Emergency Triage, Treat and Transport Model Frequently Asked Questions

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

Contents

• General Questions
• Participant/Awardee Eligibility
• Beneficiary Eligibility
• Application and Award
• Qualified Health Care Practitioners
• Alternative Destinations
• Treatment in Place/Telehealth
• Billing and Reimbursement
• Partnerships and Stakeholder Engagement
• Monitoring and Evaluation

General Questions

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

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

2. How does the Emergency Medical Treatment and Active Labor Act (EMTALA) interact with the ET3 Model? *New - August 2019*

   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 potential 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.

3. How will the ET3 model impact Medicaid? Can states implement ET3 in their Medicaid programs? *New - August 2019*

   Although ET3 is a Medicare payment model, the model will be most successful if implemented across multiple payers, including Medicaid. CMS has released an Information 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 which 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.

4. If an ambulance provider is a participant in the ET3 Model and the patient being served is assigned to a Medicare Shared Savings Program Accountable Care Organization (ACO) or the Bundled Payments for Care Improvement Advanced (BPCI Advanced) Model, will the costs incurred for medical services rendered during that patient encounter be counted as expenditures for the ACO or the BPCI Advanced Model participant? *New - October 2019*

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

5. How can ACOs and other entities responsible for total cost of care integrate with the ET3 Model? *New – September 2019*

   Through the Notice of Funding Opportunity (NOFO), the Innovation Center expects to allocate cooperative agreement funding to support successful implementation of a medical triage line integrated into the 911 dispatch system(s) in an eligible region. CMS will give preference to NOFO applicants that are able to identify a caller’s care management team and triage the caller back to that team for non-emergency health concerns. This could happen at the 911 dispatch level or after the caller has been triaged for medical advice using an electronic health information data exchange solution. This data exchange solution would be used to identify the caller as being attributed to an ACO or other total cost of care entity.

6. Can ET3 Model services be initiated through a non-911 medical advice line operated by an ACO or other entity responsible for total cost of care? *New – September 2019*

   ET3 Model services could be initiated through a non-911 line if the call first came through 911 and was triaged to the non-911 line. In these cases, the ambulance providing the ET3 Model service would need to be enrolled in the ET3 Model and subject to state and local laws.

7. What is the difference between the ET3 Model test and the Medicare Prior Authorization Model for Repetitive, Scheduled Non Emergent Ambulance Transport (RSNAT)? *New - August 2019*

   The ET3 Model tests two new Medicare payments following a 911 call: for transport to an alternative destination and treatment in place. The RSNAT Model tested 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.

8. Where can I find additional information about the ET3 Model, including past webinar slides, the Model infographic, and other resources like the HHS White Paper?

   Informational webinar slides and additional resources such as the Department of Health & Human Services/Department of Transportation White Paper: Innovation Opportunities for EMS are posted on the ET3 Model web page below the sections Webinars and Additional Information.

     

Participant/Awardee Eligibility

1. Where is the ET3 Model available?

   ET3 is a voluntary model with a national solicitation. Participant and awardee selection will be based on regional clusters and demonstrated ability to achieve ET3 Model goals. More information on participant eligibility can be found in the Request for Applications (PDF) and in the ET3 Model Eligibility Fact Sheet. More information on awardee eligibility will be found on the ET3 Model web page when the Notice of Funding Opportunity (NOFO) is released.

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

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

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

   To apply to the ET3 Model, an applicant must propose to implement the model in a state in which at least 15,000 Medicare FFS emergency ambulance transports occurred in 2017. However, if an applicant proposes to implement the model in a region that includes one or more counties in which at least one of those counties had 7,500 Medicare FFS emergency ambulance transports occur in 2017, they will receive preference during the application review. Transport totals across multiple counties or equivalent entities cannot be combined to meet the 7,500 transport preference. It is not a requirement that an applicant have at least 7,500 transports in a county in their proposed model region in order to participate in the Model.

   Each applicant should review Appendix D: Number of Medicare FFS Emergency Transport Claims by State and County Equivalent Entity 2017 (PDF) to determine whether its proposed model region is in a state that meets the 15,000 state-level transport requirement, and the volume of transports in its proposed county or counties. CMS will consider the sum of beneficiaries covered by multiple ambulance providers in a particular region when reviewing applications.

4. Must EMS suppliers or providers ensure 24/7 availability of non-ED options (treatment-in-place or alternative destination) from the start of the Model? *New – September 2019*

   Applicants must provide a detailed plan in their ET3 Model application for ensuring 24/7 availability. If applicants cannot ensure 24/7 availability at the start of the Model, the applicant should provide details in their plan such as an estimated time frame and partnerships needed to ensure 24/7 coverage is achieved.

   For example, an EMS supplier or provider may describe in their application their partnership with an Urgent Care Center opened from 7am-10pm 7 days a week, but state that their treatment-in-place program will be operational no later than June 2020, and it will be available from 10pm to 7am.

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

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

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

    

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

   No, neither participants nor awardees are required to implement all three components of the model. Applicants responding to the RFA will be required to propose an intervention design for alternative destination transport at a minimum. Applicants able to demonstrate capacity to implement treatment in place—either via telehealth or in person or both—will have the opportunity to earn additional points during application review.

   Awardees for the medical triage intervention funding will be solicited separately through the NOFO. Entities are eligible to respond to the NOFO to establish or expand a medical triage line if they propose to implement the medical triage line in a geographic area where at least one Model participant is implementing alternative destination transport and/or treatment in place interventions. An entity is not precluded from responding to both RFA and the NOFO if it is eligible for both solicitations independently.

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

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

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

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

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

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

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

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

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

     

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

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

      

Beneficiary Eligibility

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

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

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

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

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

Application and Award

1. What is an RFA? Has the ET3 RFA been released, if so, how can I find it?

   The Request for Applications (RFA) is the mechanism through which an interested and eligible ambulance supplier or hospital-based ambulance provider may apply to participate in the ET3 Model in order to implement transport to alternative destinations and/or treatment in place interventions. Yes, the ET3 Model RFA has been released and the RFA PDF and the RFA Online Portal are available in the Request for Application (RFA) section on the ET3 Model web page. To ask further questions, please email us at ET3Model@cms.hhs.gov.

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

   The Notice of Funding Opportunity (NOFO) is the mechanism through which an interested and eligible local government, its designee, or another entity that operates or has control over a 911 dispatch in a region where at least one ambulance supplier or hospital-based ambulance provider is participating in the ET3 Model can submit an application for cooperative agreement funding to establish or expand a medical triage line. A link to the NOFO for funding of a medical triage line will be posted on the ET3 Model web page in Spring 2020 and applicants must submit responses via Grants.gov. Please regularly check the ET3 Model website for NOFO announcements and current information about the Model. To ask further questions, please email us at ET3Model@cms.hhs.gov.

3. Who should submit an application for this Model?

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

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

    

4. Can two or more ambulance suppliers or providers interested in participating in the ET3 Model apply under a single application? *New - August 2019*

   No, two or more ambulance suppliers or providers interested in participating in the ET3 Model cannot submit a single application unless they share a National Provider Identifier, or NPI. Each Applicant, identified by their unique NPI, must submit a separate application. If Applicants are coordinating to implement the model they may open one user account and use it to submit multiple applications.

5. Can a third-party body apply on behalf of an ambulance supplier/provider interested in participating in the ET3 Model? *New - August 2019*

   Yes, a third-party body can provide assistance in responding to the application and can also submit an application on behalf of the Applicant organization. The Applicant organization is responsible for all information provided in response to the application. On the “Certify & Submit” page, please identify the third-party entity who assisted in completion of the application.

6. Can a multi-organization or multi-regional approach be taken in implementing the ET3 Model – if so, what impact does this have on the application? *New - August 2019*

   Yes. Ambulance suppliers and providers can implement the model through a variety of organizational structures, including varying levels of cooperation and coordination among other model Applicants or non-applicants. For example, a large academic hospital that is not eligible to be a Participant in the model could coordinate model implementation for the Applicants (i.e. multiple ambulance suppliers or providers, each with their own NPI) in surrounding jurisdictions.

   Regardless of what implementation strategy an Applicant proposes to employ, each individual Applicant defined by their unique NPI will be the entity responsible entering into a participant agreement with CMS and will be responsible for the terms and conditions listed within the agreement. An Applicant pursuing a multi-organizational or multi-regional approach should describe the organizational structure they plan to use to implement the Model in the “Governance Structure and Capacity” section of the application.

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

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

8. How will CMS select participants?

   Selection criteria is detailed in the Request for Application (PDF). The criteria includes demonstrated capacity to implement ET3 Model interventions, compliance with program integrity and compliance standards, and operates in a state with a minimum volume of unscheduled Medicare Fee-for-Service emergency ambulance transports.

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

   To apply to the ET3 Model, an applicant must propose to implement the model in a state in which at least 15,000 Medicare FFS emergency ambulance transports occurred in 2017. However, if an applicant proposes to implement the model in a region that includes one or more counties in which at least one of those counties had 7,500 Medicare FFS emergency ambulance transports occur in 2017, they will receive preference during the application review. Transport totals across multiple counties or equivalent entities cannot be combined to meet the 7,500 transport preference. It is not a requirement that an applicant have at least 7,500 transports in a county in their proposed model region in order to participate in the Model.

   Each applicant should review Appendix D: Number of Medicare FFS Emergency Transport Claims by State and County, 2017 (PDF) to determine to determine whether its proposed model region is in a state that meets the 15,000 state-level transport requirement, and the volume of transports in its proposed county or counties. CMS will consider the sum of beneficiaries covered by multiple ambulance providers in a particular region when reviewing applications.

10. Must EMS suppliers or providers ensure 24/7 availability of non-ED options (treatment-in-place or alternative destination) from the start of the Model? *New – September 2019*

    Applicants must provide a detailed plan in their ET3 Model application for ensuring 24/7 availability. If applicants cannot ensure 24/7 availability at the start of the Model, the applicant should provide details in their plan such as an estimated time frame and partnerships needed to ensure 24/7 coverage is achieved.

    For example, an EMS supplier or provider may describe in their application their partnership with an Urgent Care Center opened from 7am-10pm 7 days a week, but state that their treatment-in-place program will be operational no later than June 2020, and it will be available from 10pm to 7am.

11. Can applicants submit other supporting documentation in the ET3 Model RFA Online Portal, besides a LOI or documents submitted in lieu of a LOI? *New – October 2019*

    For all other information, such as supporting documentation or diagrams, the response fields for each question should provide sufficient space to allow applicants to submit comprehensive and concise responses.

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

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

13. Are there any Medicare waivers offered to ET3 participants?

    Yes. CMS will make available conditional waivers of certain requirements of the Medicare program as authorized under section 1115A9d)(1) of the Social Security Act that include requirements related to ambulance services, telehealth, and payments for qualified health care practitioners, as may be necessary solely for purposes of testing the ET3 Model. Additional details about waivers can be found in the Request for Application (PDF).

     

Qualified Health Care Practitioners

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

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

2. Can practitioners other than an MD, PA or NP participate in the ET3 Model as a Qualified Healthcare Practitioner (e.g. licensed clinical social workers) in the Treatment-in-Place (TIP) intervention of the Model? *New - August 2019

   Maybe. If a practitioner such as a licensed clinical social worker satisfies the requirements of a Qualified Health Care Practitioner as it pertains to the particular services the individual would render to beneficiaries in the ET3 Model, the practitioner may be eligible to participate in the ET3 Model. A Qualified Healthcare Practitioner is a Medicare-enrolled health care practitioner who meets state, local, and professional requirements to render particular health care services to beneficiaries; or, is a Medicare-enrolled group practice that includes such practitioners.

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

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

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

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

    

Alternative Destinations

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

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

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

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

   If a model participant implements only the Alternative Destination intervention, then a combination of alternative destination sites can be utilized to satisfy the 24/7 requirement. Please note, if applicants cannot ensure 24/7 availability at the start of the Model, the applicant should provide a detailed plan in their application that includes an estimated time frame and partnerships needed to ensure 24/7 coverage is achieved.

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

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

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

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

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

    

Treatment in Place/Telehealth

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

   Medicare Part B only pays for services included on the list of covered telehealth services when furnished by an interactive telecommunications system. An interactive telecommunications system means multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner. Telephone, facsimile machines, and electronic mail systems do not meet the definition of interactive telecommunications systems. The complete list of covered telehealth services can be found on the CMS website.

2. Will the use of telehealth be subject to all current requirements such as rural location and originating site?

   Waivers of the telehealth geographic and location rules will be made available as necessary to implement the ET3 Model, including waivers that will allow participants to facilitate telehealth at the scene of a 911 response. Additional information about Medicare waivers is included in the ET3 Model RFA PDF.

3. What are the telehealth connectivity requirements of the ET3 Model - for example, what happens if a Medicare-compliant telehealth episode is initiated, but poor connectivity interrupts it? *New - August 2019

   All telehealth encounters initiated under the treatment in place intervention as part of the ET3 Model 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, which define an interactive telecommunications system as multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and the distant site physician or practitioner. Telephones, facsimile machines, and electronic mail systems do not meet the definition of an interactive telecommunications system.

   The Innovation Center recognizes that there may be circumstances in which connectivity may not be sufficient to sustain the telehealth encounter. If the telehealth service is substantially completed when the disruption occurs, then the telehealth encounter is still eligible to be billed under the treatment in place intervention under the ET3 Model. However, if the telehealth treatment in place service cannot be accomplished due to technical difficulties, the patient could be transported to an alternative location or to the ER, as medically appropriate, and the telehealth services are not eligible to be billed per the Medicare Claims Processing Manual (PDF) at Chapter 12, Section 190.

4. Do qualified health care practitioners need to be onsite to provide treatment in place services? Does a qualified health care practitioner have to be part of the EMS crew to provide treatment in place services or could they arrive as a second-tier response and then provide treatment in place services?

   No, qualified health care practitioners are not required to be onsite to provide treatment in place services; they can connect via telehealth and render appropriate medical services. No, a qualified health care practitioner is not required to be part of the EMS crew to provide treatment in place services; they can arrive as a second-tier response onsite or connect anytime via telehealth to provide treatment in place services as medically necessary.

5. Will ambulance suppliers or providers have to identify their own telehealth provider(s)?

   Yes. ET3 Model participants interested in providing treatment in place via telehealth must identify and develop partnerships with qualified health care practitioners who agree to render services via telehealth. Please consult the ET3 Model Participant Partnership Guide for further details.

6. Can an ambulance supplier or provider that is a Participant in the ET3 Model subcontract with a third party to facilitate treatment in place (TIP)? *New - November 2019*

   ET3 Model Participants may partner with an individual or entity to facilitate treatment in place. These individuals and entities would be considered Non-Participant Partners under the Model, and they must be enrolled in Medicare, or employ or contract with Medicare-enrolled individuals or entities (physicians, non-physician practitioners, or group practices) that are qualified to furnish services to Model beneficiaries through the treatment in place intervention. These Non-Participant Partners must be approved by CMS before participating in the Model. Participants will have the opportunity to update their list of Non-Participant Partners during the Model.

7. Who pays for telehealth services provided?

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

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

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

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

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

    

Billing and Reimbursement

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

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

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

   For each of the ET3 Model components (treatment in place and transport to alternative destinations), participants and non-participant partners will bill Medicare using the same billing procedures they would normally use. Ambulance suppliers and providers will bill an amount equivalent to either the ambulance fee schedule Basic Life Support (BLS) base emergency rate or the Advanced Life Support, Level 1 (ALS1) base emergency rate for emergency ground ambulance services for treatment in place and transport to an alternative destination. Payment for transport to an alternative destination will include the same mileage rates and adjustments applicable to current Medicare covered transports to the Emergency Department. (See FAQ #8 and #15 in this section for more information about the ET3 Model ALS Assessment policy.)

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

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

3. In the ET3 Model, how and by whom are triage determinations made? *New - August 2019

   The determination of whether a beneficiary is appropriate for transport to an alternative destination, treatment in place, or transport to a site currently covered by Medicare (e.g. emergency department) should be based upon pre-determined clinical protocols subject to local and state emergency medical services (EMS) rules and regulations and should not depend upon the clinical assessment by a qualified health care practitioner. If an ambulance provider or supplier consults with a doctor or other qualified health care practitioner as part of the triage determination, this consult would not be considered part of the services under the ET3 Model treatment in place intervention.

4. How will participating Ambulance suppliers submit claims for transport to alternative destinations as this is outside of the current Medicare ambulance benefit?*New - October 2019

   ET3 Model participants will use new destination modifiers on their claims for transport to alternative destinations. 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. Further guidance on billing instructions will be provided at a later date.

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

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

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

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

7. What are the medical necessity criteria for treatment in place?*New - October 2019

   The medical necessity criteria for ambulance transport do not apply to treatment in place. The decision to send an ambulance to the scene following a 911 call is made at the point of dispatch. Any services provided through treatment in place, either on the scene or through telehealth, must be medically necessary. These covered services should be viewed in the same way that other covered services under Medicare are viewed in that they must be medically necessary for the beneficiary.

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

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

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

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

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

10. Can an EMS supplier bill for multiple services in the same beneficiary encounter under the ET3 Model? For example, if a patient receives Treatment-in-Place (TIP) but it is then determined the patient requires transportation to the emergency department, can a supplier bill for both TIP and transport? *New - August 2019

    No. EMS suppliers cannot bill multiple services for the same beneficiary encounter. If a beneficiary being treated-in-place has a real time deterioration in their clinical condition necessitating immediate transport to an emergency department, the EMS supplier cannot bill for both the TIP intervention and the transport to the Emergency Department (ED). In this scenario, the supplier would submit a claim for transport to the ED only.

11. If a beneficiary is successfully transported, treated, and released from an alternative destination site, such as an Urgent Care Center, but later on in the same day calls 911 again because of a deterioration in condition, will the ambulance supplier or provider be paid for services rendered in both encounters as a Participant under the ET3 Model? *New - August 2019

    Yes. A beneficiary can receive multiple treatment interventions for which the ambulance supplier or provider will be paid, as long as each intervention stems from a separate 911 call or beneficiary encounter. CMS will closely monitor all claims for fraud, waste, and abuse. Ambulances billing a large number of claims for the same beneficiary in the same day will be subject to further investigation.

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

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

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

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

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

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

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

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

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

     

Partnerships and Stakeholder Engagement

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

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

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

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

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

   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. Will the Innovation Center provide a template for legal documents such as the letter of intent (LOI) that is needed for partners (alternative destination sites, and Medicare-enrolled qualified health care practitioners who would be involved in treatment in place) as part of the application to participate in the ET3 Model? *New - August 2019

   No. The Innovation Center is unable to provide templates for legal documents, including LOIs, to applicants or model participants. For more information on what the LOI must include, please refer to the ET3 Model Request for Applications (PDF) on page 27 (alternative destinations), page 29 (treatment in place), and pages 31-32 (payer strategy).

3. Where an ET3 Model applicant has chosen to submit a multi-payer strategy, may the applicant submit documentation other than a Letter of Intent (LOI) to support the statements made in their multi-payer strategy? *New – September 2019*

   To be eligible for the ET3 Model, an applicant must provide either a plan to align ET3 innovations across multiple payers or a plan to operationalize its proposed intervention design for Medicare FFS beneficiaries only. In the event that an applicant has chosen to submit a multi-payer strategy, and that plan identifies a specific payer as a proposed partner, submission of an LOI provides evidence to support this partnership. If conversations between an applicant and a payer are not yet to the point where the two entities are comfortable signing an LOI, then other forms of documentation may be provided in lieu of the LOI to support the applicant’s description of the shared vision among the two parties.

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

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

Monitoring and Evaluation

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

   No earlier than in year three of the Model, participants who meet the criteria for a performance-based payment may be eligible for an upward adjustment to payments associated with Model interventions. Participants are not subject to downside risk under the Model. More information on this topic will be released 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 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. To ask further questions, please email us at ET3Model@cms.hhs.gov.

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

   Details regarding the collection of quality metrics will be released in subsequent model documents on the ET3 Model web page.

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