incurred for providing GEMT Services to SoonerCare members.
(c) Provider eligibility. To be eligible for supplemental payments, a GEMT provider must meet all of the following requirements:
(1) Be enrolled as an Oklahoma SoonerCare provider for the time period claimed on its annual cost report;
(2) Provide ground ambulance transportation services to SoonerCare members;
(3) Be classified as a governmental unit provider in accordance with 2 C.F.R. 200;
(4) Comply with all applicable state and federal law;
(5) Be an organization that:
(A) Is publicly owned or operated; or
(B) Is under contract with a local government unit.A copy of any such contract must be submitted to the Oklahoma Health Care Authority (OHCA) simultaneous with the submission of the GEMT provider's annual cost report; and
(6) Timely submit all relevant information requested by the OHCA, in the format as prescribed by the OHCA, including, but not limited to, a certification that conforms with 42 C.F.R. ' 433.51 that certifies that the claimed expenditures for GEMT Services are eligible for FFP.
(d) Allowable costs.
(1) Supplemental payments provided by this program are available only for the specific allowable costs per medical transport of a SoonerCare member that are in excess of the reimbursement paid by Medicaid and all other insurers and/or third-party resources.
(2) Total reimbursement from SoonerCare, including the supplemental payment, when combined with all other sources of reimbursement, must not exceed one-hundred percent (100%) of actual costs of providing services to SoonerCare members.
(e) Payments and recoupment.
(1) The OHCA will make annual supplemental payments after the conclusion of each state fiscal year (SFY) and in accordance with the methodology outlined in the State Plan.The payments will be made in the form of an interim payment and a later reconciliation payment (i.e., settle-up payment).The payments are not an increase to current fee-for-service (FFS) reimbursement rates.
(2) The interim supplemental payment will be equal to seventy-five percent (75%) of the total allowable costs as indicated on the annual approved cost report.
(3) The reconciliation payment will be computed by the OHCA based on the difference between the interim supplemental payment and total allowable costs from the approved cost report.
(4) Any excess payments determined in the reconciliation process are recouped and the federal share is returned to CMS.
(5) Cost reconciliation and cost settlement processes will be completed within twelve (12) months of the end of the cost reporting period.
(f) Reporting requirements.
(1) Eligible GEMT providers will:
(A) Submit a CMS-approved cost report annually, no later than ninety (90) days after the close of the SFY, on a form approved by the OHCA, unless a provider has made a written request for an extension and such request is granted by the OHCA;
(i) After the ninety (90) day deadline, an extension of no more than fifteen (15) calendar days can be granted; and
(ii) Extensions of time shall be requested by a letter addressed to the Finance Division.Any such request must be received by October 1, and must explain the good faith reason for the extension.OHCA shall provide a written notice of any denial of a request for an extension, which shall become effective on the date it is mailed.
(B) Provide supporting documentation simultaneous with the cost report, as required by the OHCA;
(C) Keep, maintain, and have readily retrievable, such records as specified by the OHCA to fully disclose reimbursement amounts to which the eligible governmental entity is entitled, and any other records required by CMS; and
(D) Comply with the allowable cost requirements provided in 42 C.F.R. Part 413, 2 C.F.R. Part 200, and federal Medicaid non-institutional reimbursement policy.
(2) Penalties for false statements or misrepresentations made by or on behalf of the provider are established by 42 U.S.C. Section 1320a-7b which states, in part, "WhoeverY (2) at any time knowingly and willfully makes or causes to be made any false statement or representation of a material fact for use in determining rights to such benefit or paymentYshall (i) in the case of such a statement, representation, concealment, failure, or conversion by any person in connection with the furnishing (by that person) of items or services for which payment is or may be under the program, be guilty of a felony and upon conviction thereof fined not more than $100,000 or imprisoned for not more than 10 years or both, or (ii) in the case of such a statement, representation, concealment, failure, conversion, or provision of counsel or assistance by any other person, be guilty of a misdemeanor and upon conviction thereof fined not more than $20,000 or imprisoned for not more than one (1) year, or both."
(g) Agency responsibilities.The OHCA will:
(1) Submit claims to CMS based on total computable certified expenditures for GEMT services provided, that are allowable and in compliance with federal laws and regulations and Medicaid non-institutional reimbursement policy;
(2) Submit on an annual basis, any necessary materials to the federal government to provide assurances that claims will include only those expenditures that are allowable under federal law; and
(3) Complete the audit and final reconciliation process of the interim cost settlement payments for the services provided within twelve (12) months of the postmark date of the cost report and conduct on-site audits as necessary.