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
• ET3 Model Delay Questions
• Notice of Funding Opportunity (NOFO)
• ET3 Partners – General Questions
• Alternative Destination Partners
• Qualified Health Care Partners
• In-Person and Telehealth Treatment in Place
• Multi-Payer Strategy
• Billing and Reimbursement

• Monitoring and Evaluation

   

Model Overview and General Questions

1. What is the ET3 Model? What were the goals of this Model?
   
   The Emergency Triage, Treat, and Transport (ET3) Model is a voluntary, five-year payment model. The intent of the ET3 Model is to provide greater flexibility for ambulance care teams to address emergency health care needs of Medicare Fee-for-Service beneficiaries following a 9-1-1 call. The Model’s goals are to provide person-centered care, increase efficiency in the EMS system, and encourage appropriate utilization of emergency medical services. In 2023, due to lower than expected participation and lower than projected interventions, the CMS Innovation Center made the decision to end the Model ahead of schedule on December 31, 2023. 
   
   The ET3 Model tested 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 pays 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).

2. How many applicants were selected to participate in the Model? What types of geographic 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 were from urban, suburban, and rural areas of the country and were representative of a variety of organization types including government-owned, fire-based, private non-profit, private for-profit, and hospital-based. As of June 2023, there were 151 participants, of which only a small number of participants had documented interventions through the ET3 Model.
3. 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 Public Health Emergency (PHE). 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. 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.
4. 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.
5. 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.
6. 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-
7. 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.
8. Will early termination of the ET3 Model impact states that modified their Medicaid program to align with ET3?
   
   No. Medicaid has long allowed coverage for interventions like those covered by Medicare through ET3. State Medicaid Agencies currently covering or planning to update their Medicaid program to cover treatment in place or transport to alternative destinations may continue to do after the conclusion of the ET3 Model. CMS believes that Medicaid payers are well positioned to reduce expenditures and preserve or enhance quality of care to their members through coverage of interventions like those covered by Medicare in ET3.
9. Is it possible to engage Medicaid agencies for coverage of services like the ET3 Treatment in Place (TIP) or Transport to Alternative Destination (TAD) Interventions despite the model ending announcement?
   
   Yes. Medicaid has long allowed coverage for interventions like those new services covered by Medicare through ET3. The model’s early termination will not affect the ability for Medicaid to pay for services like those currently included in the ET3 model. Organizations may choose to engage state Medicaid agencies for coverage of interventions like ET3 TIP and/or TAD.

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 COVID-19 PHE, 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. Were any flexibilities offered as a result of the COVID-19 PHE to Model participants?
   
   In response to feedback from Model Participants, CMS made a number of flexibilities available during the Public Health Emergency to encourage participation. This included relaxation of the requirement to make model interventions available 24 hours a day, 7 days a week as well as the requirement to implement the transport to alternative destination intervention prior to implementing the treatment in place intervention.
3. Who is eligible for reimbursement of 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. Payment under the model will continue for dates of service through December 31, 2023.

Notice of Funding Opportunity (NOFO)

1. Why did CMS decide not to make (NOFO) awards?
   
   CMS is not moving forward with the medical triage line component of the ET3 Model due to insufficient applications received. The NOFO offered to fund up to 40 Cooperative Agreements for up to $1.175M each. CMS received 29 applications, fewer than anticipated. 
   
   Without sufficient participation in the medical triage line intervention described in the NOFO, CMS has determined it would be difficult to adequately assess whether medical triage lines influence quality of care for beneficiaries and Medicare program spending under the Model.
2. How does CMS’ decision to not implement the medical triage line component of the ET3 Model impact participation in the ambulance payment component of the Model (the Transport to Alternative Destination and Treatment in Place Interventions)?
   
   This decision does not affect ET3 Model Participation Agreements as they relate to the ambulance payment component of the Model.
3. Did CMS explore proceeding with the NOFO with the applications it received?
   
   CMS considered its options carefully before reaching the decision to not implement the medical triage line component of the Model. Without sufficient Cooperative Agreement recipients in the Model, CMS has determined it would be difficult to adequately assess whether medical triage lines influence quality of care for beneficiaries and Medicare program spending under the Model.
4. Is the ET3 NOFO not being awarded because of the COVID-19 public health emergency?
   
   No. CMS has elected not to move forward with the ET3 NOFOs due to an insufficient number of applications received.

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 (PDF) 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.
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.
7. What types of health care providers (based on licensure/credentialing) qualify to participate in Medicare’s ET3 Model, especially in regards to telehealth-facilitated Treatment in Place (TIP)? Is this the same for Medicare and Medicaid?
   
   For Medicare fee-for-service (FFS) beneficiaries, CMS does not impose ET3 Model-specific restrictions on health care provider licensure for the furnishing of ET3 Model interventions. In order to qualify to furnish TIP interventions (either in-person or via telehealth), a health care practitioner must be Medicare-enrolled and meet federal, state, local, and professional requirements to furnish Medicare-covered services to beneficiaries. As part of their Medicare enrollment, these practitioners are regularly screened by the CMS Center for Program Integrity to ensure that both the Medicare program and its beneficiaries are protected.
   
   Paramedics and Emergency Medical Technicians (EMTs) are not among the types of health care professionals that can enroll in Medicare to furnish and bill for their professional services. Therefore, these individuals cannot independently furnish TIP interventions for Medicare payment under the ET3 Model.
   
   In Medicare, telehealth practitioners are generally required to meet the licensure standards described in 42 C.F.R. § 410.78(b)(1) in order to furnish telehealth services to Medicare FFS beneficiaries. In addition, the Medicare statute allows only certain types of practitioners listed in 42 C.F.R. § 410.78(b)(2) to furnish and bill for Medicare telehealth services. This list includes physicians, physician assistants, nurse practitioners, clinical nurse specialists, nurse-midwifes, clinical psychologists, clinical social workers, registered dieticians/nutrition professionals, and certified registered nurse anesthetists. However, during the COVID-19 PHE, all health care practitioners authorized to bill Medicare for their professional services may also furnish and bill for an expanded list of Medicare telehealth services within their scope of practice. This allows health care professionals who were not previously authorized under the statute to furnish and bill for Medicare telehealth services, including physical therapists, occupational therapists, and speech language pathologists.
   
   State Medicaid agencies interested in implementing telehealth TIP services consistent with Medicare’s ET3 Model do not have to follow Medicare’s licensure rules. There are no federal Medicaid rules that prohibit certain providers from furnishing telehealth. These licensure and scope of practice decisions are made at the state level, and state Medicaid agencies should reference their state and local scope of practice rules when designing licensure requirements for telehealth TIP interventions. States have a great deal of flexibility with respect to covering Medicaid and Children’s Health Insurance Program services provided via telehealth. States have the option to determine whether (or not) to utilize telehealth; the types of services to cover; where it can be utilized; how it is implemented; payment rates and the types of practitioners or other health care providers can deliver services via telehealth, as long as such practitioners or providers are "recognized" and qualified according to Medicaid federal and state statute and regulation. See here for more information on telehealth in the Medicaid program.
8. Which CMS authorities can state Medicaid agencies use to implement and pay for services that align with the ET3 Model?
   
   State Medicaid agencies that do not already have authority to implement payment methods that align with the ET3 Model may need to request authority from CMS through a State Plan Amendment (SPA) depending on the specific goals of the state. Please consult your State Plan and any current waivers relevant to emergency medical transportation to determine if your state already has authority to pay for services consistent with the ET3 Model. State laws and regulations may also impact your agency’s ability to implement this program.
   
   Some states may already have CMS authority to pay for services consistent with the ET3 Model. A number of states have used 1905(a)(6), services of other licensed practitioners, to recognize the professionals typically associated with the provision of emergency services rendered at the scene of a 9-1-1 response. Other licensed practitioner services, as defined by 42 CFR §440.60, are “…medical or remedial care or services, other than physicians’ services, provided by licensed practitioners within the scope of practice as defined under State law.” For example, states could consider submitting a SPA recognizing licensed paramedics under 1905(a)(6) in order to provide payment for the Treatment in Place (TIP) services furnished on the scene when no transport takes place.
   
   CMS issued a Joint Informational Bulletin in August 2019 that explores state authorities for ET3 Model alignment more fully. State Medicaid agencies interested in implementing services and payments consistent with the ET3 Model should consult this Joint Information Bulletin for more information.
9. What is Medicare’s billing methodology for Treatment in Place, and how can state Medicaid agencies align with this methodology?
   
   The ET3 Model has a two-part billing methodology to pay for Treatment in Place (TIP) services furnished to Medicare FFS beneficiaries:
   
   The first Medicare TIP payment pays ambulance providers and suppliers for initiation and facilitation of TIP. For each TIP intervention (regardless of whether it was performed in-person or via telehealth), the ambulance provider or supplier can bill Medicare for one Basic Life Support Emergency (BLS-E) or Advanced Life Support Emergency (ALS1-E) rate, in addition to any adjustments/add-ons for geographic factors and/or multiple patients. For TIP, ambulance providers and suppliers cannot bill for mileage adjustments. CMS has implemented a procedure code modifier for ambulance providers and suppliers participating in the ET3 Model to use as a TIP indicator on claims.
   
   The second Medicare TIP payment pays Medicare-enrolled health care practitioners for Medicare-covered services furnished at the scene of a 9-1-1 response, either in-person or via telehealth. At this time, CMS has not developed any Medicare-payable services (i.e., CPT®/HCPCS codes) that are specific to the ET3 Model. Practitioners furnishing TIP services are allowed to bill per standard Medicare FFS billing rules, with the only adjustments being (1) a 15 percent rate increase for services rendered between 8pm and 8am (operationalized using a procedure code modifier) and (2) inclusion of a non-payable HCPCS code for use as a TIP indicator on claims.

• For in-person TIP, Medicare-enrolled health care practitioners will follow the ET3 Model’s TIP billing guidance for what is Medicare-allowable for TIP and can work with their Medicare Administrative Contractors (MACs) to determine what is payable under the Medicare Physician Fee Schedule in their region.
   
• For telehealth TIP, Medicare-enrolled health care practitioners will be expected to bill based on Medicare telehealth billing rules and guidance. Medicare Part B only pays for services included on the list of Medicare telehealth services.
  
  State Medicaid agencies interested in implementing services and payments consistent with Medicare’s ET3 Model should reference the Joint Informational Bulletin on Medicaid Opportunities in the ET3 Model for more details about potential payment mechanisms in Medicaid. In summary, states have considerable flexibility within broad federal guidelines in financing and paying for their Medicaid program. States can establish their own Medicaid provider payment rates within federal guidelines, and can pay for services on a fee-for-service or managed care basis. States are responsible for setting rates, subject to federal standards, to pay providers for furnishing health care services to Medicaid beneficiaries. Whatever payment methodology a state elects to implement for provider payments must be described comprehensively in their Medicaid State Plan and formally approved by CMS. To the extent the services are provided under managed care contracts, payments under such contracts must be approved by CMS as actuarially sound. In order to implement services consistent with the ET3 Model, Medicaid agencies may need to develop new procedure codes or procedure code modifiers for billing. Medicaid agencies may also choose to mimic Medicare’s ET3 Model billing policies using their own payment rates for existing codes. Regardless of methodology, Medicaid agencies should carefully consider state laws and regulations, as well as IT system implications, when developing their billing policies. States interested in establishing payments for services aligned with the ET3 model are encouraged to discuss their ideas with their federal Medicaid representatives or "state lead” before implementation.

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.
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. Will an evaluation of the ET3 Model be released to the public?
   
   Yes. Per section 1115A(b)(4) of the Social Security Act, CMS will publish a document describing the differences in Medicare spending and the risk of potential adverse events for Medicare beneficiaries that received ET3 interventions compared to beneficiaries who didn’t receive ET3 interventions on the ET3 Model landing page. CMS anticipates release of the evaluation results for the ET3 Model by end of the third quarter in 2024 or earlier.
2. 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.

3. 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 (PDF), and will be further detailed in subsequent Model documents.

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