PURPOSE: This rule establishes the formula for determining the Ambulance Service Reimbursement Allowance each ground emergency ambulance service must pay, except for any ambulance service owned and operated by an entity owned or operated by the board of curators, as defined in Chapter 172, RSMo, or any department of the state, in addition to all other fees and taxes now required or paid, for the privilege of engaging in the business of providing ground emergency ambulance services in Missouri.

1. (1) Ambulance service reimbursement allowance shall be assessed as described in this section.

   1. (A) Definitions.

      1. 1. Ambulance. Ambulance shall have the same meaning as

such term is defined in section 190.100, RSMo.

1. 2. Department. Department of Social Services.
2. 3. Director. Director of the Department of Social Services.
3. 4. Division. MO HealthNet Division.
4. 5. Emergency Transport Mileage. Emergency ambulance

mileage from Medicare, Medicaid, insurance, and private payments received by an ambulance service licensed under section 190.109, RSMo (or by its predecessor in interest following a change of ownership). Mileage from CPT Code A0427/ A0425 ambulance service, advanced life support, emergency transport, level 1 (ALS1–emergency); CPT Code A0429/A0425 ambulance services, basic life support, emergency transport (BLS–emergency); and CPT Code A0433/A0425 advanced life support, level 2 (ALS2).

1. 6. Engaging in the business of providing ambulance

services. Accepting payment for ambulance services as such term is defined in section 190.100, RSMo.

1. (B) Beginning October 1, 2013, each ground emergency ambulance services provider in this state, except for any ambulance service owned and operated by an entity owned and operated by the state of Missouri, including but not limited to any hospital owned or operated by the board of curators, as defined in Chapter 172, RSMo, or any department of the state, shall, in addition to all other fees and taxes now required or paid, pay an ambulance service reimbursement allowance for the privilege of engaging in the business of providing ambulance services as defined in section 190.100, RSMo. Emergency transport mileage shall be obtained by the division from the providers six (6) months after calendar year end (i.e., calendar year 2021 mileage will be obtained through an affidavit sent out by the state in 2022). Collection of the ambulance service reimbursement allowance beginning October 1, 2022, and thereafter each October 1, shall be based on emergency transport mileage from the prior calendar year. (i.e., October 1, 2022, shall be based on emergency transport mileage from calendar year 2021).

   1. 1. The ambulance service reimbursement allowance owed

for currently licensed emergency ambulance providers as defined in section 190.100, RSMo, shall be calculated by multiplying the ambulance service reimbursement allowance tax rate by the emergency transport mileage, as defined above in paragraph (1)(A)5.

1. A. Exceptions.

   1. (I) For emergency ambulance providers without

reported data, emergency transport mileage used to determine the ambulance service reimbursement allowance shall be estimated as follows:

1. (a) Emergency ambulance providers shall be

divided into quartiles based on total emergency ambulance transports;

1. (b) Emergency transport mileage shall be

individually summed and divided by the total emergency ambulance transports in the quartile to yield an average per emergency ambulance transport; and

1. (c) The number of emergency ambulance

transports as reported to the Department of Health and Senior Services (Bureau of Emergency Medical Services (BEMS) data) as required by 19 CSR 30-40.375(3) for the emergency ambulance provider without reported data shall be multiplied by the average emergency transport mileage.

1. 2. Each ambulance provider shall submit an affidavit to

the department with the following information:

1. A. Provider name;
2. B. Contact;
3. C. Telephone number;
4. D. Address:
5. E. Federal tax ID number;
6. F. MO HealthNet provider number;
7. G. Emergency transport mileage; and
8. H. Gross receipts attributable to emergency ambulance

revenue from Medicare, Medicaid, insurance, and private payments received by the ambulance service.

1. (C) The Department of Social Services shall provide each emergency ambulance provider with a final determination letter. The letter shall include emergency ambulance provider name, National Provider Identifier (NPI) number, total emergency transport mileage, ambulance service reimbursement allowance tax rate, and annual tax amount.

   1. 1. Each emergency ambulance provider required to pay

the ambulance service reimbursement allowance shall review the information in the letter and, if necessary, provide the department with correct information. If the information supplied by the department is incorrect, the emergency ambulance provider, within fifteen (15) calendar days of receiving the confirmation schedule, must notify the division and explain the corrections. If the division does not receive corrected information within fifteen (15) calendar days, it will be assumed to be correct, unless the emergency ambulance provider files a protest in accordance with subsection (1)(E) of this regulation.

1. (D) Payment of the Ambulance Service Reimbursement Allowance.

   1. 1. Offset. Each emergency ambulance provider may

request that its ambulance service reimbursement allowance be offset against any Missouri Medicaid payment due to that emergency ambulance provider. A statement authorizing the offset must be on file with the division before any offset may be made relative to the ambulance service reimbursement allowance by the emergency ambulance provider. Assessments shall be allocated and deducted over the applicable service period. Any balance due after the offset shall be remitted by the emergency ambulance provider to the department. The remittance shall be made payable to the director of the Department of Revenue and deposited in the state treasury to the credit of the ambulance service reimbursement allowance fund. If the remittance is not received before the next MO HealthNet payment cycle, the division shall offset the balance due from that check.

1. 2. Check. If no offset has been authorized by the emergency

ambulance provider, the division will begin collecting the ambulance service reimbursement allowance on the first day of each month. The ambulance service reimbursement allowance shall be remitted by the emergency ambulance provider to the department. The remittance shall be made payable to the director of the Department of Revenue and deposited in the state treasury to the credit of the ambulance service reimbursement allowance fund.

1. 3. Failure to pay the ambulance service reimbursement

allowance. If an emergency ambulance provider fails to pay its ambulance service reimbursement allowance within thirty (30) days of notice, the ambulance service reimbursement allowance shall be delinquent. For any delinquent ambulance service reimbursement allowance, the department may compel the payment of such reimbursement allowance in the circuit court having jurisdiction in the county where the main office of the emergency ambulance provider is located. In addition, the director of the Department of Social Services or the director’s designee may cancel or refuse to issue, extend, or reinstate an emergency ambulance provider agreement to any emergency ambulance provider that fails to pay such delinquent reimbursement allowance required unless under appeal.

1. (E) Each emergency ambulance provider, upon receiving written notice of the final determination of its ambulance service reimbursement allowance, may file a protest with the director of the department setting forth the grounds on which the protest is based, within thirty (30) days from the date of receipt of written notice from the department. The director of the department shall reconsider the determination and, if the emergency ambulance provider so requested, the director or the director’s designee shall grant the emergency ambulance provider a hearing to be held within forty-five (45) days after the protest is filed, unless extended by agreement between the emergency ambulance provider and the director. The director shall issue a final decision within forty-five (45) days of the completion of the hearing. After a final decision by the director, an emergency ambulance provider’s appeal of the director’s final decision shall be to the Administrative Hearing Commission in accordance with sections 208.156 and 621.055, RSMo.

1. (2) Ambulance service reimbursement allowance rate beginning October 1, 2022. The ambulance service reimbursement allowance rate beginning October 1, 2022, determined by the division, as set forth in subsection (1)(B) above, is as follows:

   1. (A) Beginning October 1, 2022, the tax rate will be one dollar and fifty-eight cents ($1.58) per mile. MO HealthNet Division will have the discretion to adjust the tax rate on a quarterly basis. No ambulance service reimbursement allowance shall be collected by the Department of Social Services if the federal Centers for Medicare & Medicaid Services (CMS) determines that such reimbursement allowance is not authorized under Title XIX of the Social Security Act;
   2. (B) Beginning October 1, 2023, the tax rate will be eightyfive cents ($0.85) per mile. MO HealthNet Division will have the discretion to adjust the tax rate on a quarterly basis. No ambulance service reimbursement allowance shall be collected by the Department of Social Services if the federal Centers for Medicare & Medicaid Services (CMS) determines that such reimbursement allowance is not authorized under Title XIX of the Social Security Act;
   3. (C) Beginning July 1, 2025, the tax rate will be one dollar and sixty-four cents ($1.64) per mile. MO HealthNet Division will have the discretion to adjust the tax rate on a quarterly basis. No ambulance service reimbursement allowance shall be collected by the department if the federal Centers for Medicare & Medicaid Services (CMS) determines that such reimbursement allowance is not authorized under Title XIX of the Social Security Act; and
   4. (D) For each year (October thru September), the total tax amount collected shall not exceed six percent (6%) of emergency ambulance gross receipts in the aggregate as reported in subparagraph (1)(B)2.H.

AUTHORITY: sections 190.836, 208.201, and 660.017, RSMo 2016, and section 190.815, RSMo Supp. 2025.* Original rule filed March 19, 2010, effective Nov. 30, 2010. Amended: Filed Oct. 10, 2013, effective April 30, 2014. Emergency amendment filed Feb. 3, 2023, effective Feb. 22, 2023, expired Aug. 20, 2023. Amended: Filed Feb. 2, 2023, effective Aug. 30, 2023. Amended: Filed March 20, 2024, effective Nov. 30, 2024. Emergency amendment filed June 20, 2025, effective July 7, 2025, expired Feb. 26, 2026. Amended: Filed June 23, 2025, effective Jan. 30, 2026. *Original authority: 190.815, RSMo 2009, amended 2022; 190.836, RSMo 2009; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.