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

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

The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing requirements under the law.

Contents

Model Overview and General Questions

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

The Emergency Triage, Treat, and Transport (ET3) Model 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 9-1-1 call. The goals of the Model are to provide person-centered care, increase efficiency in the EMS system, and encourage appropriate utilization of emergency medical services.

There are two components to the ET3 Model. First, CMS will test two new ambulance payments, while continuing to pay for emergency transport of a Medicare beneficiary to a hospital Emergency Department (ED) or other destination covered under current Medicare requirements. Under the ET3 Model, Medicare will pay Model Participants, who are Medicare-enrolled ambulance suppliers and hospital-owned ambulance providers to:

  • Transport a beneficiary to an Alternative Destination Partner such as a primary care doctor’s office or an urgent care clinic (Transport to an Alternative Destination Partner), or
  • Initiate and facilitate beneficiary receipt of a medically necessary covered service by a Qualified Health Care Partner or Downstream Practitioner at the scene of a 9-1-1 response, either in-person on the scene or via telehealth (Treatment in Place).

Second, cooperative agreements will be awarded to fund the establishment or expansion of a medical triage line integrated with the Public Service Answering Point (PSAP) in geographic regions where ambulance suppliers and providers have been selected to participate in the ET3 Model. This second component of the Model will be issued as a Notice of Funding Opportunity (NOFO) for state and local governments, their designees, or other entities that operate or have oversight over a Public Safety Answering Point (PSAP) that are located in an eligible geographic region. These two components of the Model are designed to work synergistically to reduce avoidable transports to the ED and unnecessary hospitalizations following those transports.

2. What is the difference between a Model Participant and a Model Recipient?

Model Participants are Medicare-enrolled ambulance suppliers and hospital-based ambulance providers selected based on their responses to the ET3 Request for Applications (RFA) that enter into a participation agreement with CMS. Model Participants are eligible to be paid for implementing the Transport to an Alternative Destination Partner and Treatment in Place interventions, provided all ET3 Model requirements are met.

Model Recipients will be selected in response to the ET3 NOFO and will be state and local governments, their designees, or other entities that operate or have authority over a PSAP in a region where Model Participants are participating in the Model. Each Model Recipient will receive funding via a cooperative agreement with CMS to establish or expand upon an existing medical triage line. 

3. Who will be eligible to respond to the Notice of Funding Opportunity (NOFO) to be considered for selection as a Model Recipient?

Eligible NOFO applicants include state and local governments, their designees, or other entities that operate or have authority over a Public Safety Answering Point in a region where at least one ambulance supplier or hospital-based ambulance provider is participating in the ET3 Model and also meet the requirements set forth in the NOFO.

4. If I was eligible to apply to the RFA as an ambulance supplier or hospital-based ambulance provider, can I apply to the NOFO if I am also a local government with authority over Public Safety Answering Point?

Yes, if an entity met the eligibility requirements to apply to the RFA, it could also apply to the NOFO if it independently meets the eligibility requirements to apply to the NOFO.

5. How many applicants that responded to the RFA were selected to participate in the Model? What types of geographical areas and what types of ambulance providers and suppliers were selected?

205 applicants were selected to participate in the Model as Model Participants from 36 states and the District of Columbia. Selected applicants are from urban, suburban, and rural areas of the country and are representative of a variety of organization types including government-owned, fire-based, private non-profit, private for-profit, and hospital-based.

6. Will there be a limit on the number of Recipients who receive cooperative agreement funding?

Through a competitive process, CMS will award up to 40 cooperative agreements to eligible NOFO applicants.

7. Must a Model Participant implement both the Transport to an Alternative Destination and Treatment in Place intervention?

No, Model Participants are not required to implement both the Transport to an Alternative Destination and the Treatment in Place interventions. All Model Participants are required to implement the Transport to an Alternative Destination intervention by Performance Year 2 of the Model; implementation of the Treatment in Place intervention is optional. Please also note that CMS issued an Interim Final Rule with Comment Period (IFC) (CMS-1744-IFC) that provides temporary regulatory waivers and new rules to equip the American healthcare system with maximum flexibility to respond to the COVID-19 pandemic. The IFC and all of CMS’s Coronavirus Waivers & Flexibilities can be found here.

This IFC includes temporarily expanding the list of allowable destinations for ground ambulance transports during the COVID-19 PHE to include any destination that is equipped to treat the condition of the patient in a manner consistent with any applicable state or local Emergency Medical Services (EMS) protocol that governs the destination location. These destinations may include, but are not limited to: any location that is an alternative site determined to be part of a hospital, critical access hospital (CAH) or skilled nursing facility (SNF), community mental health centers, federally qualified health centers (FQHCs), rural health clinics (RHCs), physician’s offices, urgent care facilities, ambulatory surgical centers (ASCs), any location furnishing dialysis services outside of the ESRD facility when an ESRD facility is not available, and the beneficiary’s home. Home may be an appropriate destination for a COVID-19 patient who is discharged from the hospital to home to be under quarantine. There must be a medically necessary ground ambulance transport of a patient in order for an ambulance service to be covered.

Model Participants will be able to continue to access these PHE flexibilities while participating in the Model, for as long as they are available, and bill Medicare as usual. These transports will not be considered ET3 Model Interventions. The flexibilities offered specifically to ambulances during the Public Health Emergency (PHE) can be found at this link: Covid Ambulances List (PDF). For a complete and updated list of CMS actions, and other information specific to CMS, please visit the Current Emergencies website.

Once the PHE ends, Model Participants will be required to implement the ET3 Transport to an Alternative Destination intervention consistent with ET3 Model requirements, under which the Model Participant may transport only to ET3 Alternative Destinations.

8. How does the Emergency Medical Treatment and Active Labor Act (EMTALA) interact with the ET3 Model?

The ET3 Model does not waive or alter EMTALA requirements, which provide critical protections for individuals, including Medicare beneficiaries. The Center for Medicare and Medicaid Innovation (Innovation Center) encourages selected applicants to consult with their own legal counsel to determine whether they are subject to EMTALA and whether the applicant’s plan for successfully implementing the Model complies with all relevant emergency medical services policies, regulations, and laws in the region in which they operate.

9. If an ET3 Model Participant provides an ET3 Model Intervention to a patient who is assigned to a Medicare Shared Savings Program Accountable Care Organization (ACO) or attributed to a participant in the Bundled Payments for Care Improvement Advanced (BPCI Advanced) Model, will the costs incurred for medical services rendered during that encounter be counted as expenditures for the ACO or the BPCI Advanced Model Participant?

Yes. Payments made under the ET3 Model to ET3 Model Participants are for services furnished to fee-for-service (FFS) Medicare beneficiaries and are paid through the fee-for service claims system. Therefore, any care rendered as part of the ET3 Model for patients assigned to participants in a shared risk initiative, such as an ACO in the Medicare Shared Savings Program or a participant in the BPCI Advanced Model, will be included as expenditures during the applicable benchmark and performance years.

10. What is the difference between the ET3 Model and the Medicare Prior Authorization Model for Repetitive, Scheduled Non Emergent Ambulance Transport (RSNAT)?

The ET3 Model tests two new Medicare payments following a 9-1-1 call: for Transport to an Alternative Destination Partner and Treatment in Place. The RSNAT Model tests prior-authorization for scheduled and repetitive transport. A repetitive ambulance service is defined as medically necessary ambulance transportation that is furnished in 3 or more round trips during a 10-day period; or at least one round trip per week for at least 3 weeks. Repetitive ambulance services are often needed by beneficiaries receiving dialysis or cancer treatment. More information can be found on the RSNAT Model web page. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Prior-Authorization-Initiatives/Prior-Authorization-of-Repetitive-Scheduled-Non-Emergent-Ambulance-Transport-

11. Where can I find additional information about the ET3 Model?

Additional information can be found on the ET3 Model web page https://innovation.cms.gov/innovation-models/et3.  It includes an overview of the Model, current Model status, informational PowerPoint slides from past webinars, and other information.

ET3 Model Delay Questions

1. What is the delayed ET3 Model start date?

To support the community of organizations that are responding to the public health emergency stemming from the Novel Coronavirus Disease (COVID-19), CMS decided to delay the start of the ET3 Model from May 1, 2020 until January 1, 2021 as CMS and ET3 Model selected applicants work to respond to needs due to COVID-19. The new date was communicated directly to selected applicants and through the ET3 Model Listserv on September 16, 2020.

2. When will reimbursement be available for ET3 Model Interventions?

Only ET3 Model Participants and their partners are eligible to receive payment for ET3 Model Interventions. As of the start date of the Model, selected applicants that meet Model Participant requirements, including executing a Participation Agreement with CMS, will be eligible to receive Medicare reimbursement for ET3 Model Interventions. On September 16, 2020 CMS announced that the ET3 Model would start on January 1, 2021.

Please also note that CMS issued an Interim Final Rule with Comment Period (IFC) that provides temporary regulatory waivers and new rules to equip the American healthcare system with maximum flexibility to respond to the COVID-19 pandemic. The IFC and all of CMS’s Coronavirus Waivers & Flexibilities can be found here.

This includes temporarily broadening the list of allowable destinations for ground ambulance transports during the COVID-19 PHE to include any destination that is equipped to treat the condition of the patient in a manner consistent with any applicable state or local Emergency Medical Services (EMS) protocols that governs the destination location. These destinations may include, but are not limited to: any location that is an alternative site determined to be part of a hospital, critical access hospital (CAH) or skilled nursing facility (SNF), community mental health centers, federally qualified health centers (FQHCs), rural health clinics (RHCs), physician offices, urgent care facilities, ambulatory surgical centers (ASCs), any location furnishing dialysis services outside of the ESRD facility when an ESRD facility is not available, and the beneficiary’s home. Home may be an appropriate destination for a COVID-19 patient who is discharged from the hospital to home to be under quarantine. There must be a medically necessary ground ambulance transport of a patient in order for an ambulance service to be covered.

Participants may also transport beneficiaries to covered destinations under these ambulance flexibilities and bill Medicare as usual. These transports will not be considered ET3 Model Interventions, although, during the first Performance Year, they will suffice to allow ET3 Participants to also implement the Treatment in Place intervention for the duration of the PHE.

For a complete and updated list of CMS actions, and other information specific to CMS’s response to the COVID-19 PHE, please visit the Current Emergencies website.

3. Will CMS be issuing a new ET3 Model Participation Agreement?

Yes. On April 8, 2020, CMS rescinded the ET3 Model Participation Agreement (PA) issued to selected applicants on March 10, 2020. CMS issued a revised PA on October 8, 2020.

Notice of Funding Opportunity (NOFO) Eligibility and Application Questions

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

The NOFO is the mechanism through which an interested and eligible state or local government, its designee, or other entity that operates or has control over a Public Safety Answering Point in a region where at least one ambulance supplier or 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 ET3 Model NOFO will be posted on theET3 Model web page after Model Participants have been announced. Interested and eligible NOFO 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 further questions, please email us at ET3Model@cms.hhs.gov.

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

Certification and training standards for medical triage line staff will be detailed in the anticipated NOFO and subsequent Model NOFO documents and guidance.

ET3 Partners - General Questions

1. Will ET3 Model Participants be responsible for identifying and forming arrangements with third parties to implement ET3 Model Interventions?

Yes. Model Participants must partner with appropriate ET3 Partners (Alternative Destination Partners or Qualified Health Care Partners) to implement an ET3 Model Intervention. All Model Participants must partner with at least one Alternative Destination Partner to implement the Transport to an Alternative Destination intervention.

When implementing the Transport to an Alternative Destination intervention, the Participant must establish arrangements with Alternative Destination Partners located within their model region and that agree to comply with all related ET3 model requirements.

For the duration of the PHE, participants may also transport beneficiaries to covered destinations under the PHE ambulance flexibilities and bill Medicare as usual. These transports will not be considered ET3 Model Interventions, although, in many cases, they will suffice to allow ET3 Participants to also implement the optional Treatment in Place intervention. Payment rates for transport under the flexibilities and under the ET3 Model are the same.

Once the PHE ends, Participants will still be required to implement the Transport to an Alternative Destination intervention consistent with ET3 Model requirements and may transport only to ET3 Alternative Destination Partners.

Additionally, if a Model Participant chooses to implement the optional Treatment in Place intervention, it must also partner with at least one Qualified Health Care Partner.  Model Participants will be responsible for identifying potential ET3 Partners and entering into arrangements with them. All ET3 Partners must be enrolled in Medicare or employ or contract with Medicare-enrolled individuals or entities that are qualified to furnish services to ET3 Model Beneficiaries. All ET3 Partners must be approved by CMS before participating in the Model. CMS will provide this approval on an ongoing basis during the Model and Model Participants will have the opportunity to update their list of ET3 Partners during the Model.

Please see the resources under the “Additional Information” tab on the ET3 Model web page for more information on how to engage potential partners.

2. Can Model Participants partner with non-emergency medical transportation like Uber/Lyft/taxi vouchers for non-emergency transport?

The ET3 Model is aimed at emergency ambulance transport only. CMS will not reimburse Model Participants for non-emergency medical transportation such, as Uber, Lyft, or taxi vouchers for non-emergency transport under the ET3 Model.

3. I am interested in becoming an ET3 Partner/Downstream Practitioner. What must I do to participate in the ET3 Model as an ET3 Partner (i.e. Alternative Destination Partner or Qualified Health Care Partner) or Downstream Practitioner?

ET3 Partners will furnish covered services to ET3 Model Beneficiaries, or arrange for such services to be furnished to an ET3 Model Beneficiary by a Downstream Practitioner, during Treatment in Place or following Transport to an Alternative Destination. If you have partnered with a selected applicant as an ET3 Partner, they will provide you with further instruction(s.) If you have partnered with an ET3 Partner as a Downstream Practitioner, you will receive this information from the ET3 Partner.  While not required, all ET3 Partners and Downstream Practitioners will be encouraged to participate in the ET3 Model Learning System. If you were not contacted to be a potential ET3 Partner or Downstream Practitioner by a selected applicant, a full list of Model Participants will be made available on the ET3 Model Website prior to the model start date.

Alternate Destination Partners

1. What are some examples of Alternative Destination Partners?

Examples of Alternative Destination Partners include federally qualified health centers, physician offices, behavioral health centers, and urgent care centers.

2. Does every Alternative Destination Partner need to be available 24/7?

No, unless the Model Participant is only implementing the Transport to an Alternative Destination intervention and has only one Alternative Destination Partner. Each Model Participant must demonstrate that at least one of the two ET3 Model Interventions (Treatment in Place or Transport to an Alternative Destination) is available at all times. It is not required that both interventions be available at all times, and Model Participants can combine interventions to meet this requirement. For example, the Model Participant may have one Alternative Destination available between 6am and 8pm and one onsite or Qualified Health Care Partner available for Telehealth Treatment in Place between the hours of 8pm and 6am.

If a Model Participant implements only the Transport to an Alternative Destination intervention, then a combination of Alternative Destination Partners can be utilized to satisfy the 24/7 requirement. For example, if one Alternative Destination is open from 8:00 am to midnight and a second Alternative Destination Partner is open from midnight to 8:00am, 24/7 coverage would be achieved because at least one of the two Alternative Destination Partners is available 24/7. Please note, if applicants are not able to ensure 24/7 availability at the start of the Model, the applicant will need to provide a detailed Implementation Plan that includes an estimated time frame and partnerships needed to ensure 24/7 coverage is achieved during the performance period.

3. Will the Advanced Life Support (ALS)Assessment policy be in effect at all for Alternative Destination Partners?

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 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.

Qualified Healthcare Partners

1. What are some examples of a Qualified Health Care Partner Can practitioners other than an MD, PA or NP participate in the ET3 Model as a Qualified Healthcare Partner (e.g. paramedics)?

A Qualified Health Care Partner furnishes covered services to ET3 Model Beneficiaries as part of an In-Person Treatment in Place Intervention or Telehealth Treatment in Place intervention. Examples of a Qualified Health Care Partner include, but are not limited to, a Medicare-enrolled group practice, a Medicare-enrolled physician or non-physician practitioner, or a non-Medicare enrolled entity that contracts or employs a Medicare-enrolled physician or non-physician practitioner to furnish services to ET3 Model Beneficiaries as part of a Treatment in Place intervention.

An individual practitioner must be a physician or non-physician practitioner who meets all State and local laws, regulatory requirements, accreditation standards, and licensing guidelines or rules to render the particular Medicare-covered service furnished to the ET3 Model Beneficiary as part of a Treatment in Place intervention. Unless also licensed as a physician or non-physician 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 Partner under this Model.

2. May an ET3 Model Participant consult with a physician or non-physician practitioner in order to assist the Participant in making a Triage Decision to identify the most appropriate Available Intervention (if any) to offer a given ET3 Model Beneficiary?

Yes. The decision of which Available Intervention to offer an ET3 Model Beneficiary will be driven by the Model Participant’s specific pre-determined Clinical Protocols that have been approved by the Model Participant’s medical director. These protocols will be governed by state and local requirements as well as Medicare medical necessity requirements, and may include consultation with a physician or non-physician practitioner as needed.

Note that a Participant must use its Clinical Protocols to make a Triage Decision for any patient identified as an ET3 Model Beneficiary before the Participant may offer an ET3 Model Intervention to the ET3 Model Beneficiary. As such, if an individual physician or non-physician practitioner is consulted during a Triage Decision who is also a Qualified Health Care Partner or Downstream Practitioner, the consultation does not qualify as a Treatment in Place intervention.

In-Person and Telehealth Treatment in Place Intervention

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

In the ET3 Model, telehealth service means Medicare covered services that are telehealth services as described in 42 C.F.R. § 410.78. The complete list of covered telehealth services can be found on the CMS website.

2. What are the telehealth connectivity requirements of the ET3 Model? For example, what happens if a Medicare-compliant Telehealth Treatment in Place intervention is initiated, but poor connectivity interrupts it?

Covered services furnished to ET3 Model Beneficiary as part of a Telehealth Treatment in Place intervention must follow the Centers for Medicare & Medicaid Services (CMS) requirements for use of an interactive telecommunications system for telehealth services at 42 CFR §410.78(a)(3)

The Innovation Center recognizes that there may be circumstances in which connectivity may not be sufficient to sustain the Telehealth Treatment in Place intervention. In such circumstances, Payment to the Qualified Health Care Partner or Downstream Practitioner who furnishes the services depends on whether the service is “substantially completed” when the connectivity is interrupted. If an ET3 Model Beneficiary is in the process of receiving a covered service as part of a Telehealth Treatment in Place Intervention and the service is interrupted due to poor connectivity and cannot be completed using an interactive telecommunications system, the Qualified Health Care Partner or Downstream Practitioner furnishing the service is eligible to bill and receive payment for the covered service only if the service furnished was “substantially completed” when the disruption occurs. A service may not be considered “substantially completed” if, after the disruption in connectivity, the ET3 Model Beneficiary is offered another Available Intervention during the same Encounter.

Participants are eligible to bill and receive payment for initiating and facilitating a Telehealth Treatment in Place intervention regardless of whether the service furnished as part of the Treatment in Place Intervention is substantially completed. However, if a service furnished as part of a Telehealth Treatment in Place intervention cannot be substantially completed due to technical difficulties, and the Model Participant then furnishes an additional Available Intervention during the same Encounter, the Participant is eligible to bill and receive payment only for the Available Intervention furnished last in time. For example, if a beneficiary must be transported to an emergency department (ED) because a poor internet connection resulted in a failed Treatment in Place encounter, the Participant may bill and receive compensation only for the transport to the ED, but not for the failed TIP facilitation.

3. Do Qualified Health Care Partners or Downstream Practitioners need to be onsite to furnish Treatment in Place?

It depends on the type of Treatment in Place intervention provided. Participants have the option to offer a Treatment in Place Intervention to ET3 Model Beneficiaries, and may offer the intervention in-person, via telehealth, or both. For an In-Person Treatment in Place Intervention, the QHCP or DSP must be at the scene of the 9-1-1 response to furnish medically necessary covered services. For a Telehealth Treatment in Place intervention, the Qualified Health Care Practitioner or Downstream Practitioner will be located at a distant site that is not the scene of the 9-1-1 response.

4. Must a Qualified Health Care Partner ride in the ambulance of the EMS crew to provide covered services as part of an In-Person Treatment in Place intervention?

No, a Qualified Health Care Partner is not required to ride in the ambulance with the EMS crew to provide Treatment in Place services. QHCPs can arrive after the Model Participant has made a triage decision to provide Treatment in Place as a second-tier response onsite, or connect via telehealth.

5. Will Model Participants who offer Telehealth Treatment in Place have to identify their own Qualified Health Care Partners to provide telehealth services to ET3 Model Beneficiaries?

Yes. ET3 Model Participants interested in offering the optional Telehealth Treatment in Place intervention must identify and enter into agreements with Qualified Health Care Partners who agree to render telehealth services to ET3 Model Beneficiaries as part of a Telehealth Treatment in Place intervention. Please consult the ET3 Model Participant Partnership Guide for further details.

6. Who pays for telehealth services furnished to ET3 Model Beneficiaries as part of a Telehealth Treatment in Place Intervention?

Medicare will reimburse Qualified Health Care Partners for medically necessary covered services that are telehealth services as described in 42 C.F.R. § 410.78 that are furnished as part of a Telehealth Treatment in Place intervention.

7. If a Model Participant furnishes services to an ET3 Model Beneficiary at the scene of a 9-1-1 response, can the Model Participant bill separately for those services and receive payment?

No. Model Participants are only eligible to bill and receive payment for initiating and facilitating a Treatment in Place Intervention where a QHCP or the DSP of a QHCP furnishes medically necessary covered services to an ET3 Model Beneficiaries. All services provided by Model Participants during the initiation and facilitation of the Treatment in Place Intervention are covered by the associated BLS-E emergency base rate or the ALS1-E, Level 1 emergency base rate. Model Participants are not eligible to bill or receive payment for other services (except for transport) at the scene of the 9-1-1 response, such as community paramedic services or other treat and release services.

Multi-Payer Strategy

1. How will the ET3 Model impact Medicaid? Can states implement ET3 in their Medicaid programs?  

Although ET3 is a Medicare payment model, the Model will be most successful if implemented across multiple payers, including Medicaid. CMS has released an Informational Bulletin that provides guidance to states interested in replicating the flexibilities of the ET3 Model within their Medicaid program to develop an ET3-aligned intervention. The Informational Bulletin provides a framework that states may use to assess their individual regulatory landscape and Medicaid payment structure to determine readiness to implement ET3-aligned interventions and identifies flexibilities within federal guidelines that states may leverage to design ET3-aligned interventions. The Informational Bulletin also describes targeted learning opportunities for state Medicaid programs interested in implementing ET3-aligned innovations that will be available through the ET3 Model Learning System.

2. When would a state Medicaid agency need to complete a state plan amendment to allow ambulance providers or suppliers in their state to provide the treatment in place intervention? 

State Medicaid agencies will need to work directly with the Center for Medicaid and CHIP Services (CMCS)’s office regarding what is required in the state plan amendment using the ET3 Model CMCS Information Bulletin as reference. An amendment for transport to Alternative Destination Partner should not be required, but please consult legal counsel for additional clarification.

3. Will patients enrolled in a Medicare Advantage plan, private insurance, and/or Medicaid qualify to receive an ET3 Model Intervention?

Model payments for Transport to an Alternative Destination 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 ET3 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 was not required to be eligible to respond to the RFA.

While the Alternative Destination and Treatment-in-Place Interventions are limited to Medicare-Fee-for-Service beneficiaries, the medical triage line must be incorporated into a Model Recipient’s Public Safety Answering Point system. Callers will be able to access the medical triage intervention in areas where the cooperative agreement is awarded regardless of their coverage status.

4. How should a Model Participant verify that a patient has Medicare FFS coverage and is therefore eligible to receive an ET3 Model Intervention?

Each Model Participant will be responsible for establishing a process to verify that a patient is a Medicare Fee-for-Service beneficiary who is eligible for an ET3 Model intervention. However, if all payers in a particular region are independently implementing ET3-like 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 that are furnished to patients who are not Medicare Fee-for-Service beneficiaries under the Model.

5. Are there any Medicare waivers offered to ET3 Model Participants?

Yes. CMS will make available conditional waivers of certain requirements of the Medicare program as authorized under section 1115A(d)(1) of the Social Security Act that include requirements related to ambulance services, telehealth, and payments for Qualified Health Care Partners, as may be necessary solely for purposes of testing the ET3 Model. Additional details about waivers can be found in the Request for Application (PDF).

6. Can ET3 Model Interventions be initiated through a non-9-1-1 medical advice line operated by an entity responsible for total cost of care?

ET3 Model services could be initiated through a non-9-1-1 line if the call first came through 9-1-1 and was triaged to the non-9-1-1 line. In these cases, the entity providing the ET3 Model Intervention would need to be a Model Participant and subject to state and local laws.

Billing and Reimbursement

1. Is CMS providing any initial funding to assist Model Participants or NOFO Recipients in the start-up costs for things such as staffing, equipment, data systems, and training?

Model Participants are eligible to receive Medicare payments for services furnished as part of an ET3 Model Intervention. Additional funding for start-up costs associated with implementing ET3 Model Interventions is not available from CMS.

NOFO Recipients—including local governments, their designees, or other entities that are operating a Public Safety Answering Point—may receive funding via cooperative agreements with CMS to establish or expand upon an existing medical triage line, which may be used for things such as staffing, equipment, data systems, and training. The NOFO will provide additional guidance regarding appropriate use of cooperative agreement funding.

2. How does the billing and payment process work for Treatment in Place and Transport to an Alternative Destination?

For each ET3 Model Intervention, Model Participants and ET3 Partners (or the DSP/Billing Party of an ET3 Partner) will separately bill Medicare using billing procedures similar to ones they would normally use.

Model Participants will bill an amount equivalent to either the ambulance fee schedule Basic Life Support (BLS-E) base emergency rate or the Advanced Life Support, Level 1 (ALS1-E) base emergency rate for emergency ground ambulance services for initiation and facilitation of a Treatment in Place intervention or for 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 #6 and FAQ #10 in this section for more information about the ET3 Model ALS Assessment policy.)

Qualified Health Care Partners providing services either on-site or by telehealth will bill Medicare Part B as normal, based on services provided.

3. How will Model Participants submit claims for Transport to an Alternative Destination?

ET3 Model Participants will use new destination modifiers on their claims for Transport to an Alternative Destination intervention. These modifiers coupled with a demonstration code that will be added to the claims of Model Participants by the Medicare Administrative Contractors will enable payment of these claims. Billing and payment guidance will be provided as part of the Participant onboarding process. Further guidance on billing instructions will be provided at a later date.

4. How will Model Participants submit claims for transport to the expanded list of allowable destinations temporarily available under the PHE?

ET3 Model Participants who transport beneficiaries to covered destinations under these ambulance flexibilities will bill Medicare as usual. It is essential that Participants bill properly, both when implementing the ET3 Alternative Destination intervention and when transporting patients as allowed under the PHE ambulance flexibilities. If billing errors are made, claims may be denied and/or CMS may need to recoup funds from Participants.

5. If a beneficiary who is offered an ET3 Model Intervention but declines the offer and requests to be 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 the Model Participant’s offer to provide an ET3 Model Intervention and requests to be transported to 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.

6. Does the ET3 Model modify the Medicare requirement that a ground ambulance transport must be medically necessary in order for the ambulance provider or supplier to be eligible to receive payment for the transport?

No, the ET3 Model does not modify the medical necessity requirement.

7. How does the medical necessity requirement apply to transport to an Alternative Destination for Transports made by a Model Participant as part of a Transport to an Alternative Destination intervention.

Medicare requires ambulance transports to be medically necessary as described in 42 C.F.R. § 410.40(e), in order for the transport to be eligible for payment as a Medicare Part B service. The ET3 Model does not alter or eliminate this requirement for transports made as part of the Transport to an Alternative Destination intervention.

Under § 410.40(e)(1), ambulance transportation is covered by Medicare Part B only if 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.

8. If a Qualified Health Care Partner furnishes services to an ET3 Model Beneficiary as part of a Treatment in Place intervention, is the Model Participant eligible for reimbursement?

Yes. Model Participants are eligible to receive an amount equivalent to the emergency BLS-E or emergency ALS1-E ground ambulance base rate for the initiation and facilitation of a Treatment in Place intervention. In order to bill at the ALS1-E emergency base rate, a Model 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.

The Qualified Health Care Partner administering the treatment may bill for the Part B services they render, whether services were furnished as telehealth services or in-person with the ET3 Model Beneficiary

9. Will CMS reimburse for more than one ambulance service in one day? For example, if the ambulance transports the patient to a clinic, where it is later determined that the patient must be transported to the Emergency Department, will the ambulance provider be reimbursed for both transports?

Medicare allows 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 Model Participants should consult their Medicare Administrative Contractors (MACs) to ensure compliance with billing requirements in their region. All ET3 Model Participants will be monitored to ensure that services are being rendered and billed appropriately.

10.Will beneficiaries be responsible for 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 otherwise alter beneficiary cost-sharing requirements for Medicare covered services.

11. In what circumstances would a Model Participant be reimbursed the BLS-E rate versus the ALS1-E rate?

A Model Participant that renders 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 hospital, critical access hospital or skilled nursing facility participants will be paid based on the Ambulance Fee Schedule.

Monitoring and Evaluation

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

Prior to year three of the Model, CMS will determine, in its sole discretion, the availability of a performance-based upward payment adjustment for Model Participants. The availability of such upward payment adjustments is not guaranteed. Participants are not subject to downside risk under the Model. More information on this topic will be released at a later date.

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

Information regarding data submission requirements, quality metrics, required monitoring and reporting, and data available to ET3 Model Participants is available in the ET3 Model RFA, and will be further detailed in subsequent Model documents.

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

Last updated on:
11/13/2020