Info from ADPH: Ambulance reimbursement
Question:  In emergency/disaster situations how does CMS define an “approved destination” for ambulance transports and would it include alternate care centers, field hospitals and other facilities set up to provide patient care in response to the emergency/disaster?
 
Answer:  CMS defines “approved destination” in the Code of Federal Regulations (CFR), 42 CFR
§ 410.40(e), Origin and Destination requirements.  Medicare can only pay for ambulance transportation when it meets the Origin and Destination Requirements and all other coverage requirements in Medicare regulations and manuals.  These requirements specify that an appropriate destination is one of the following for all beneficiaries covered under either Medicare Part A or Part B:
∙ Hospital;
∙ Critical Access Hospital (CAH);
∙ Skilled Nursing Facility (SNF);
∙ Beneficiary’s home;
∙ Dialysis facility for ESRD patient who requires dialysis.
 
Beneficiaries residing in a SNF who are receiving Part B benefits only are eligible for ambulance transport to one additional “approved destination”:  From a SNF to the nearest supplier of medically necessary services not available at the SNF where the beneficiary is a resident.  For SNF residents receiving Medicare Part A benefits, this type of ambulance service is subject to SNF consolidated billing.
 
A physician’s office is not a covered destination. However, under certain circumstances an ambulance transport may temporarily stop at a physician’s office without affecting the coverage status of the transport.
 
We do not expect an emergency/disaster to affect the availability of hospital or other facility services; however, should a facility which would normally be the nearest appropriate facility be unavailable during an emergency/disaster, Medicare may pay for transportation to another facility so long as that facility meets all Medicare requirements and is still the nearest facility that is available and equipped to provide the needed care for the illness or injury involved.  
 
42 CFR 410.40 allows Medicare to pay for an ambulance transport (provided that transportation by any other means is contraindicated by the patient’s condition and all other Medicare requirements are met) from any point of origin to the nearest hospital, CAH, or SNF that is capable of furnishing the required level and type of care for the beneficiary’s illness or injury. The hospital or CAH must have available the type of physician or physician specialist needed to treat the beneficiary’s condition.
 
The waiver authority under § 1135 does not authorize a waiver of the ambulance payment and coverage requirements, such as the approved destination requirements described above.  However, Medicare payment for an ambulance transport to an alternative care site may be available if the alternative care site is determined to be part of an institutional provider (hospital, CAH or SNF) that is an approved destination for an ambulance transport under 42 CFR § 410.40 (whether under a § 1135 waiver or existing rules).  If the alternative care site is granted approval by the State Agency to be part of an institutional provider (hospital, CAH or SNF) that is an approved destination under 42 CFR § 410.40 for an ambulance transport, Medicare will pay for the transport on the same basis as it would to any other approved destination in the absence an 1135 waiver.  CMS has developed the Hospital Alternate Care Site Fact Sheet, which provides detailed information regarding permitted actions with or without section 1135 waiver authorization.  This Fact Sheet can be accessed at:  http://www.cms.hhs.gov/H1N1/Downloads/AlternativeCareSiteFactSheet.pdf
 
 
Kathy Robinson, RN, EMT-P
Program Manager
National Association of State EMS Officials
201 Park Washington Court
Falls Church, VA  22046
Voicemail:  703.538.1799 x1708
Email: robinson@nasemso.org