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TITLE 25HEALTH SERVICES
PART 1DEPARTMENT OF STATE HEALTH SERVICES
CHAPTER 157EMERGENCY MEDICAL CARE
SUBCHAPTER GEMERGENCY MEDICAL SERVICES TRAUMA SYSTEMS
RULE §157.131Designated Trauma Facility and Emergency Medical Services Account

(a) Definitions. The following words and terms, when used in this section, shall have the following meanings, unless the context clearly indicates otherwise.

  (1) Extraordinary emergency--An event or situation which may disrupt the services of an EMS/trauma system.

  (2) Rural county--A county with a population of less than 50,000 based on the latest official federal census population figures.

  (3) Urban county--A county with a population of 50,000 or more based on the latest official federal census population figures.

  (4) Emergency transfer--Any immediate transfer of an emergent or unstable patient, ordered by a licensed physician, from a health care facility to a health care facility which has the capability of providing a higher level of care or of providing a specialized type of care not available at the transferring facility.

  (5) Trauma care--Care provided to patients who met the facility's trauma team activation criteria and/or were entered into the facility's Trauma Registry and underwent treatment specified in at least one of the following ICD-9 (International Classification of Diseases, 9th Revision, of the National Center of Health Statistics) codes: between 800 and 959.9, including 940-949 (burns), excluding 905-909 (late effects of injuries), 910-924 (blisters, contusions, abrasions, and insect bites), 930-939 (foreign bodies), and who underwent an operative intervention as defined in paragraph (9) of this subsection or was admitted as an inpatient for greater than 23-hours or who died after receiving any emergency department evaluation or treatment or was dead on arrival to the facility or who transferred into or out of the hospital.

  (6) Uncompensated trauma care--The sum of "charity care" and "bad debt" resulting from trauma care as defined in (a)(5) of this section after due diligence to collect. Contractual adjustments in reimbursement for trauma services based upon an agreement with a payor (to include but not limited to Medicaid, Medicare, Children's Health Insurance Program (CHIP), etc.) is not uncompensated trauma care.

  (7) Charity care--The unreimbursed cost to a hospital of providing health care services on an inpatient or emergency department basis to a person classified by the hospital as "financially indigent" or "medically indigent".

    (A) Financially indigent--An uninsured or underinsured person who is accepted for care with no obligation or a discounted obligation to pay for the services rendered based on the hospital's eligibility system.

    (B) Medically indigent--A person whose medical or hospital bills after payment by third-party payors (to include but not limited to Medicaid, Medicare, CHIP, etc.) exceed a specified percentage of the patient's annual gross income, determined in accordance with the hospital's eligibility system, and the person is financially unable to pay the remaining bill.

  (8) Bad debt--The unreimbursed cost to a hospital of providing health care services on an inpatient or emergency department basis to a person who is financially unable to pay, in whole or in part, for the services rendered and whose account has been classified as bad debt based upon the hospital's bad debt policy. A hospital's bad debt policy should be in accordance with generally accepted accounting principles.

  (9) Operative intervention--Any surgical procedure resulting from a patient being taken directly from the emergency department to an operating suite regardless of whether the patient was admitted to the hospital.

  (10) Active pursuit of department designation as a trauma facility--means that an undesignated licensed facility, applying for designation from the department as a trauma facility after September 1, 2005, must submit to the department:

    (A) a statement of intent to seek designation;

    (B) a timely and sufficient application to the department's trauma facility designation program or appropriate agency for trauma verification;

    (C) evidence of participation in Trauma Services Area (TSA) Regional Advisory Council (RAC) initiatives;

    (D) evidence of a hospital trauma performance improvement committee; and

    (E) data to the department's EMS/Trauma Registry.

  (11) Calculation of the costs of uncompensated trauma care--For the purposes of this section, a hospital will calculate its total costs of uncompensated trauma care by summing its charges related to uncompensated trauma care as defined in paragraph (6) of this subsection, then applying the cost to charge ratio defined in paragraph (13) of this subsection and derived in accordance with generally accepted accounting principles.

  (12) County of licensure--The county within which lies the location of the business mailing address of a licensed ambulance provider, as indicated by the provider on the application for licensure form that it filed with the department.

  (13) Cost-to-charge ratio--A hospital's overall cost-to-charge ratio determined by the Health and Human Services Commission from the hospital's Medicaid cost report. The hospital's latest available cost-to-charge ratio shall be used to calculate its uncompensated trauma care costs.

(b) Reserve. On September 1 of each year, there shall be a reserve of $500,000 in the designated trauma facility and emergency medical services account (account) for extraordinary emergencies. During the fiscal year, distributions may be made from the reserve by the commissioner of health based on requests which demonstrate need and impact on the EMS and trauma care system (system). Proposals not immediately recommended for funding will be reconsidered at the end of each fiscal year, if funding is available, and a need is still present.

(c) Allocations. The EMS allocation shall be not more than 2%, the TSA allocation shall be not more than 1%, and the hospital allocation shall be at least 96% of the funds appropriated from the account, after the extraordinary emergency reserve of $500,000 has been deducted.

  (1) Allocation Determination. Each year, the department shall determine:

    (A) eligible recipients for the EMS allocation, TSA allocation, and hospital allocation;

    (B) the amount of the TSA allocation, the EMS allocation, and the hospital allocation;

    (C) each county's share of the EMS allocation for eligible recipients in the county;

    (D) each RAC's share of the TSA allocation; and

    (E) each facility's share of the hospital allocation.

  (2) EMS Allocation. The department shall contract with each eligible RAC to distribute the county shares of the EMS allocation to eligible EMS providers based within counties which are aligned within the relevant RAC. Prior to distribution of the county shares to eligible providers, the RAC shall submit a distribution proposal, approved by the RAC's voting membership, to the department for approval.

    (A) The county portion of the EMS allocation shall be distributed directly to eligible recipients without any reduction in the total amount allocated by the department and shall be used as an addition to current county EMS funding of eligible recipients, not as a replacement.

    (B) The department shall evaluate each RAC's distribution plan based on the following:

      (i) fair distribution process to all eligible providers, taking into account all eligible providers participating in contiguous TSAs;

      (ii) needs of the EMS providers; and

      (iii) evidence of consensus opinion for eligible entities.

    (C) A RAC opting to use a distribution plan from the previous fiscal year shall submit, to the department, a letter or email of intent to do so.

    (D) Eligible EMS providers may opt to pool funds or contribute funds for a specified RAC purpose.

  (3) TSA Allocation. The department shall contract with eligible RACs to distribute the TSA allocation. Prior to distribution of the TSA allocation, the RAC shall submit a budget proposal to the department for approval. The department shall evaluate each RAC's budget according to the following:

    (A) budget reflects all funds received by the RAC, including funds not expended in the previous fiscal year;

    (B) budget contains no ineligible expenses;

    (C) appropriate mechanism is used by RAC for budgetary planning; and

    (D) program areas receiving funding are identified by budget categories.

  (4) Hospital Allocation. The department shall distribute funds directly to facilities eligible to receive funds from the hospital allocation to subsidize a portion of uncompensated trauma care provided or to fund innovative projects to enhance the delivery of patient care in the overall EMS/Trauma System. Funds distributed from the hospital allocations shall be made based on, but not limited to:

    (A) the percentage of the hospital's uncompensated trauma care cost in relation to total uncompensated trauma care cost reported by qualified hospitals that year; and

    (B) availability of funds.

(d) Eligibility requirements. To be eligible for funding from the account, all potential recipients (EMS Providers, RACs, Registered First Responder Organizations and hospitals) must maintain active involvement in regional system development. Potential recipients also must meet requirements for reports of expenditures from the previous year and planning for use of the funding in the upcoming year.

  (1) Extraordinary Emergency Funding. To be eligible to receive extraordinary emergency funding, an entity must:

    (A) be a licensed EMS provider, a licensed hospital, or a registered first responder organization;

    (B) submit to the department a signed written request, containing the entity name, contact information, amount of funding requested, and a description of the extraordinary emergency; and

    (C) timely submit a signed and fully completed extraordinary emergency information checklist (on the department's form) to the department.

  (2) EMS Allocation. To be eligible for funding from the EMS allocation an EMS provider must meet the following requirements:

    (A) maintain provider licensure as described in §157.11 of this title and provide emergency medical services and/or emergency transfers;

    (B) demonstrate utilization of the RAC regional protocols regarding patient destination and transport in all TSAs in which they operate (verified by each RAC);

    (C) demonstrate active participation in the regional system performance improvement (PI) program in all TSAs in which they operate (verified by each RAC);

    (D) if an EMS provider is licensed in a county or contracted to provide emergency medical services in a county that is contiguous with a neighboring TSA, it must participate on at least one RAC of the TSAs:

      (i) participation on both RACs is encouraged;

      (ii) RAC participation shall follow actual patient referral patterns;

      (iii) an EMS provider contracted to provide emergency medical services within a county of any one TSA and whose county of licensure is another county not in or contiguous with that TSA must be an active member of the RAC for the TSA of their contracted service area and meet that RAC's definition of participation and requirements listed in subparagraph (E)(i) - (vi) of this paragraph; and

      (iv) it is the responsibility of an EMS provider to contact each RAC in which it operates to ensure knowledge of the provider's presence and potential eligibility for funding from the EMS allotment related to that RAC's TSA;

    (E) if an EMS provider is serving any county beyond its county of licensure it must provide to the department evidence of a contract or letter of agreement with each additional county government or taxing authority in which service is provided:

      (i) inter-facility transfer letters of agreement and/or contracts, as well as mutual aid letters of agreement and/or contracts, do not meet this requirement;

      (ii) contracts or letters of agreement must be dated and submitted to the department on or before August 31 of the respective year, and be effective more than six months of the upcoming fiscal year;

      (iii) effective dates of the contracts or letters of agreement should be provided;

      (iv) EMS providers with contracts or letters of agreement on file with the department which include contract service dates that meet the required time period (noted in this subsection) need not resubmit;

      (v) EMS providers are responsible for assuring that all necessary portions of their contracts and letters of agreement have been received by the department; and

      (vi) air ambulance providers must meet the same requirements as ground transport EMS providers to be eligible to receive funds from a specific county other than the county of licensure; and

    (F) if a EMS provider is licensed in a particular county and has a contract (with a county government or taxing authority) for a service area which is a geopolitical subdivision (examples listed below) whose boundary lines cross multiple county lines, it will be considered eligible for the 911 EMS Allocation for all counties overlapped by that geopolitical subdivision's boundary lines. A contract with every county that composes the geopolitical subdivision is not necessary. And, the eligibility of EMS providers, whose county of licensure is in a geopolitical subdivision other than those listed in clauses (i) - (vi) of this subparagraph, will be evaluated on a case-by-case basis.

      (i) Municipalities.

Cont'd...

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