PURPOSE: This rule implements the Ground Emergency Medical Transportation (GEMT) Uncompensated Cost Reimbursement Program established pursuant to section 208.1030, RSMo, which is a voluntary program that makes reconciled cost reimbursement to eligible GEMT providers that furnish qualifying emergency ambulance services to MO HealthNet participants on or after July 1, 2017.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

1. (1) Scope and Definitions.

   1. (A) Under the Ground Emergency Medical Transportation (GEMT) Uncompensated Cost Reimbursement Program (hereinafter the “program”), the MO HealthNet Division

2. (MHD) makes reconciled cost reimbursement to eligible GEMT providers up to the uncompensated Medicaid costs associated with GEMT services. This reconciled cost reimbursement applies only to GEMT services rendered to MHD participants by eligible GEMT providers on or after July 1, 2017. Total reimbursements from MHD, including the reconciled cost reimbursement, will not exceed one hundred percent (100%) of the eligible GEMT provider’s actual costs of providing GEMT services to MHD participants. The supplemental MHD reimbursement shall be distributed to eligible GEMT providers based on GEMT services provided to MHD participants on a per-transport basis. The reconciled cost reimbursement is not an individual increase to current fee-for-service reimbursement rates.

   1. (B) Definitions.

      1. 1. Cost objective means a function or

category of service for which costs are incurred.

1. 2. Direct cost means, in accordance with

2 CFR 200.413, direct costs are those costs that—

1. A. Can be identified specifically with

a particular final cost objective, such as a federal award, or other internally or externally funded activity; or

1. B. Can be directly assigned to such

activities relatively easily with a high degree of accuracy.

1. 3. Eligible GEMT provider means a

provider who is eligible to receive reconciled cost reimbursement under this program because it meets the following requirements continuously during the claiming period:

1. A. Provides GEMT services to MHD

participants;

1. B. Is enrolled as an MHD provider for

the period being claimed; and

1. C. Is owned, operated, or contracted

by the state or a political subdivision of the state.

1. 4. Emergency Medical Response (EMR)

means a cost objective that includes all expenditures for GEMT services.

1. 5. GEMT services means both the act of 13 CSR 70-6

transporting an individual 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, limitedadvanced, and basic life support services provided to an individual by eligible GEMT providers before or during the act of transportation. As of January 1, 2020, GEMT services also include advanced, limitedadvanced, and basic life support services provided to an individual who is released on the scene without transportation by ambulance to a medical facility. Advanced, limited-advanced, or basic life support services provided to an individual who is released on the scene without transportation by ambulance to a medical facility prior to January 1, 2020, shall not be considered GEMT services. A run that does not result in a transport or delivery of on-site advanced, limitedadvanced, or basic life support services shall not be considered GEMT services.

1. 6. Indirect cost means those costs that

are incurred by a supporting organization or related party which are not directly accounted for as costs for EMR services, non-EMR services or shared costs. Examples of indirect costs include overhead costs (i.e. accounting, human resources, etc.) incurred by a city, county, or other local government agency or special district that benefit the eligible GEMT provider, but the eligible GEMT provider has not been charged for those costs. The identification of shared costs does not preclude an eligible GEMT provider from also incurring indirect costs, and it is appropriate in certain cases for the uncompensated Medicaid costs to include both shared costs and indirect costs.

1. 7. MHD participant means a patient

enrolled in fee-for-service Missouri Medicaid.

1. 8. Non-Emergency Medical Response

(non-EMR) means a cost objective that includes expenditures for non-medical emergency services, such as fire suppression not including medical services, and non-emergency ancillary services, such as fire prevention and fire permit issuance that are performed in the absence of an emergency in order to support preparedness, mitigate the need for emergency response, or lessen the severity of an emergency that might occur.

1. 9. Reconciled cost reimbursement means

a payment to eligible GEMT providers up to the uncompensated Medicaid costs associated with GEMT services for MHD participants.

1. 10. Shared costs means costs that cannot

be directly assigned to EMR services or non- EMR services relatively easily with a high degree of accuracy. Examples of shared costs include personnel who perform EMR and non-EMR services and overhead departments who perform EMR and non-EMR services.

1. 11. Shift means a standard period of

time assigned for a complete cycle of work, as set by each eligible GEMT provider. The number of hours in a shift may vary among providers but will be consistent for each individual provider.

1. 12. Service period means July 1 through

June 30 of each Missouri State fiscal year.

1. 13. Transport means GEMT services

that are provided by eligible GEMT providers to individuals, regardless of whether the service was billed or paid. Medicaid transports includes GEMT services for Medicaid managed care, Medicaid crossover, and Medicaid fee for service patients. Other payer program transports shall be GEMT services provided to patients with payer sources other than Medicaid. Transportation services that do not involve an emergency or which are non-medical emergencies shall not be included as Transports. GEMT services that are denied as not medically necessary shall not be included as transports.

1. 14. Uncompensated Medicaid costs

means the cost of GEMT services for MHD participants that exceeds the reimbursement received from, but not limited to, Medicaid, patients, and enhanced supplemental payments received from the ambulance service reimbursement allowance under 13 CSR 70- 3.200. Cost excludes Medicaid managed care and dual-eligible Medicaid Transports.

1. 15. Dual-eligible Medicaid transport

means any transport where Medicaid is not the primary payor due to other coverage including Medicare or other private insurance. These costs will not be reimbursed in the GEMT supplemental program.

1. (2) Participation and Enrollment Requirements.

   1. (A) Participation in the GEMT program is voluntary.
   2. (B) Ambulance providers that are not owned, operated, or contracted by the state or a political subdivision of the state are not eligible to participate in the program.
   3. (C) As a condition of participation under this program, eligible GEMT providers shall transfer an administrative fee to MHD in an amount not to exceed five percent (5%) of the nonfederal share of the uncompensated Medicaid costs associated with GEMT services as identified in the eligible GEMT provider’s as-filed cost report. Such fee shall be transferred separately from the intergovernmental transfer of funds to MHD.

   4. (D) An eligible GEMT provider must complete and submit to MHD the following forms, which are incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, September 22, 2021, and may be downloaded from https://dss.mo.gov/mhd/providers/gemt.htm, obtained by emailing a written request to Ask.GEMT@dss.mo.gov, or acquired in-person at 615 Howerton Court, Jefferson City, MO 65109. This rule does not include any subsequent amendments or additions:

      1. 1. GEMT Program Provider Agreement

for the MO HealthNet Division Ground Emergency Medical Transportation (GEMT) Uncompensated Cost Reimbursement Program;

1. 2. Electronic Funds Transfer Authoriza-

tion Agreement;

1. 3. Intergovernmental Transfer of Public

Funds Agreement; and

1. 4. Administration Fee Agreement.

1. (3) Interim Payments and Cost Settlement Process.

   1. (A) If the eligible GEMT provider’s asfiled cost report reflects that the eligible GEMT provider has uncompensated Medicaid costs associated with GEMT services, the eligible GEMT provider is eligible to receive an interim payment from MHD. The eligible GEMT provider will make an intergovernmental transfer of funds to MHD in an amount equivalent to the nonfederal share of the uncompensated Medicaid costs amount shown on the as-filed cost report. MHD will then make an interim payment to the eligible GEMT provider in the amount of the total uncompensated Medicaid costs.
   2. (B) If the eligible GEMT provider’s asfiled cost report does not reflect any uncompensated Medicaid costs associated with GEMT services, then the provider is not entitled to receive an interim payment from MHD under this supplemental payment program and will not be responsible for any costs associated with implementing the GEMT program.
   3. (C) MHD will audit and reconcile the asfiled cost reports within one (1) year of receipt of the as-filed cost reports, unless MHD determines that additional time is needed, not to exceed three (3) years from receipt of the as-filed cost reports. To audit and reconcile the as-filed cost reports, MHD will use paid claims data for the service period generated from the Medicaid Managed Information Systems (MMIS) and eligible GEMT provider records. MHD will make adjustments to the as-filed cost report based on the audit and reconciliation and send the provider its preliminary findings within sixty

2. (60) days of initiating the audit and reconciliation process and receiving all relevant data from providers. The provider will be given sixty (60) days to respond to MHD’s preliminary findings, unless an extension is granted by MHD. MHD’s final audit and reconciliation decision will be issued within sixty (60) days after receipt of MHD’s preliminary findings. If at the end of the final audit and reconciliation it is determined that the interim payment made to the eligible GEMT provider exceeded the provider’s uncompensated Medicaid costs associated with GEMT services, the provider shall return the excess amount associated with the federal share to MHD and MHD will return the amount to the federal government pursuant to 42 CFR 433.316. If at the end of the final reconciliation it is determined that the interim payment made to the eligible GEMT provider was lower than the provider’s uncompensated Medicaid costs associated with GEMT services, the eligible GEMT provider shall make an additional intergovernmental transfer to MHD in an amount equivalent to the nonfederal share of the underpayment, and MHD will then make an additional payment to the eligible GEMT provider of the full underpayment amount. MHD shall recoup funds paid out under section 208.1030, RSMo, and this regulation upon a disallowance of federal financial participation (FFP) for those funds. The recoupment will follow the process outlined in 13 CSR 70-3.030(6).

   1. (D) Each provider’s uncompensated Medicaid cost associated with GEMT services is the sum of the number of transports for MHD participants provided during the applicable service period shown as paid in MMIS data, excluding Medicaid managed care and dualeligible Medicaid transports, and contained in eligible GEMT provider records, multiplied by the provider’s per-transport cost rate, less all amounts received and payable from MHD (excluding Medicaid managed care payments) and patients for such transports as shown in the MMIS and eligible GEMT provider records, and all other sources of reimbursement for such transports. Other sources of reimbursement include, but are not limited to, co-payments received from participants, and enhanced supplemental payments received from the ambulance service reimbursement allowance under 13 CSR 70-3.200.
   2. (E) Each provider’s per-transport cost rate is determined by adding the provider’s allowable direct, shared, and indirect costs of providing GEMT services divided by the total number of transports provided for the applicable service period.

3. (4) Cost Report Requirements.

   1. (A) To receive reconciled cost reimbursement under the GEMT program, each eligible GEMT provider must submit an annual cost report to MHD. The cost report form and the cost report instructions are incorporated by reference and made a part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, and available at https://dss.mo.gov/mhd/providers/gemt.htm, or by emailing a written request to Ask.GEMT@dss.mo.gov, September 22, 2021. This rule does not incorporate any subsequent amendments or additions.
   2. (B) The cost report must be completed in compliance with the requirements set forth in this regulation and the cost report instructions incorporated herein. The eligible GEMT provider shall submit the cost report to MHD by November 30 for the prior state fiscal year ending June 30, unless the provider has submitted a written request to MHD for an extension and such request is granted by MHD. Any written request for an extension must include a detailed explanation of the circumstances supporting the need for additional time. Extensions may be granted by MHD for good cause.

   3. (C) Each provider shall maintain fiscal and statistical records for the services period covered by the cost report. All records must be accurate and sufficiently detailed to substantiate the cost report data. The records must be maintained until the later of—

      1. 1. The division certifies that the cost

report is finalized and settled; or

1. 2. A period of six (6) years following the

submission of the cost report. If an audit is in progress, all records relevant to the audit must be retained until the audit is completed or the final resolution of all audit exceptions, deferrals, and/or disallowances.

1. (D) All costs reported must be in accordance with the following:

   1. 1. Allowable and unallowable costs.

      1. A. Reconciled cost reimbursement is

available only for allowable costs incurred for GEMT services rendered to MHD participants based on the provider’s financial data reported on the cost report.

1. B. Computation of allowable costs

and their allocation methodology must be determined in accordance with the Centers for Medicare and Medicaid Services (CMS) Provider Reimbursement Manual (CMS Pub. 15-1), 2 CFR Part 200, and 42 CFR Part 413, except as expressly modified herein.

1. (I) Part 200 of Title 2, Code of Fed-

eral Regulations, is incorporated by reference and made a part of this rule as published by the Office of the Federal Register, 800 North Capitol Street NW, Suite 700, Washington, D.C. 20408, and available at https://dssruletracker.mo.gov/dss-proposed-rules/welcome.action, January 1, 2021. This rule does not incorporate any subsequent amendments or additions.

1. (II) Part 413 of Title 42, Code of

Federal Regulations, is incorporated by reference and made a part of this rule as published by the Office of the Federal Register, 800 North Capitol Street NW, Suite 700, Washington, D.C. 20408, and available at https://dssruletracker.mo.gov/dss-proposedrules/welcome.action, October 1, 2020. This rule does not incorporate any subsequent amendments or additions.

1. (III) The Provider Reimbursement

Manual—Part 1 (CMS Pub. 15-1) is incorporated by reference and made a part of this rule as published by the Centers for Medicare and Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244, and available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021929, September 22, 2021. A copy is available at the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109. This rule does not incorporate any subsequent amendments or additions.

1. C. Costs which are considered unal-

lowable include expenditures, such as bad debts, contributions and donations, entertainment including alcoholic beverages, fundraising costs, lobbying, legal judgments, and fines or penalties, which 2 CFR Part 200 does not permit to be charged to federal programs. If unallowable costs are not easily identifiable from allowable costs, the associated revenues received for providing the unallowable services will be offset against allowable cost. Additionally, for the purposes of Medicaid cost identification for the GEMT program, expenditures attributed to the nonemergency medical response cost objective are not costs incurred for GEMT services.

1. D. Amounts required to be paid pur-

suant to the ambulance service reimbursement allowance (AFRA) under 13 CSR 70- 3.200, excluding administrative fees and pooling fees, are allowable for GEMT services. Pooling payments received from participation in the ambulance service reimbursement allowance program shall reduce the ambulance service reimbursement allowance amount reported as allowable by the provider.

1. E. Administrative costs incurred for

reimbursing MHD for costs associated with implementing the GEMT program must be excluded from the cost report.

1. F. Eligible GEMT providers routinely

use contract billing service providers to assist with the administrative functions of billing and collecting on patient accounts. Payments 13 CSR 70-6

to contract billing service providers are an allowable administrative cost. Fee arrangements based on hourly rates, fixed amounts, percentage of collection, or other methods are all considered allowable for computing uncompensated Medicaid costs, however, all payments to contract billing service providers must not exceed fair market value; and

1. 2. Direct and Indirect Costs.

   1. A. All direct costs must be reasonable

and necessary and must be supported by documentation from which the costs incurred by the provider can be readily discerned and verified with reasonable certainty. Such documentation shall be subject to review by MHD.

1. B. Eligible GEMT providers that do

not provide fire services would not have shared costs and the cost report would reflect only EMR direct costs. Eligible GEMT providers that do not provide fire services but provide training (of non-employees) or nonemergency medical transportation services (e.g., non-emergency transportation between medical facilities or patient homes) shall include the costs of such services in their EMR direct costs, but shall offset those costs by any reimbursement received for such services up to the amount of costs for such services.

1. C. There is no universal rule for clas-

sifying certain costs as either direct cost or shared cost under every accounting system. A cost may be direct cost with respect to some specific service or cost objective, but shared cost with respect to the federal award or other final cost objective. Therefore, it is essential that each item of cost incurred for the same purpose be treated consistently in like circumstances as a direct cost or a shared cost in order to avoid possible double-charging of federal awards. For example, any cost incurred by an eligible GEMT provider which includes both costs incurred applicable to non-EMR services as well as GEMT services must in their entirety be consistently classified as direct or shared costs.

1. D. Direct costs for providing GEMT

services include only the unallocated payroll costs for the shifts in which personnel dedicate one hundred percent (100%) of their time to providing GEMT services, medical equipment and supplies, and other costs directly related to the delivery of GEMT services, such as first-line supervision, materials and supplies, professional and contracted services, capital outlay, travel, and training. These costs must be in compliance with federal Medicaid non-institutional reimbursement policy and are directly attributable to the provision of the GEMT services.

1. E. Shared costs for EMR and non-

EMR services shall be allocated based on a reasonable method in accordance with the guidelines in 2 CFR Part 200. The cost report shall allow the provider to use any reasonable method allowed in the Centers for Medicare and Medicaid Services (CMS) Provider Reimbursement Manual (CMS Pub. 15-1), 2 CFR Part 200, and 42 CFR Part 413, an example of reasonable methods include, among others:

1. (I) Square footage allocations for

capital cost;

1. (II) Depreciation cost for capital

cost; or

1. (III) Time studies for salaries and

benefits.

1. F. When providing allocation infor-

mation, statistics from the shared costs should not be included in the calculations for allocation between EMR and non-EMR services.

1. G. Pursuant to 2 CFR Part 200, indi-

rect costs are determined in accordance to one (1) of the following options:

1. (I) Eligible GEMT providers that

receive more than thirty-five million dollars ($35,000,000) in direct federal awards must either have a Cost Allocation Plan (CAP) or a cognizant agency approved indirect rate agreement in place with its federal cognizant agency to identify indirect cost. If the provider does not have a CAP or an indirect rate agreement in place with its federal cognizant agency and it would like to claim indirect cost in association with a non-institutional service, it must obtain one (1) or the other before it can claim any indirect cost;

1. (II) Eligible GEMT providers that

receive less than thirty-five million dollars ($35,000,000) of direct federal awards are required to develop and maintain an indirect rate proposal for purposes of audit. In the absence of an indirect rate proposal, providers may use methods originating from a CAP to identify its indirect cost. If the provider does not have an indirect rate proposal on file or a CAP in place and it would like to claim indirect cost in association with a non-institutional service, it must secure one (1) or the other before it can claim any indirect cost;

1. (III) Eligible GEMT providers

which receive no direct federal funding can use any of the following previously established methodologies to identify indirect cost:

1. (a) A CAP with its local govern-

ment;

1. (b) An indirect rate negotiated

with its local government; or

1. (c) Direct identification through

use of a cost report; and

1. (IV) If the GEMT provider never

established any of the above methodologies, it may do so, or it may elect to use the ten percent (10%) de minimis rate to identify its indirect cost.

AUTHORITY sections 208.201, 208.1030, and 660.017, RSMo 2016.* Original rule filed Sept. 22, 2021, effective April 30, 2022. *Original authority: 208.201, RSMo 1987, amended 2007; 208.1030, RSMo 2016; and 660.017, RSMo 1993, amended 1995.