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1 Table of Contents State/Territory N arne: California State Plan Amendment (SPA) #: 12-00lB This file contains the following documents in the order Fsted: 1) Approval Letter 2) CMS 179 Form/Summary Form (with 179-like data) 3) Approved SPA Pages
2 DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services San Francisco Regional Office 90 Seventh Street, Suite (5W) San Francisco, CA CENTERS FOR MEDICARE & MEDICAID SERVICES DIVISION OF MEDICAID & CHILDREN'S HEALTH OPERATIONS Toby Douglas, Director California Department of Health Care Services P.O. Box , MS 0000 Sacramento, CA Dear Mr. Douglas: Enclosed is an approved copy of California State Plan Amendment (SPA) B. SPA was submitted to my office on February 15, 2012 to authorize supplemental payments for emergency air medical transportation (EMATA) providers. A Request for Additional Information (RAI) was issued on May 15, In the State's August 7 1 h response to the RAI, the State requested that the SPA be split. SPA B implements a payment rate augmentation to provide enhanced fee for service payments to EMA T A providers for transports provided during the 2012/2013 and 2013/2014 rate years. Additional SPAs will be needed annually to update the pool amounts available for the rate augmentation in each subsequent year. The effective date of this SPA is January 7, Enclosed are the following approved SPA pages that should be incorporated into your approved State Plan: Supplement 16 to Attachment 4.19-B. pages 4-6. If you have any questions, please contact Tom Schenck by phone at (415) or by at tom.schenck@cms.hhs.gov. Sincerely, Associate Regional Administrator Division of Medicaid & Children's Health Operations Enclosure cc: Connie Florez, California Department of Health Care Services Wendy Ly, California Department of Health Care Services
3 DBPARTMBNT OF HBALTH AND HUMAN SBRVICBS.HBALTH CARBFINANCINO ADMlNlSTRATION TRANSMITTAL AND NOTICE OF APPROVAL OF 1. TRANSMITTAL NUMBER: 2.STATE STATE PLAN MATERIAL 12-00lB FOR: HEALTH CARE FINANCING ADMINISTRATION TO: REGIONAL ADMlNISTRATOR HEAL1ll CARE FINANCING ADMINISTRATION DEPARTMENT OF HEALTH AND HUMAN SERVICES 5. TYPE OF PL~N MATERIAL (Check One): FORM APPROVED OMB NO California 3. PROGRAM IDBNTIFICATION: TITLE XIX OF THE SOCIAL SECURITY ACT (MEDICAID) 4. PROPOSED BFFECTIVB DATE January 7, NEW STATE PLAN 0 AMENDMENT TO BE CONSIDERED AS NEW PLAN 181 AMENDMENT COMPLETE BLOCKS 6 THRU 10 IF THIS IS AN AMENDMENT arate. Transmittal or each amendment 6. FEDERAL STATUTE/REGULATION CITATION: 7. FEDERAL BUDGET IMP:c\.CT: 4l CFR 447.Subpart F a. FFY 2012 $3,119;388 $5, b. FFY PAGE NUMBER OF THE PLAN SECTION OR ATTACHMENT: 9. PAGE NUMBER OF THE SUPERSEDED PLAN SECTION OR A TIACHMENT (Q' Applicable): Supplement 16 to Attachment 4.19MB Pages N/A 10. SUBJECT OF AMENDMENT: Reimbursement for Air Medical Transportation Services 11. GOVERNOR'S REVIEW (Chsck On~): 0 GOVERNOR'S OFFICE REPORTED NO COMMENT 0 COMMENTS OF GOVERNOR'S OFFICE ENCLOSED 0 NO REPLY. RECEIVED WITHIN 45 DAYS OF SUBMITIAL 181 OTHER, AS SPECJFJED: l'he Governor's Office does not wish to.:review the State Plan Amendment. TO: Department of Health Care Services Attn: State Plan Coordinator 1501 Capitol Avenue, Suite P.O. Box Sacramento, CA FOR;MHCFA-179 (07-92)
4 Supplement 16 To Attachment 4.19B Page 4 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: CALIFORNIA REIMBURSEMENT FOR EMERGENCY AIR MEDICAL TRANSPORTATION SERVICES A. Emergency Air Medical Transportation Service Payment Augmentation 1. Effective for dates of service on and after July 1, 2012, the Department will implement a payment augmentation to eligible Medi-Cal air medical transportation providers, as defined in Supplement 16 to Attachment 4.19-B, Page 1, Section B.'l, that provide Fee-for-Service (FFS) emergency air medical transportation services. 2. The payment augmentation amount will be in addition to the existing fee schedule rate for emergency air medical transportation and mileage services, as defined in Supplement 16 to Attachment 4.19-B, Page 1, Section C.1 and will not affect any other payments to air medical transportation providers. The sum of the payment augmentation amount and the existing fee schedule rate must not exceed a provider's usual and customary rates charged to the general public for an emergency air medical transport. B. Payment Augmentation Methodology 1. The payment augmentation will apply to Medi-Cal emergency air transportation services paid for dates of service on and after July 1, The payment augmentation amount for each emergency air medical transportation service will be calculated by multiplying the respective base rate for each service by the adjustment factor. (a) Base rates for emergency air medical transportation services are the State Agency's rates per procedure code as posted on the Medi-Cal Rates web site: (b) The current Medi-Cal costs of providing air medical transportation services will be the sum of all eligible emergency air medical transportation costs calculated by multiplying the respective Medi-Cal base rate for each eligible emergency air medical transportation service and the number of total paid claims for the dates of service period. (c) The adjustment factor is the ratio of the annual amount available (as defined by (c)(i)/(c)(ii) below) and the total cost of providing air medical transportation services and will be calculated by dividing the amount available (as defined by (c)(i)l(c)(ii) below) by the current Medi-Cal costs. TN B Supersedes TN: None Approval Date: May 19,2014 Effective Date: January 7, 2012
5 Supplement 16 To Attachment 4.19B Page5 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: CALIFORNIA REIMBURSEMENT FOR EMERGENCY AIR MEDICAL TRANSPORTATION SERVICES (i) For the 2012/13 rate year, the annual amount available for the payment augmentation will be based on a total pool amount of $11,220,000. This pool amount will be distributed to the eligible air medical transportation providers, using the methodology as described in B(2), that have submitted claims and received payment for the dates of service period July 1, 2012 to June 30, (ii) For the 2013/14 rate year, the annual amount available for the payment augmentation will be based on a total pool amount of $9,000,000. This pool amount will be distributed to the eligible air medical transportation providers, using the methodology as described in B(2), that have submitted claims and received payment for the dates of service period July 1, 2013 to June 30, The payment augmentation amount per transport will be calculated annually. Rates will be updated on 7/1/2014 and will be effective for services rendered on or after that date. TN B Supersedes TN: None Approval Date: May 19,2014 Effective Date: January 7, 2012
6 Supplement 16 To Attachment 4.19B Page 6 STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT STATE: CALIFORNIA REIMBURSEMENT FOR EMERGENCY AIR MEDICAL TRANSPORTATION SERVICES D. Payment Augmentation and Effective Date 1. The payment augmentation amount be an add-on to the existing rate for FFS emergency air medical transportation and will be posted on the State Agency's rates web site for each applicable date of service period. 2. The State Agency's initial rates for FFS emergency air transportation services were last updated on July 1, 2012 and are effective for dates of service on or after that date. The rates for FFS emergency air transportation services are posted on the Medi-Cal Rates web site at: TN B Supersedes TN: None Approval Date: May 19,2014 Effective Date: January 7, 2012
REIMBURSEMENT FOR EMERGENCY AIR MEDICAL TRANSPORTATION SERVICES
Supplement 16 To Attachment 4. l 9B ' Page 1 A. Amendment Scope and Authority This amendment provides the authority to implement a payment methodology to provide for supplemental payments to eligible Medi-Cal
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This file contains the following documents in the order listed:
Table of Contents State/Territory Name: North Carolina State Plan Amendment (SPA) #: 1 0-35B This file contains the following documents in the order listed: 1) Approval Letter 2) Summary Form (with 179-like
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State of California-Health and Human Services Agency Department of Health Care Services
.,HCS ~" JENNIFER KENT Director State of California-Health and Human Services Agency Department of Health Care Services EDMUND G. BROWN JR. Governor JUL n 2 201s Ms. Hye Sun Lee Acting Associate Regional
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Table of Contents. This file contains the following documents in the order listed:
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I 1. TRANSMITTAL NUMBER: 1 2. STATE: TRANSMITTAL AND NOTICE OF APPROVAL OF 0 7 STATE PLAN MATERIAL
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[XI OTHER, AS SPECIFIED: Paul Reinhart, Director Medical Services Administration
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February 26, 2015. Enclosed for your records is an approved copy of the following State Plan Amendment: --Effective Date: July 1, 2013
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