The Centers for Medicare and Medicaid Services (CMS) have extended prior authorization for repetitive non-emergent transports through December 1, 2019 to eight states and Washington DC.  The agency recently issued a notice about the extension of the prior authorization program that began in 2014 to test a new payment and service delivery model and to reduce spending for the Medicare program.  Under the model, ambulance suppliers must obtain prior authorization from the Medicare Administrative Contractor (MAC) for repetitive non-emergency transports.  Phase I of the model program was started in three states in 2014, including South Carolina, New Jersey, and Pennsylvania.

An expanded Phase II of the model program occurred in 2016 to include five additional states.  CMS included Maryland, Delaware, District of Columbia, North Carolina, West Virginia, and Virginia in the prior authorization model program beginning January 1, 2016.  Now the CMS has extended this model program for these eight states through December 1, 2019.  These eight states must continue prior authorization for scheduled, repetitive non-emergency transports.

The agency has yet to expand the model nationwide, and has missed its original deadline of December 2017 to do so.  Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which stated that if Phase I and Phase II of the model program met certain requirements, CMS would expand the program nationwide. A Federal Register noticed issued by CMS in October 2015 that mandated the extension of the program to the five additional states, failed to outline and give clear guidance concerning when and if the prior authorization program would be implemented nationwide.

CMS is not required to implement the prior authorization program nationwide unless it meets two primary criteria:

  • First, the program should not reduce access to care for Medicare beneficiaries; and
  • Secondly, Phase I and Phase II programs should lead to savings for the Medicare program.

The Medicare contractor is responsible for making the determination on whether to expand prior authorization nationwide.  In the meantime, the November 30, 2018 extension notice has been issued for ambulance suppliers in Delaware, District of Columbia, Maryland, North Carolina, West Virginia, Virginia, Pennsylvania, New Jersey, and South Carolina to continue the program through December 1, 2019.  Ambulance suppliers in other states should continue to monitor the model program for expansion in the future to their states.

The CMS has defined a repetitive ambulance service 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 three weeks.  Medicare will provide coverage if the ambulance service obtains prior written order from the beneficiary’s physician certifying that medically necessary requirements are met for transport.

MedTrust Transport provides emergent and non-emergent ambulance services in Charleston, Myrtle Beach and Georgetown, South Carolina.  We have trained EMT personnel and a fleet of fully-equipped ambulances.  We aim to provide compassionate and timely patient care.