Apple Health - Settle payments for GEMT claims submitted to MCOs

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Apple Health (Medicaid) Provider Alert

What is changing?

The Health Care Authority (the agency) has received approval from the Centers for Medicare and Medicaid Services (CMS) to provide settlement payments for Ground Emergency Medical Transportation (GEMT) claims submitted to managed care organizations (MCOs). The payments are to bring providers up to their determined average cost per transport.

Please note, the mechanism for this process is still in development. The agency will disburse MCO settlement payments in late 2018. 

What time period will be settled for MCO claims?

As approved by CMS, the MCO settlement period is for calendar year 2017 (January 1, 2017 – December 31, 2017) only.

The agency will not be able to provide any settlement payments back to the program implementation date (June 2, 2016).

How will providers receive settlement funds for MCO claims?

The agency is working closely with MCOs and stakeholders to determine the process. The agency will provide more information as it is available.

The agency will invoice providers for the non-federal share of the average cost per transport and participating providers will need to send the funds to the agency as an intergovernmental transfer (IGT). 

  • An IGT is a transfer of funds from one governmental entity (e.g. city, county, state, or federal) to the state Medicaid agency.
  • The ability of states to use IGTs to fund their Medicaid program is recognized in statute (§1903(w)(6) of the Social Security Act) and rule (42 CFR §433.51). 

Upon receipt of the IGT, the full cost per transport (minus 20% of the IGT) will be returned to the provider via the MCOs as a one-time settlement payment.

Going forward, the agency will perform and reconcile all settlement activity.

For more information, contact Shauna Penn, GEMT Program Manager.