Emergency Triage, Treat, and Transport (ET3) - Frequently Asked Questions

For more information about this model, please visit the ET3 Model landing page.

Contents

General Questions

  1. What is the ET3 Model? What are the goals of this Model?

    Emergency Triage, Treat, and Transport (ET3) is a voluntary, five-year payment model that will provide greater flexibility to ambulance care teams to address emergency health care needs of Medicare Fee-for-Service beneficiaries following a 911 call. Under the ET3 model, the Centers for Medicare & Medicaid Services (CMS) will pay participating ambulance suppliers and providers to 1) transport an individual to a hospital emergency department (ED) or other destination covered under the regulations, 2) transport to an alternative destination (such as a primary care doctor’s office or an urgent care clinic), or 3) provide treatment in place with a qualified health care practitioner, either on the scene or connected using telehealth. The model will allow beneficiaries to access the most appropriate emergency services at the right time and place. The model will also encourage local governments, their designees, or other entities that operate or have authority over one or more 911 dispatches to promote successful model implementation by establishing a medical triage line for low-acuity 911 calls. As a result, the ET3 model aims to improve quality and lower costs by reducing avoidable transports to the ED and unnecessary hospitalizations following those transports.

     

  2. Where can I find additional information about the ET3 Model, including the informational webinar slides and white paper?

    Informational webinar slides and the Department of Health & Human Services/Department of Transportation white paper: Innovation Opportunities for EMS, are posted on the ET3 Model web page.

      

Participant/Awardee Eligibility Questions

  1. Where is the ET3 Model available?

    ET3 is a voluntary model with a national solicitation. Participant and awardee selection will be based on regional clusters and demonstrated ability to achieve ET3 Model goals. More information on eligibility will be provided in the Request for Applications (RFA) and Notice of Funding Opportunity (NOFO) released in the coming months.

     

  2. Who is eligible to respond to the Request for Applications (RFA) to be considered for selection as a Model participant? Who is eligible to respond to the Notice of Funding Opportunity (NOFO) to be considered for selection as a Model awardee?

    Any Medicare-enrolled ambulance suppliers or hospital-based ambulance provider that meets the requirements set forth in the RFA is eligible to apply to become a participant in the Model. Local governments, their designees, or other entities that operate or have authority over a 911 dispatch in a region where at least one ambulance supplier or hospital-based ambulance provider is participating in the ET3 Model, and meet the requirements set forth in the NOFO, are eligible to apply for selection as a Model awardee.

     

  3. What are the transport volume requirements to apply to the ET3 Model? Is there any advantage for applicants who transport a higher volume of Medicare Fee for Service (FFS) beneficiaries?

    To apply to the ET3 Model, an applicant must propose to implement the model in a state in which at least 15,000 Medicare FFS emergency ambulance transports occurred in 2017. An applicant that proposes to implement the model in a region that includes one or more counties in which at least 7,500 Medicare FFS emergency ambulance transports occurred in 2017, will receive preference during the application review. Each applicant should review Appendix D: Number of Medicare FFS Emergency Transport Claims by State and County Equivalent Entity 2017 (PDF) to determine whether its proposed model region is in a state that meets the 15,000 state-level transport requirement and/or includes a county that meets the 7,500 county-level optional preference.

     

  4. What is the difference between an awardee and a participant?

    The ET3 Model offers two distinct opportunities for participants and awardees:

    • Participants will be Medicare-enrolled ambulance suppliers and hospital-based ambulance providers selected based on their responses to the anticipated Request for Applications (RFA). Each participant will enter into a participation agreement with CMS in order to be eligible to be paid for implementing the transport to alternative destinations and treatment in place (if applicable) interventions, provided all ET3 Model requirements are met.
    • Awardees will be, local governments, their designees, or other entities that are operating or have control over a 911 dispatch, selected based on their responses to the anticipated Notice of Funding Opportunity (NOFO) announcement. Each awardee will receive funding via a cooperative agreement with CMS to establish a medical triage line or expand upon an existing line.

     

  5. Is participation by ambulance suppliers and providers dependent on a cooperative agreement being awarded to the 911 entity in their geographic region?

    No, participation by ambulance suppliers and providers is not dependent on a cooperative agreement being awarded to the 911 entity in their geographic region. All ambulance suppliers and providers who meet the requirements listed in the RFA may submit an application and will be considered for participation. Conversely, an applicant to the NOFO must operate or have authority over a 911 dispatch in a region where at least one ambulance supplier or hospital-based ambulance provider is participating in the ET3 Model.

     

  6. Must a participant or awardee implement all three components of the program (transport to alternative destinations, treatment in place, medical triage line), or could a participant or awardee just transport to an alternative destination, for example?

    No, neither participants nor awardees are required to implement all three components of the model. Applicants responding to the RFA will be required to propose an intervention design for alternative destination transport at a minimum. Applicants able to demonstrate capacity to implement treatment in place—either via telehealth or in person or both—will have the opportunity to earn additional points during application review. Awardees for the medical triage intervention funding will be solicited separately through the NOFO. Entities are eligible to respond to the NOFO to establish or expand a medical triage line if they propose to implement the medical triage line in a geographic area where at least one Model participant is implementing alternative destination transport and/or treatment in place interventions.

    An entity is not precluded from responding to both RFA and the NOFO if it is eligible for both solicitations independently. In most cases, CMS does not anticipate that eligible applicants for the RFA (Medicare-enrolled ambulance suppliers and hospital-based ambulance providers) and eligible applicants for the NOFO (local governments, their designees, or other entities that are operating or have control over a 911 dispatch will overlap.

     

  7. What is the role of the state and any restrictions that may currently exist in state regulations or statutes that limit EMS transport to Emergency Departments (EDs) only?

    CMS recognizes the diverse legal landscape governing emergency medical services, including differing standards across and within states. Each applicant will be required to provide a plan for successfully implementing the proposed intervention design within the context of applicable laws, regulations, and policies (including policies of individual applicants, alternative destination sites, or qualified health care practitioners) in the proposed geographic service area.

     

  8. Will rural/frontier areas without current medical dispatch and/or telehealth be eligible to participate?

    Yes. Interested applicants that meet eligibility requirements may submit an application to participate in the ET3 Model. Applicants will be required to propose an intervention design for alternative destination transport at a minimum, although applicants able to demonstrate capacity to implement treatment in place—either via telehealth, in person, or both—have the opportunity to earn additional points.

     

  9. If the local 911 center is not able to provide a medical triage line, can the ambulance suppliers and providers in the region still respond to the RFA?

    Yes. Eligible ambulance suppliers and providers may apply to participate regardless of whether their local 911 dispatch center implements a medical triage line.

     

  10. Will an ambulance supplier or provider be eligible if they respond to a 911 call in a licensed EMS response non-transporting vehicle?

    No. The ET3 Model is adopting the Medicare regulatory requirements that apply to vehicles used as ambulances, found at 42 C.F.R. 410.41(a). A vehicle used as an ambulance must meet these requirements in order to be eligible for payment under Medicare rules and in the ET3 Model:

    1. Be specially designed to respond to medical emergencies or provide acute medical care to transport the sick and injured and comply with all State and local laws governing an emergency transportation vehicle;
    2. Be equipped with emergency warning lights and sirens, as required by State or local laws;
    3. Be equipped with telecommunications equipment as required by State or local law to include, at a minimum, one two-way voice radio or wireless telephone; and
    4. Be equipped with a stretcher, linens, emergency medical supplies, oxygen equipment, and other lifesaving emergency medical equipment as required by State or local laws.

     

  11. What certification or training standards will be required for personnel answering the medical triage lines?

    Certification and training standards for personnel answering the medical triage lines will be detailed in the anticipated Notice of Funding Opportunity (NOFO) and subsequent Model documents.

      

Beneficiary Eligibility

  1. Will patients enrolled in a Medicare Advantage plan, private insurance, and/or Medicaid qualify for treatment under the ET3 Model?

    Model payments for alternative destination transport and treatment in place interventions will be made available for Medicare Fee-for-Service beneficiaries only. Applicants responding to the RFA will be required to identify whether they plan to implement the Model in Medicare Fee-for-Service only; or plan to align the Model interventions across additional payers, such as Medicare Advantage plans, Medicaid plans, or commercial payers. The Innovation Center encourages multi-payer alignment as a strategy for success in the ET3 Model, although it is not required to be eligible to respond to the RFA.

    Because the medical triage line must be incorporated into an awardee’s 911 dispatch system, callers will be able to access the medical triage intervention in areas where the cooperative agreement is awarded regardless of their coverage status.

     

  2. How should an ambulance supplier or provider verify that a patient has Medicare FFS coverage and is therefore eligible for transport to an alternative destination or treatment in place?

    Each participant will be responsible for establishing a process to verify that a patient is eligible for an ET3 Model intervention. However, if all payers in a particular region are independently implementing alternative destination and treatment in place interventions, it may be less critical to determine the payer at the point of intervention. Model participants are encouraged to take a multi-payer approach. It is important to note that CMS will not pay for services associated with Model interventions that are furnished to patients who are not Medicare Fee-for-Service beneficiaries. 

Application and Award

  1. What is an RFA? When will the ET3 RFA be released, and how can I find it?

    The Request for Applications (RFA) is the mechanism through which an interested and eligible ambulance supplier or hospital-based ambulance provider may apply to participate in the ET3 Model in order to implement transport to alternative destinations and/or treatment in place interventions. A link to the RFA will be posted on the ET3 Model web page in summer 2019. To ask questions and be added to our distribution list, email us at ET3Model@cms.hhs.gov.

     

  2. What is a NOFO? When will the ET3 Model NOFO be released, and how can I find it?

    The Notice of Funding Opportunity (NOFO) is the mechanism through which an interested and eligible local government, its designee, or another entity that operates or has control over a 911 dispatch in a region where at least one ambulance supplier or hospital-based ambulance provider is participating in the ET3 Model can submit an application for cooperative agreement funding to establish or expand a medical triage line. A link to the NOFO for funding of a medical triage line will be posted on the ET3 Model web page in fall 2019 and applicants must submit responses via Grants.gov. Please regularly check the ET3 Model website for NOFO announcements and current information about the Model. To ask questions and be added to our distribution list, email us at ET3Model@cms.hhs.gov.

     

  3. Who should submit an application for this Model?

    There are two distinct opportunities to apply for support under the ET3 Model:

    • The first opportunity is for Medicare-enrolled ambulance suppliers and providers to enter into participation agreements with CMS and receive payments for emergency ambulance services that are not currently covered under the Medicare Fee-for-Service ambulance services benefit: transport to alternative destinations not currently covered by Medicare, and treatment in place, where appropriate, by a qualified health care practitioner either at the scene of a 911 emergency response or via telehealth. Medicare-enrolled ambulance suppliers and hospital-based ambulance providers are eligible to respond to the RFA.
    • The other opportunity is for local governments, their designees, or other entities that operate or have control over a 911 dispatch to enter into cooperative agreements with CMS to establish or expand a medical triage line. These entities are only eligible to respond to the NOFO if they operate in a geographic area where at least one ambulance supplier or hospital-based ambulance provider is participating in the ET3 Model.

     

  4. If I am both an ambulance supplier or hospital-based ambulance provider and a local government with authority over 911 call centers, should I respond to both the RFA and the NOFO?

    If an entity meets eligibility requirements for both participation through the RFA and award under the NOFO, it would be independently eligible to respond to both opportunities.

     

  5. If multiple ambulance suppliers and providers serve the same dispatch area of a 911 call center, would each need to apply to participate separately?

    Yes. Each individual ambulance supplier or hospital-based ambulance provider should apply separately. It is possible that multiple participants could be selected to operate within the same region.

     

  6. How will CMS select participants?

    Selection criteria is detailed in the RFA. CMMI anticipates that criteria may include demonstrated capacity to implement ET3 Model interventions, compliance with program integrity and compliance standards, and operations in a region with a minimum volume of unscheduled Medicare Fee-for-Service emergency ambulance transports.

     

  7. What are the transport volume requirements to apply to the ET3 Model? Is there any advantage for applicants who transport a higher volume of Medicare Fee for Service (FFS) beneficiaries?

    To apply to the ET3 Model, an applicant must propose to implement the model in a state in which at least 15,000 Medicare FFS emergency ambulance transports occurred in 2017. An applicant that proposes to implement the model in a region that includes one or more counties in which at least 7,500 Medicare FFS emergency ambulance transports occurred in 2017, will receive preference during the application review. Each applicant should review Appendix D: Number of Medicare FFS Emergency Transport Claims by State and County, 2017 (PDF) to determine whether its proposed model region is in a state that meets the 15,000 state-level transport requirement and/or includes a county that meets the 7,500 county-level optional preference.

     

  8. How many participants and awardees are anticipated? Will area type variation be considered (e.g., rural, suburban, urban)?

    The RFA opportunity for ambulance suppliers and providers does not have a set cap in terms of the number of participants who may be approved. The NOFO for local governments and their designees to develop a medical triage line or expand an existing medical triage line will be limited to 40 separate awards.

     

  9. Will there be any Medicare waivers offered to ET3 participants?

    CMS expects to make available conditional waivers of certain requirements of the Medicare program as authorized under section 1115A9d)(1) of the Social Security Act that may include, without limitation, requirements related to ambulance services, telehealth, and payments for qualified health care practitioners, as may be necessary solely for purposes of testing the ET3 Model. Additional details about payment and policy waivers would be available in the Request for Applications. At this time, CMS does not intend to make available fraud and abuse waivers for the ET3 Model.

     

Qualified Health Care Practitioners

  1. Who qualifies as a “qualified health care practitioner,” and does a licensed paramedic ever qualify as a qualified health care practitioner in the ET3 Model?

    A qualified health care practitioner is a Medicare-enrolled health care practitioner who meets state, local, and professional requirements to render particular health care services to beneficiaries and will partner individually or through their group practice with a participant to render such services through the ET3 Model. These health care practitioners will be vetted by CMS to assure quality of care for beneficiaries. Unless also licensed as a practitioner, paramedics and Emergency Medical Technicians (EMTs) are not eligible to enroll in Medicare at the individual practitioner level, and therefore do not meet the standard for a qualified health care practitioner under this Model.

     

  2. Will qualified health care practitioners be required to sign any participation or cooperative agreements with CMS?

    Qualified health care practitioners (individually or through their group practice) must enter into an agreement with a participant to implement the Model interventions. Each qualified health care practitioner or alternative destination site will be vetted by CMS to assure quality of care for beneficiaries. However, these practitioners will not be Model participants and will not sign a participation agreement or other agreement with CMS as part of the ET3 Model.

     

  3. Will an ET3 Model participant be required to consult with qualified health care practitioners to transport a beneficiary to an alternative destination, or will these practitioners only be required when treating in place?

    No. Transport to an alternative destination does not require an ET3 Model participant to consult with a qualified health care practitioner. The decision to offer a beneficiary the option to be transported to an alternative destination will be driven by the participant’s specific clinical protocols that have been approved by the participant’s Medical Director. These protocols will be governed by state and local requirements as well as Medicare medical necessity requirements. Therefore, transport to an alternative destination may not require an ET3 participant to consult with a medical professional. A qualified health care practitioner is always required for treatment in place without transport. 

     

Alternative Destinations

  1. Which types of health care provider sites qualify as alternative destinations?

    An alternative destination site must have sufficient Medicare-enrolled physicians or other practitioners to meet the needs of Medicare Fee-for-Service beneficiaries who require services through the Model. Additional eligibility requirements for alternative destinations can be found in the RFA. Examples of alternative destinations may include federally qualified health centers, physician offices, behavioral health centers, and urgent care centers.

     

  2. Does every alternative destination need to be available 24/7?

    No. Each participant must demonstrate that at least one of its non-ED options (treatment in place or alternative destinations) is available at all times. If a model participant is implementing both the alternative destination intervention and a treatment in place intervention, at least one of the two options must be available at all times. It is not required that both interventions be available at all times and participants can combine interventions to meet this requirement. For example, the model participant may have at least one alternative destination available between 6 am and 8pm and at least one onsite or telehealth qualified health provider available for treatment in place between the hours of 8pm and 6 am.

    If a model participant implements only the Alternative Destination intervention, the participant must have at least one alternative destination available at all times. These locations can be combined to meet the 24/7 requirement so that not one location needs to be open 24/7.

     

  3. Will ambulance crews be able to transport patients to any alternative destination, or does the ET3 Model participant need to have an agreement in place with designated alternatives?

    A participant must enter into an agreement with an alternative destination site to transport patients to the site to ensure the site is aware of the types of interventions and types of patients that may be received through the ET3 Model and is willing to accept these patients arriving via ambulance.

     

  4. Will the Advanced Life Support (ALS) Assessment policy be in effect at all for alternative destinations?

    The ET3 Model will not alter requirements related to ALS assessment. Information regarding ALS assessment can be found in 42 C.F.R. 414.605 and the the Medicare Benefit Policy Manual, Chapter 10, Ambulance Services, Section 30.1.1, Ground Ambulance Services:

    An ALS assessment is an assessment performed by an ALS crew as part of an emergency response that was necessary because the patient's reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment. An ALS assessment does not necessarily result in a determination that the patient requires an ALS level of service. In the case of an appropriately dispatched ALS Emergency service, if the ALS crew completes an ALS assessment, the services provided by the ambulance transportation service provider or supplier shall be covered at the ALS emergency level, regardless of whether the patient required ALS intervention services during the transport, provided that ambulance transportation itself was medically reasonable and necessary, and all other coverage requirements are met.

     

Telehealth

  1. How is CMS defining “telehealth” in the ET3 Model? What services are required?

    Medicare Part B only pays for services included on the list of covered telehealth services when furnished by an interactive telecommunications system. An interactive telecommunications system means multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner. Telephone, facsimile machines, and electronic mail systems do not meet the definition of interactive telecommunications systems. The complete list of covered telehealth services can be found on the CMS website. CMS expects to make waivers of the telehealth geographic and location rules as necessary to implement the ET3 model, including waivers that will allow Participants to facilitate telehealth at the scene of a 911 response. Additional information about Medicare waivers will be included in the ET3 RFA.

     

  2. What are the requirements for the telehealth provider? Will the use of telehealth be subject to all current requirements such as rural location?

    CMS will release additional information about telehealth providers and specific requirements and rules related to the use of telehealth in the RFA and subsequent model documents.

     

  3. Do qualified health care practitioners need to be onsite during the ambulance transport or may they be connected through a telehealth visit? Will there be any requirement that the qualified practitioner arrive with or be part of the EMS crew or could they be a second-tier response to assist the EMS crew with on-scene treatment?

    Qualified health care practitioners do not need to be onsite during the ambulance transport. Qualified health care practitioners are required for a treatment in place scenario—either in person or via telehealth.

     

  4. Will ambulance services have to supply their own telehealth provider, or will there be a regional system set up?

    Participants must develop partnerships with qualified health care practitioners who agree to render services via telehealth. CMS will not create a centralized telehealth service for ET3 Model participants.

     

  5. Who pays for telehealth services provided?

     Medicare will reimburse qualified health care practitioners for medically necessary services covered by Medicare and rendered via telehealth under the ET3 Model.

     

  6. If an ambulance supplier or provider treats a patient without using telehealth, are those calls eligible for payment under the ET3 Model?

    Under the ET3 Model, a qualified health care practitioner must be involved in a treatment in place scenario—either in person or via telehealth—to be eligible for payment.

     

  7. Will the qualified health care practitioner still receive payment if the patient requires transport to an alternative destination or the Emergency Department?

    An ET3 Model participant may offer treatment in place when clinically appropriate as an alternative to transport. If a beneficiary requires transport to an alternative destination or the Emergency Department, it is not appropriate to offer that beneficiary treatment in place. CMS recognizes that an individual’s condition could change substantially over a short time; or, a beneficiary could experience multiple unrelated events in a single day. Therefore, ET3 Model participants may render multiple services in one day, provided that each service is medically necessary and meets all other Medicare requirements. CMS will closely monitor these occurrences to ensure that they do not signify under-triage problems or other inappropriate patterns of service.

     

Billing and Reimbursement

  1. Is there any initial funding to assist in the start-up costs such as staffing/equipment/data systems/training/telehealth?

    Model participants who are selected via the RFA will not receive additional funding beyond model payments for eligible services. NOFO awardees—including local governments, their designees, or other entities that are operating a 911 dispatch—may receive funding via cooperative agreements with CMS to establish a medical triage line or expand upon an existing line. The NOFO will provide additional guidance regarding appropriate use of cooperative agreement funding.

     

  2. How does the billing and payment process work for the following components of the ET3 Model treatment in place, and transport to alternative destinations? Should ambulance suppliers or providers, qualified health care practitioners, telehealth providers, and/or alternative destination providers bill Medicare separately?

    For each of the ET3 Model components (treatment in place and transport to alternative destinations) participants and non-participant partners will bill Medicare using the same billing procedures they would normally use. Ambulance suppliers and providers will bill an amount equivalent to either the ambulance fee schedule Basic Life Support (BLS) base emergency rate or the Advanced Life Support, Level 1 (ALS1) base emergency rate for emergency ground ambulance services for treatment in place and transport to an alternative destination. Payment for transport to an alternative destination will include the same mileage rates and adjustments applicable to current Medicare covered transports to the Emergency Department. (See FAQ #7 and #12 in this section for more information about the ET3 Model ALS Assessment policy.)

    Qualified health care practitioners and telehealth practitioners will bill Medicare Part B as normal, based on services provided.

    No earlier than in year 3 of the Model, participants who meet the criteria for a performance-based payment may be eligible for an upward adjustment to payments associated with Model interventions. More information on this topic will be released in the coming months.

     

  3. Which billing codes should be used? Will there be modifiers to be paid for services under the ET3 Model?

    Specific billing information for services provided under the ET3 Model will be made available in the RFA and subsequent model documents.

     

  4. If a beneficiary is deemed eligible for treatment in place or transport to an alternative destination but insists on being taken to the Emergency Department, is the emergency transportation subject to claim denial as it will not be medically necessary?

    One goal of the ET3 Model is to increase beneficiary choice by presenting options to the beneficiary when appropriate. Ultimately, if the beneficiary declines any options offered and wants to be treated in an Emergency Department, they must be taken there. Medical necessity requirements will apply for all Medicare services, including ambulance services and covered services provided at an emergency department.

     

  5. Will the medical necessity criteria change for alternative destinations, or will CMS release new medical necessity guidelines?

    The ET3 Model will apply Medicare’s medical necessity requirements for Part B ambulance services to transportation by ambulance to an alternative destination under the ET3 Model. Ambulance transportation is covered under Medicare Part B only to the extent that other means of transportation are contraindicated by the beneficiary’s medical condition. The beneficiary's condition must require both the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary. In any case in which some means of transportation other than an ambulance could be used without endangering the individual's health, no payment may be made for ambulance services. The Innovation Center will work closely with all Medicare Administrative Contractors (MACs) to provide education and guidance related to the ET3 Model to ensure that claims for Model interventions are processed uniformly and appropriately.

     

  6. What are the medical necessity criteria for treatment in place?

    The ET3 Model maintains Medicare medical necessity requirements for covered services rendered to beneficiaries. All such services must be medically required.

     

  7. If an individual is treated on site, is there any reimbursement to the ambulance supplier or provider?

    In the case of a treatment in place intervention, where a qualified health care practitioner is involved and has rendered services, an ambulance supplier or provider would be paid an amount equivalent to the emergency BLS or emergency ALS1 (ALS1-E) ground ambulance base rate. In order to bill at the ALS1 emergency base rate, a participant must provide medically necessary supplies and services including the provision of an an ALS assessment by ALS personnel that was necessary because the patient's reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment or at least one ALS intervention.

    The qualified health care practitioner administering the treatment may bill for the Part B services he/she renders, whether services were furnished as telehealth services or in-person with the patient.

     

  8. Will CMS amend the policy regarding two ambulance services in one day? Meaning the ambulance transports the patient to a clinic who later determines the patient must go to an Emergency Department and the patient is then transported by ambulance to the Emergency Department.

    Medicare does not bar payment for multiple ambulance transports for the same patient on the same day, provided each transport is medically necessary and meets all other Medicare requirements. ET3 participants should consult their Medicare Administrative Contractors (MACs) to ensure compliance with billing requirements in their region. All ET3 Participants will be monitored to ensure that services are being rendered and billed appropriately.

     

  9. If a patient elects to go to an alternative destination, will the ambulance service be reimbursed for transport back to their residence?

    The ET3 Model is aimed at emergency ambulance transport only and CMS would not reimburse a participant for non-emergency transport back to a beneficiary’s home.

     

  10. Are scheduled appointments covered, including prearranged Community Paramedic home visits?

    No. The ET3 Model does not cover any scheduled appointments. The ET3 Model is aimed at reducing unnecessary emergency ambulance transports to hospital Emergency Departments or other high-acuity destinations when beneficiaries could be effectively treated in other settings.

     

  11. Will beneficiaries be responsible for a cost-sharing for transport to an alternative destination or treatment in place?

    All services will be subject to existing beneficiary cost-sharing rules. The ET3 Model does not waive or alter beneficiary cost-sharing requirements for Medicare covered services. Some Medicare Fee-for-Service beneficiaries have supplemental insurance which may cover beneficiary cost-sharing for Medicare-covered services, including those services rendered through the ET3 Model.

     

  12. In what circumstances would an ambulance supplier or provider be reimbursed the BLS rate versus the ALS1 rate?

    A participant that renders ambulance transport to an alternative destination or facilitates treatment in place will be paid an amount equivalent to the BLS-E or ALS1-E base rate based on current Medicare rules governing the levels of ambulance services. In order to bill at the ALS1-E base rate, a Participant must provide medically necessary supplies and services including the provision of an ALS assessment by ALS personnel that was necessary because the patient's reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment or at least one ALS intervention.

    If the patient elects not to take advantage of the ET3 Model intervention and is transported to the Emergency Department, participants will be paid based on the Ambulance Fee Schedule.

     

Partnerships and Stakeholder Engagement

  1. Are ET3 Model participants and awardees responsible for identifying and forming agreements with third parties to implement model interventions?

    Yes. Model participants must partner with Non-Participant Partners to implement the treatment in place and/or transport to alternative destination site interventions. ET3 Model participants will be responsible for identifying potential partners and entering into agreements with them.

    Model awardees who receive funding to implement the medical triage line will also be required to engage partners to meet the needs of triage line callers. Additional details about these partnerships will be released in the anticipated Notice of Funding Opportunity. Participants may form partnerships with regional dispatch centers that have an established medical triage line but are not required to form these partnerships to participate in the ET3 Model.

    Applicants to the RFA are required to provide a plan for successfully implementing the proposed intervention design within the context of relevant emergency medical services within their geographic area, including necessary partnerships. CMS does not anticipate providing agreement templates for these independent arrangements.

    Clinical protocols must be developed and approved by the ambulance supplier or provider’s medical director, based on the intervention design proposed by the participant. All protocols must be compliant with local and state regulations. Therefore, CMS will not provide protocols to participants.

    CMS plans to release more information on how to engage partners in the coming months on the ET3 Model web page.

     

  2. Can ambulance suppliers and providers partner with Non-Emergency Medical Transportation (NEMT) like Uber/Lyft/taxi vouchers for non-emergency transport?

    The ET3 Model is aimed at emergency ambulance transport only. ET3 will not pay for NEMT such as Uber, Lyft, or taxi vouchers for non-emergency transport.

     

  3. Will local government cooperative agreement awardees overseeing a 911 center be required to establish an agreement with each participant ambulance supplier or provider?

    Additional information regarding partnership requirements will be made available in the RFA, NOFO, and subsequent model documents.

     

  4. Can a county government that manages one or more 911 centers contract with an organization that provides an existing medical triage line for triage of low-level 911 calls, a national medical triage line, or private ambulance supplier or provider?

    Additional information regarding allowable partnerships will be included in the RFA, NOFO, and subsequent model documents. These will be released in the coming months on the ET3 Model web page.

     

Monitoring and Evaluation

  1. What performance-based payments are under consideration in the ET3 Model?

    No earlier than in year three of the Model, participants who meet the criteria for a performance-based payment may be eligible for an upward adjustment to payments associated with Model interventions. Participants are not subject to downside risk under the Model. More information on this topic will be released in the coming months.

     

  2. What quality metrics and associated documentation, monitoring and reporting are being considered? Will any data be made available to participants?

    Information regarding quality metrics, required monitoring and reporting, and data available to ET3 Model participants will be available in the RFA and subsequent model documents. To ask questions and be added to our distribution list, email us at ET3Model@cms.hhs.gov.

     

  3. Is CMS going to provide a database to collect quality metrics?

    Details regarding quality metrics collection will be available in the RFA and subsequent model documents.

     

For more information about this model, please visit the ET3 Model web page.