Medicare Pilots a Program for Emergency Triage Outside of the Hospital

The Emergency Triage, Treat, and Transport Model

Two ambulance EMS vehicles

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Ambulance care tends to be expensive. The average cost per ride is $400 to $1,200 or more plus mileage. Unfortunately, having insurance does not necessarily reduce those costs. Medicare has traditionally limited what it covers and many other insurance plans will not pay for transportation if the ambulance company is out of their network. That is about to change, at least for Medicare beneficiaries.

Center for Medicare and Medicaid Innovation (CMMI)

The Center for Medicare and Medicaid Innovation, also known as the CMS Innovation Center, was created by the Affordable Care Act in 2010. Its goal was to investigate different payment and health care delivery models that would not only improve health care for Medicare and Medicaid beneficiaries but that would also decrease overall health expenditures.

Successful models to date have included the Independence at Home program which increases house calls for Medicare beneficiaries with chronic medical conditions and the Diabetes Prevention Program which provides increased education and resources for those at risk for diabetes. Each program reduced annual spending by thousands of dollars per person.

Now, the CMMI is looking to see whether changing Medicare coverage for ambulance services will help to decrease the need for care in the emergency room.

Traditional Medicare Coverage for Ambulance Transportation

Until now, Medicare has restricted coverage of ambulance ground transportation. It is only indicated if there is no other safe means of transportation and you are being transported to receive care covered by Medicare. The ambulance must transport you to the nearest medical facility that can provide the appropriate level of care. That may include hospitals, critical access hospitals, and skilled nursing facilities.

If all these criteria are met and Medicare considers the service to be medically necessary, they will cover 80% of the charges, leaving you to pay a 20% coinsurance. Your Medicare Part B deductible applies in this case.

In a medical emergency, your health is immediately at stake. However, there will be times when you need non-emergent medical care.

For example, people who have end-stage renal disease (kidney failure) may require multiple dialysis sessions per week. Ambulance transportation may be the only way some people can get to their appointments.

In cases like this, Medicare may cover transportation but only after a prior authorization has been granted. This means your doctor must complete paperwork to prove that the service is medically necessary, and then Medicare must approve the transportation in advance.

Emergency Triage, Treat, and Transport (ET3) Model

Under the traditional Medicare model, emergency ambulance services are only covered when the patient is transported to facilities that provide the most expensive care. Not only does this increase total expenditures for Medicare, the increased out of pocket costs may dissuade people from seeking help when they need it most.

CMMI's new pilot program, also known as the Emergency Triage, Treat, and Transport (ET3) Model, shifts the paradigm. It allows first responders to triage and direct people to alternative destinations based on their medical needs.

Instead of being limited to emergency departments and hospitals, they can transport people to doctor's offices and urgent care clinics. They may even recommend that the person remains in their home with care supervised by a qualified health care practitioner via telehealth.

The goal is to provide quality, appropriate care that is cost-effective. To this end, CMS is providing 40 grants to local governments or agencies that operate 911 dispatch centers. The pilot will begin in 2020 and will be monitored over five years for clinical outcomes and health care spending. It is estimated the ET3 model could save Medicare as much as $500 million per year if it were adopted nationwide.

A Word From Verywell

Medicare may be expanding services to cut costs. It may sound like an oxymoron but it makes sense. Until now, Medicare ambulance services were only covered for transportation to the most expensive facilities, namely emergency departments and critical access hospitals.

Now a pilot program is being put in place that will allow first responders to direct care to alternate facilities as appropriate. Although Medicare will end up paying more for ambulance services, it may pay considerably less for hospital care. Medicare is expected to save millions.

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