DEPARTMENT OF HEALTH AND HUMAN SERVICES 
Centers for Medicare & Medicaid Services  
7500 Security Boulevard, Mail Stop S2-26-12  
Baltimore, MD 21244-1850 
Joint Informational Bulletin 
DATE:  August 8, 2019 
FROM:  Adam Boehler 
Deputy Administrator and Director 
Center for Medicare and Medicaid Innovation 
Calder Lynch, Acting Deputy Administrator and Director 
Center for Medicaid and CHIP Services 
SUBJECT:  Medicaid Opportunities in the Emergency Triage, Treat, and Transport 
(ET3) Model 
This informational bulletin describes ways in which state Medicaid agencies can support the 
implementation of the Emergency Triage, Treat, and Transport (ET3) Model, a voluntary, five-
year Center for Medicare and Medicaid Innovation (Innovation Center) payment model designed 
to reduce unnecessary transport to the Emergency Department (ED).  Specifically, the ET3 Model 
will provide greater flexibility to ambulance care teams to address emergency health care needs of 
Medicare Fee-for-Service (FFS) beneficiaries following a 911 call, with the goal of improving 
quality of care to Medicare beneficiaries1 and lowering costs to Medicare. Although ET3 is a 
Medicare payment model, the Innovation Center recognizes that Medicare-enrolled ambulance 
suppliers or hospital-based ambulance providers that participate in the model and implement the 
model interventions across multiple payers, including Medicaid, will be in the best position to 
achieve ET3s cost and quality goals.  For states interested in replicating the flexibilities of this 
new model within their Medicaid program, this bulletin provides information for consideration 
when designing ET3-alligned interventions for ambulance care teams that address emergency 
health care needs of Medicaid beneficiaries. It also summarizes current studies, which suggest 
possible strategies states may want to consider in building effective payment approaches to avert 
unnecessary transport to the ED. 
To incentivize multi-payer alignment in the ambulance services sector, and in recognition of 
Medicaids role as a driver for state-based innovation in the unscheduled, emergency ambulance 
sector, the Innovation Center will provide an interactive ET3 Model Learning System with 
targeted learning opportunities for state Medicaid programs.  These opportunities will provide 
states with a structured forum to address payment development and barriers to the 
implementation of ET3-aligned innovations, and is meant to further facilitate Medicaid 
incorporation in the multi-payer strategies submitted by ET3 applicants.  To the extent possible, 
CMS also plans to evaluate ET3-aligned innovations implemented within Medicaid during the 
1As designed by the Innovation Center, the model population for the ET3 Model is fee-for-service beneficiaries, including those dually-eligible 
for Medicare and Medicaid coverage.   
Informational Bulletin  Page 2 
 
course of the Model using available data sources such as T-MSIS data or data voluntarily 
provided by States. State Medicaid agencies that are interested in working with ET3 Model 
Participants to pilot multi-payer alignment in states or sub-state regions will be able to participate 
in ET3 Model Learning System activities, which may include: assistance with exploring and 
creating plans that may facilitate multi-payers alignment or other relevant needs; training to 
promote spread and scale; activities that address barriers to payment development and 
implementation; and peer-to-peer learning among states to encourage state-to-state knowledge 
transfer about model implementation in unique state environments.  Details on how states can 
join the ET3 Model Learning System will be shared after Participant selection.  If no Participants 
are selected in a given state, interested states will not be precluded from engaging in ET3 Model 
Learning System activities. 
 
Background on the ET3 Model 
 
Currently, Medicare may pay for emergency ground ambulance services when individuals are 
transported to a limited number of covered destinations set forth in the regulations. This creates a 
perverse incentive to bring Medicare beneficiaries to high-acuity, high-cost settings (e.g., hospital 
emergency  departments  (EDs)),  even  when  a  lower-acuity,  lower-cost  setting  may  more 
appropriately meet an individuals needs. The ET3 Model aims to address these misaligned 
incentives by providing greater person-centered care options, encouraging appropriate utilization 
of services, and increasing efficiency in the emergency medical services system. The ET3 Model 
will test the following new Medicare payments to the Medicare-enrolled ambulance suppliers or 
hospital-based ambulance providers participating in the ET3 Model: 1) payment for unscheduled 
emergency ambulance transport of Medicare FFS beneficiaries to alternative destinations2 not 
currently covered by Medicare; and, 2) payment for treatment in place3 where appropriate, 
rendered by a qualified health care practitioner4 either on-the-scene or via telehealth.  
 
To ensure that these payment innovations achieve the models goals, the ET3 Model was designed 
around three core features: 
 
1.  Payments for emergency medical services (EMS) innovations.  ET3 Participants will 
be eligible for payments for 1) transporting Medicare FFS beneficiaries to alternative 
destinations approved in advance by CMS; and, 2) facilitating appropriate treatment in 
place at the scene or via telehealth. Participants who demonstrate high quality of care 
based on performance metrics described in the ET3 Request for Applications (RFA)5 and 
finalized in the Model Participant Agreement may be eligible for an additional 
performance-based payment adjustment beginning no sooner than year three of the 
                                                           
2 An alternative destination is destination to which model Participants may transport a beneficiary who meets medical necessity requirements, 
as an alternative to a hospital emergency department or other site traditionally covered by Medicare. Examples of allowable alternative 
destinations under the model may include: federally qualified health centers, physician offices, or urgent care centers. 
3 In the ET3 Model, treatment in place is a non-transport intervention facilitated by model Participants, which may include: (1) telehealth 
services rendered by a qualified health care practitioner located at a distant site or (2) in-person services rendered by a qualified health care 
practitioner at the scene of the emergency response.  
4 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. Only qualified health care practitioners may provide treatment in place in the ET3 Model. 
5 The ET3 Request for Applications can be found at < https://innovation.cms.gov/Files/x/et3-rfa-preview.pdf>. Please note that this is only the 
PDF form of the RFA. The online portal where ambulance providers and suppliers will be able to apply to participate in the ET3 Model will 
become available later this summer (2019).   
Informational Bulletin  Page 3 
 
model.  The model does not alter coverage or payment for Part B ambulance services that 
are not provided in connection with this model. A Medicare beneficiary who is eligible 
for the interventions available under the ET3 Model may elect to receive an intervention 
or may choose to be transported to a covered destination pursuant to existing state and 
local EMS protocols and Medicare requirements.  All non-ambulance services furnished 
to ET3 Model beneficiaries will be furnished by Medicare-enrolled providers and 
suppliers, such as the alternative destination sites and qualified health care practitioners 
discussed below, who have been vetted and approved in advance by CMS to promote 
beneficiary safety and reduce program integrity risks.  
 
2.  Multi-payer participation. Participants will be chosen in part based on their ability to 
implement the ET3 Model interventions within the context of a multi-payer environment. 
In their responses to the ET3 RFA, each Applicant must set forth a feasible multi-payer 
alignment strategy within the context of its proposed plan for implementing the model 
interventions; or, explain how the Applicant would successfully implement the model 
interventions for Medicare FFS beneficiaries only.  (See ET3 RFA Section VIII, 
Selection Criteria). 
  
3.  Enhanced monitoring and enforcement. While state Medicaid agencies may establish 
their  own  medical  necessity  criteria  for  ambulance  services  rendered  to  Medicaid 
beneficiaries, ambulance transportation is covered under Medicare Part B only to the extent 
that  other  means  of  transportation  are  contraindicated  by  the  beneficiarys  medical 
condition.  In any case in which some means of transportation other than an ambulance 
could be used without endangering the individual's health, whether or not such other 
transportation is actually available, no payment may be made for ambulance services. 
Robust monitoring and enforcement will be designed to ensure that payment and services 
are consistent with applicable coverage policies, and that the model achieves its goals, 
including those related to saving lives by creating greater efficiencies in use of emergency 
transport.  
 
In total, these innovations will help ensure Medicare FFS beneficiaries have access to a fuller scope 
of ambulance services, incur fewer out-of-pocket costs by facilitating lower-cost treatment in 
lower-acuity settings, and receive the most appropriate level of care at the right time and place. 
Available data also demonstrate that treatment in place and alternative destination programs have 
the potential to improve outcomes in costs, avert ED visits, and reduce time to discharge (see 
Appendix A Tables I and II).  By allowing beneficiaries with lower-acuity needs the opportunity 
to access care in more appropriate settings, the ET3 Model could also allow EMS time and 
resources to more readily respond to and focus on high-acuity cases. Furthermore, the ET3 Model 
presents an opportunity to build accountability through monitoring of specific quality metrics and 
adverse events in a new system of EMS care delivery.  
 
While the model population for ET3 Model is Medicare FFS beneficiaries, in areas where ET3 
Participants are able to foster multi-payer participation, the anticipated outcomes of the ET3 model 
have the potential to accrue to a larger patient population that could include Medicaid beneficiaries 
and those who receive insurance coverage through commercial payers. 
    
Informational Bulletin  Page 4 
 
ET3 Model Payments 
 
In order for states to understand how they may wish to align their Medicaid payments with the 
ET3 Model, this section describes Medicare payments under the model.  While all ET3 Model 
Participants are required to implement the alternative destination intervention; applicants who also 
propose to implement the optional treatment in place intervention have the opportunity to earn 
additional points towards their overall application score. 
 
Medicare Payment for Transport to Alternative Destinations  
 
A Participant that transports a Medicare beneficiary to an approved alternative destination through 
the model must bill for and will receive payment at a rate equivalent to the appropriate Medicare 
Part B ambulance fee schedule base rate for emergency Basic Life Support (BLS-E) ground 
ambulance (HCPCS code A0429) transport or emergency Advanced Life Support, Level 1 (ALS1-
E) ground ambulance (HCPCS code A0427) transport in addition to mileage (HCPCS A0425). 
The appropriate payment rate is based on the existing Medicare definitions of BLS-E and ALS1-
E services. In order to bill at the ALS1-E level, a Participant must render services that meet the 
Medicare definition of Advanced Life Support, including transportation by ground ambulance 
vehicle and the provision of medically necessary supplies and services including the provision of 
an ALS assessment by ALS personnel or at least one ALS intervention.  Payment for transport to 
an alternative destination will include the same mileage rates and adjustments as current BLS-E or 
ALS1-E Medicare-covered transports to the ED.  Aligning Participant payments with the BLS-E 
or ALS1-E base rate payment for transport to the ED will align incentives to promote interventions 
that most appropriately address beneficiary needs. Over the life of the model, payments will be 
updated annually to match the BLS-E and ALS1-E base rates in the Medicare Ambulance Fee 
Schedule (AFS). 
 
An  alternative  destination  site  must  have  sufficient  Medicare-enrolled  physicians  or  other 
practitioners to meet the needs of Medicare FFS beneficiaries who require services through the 
model.  An alternative destination site may be a Medicare-enrolled institutional provider; or, may 
be an entity that is not enrolled in Medicare but engages Medicare-enrolled qualified health care 
practitioners that have the capacity to render covered services to Medicare FFS beneficiaries.  
 
Payment for Treatment in Place 
 
A Participant that facilitates in-person treatment in place will be paid an amount equivalent to the 
BLS-E or ALS1-E base rate. In order to bill at the ALS1-E base rate, a Participant must provide 
medically necessary supplies and services and either an ALS assessment by ALS personnel or the 
provision of at least one ALS intervention.6 A Participant that facilitates treatment in place via 
telehealth will be paid a modified telehealth originating site facility fee equivalent to the BLS-E 
or ALS1-E base rate, depending on the level of service provided.  A Participant that facilitates in-
person or telehealth treatment in place must separately bill Medicare using a model-specific code 
for an amount equal to the BLS-E base rate under HCPCS A0429 or, if the Participant meets the 
requirements for billing at an ALS1-E rate, under HCPCS A0427.  Similar to the payments for 
                                                           
6 42 C.F.R. 414.605, Fee Schedule for Ambulance Services, Definitions.   
Informational Bulletin  Page 5 
 
transport to alternative destinations, aligning Participant payments for treatment in place with the 
appropriate BLS-E or ALS1-E base rate payment will align incentives to promote interventions 
that most appropriately address beneficiary needs. Over the life of the model, payments will be 
updated annually to match the emergency BLS-E or ALS1-E base rates in the Medicare AFS. 
  
Table 1. Example of Possible ET3 Payment Scenarios 
 
PAYMENT 
INTERVENTION 
Participant  Non-Participant Partner7 
Medicare billed for services 
BLS-E or ALS1-E base rate + 
Transport to  furnished under the applicable FFS 
mileage and adjustments8 
Alternative  rules. Payment amount depends on 
 
Destination  service rendered at the alternative 
 
destination site. 
Medicare billed under Physician 
  Payment equal to BLS-E or  Fee Schedule for telehealth 
Treatment in Place  ALS1-E base rate = Telehealth  services furnished 
(qualified health care  originating site fee + modifier to   
practitioner, via  equal BLS-E or ALS1-E base  Payment = Medicare Physician 
Telehealth)  rate  Fee Schedule amount for furnished 
service 
Medicare billed under Physician 
 
Fee Schedule for services 
Treatment in Place 
Payment = BLS-E or ALS1-E  furnished 
(qualified health care 
base rate   
practitioner,  
  Payment = Medicare Physician 
in-person ) 
Fee Schedule amount for furnished 
 
service 
 
Medicaid Coverage of Emergency Transportation Services 
 
Transportation to medical care is a mandatory assurance in the Medicaid program. Accordingly, 
42 CFR 431.53 requires states to assure necessary transportation for beneficiaries to and from 
providers, as well as detail the methods that the state will use to meet this requirement.  Federal 
law does not recognize emergency transportation services as distinct from the overall assurance 
of transportation in Medicaid.  Additionally, federal Medicaid law and regulations do not specify 
that emergency transportation must be to an emergency department of a hospital.  Due to this 
framework, states have the flexibility to structure emergency transportation services that would 
meet the goals of the ET3 Model.  Below, we highlight a range of options for states wishing to 
use the provided evidence base and the ET3 Model framework to consider changes or 
enhancements to their EMS systems.  
                                                           
7 A CMS-approved qualified health care practitioner or an alternative destination site that partners with the Participant to furnish services to a 
Medicare beneficiary through the ET3 Model, and has entered into a voluntary agreement with a Participant that satisfies all of the applicable 
requirements of the ET3 Model Participation Agreement. 
8 Adjustments include the geographic adjustment factor ( 414.610(c)(4)), the rural adjustment factors ( 414.610(c)(5)(i) and (ii)), and rural and 
urban add-ons ( 414.610(c)(1)(ii)), and the multiple patient rule, if applicable ( 414.610(c)(6)).   
Informational Bulletin  Page 6 
 
 
Medicaid Flexibilities in Implementing the Goals of the ET3 Model 
 
State Medicaid agencies have considerable flexibility within federal guidelines to achieve the 
aims of the ET3 Model.  The assurance of transportation requires transport of the Medicaid 
beneficiary to a covered service; thus, when considering implementation of the ET3 Model 
framework to provide treatment on scene (with no transport), states have the flexibility to 
recognize these professionals under various Medicaid coverage authorities.  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 on scene. Other licensed 
practitioner services, defined at 42 CFR 440.60, are ... medical or remedial care or services, 
other than physicians services, provided by licensed practitioners within the scope of practices 
as defined under State law. For example, states could consider submitting a State Plan 
Amendment (SPA) recognizing licensed paramedics under 1905(a)(6) in order to provide 
payment for the treatment of services furnished on the scene when no transport takes place.  In 
these instances, states should assess the type of professionals furnishing services and their 
qualifications to determine the appropriate coverage authorities. 
  
A number of state Medicaid agencies have implemented or plan to implement ambulance service 
innovations, including opportunities to provide transport to alternative destinations or treatment 
in place similar to those in the ET3 Model, as well as additional EMS interventions beyond the 
scope of the ET3 Model.  Examples of alternative destination locations include urgent care and 
freestanding behavioral and mental health facilities, group practices, ambulatory care settings, 
crisis centers, and community clinics. Generally, regulations for alternative destination or 
treatment in place policies differ among states. State regulationssuch as those explicitly 
prohibiting alternative destinations, restricting to one or two explicit destinations, or those with 
vague or conflicting requirementscan make it difficult to establish and operate the ET3 Model 
framework.  Thus, states electing to implement the aims of the ET3 Models should assess their 
state policies to determine to what extent changes to their policies are necessary. 
 
Mandatory and optional benefits available through a states Medicaid plan must be offered within 
federal requirements for statewideness,  comparability,  and freedom of  choice. Additionally, 
individual rules governing a Medicaid benefit must be followed.  Depending on the state specific 
design, state Medicaid agencies may need to pursue SPAs for CMS approval or seek waivers of 
statewideness, comparability, and/or freedom of choice to implement new services aligned with 
the ET3 Model to receive federal payment for those services. States that have begun to develop 
the infrastructure and expertise necessary to innovate in the Medicaid ambulance space may be 
well-positioned to implement complementary multi-payer interventions outside the Medicare 
population.  
 
Finally, states also have a variety of delivery system options for providing transportation services 
to Medicaid beneficiaries. States choosing to use a managed care plan to deliver benefits may have 
additional flexibilities than those afforded through the state plan. While managed care plans would 
still be required to follow applicable laws and regulations related to transportation, a managed care 
plan may be able to more easily pay for alternative destinations or on-site care even if those are 
not included in the Medicaid state plan.  For example, a state may consider on-site care as an in-  
Informational Bulletin  Page 7 
 
lieu of service if it determines that the on-site care is an appropriate alternative service or setting 
to a Medicaid service covered under the managed care plan contract.  A state that plan to utilize a 
managed care delivery system should discuss these options with CMS as well as its Medicaid 
managed care plans to determine how best to implement the ET3 Model within the state.  
 
Medicaid Payment for Emergency Transportation Services 
The scope of services offered through the ET3 Model are available only to Medicare FFS 
beneficiaries, including beneficiaries dually eligible for Medicare and Medicaid. States that 
choose to offer services aligned with the ET3 Model in their Medicaid programs must pay for 
such services, including treatment in place and transportation to an alternative destination, with 
Medicaid funds at the applicable federal medical assistance percentages.  
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 typically for services through fee-for-service or managed care 
arrangements.   States are responsible for setting rates to pay providers for furnishing health care 
services to Medicaid beneficiaries.  
Whatever payment methodology a state elects to implement, once developed, states must 
describe it comprehensively in their Medicaid state plan.  Typically state payment methodologies 
provide for a standard payment rate to all Medicaid providers on a per claim basis for services 
rendered to a Medicaid beneficiary, but there is flexibility in this as well.  Federal guidelines 
require states to be prudent purchasers of health care services with states sharing in the 
responsibility to pay for a portion of Medicaid expenditures through non-federal funding sources.  
Accordingly, section 1902(a)(30)(A) of the Social Security Act requires states to have methods 
and procedures for the utilization of, and payment for, care and services available under the state 
plan to assure Medicaid payments for services are consistent with efficiency, economy, and 
quality of care. Further, these methods and procedures must be sufficient to enlist enough 
providers so that care and services are available under the plan at least to the extent that such 
care and services are available to the general population in the geographic area.   
States have great flexibility in the Medicaid program, but implementing innovations aligned with 
the ET3 Model may require changes to state plan language, and we encourage states to discuss 
their ideas with CMS before implementation.  
State Medicaid Participation Assessment for ET3 Readiness 
Given the flexibilities described above, a state seeking alignment with the model should conduct 
an assessment that includes reviewing the operational environment for ambulance providers and 
their professionals.  
The following questions should help a state determine which paths to pursue to align with the 
model. 
1.  Assess the state operational environment by reviewing state policies and regulations 
governing emergency ambulance services.   
Informational Bulletin  Page 8 
 
a.  Do state policies/regulations prohibit emergency ambulance providers from 
transporting beneficiaries to alternative destinations?  
Transport to alternative destinations is a key service to test under the ET3 model. 
State policies/regulations that prescribe certain locations to which a beneficiary may 
be transported may need updating. 
b.  Do state policies/regulations prohibit emergency medical professionals from 
providing treatment without transportation? 
The ET3 Model Participants are required to implement the alternative destination 
intervention. Applicants may also implement treatment in place by a qualified health 
care practitioner as another alternative, when appropriate. Thus, states should review 
whether there are state specific policies/regulations that would prohibit or limit 
treatment in place from being implemented within their Medicaid programs. 
c.  Does the state need to establish new regulations or seek authority from their 
legislature? 
  Depending on the state regulatory requirements and process, states may need to 
establish regulations in their state to make changes that will align with the model. 
States will need to conduct this analysis to permit either treatment in place (on scene 
and via telehealth) or transport to an alternative destination. 
d.  Does the state Medicaid program currently cover the HCPCs codes associated with 
this model? 
The codes identified in this model will be used in the evaluation of the model. States 
should review whether they currently cover these codes and to what extent changes 
are necessary, including changes to billing instructions, in order to align with the 
model. 
2.  Assess whether a state plan change is necessary for coverage/benefit alignment. 
 
a.  For transport to alternative destinations, does the existing state plan include 
language prohibiting the locations to which an emergency ambulance provider may 
transport beneficiaries? 
 
In some states, state plan language can limit how a service is furnished.  States should 
review their current approved state plan pages for emergency transportation to 
determine if changes are necessary.  If the approved state plan limits the destinations 
to which an emergency ambulance provider may transport beneficiaries, the state 
should submit a state plan amendment to revise their coverage policies.  If the 
emergency transportation language does not prohibit transports to alternative 
destinations, no state plan submission is necessary. 
   
Informational Bulletin  Page 9 
 
b.  For treatment in place, does the state currently recognize the EMS professionals 
independently from an ambulance transport? 
 
Under the treatment in place intervention, the state must have state plan authority to 
cover/reimburse health care practitioners who provide care on the scene when no 
transport occurs.  This assessment may require a state plan submission depending 
upon how the emergency professionals furnish care in the state and the existing 
descriptions in the approved state plan.  Many states have licensure requirements for 
emergency professionals such as paramedics while other states require a combination 
of education and certification for emergency medical technicians (EMTs).  This 
bulletin described a pathway for licensed paramedics but there are other paths for 
professionals who do not possess licensure. 
 
  For example, in some states, EMTs are under the supervision of a physician 
who provides supervision of care on the scene. In this example, since the 
physician assumes professional responsibility, services provided by EMTs 
working under the supervision of a physician can be covered under the 
physician services benefit (42 CFR 440.50). No state plan submission would 
be necessary, as the physician benefit does not require identification of every 
professional working under their supervision. 
 
   Alternatively, EMTs could operate under the supervision of a licensed 
paramedic, if the scope of practice as defined by state law for the licensed 
paramedic authorizes such supervision.  This path would require that the other 
licensed practitioner benefit (42 CFR 440.60) described in the state plan 
include the services of a licensed paramedic and the individuals under the 
supervision of the paramedic.  
 
  States may also consider the preventive services benefit to cover services 
furnished by unlicensed professionals.  Preventive services are services 
recommended by a physician or other licensed practitioner of the healing arts 
that prevent disease, disability, and other health conditions or their 
progression, prolong life, and promote physical and mental health and 
efficiency.  (42 CFR 440.130(c))  A state plan amendment is necessary to 
elect coverage of preventive services.  Licensed as well as unlicensed 
professionals may furnish the services, and the state would include a summary 
of the qualifications of an unlicensed professional in the state plan 
amendment, such as the training, experience, and supervisory arrangements 
for the unlicensed professional. 
   
3.  Assess whether a state plan change is necessary for payment alignment.   
Informational Bulletin  Page 10 
 
a.  For transports to alternative destinations, is the current reimbursement provision for 
transportation specific with regard to the destination? 
 
  If not, and the state plan methodology allows for the rates paid via the ET3 
model for Advanced Life Support and Basic Life Support, no state plan 
change will be necessary. 
  If so, a state plan change may be necessary to: 1) authorize reimbursement for 
a transport to additional or alternative destinations, and 2) align the payment 
methodology with the rates paid via the ET3 model for Advanced Life 
Support and Basic Life Support. 
 
b.  For treatment in place, does the states Medicaid State plan include a reimbursement 
provision that allows for payment to Medicaid-enrolled EMS professionals? 
 
  If so, and the State plan methodology allows for the rates paid via the ET3 
model for Advanced Life Support and Basic Life Support, no state plan 
change is needed. 
  If not, a state plan change may be necessary to: 1) authorize payment to 
Medicaid-enrolled EMS professionals, and 2) align the payment methodology 
with the rates paid via the ET3 model for Advanced Life Support and Basic 
Life Support. 
CMS acknowledges that ET3 model policies for Medicare payment require the treatment in place 
intervention be provided by a Medicare enrolled practitioner. Emergency medical technicians 
(EMTs) and paramedics do not meet this definition and are therefore unable to provide the 
treatment in place intervention under the Medicare model test. CMS also recognize that states 
have additional flexibilities in the Medicaid program. We defer to states to determine which 
practitioners are eligible to provide treatment in place interventions within their Medicaid 
programs based upon their state policies/regulations. 
     
Informational Bulletin  Page 11 
 
Appendix A: ET3 Model Evidence Base  
 
Reduction in Inpatient Admissions 
 
  In a pilot focused on frequent EMS utilizers that tested transport to alternative destinations 
coupled with case management, one hospital experienced a 28% reduction in ED visits, 
along with a 9% reduction in hospitalizations.9  
  The Innovation Center conducted additional analyses of the literature as well as analysis 
of 2017 Medicare FFS claims and determined an estimated range of potentially avoidable 
admissions of 7.5% to 12% if patients were transported to alternative destinations. 
 
Improvements in Ambulance Efficiency 
 
  Evidence from stakeholder feedback and pilots similar to ET3 interventions suggests the 
time from ambulance initiation to being back in service after treatment in place is less than 
half the time required for transport to an ED (39 minutes vs. 84 minutes, respectively).10  
  Stakeholders estimate that transport to an alternative destination is somewhere in between 
these two estimates, but less than the transfer time at an ED.  
                                                           
9 Tadrops AS, Castillo EM, Chan TC, Jensen AM, Watts K, Dunford JD. (2012) Effects of an Emergency Medical Servicesbased Resource Access 
Program on Frequent Users of Health Services, Prehospital Emergency Care, 16:4, 541-547 
10 Langabeer JR, Gonzalez M, Alqusairi D, et al. Telehealth-Enabled Emergency Medical Services Program Reduces Ambulance Transport to 
Urban Emergency Departments. West J Emerg Med. /2016;17(6):713-720.   
Informational Bulletin  Page 12 
 
Table I. Alternative Destination Programs and Outcomes 
 
Program Title or  Program Description  Available Outcomes 
Study Author 
(Location) 
 Mobile Health    Metropolitan Area EMS Authority in Fort Worth operates a range of EMS  Individuals served under 
Care   innovation in their community, including an Ambulance Transport  this program since its 
(Fort Worth,  Alternative (ATA) initiative.  initiation in 2009 
Texas) 11    Alternative destinations primarily include urgent care centers and  experienced a 55.6% 
community clinics.  reduction in ED use for the 
  To participate, alternative destinations must agree to receive individuals  12 months post-treatment 
transported or referred within a certain timeframe and to provide follow up  compared to the 12 months 
data on quality of care.  pre-enrollment in the ATA. 
  Upon identifying an individual eligible for transport to alternative 
destination and obtaining his or her consent, the EMS professionals discuss 
the patients complaint and the EMS teams assessment with a provider at 
the alternate destination who then approves or denies transport based on 
clinical appropriateness. 
Nevadas Regional    Operated an alternative destination program for three and a half years as  Resulted in roughly 1,430 
Emergency  part of a multi-pronged community health initiative called Ambulance  avoided ED visits. 
Medical Services  Transport Alternatives (ATA).  REMSAs reported12 
Authority    Targeted ambulance episodes involving mental health, substance abuse,  savings estimated 1.8M in 
(REMSA)   and urgent medical care complaints.  total. According to its 
Funding through    Roughly 1500 transports, or about 10% of all transports that paramedics  HCIA evaluation, Medicare 
the Innovation  deemed eligible, were successfully routed to an alternative destination.   savings under this multi-
Centers HCIA    84% of ATA transports went to a detox center, 9% went to a mental health  payer model were estimated 
program  hospital, and 7% went to an urgent care center.  to be $1.1M.13 
(Nevada) 
Californias    Pilot focused on non ED-transport for individuals with mental health  Averted ED visits saved an 
Community  conditions.   estimated $330,000 over 
                                                           
11 Data provided by organization directly to the Innovation Center. 
12 Regional Emergency Medical Services Authority. (2017). A model for better community healthcare: How one EMS system achieved the triple aim from a federal Health Care Innovation Award grant. 
13 Smith, L. R., Amico, P., Hoerger, T., Jacobs, S., Payne, J., & Renaud, J. (August 2017). Evaluation of the Health Care Innovation Awards: Community resource planning, prevention, and monitoring: 
Third annual report addendum. RTI International.   
Informational Bulletin  Page 13 
 
Program Title or  Program Description  Available Outcomes 
Study Author 
(Location) 
Paramedicine Pilot    301 of 311 individuals presenting with mental health conditions were  the two and a half year 
Program (CCPPP)  successfully transported to a crisis center instead of the ED.  model period. 
 Mental health 14    Notably, an additional 300 patients were eligible for transport to an   
(California)  alternative destination but did not participate due to funding and capacity 
issues at the alternative destination sites. 
CCPPP     CCPPP pilot focused on non-ED transport for individuals presenting with  Averted ED visits resulted 
Substance Abuse  substance use served 730 patients over 13 months.  an estimated $240,000 in 
(California)15    Only 2.4% of individuals initially transported to a sobering center were  savings. 
subsequently transferred to the ED.  
Seattle Alternative    Under this year-long program, 18% of basic life support ambulance  8% of the eligible episodes 
Destination  episodes were eligible for transport to an alternative destination.  (or roughly 1.5% of all 
Program16    Alternative destinations included urgent care centers, walk-in clinics, or  basic life support 
(Seattle,  office-based practices that accepted walk-in patients.   ambulance episodes) were 
Washington)    Eligibility criteria included a non-urgent presentation for a limited set of  transported to a non-ED 
clinical conditions,17 which were selected for ease of implementation and  medical clinic. Though 
safety.  uptake was limited, this 
  Limited operating hours at alternative destinations were a primary reason  represented a 5x increase 
compared to a matched 
for lack of uptake, which occurred in roughly 45% of eligible cases. 
historical control 
population.18 
Advanced Practice    Focused on alternative transport for cases of mental health or substance  Each psychiatric patient 
Paramedic  abuse.  seen outside of the ED 
Program      Among episodes for which the service was called, 40% were eligible.  
                                                           
14 Coffman, J. M., Wides, C., Blash, L., Amah, G., Geyn, I., & Niedzwiecki, M. (July 11, 2018). Evaluation of Californias Community Paramedicine Pilot Program. Healthforce Center at University of 
California, San Francisco. 
15 Coffman, J. M., Wides, C., Blash, L., Amah, G., Geyn, I., & Niedzwiecki, M. (July 11, 2018). Evaluation of Californias Community Paramedicine Pilot Program. Healthforce Center at University of 
California, San Francisco. 
16 Schaefer, R. A., Rea, T. D., Plorde, M., Peiguss, K., Goldberg, P., & Murray, J. A. (2002). An emergency medical services program of alternate destination of patient care. Prehospital Emergency 
Care, 6(3), 309-314. 
17 These were minor trauma, a minor respiratory issue, noncardiac chest pain, undefined musculoskeletal pain, syncope, headache, an abdominal issue, or anxiety/grief. 
18 It is unclear why any patients in the control population were transported to locations other than the ED.   
Informational Bulletin  Page 14 
 
Program Title or  Program Description  Available Outcomes 
Study Author 
(Location) 
(North Carolina) 19    63% of these patients (25% of the total) were then transported to the  freed up 14 ED bed-
alternative setting.  hours.20 
Cheney, P. et. al.21    Allowed transport of individuals with mental health needs to a Psychiatric  N/A 
(New Mexico)  Emergency Service rather than a hospital ED. 
  Achieved in a 25% alternate transport rate for eligible patients. 
Zeller, et. al. 22    Transported individuals with mental health concerns who passed medical  Time to discharge eight 
(California)  clearance to a psychiatric emergency service   hours less than estimated 
statewide average ED 
psychiatric time. 
   
                                                           
19 Creed, J. O., Cyr, J. M., Owino, H., Box, S. E., Ives-Rublee, M., Sheitman, B. B.,.., ... & Myers, J. B. (2018). Acute Crisis Care for Patients with Mental Health Crises: Initial Assessment of an Innovative 
Prehospital Alternative Destination Program in North Carolina. Prehospital Emergency Care, 22(5), 555-564. 
20 No Author. (March 1, 2014). Community paramedics fill gaps, take load off EDs. Relias Media. 
21 Cheney, P., Haddock, T., Sanchez, L., Ernst, A., & Weiss, S. (2008). Safety and compliance with an emergency medical service direct psychiatric center transport protocol. The American Journal of 
Emergency Medicine, 26(7), 750-756. 
22 Zeller, S., Calma, N., & Stone, A. (2014). Effects of a dedicated regional psychiatric emergency service on boarding of psychiatric patients in area emergency departments. Western Journal of 
Emergency Medicine, 15(1), 1-6.   
Informational Bulletin  Page 15 
 
Table II. Treatment in Place Programs and Outcomes 
Program Title or  Program Description   Available Outcomes 
Study Author  
ETHAN program23    Local EMS services allowed paramedics on scene to utilize telehealth triage for  The median time each 
(Houston, Texas)  low-acuity patients.   unit spent responding 
  In 2015 the EMS system received 288,000 calls, with ETHAN utilized for over  to each call under 
5,500 cases (2%).   ETHAN was more 
  Individuals received the following interventions:  than 40 minutes less 
  18% provided ambulance transport to the ED   than control. 
  59% received vouchers for taxi transport to the ED  
  8% received vouchers for taxi transport to a clinic  
  8% received a general referral or home care. 
Substantial decrease in ambulance transport to the ED (18% vs 74% in matched 
controls). 
Morganti, KG et.    Program combined treatment in place with a taxi voucher program.   EMTs avoided 200 
al.24    Prior to providing taxi vouchers, field EMTs consulted with hospital physicians  trips to the ED, saving 
(Seattle, WA)  as part of their on-site triage.   an estimated 
  In six months, the program served 204 patients with physician-EMT agreement  $750,000. 
on triage occurring for over 90% of the cases.    
Willings, JG    Provided treatment in place after falls among assisted living facility residents.  99% of those not 
(2018)25    Applying a non-transport protocol resulted in a 66% non-transport rate.  transported received 
the appropriate level 
of care. 
Krumperman, K     Treatment in place initiative implemented in a rural area   N/A 
et. al. 26      1,512 treatments in place and 6,100 EMS transports occurred, corresponding to 
a treatment in place use rate of roughly 20%.  
 
                                                           
23 Langabeer, JR, Gonzalez, M,  Alqusairi D, Champagne-Langabeer T, Jackson A, Mikhail J, Persse D. (2016) Telehealth-Enabled Emergency Medical Services Program Reduces Ambulance Transport to 
Urban Emergency Departments West J Emerg Med. 17(6): 713720.  
24 Morganti, K. G., Alpert, A., Margolis, G., Wasserman, J., & Kellermann, A. L. (2014). The state of innovative emergency medical service programs in the United States. Prehospital Emergency Care, 
18(1), 76-85. 
25 Williams, JG., Bachman, MW., Lyons, ZD., Currie, BB., Brown, AW., Cabanas, JG., Kronhaus, AK., Myers, J.B.. (2018). Improving decisions about transport to the emergency department for assisted 
living residents who fall. Annals of internal medicine, 168(3), 179-186. 
26 Krumperman, K., Weiss, S., & Fullerton, L. (2015). Two types of prehospital systems interventions that triage low-acuity patients to alternative sites of care. South Med J, 108(7), 381-386.   
Informational Bulletin  Page 16 
 
 
Table III. Medical Triage Programs 
Program Title or   
 Study Author   Program Description  
Measuring accuracy of triage   
Scott, G et. al. 27    Evaluated whether medical dispatchers could accurately identify low acuity cases appropriate for 
medical triage (as opposed to requiring ambulance transport). 
  Examined medical-related 911 calls and compared the triage level assigned by the dispatchers to the 
individuals severity level defined by vital signs taken by the EMS crew. Of roughly 20,000 cases 
identified by the medical dispatchers as the lowest severity, 89% did not have a single unstable vital sign 
and only 1% were transported with lights and siren (a proxy for severity). 
Measuring utilization/uptake   
Murphy, ER et. al.    6% of all EMS calls were diverted to a medical triage line rather than initiation of an ambulance. 
28 (Texas) 
REMSA 29 (Nevada)    Though the exact figure is unclear, numbers published by REMSA suggest that the medical triage 
program had roughly a 2.5% to 3% dispatcher transfer rate to the service. 
Smith, JR et. al. 30    Roughly 3.5% of all 911 callers were eligible for transfer to a medical triage line.  
(Seattle, WA)    Given limited operating hours of the triage line, only one third of eligible callers were successfully 
transferred to the service. 
 
 
                                                           
27Scott G, et al. Using on-scene EMS responders Assessment and Electronic Patient Care Records to Evaluate the Suitability of EMD-Triaged, Low-acuity Calls for Secondary Nurse Triage in 911 
Centers. (Feb 2016). Prehospital and Disaster Medicine. Vol 31 Issue 1. Pp 46-57. 
28 Murphy, E. R., et al. (2017). 911 Triage: Implications of an Emergency Diversion Collaboration Effort. Perspectives on Social Work, 13(1), 23-29. 
29 Smith, L. R., Amico, P., Hoerger, T., Jacobs, S., Payne, J., & Renaud, J. (August 2017). Evaluation of the Health Care Innovation Awards: Community resource planning, prevention, and monitoring: 
Third annual report addendum. RTI International. 
30 Smith, W. R., Culley, L., Plorde, M., Murray, J. A., Hearne, T., Goldberg, P., & Eisenberg, M. (2001). Emergency medical services telephone referral program: An alternative approach to nonurgent 
911 calls. Prehospital Emergency Care, 5(2), 174-180.   
Informational Bulletin  Page 17 
 
 
 
Program Title or   
 Study Author   Program Description  
Triage level by age   
Richmond, N. J. and    Among medical triage calls from individuals over age 64: 68% were classified as needing emergency 
MedStar Mobile  care as soon as possible, but not warranting emergency transport. Of those, 8% were advised to seek care 
Healthcare31,32  within 1 to 4 hours. 8% triaged as only needing self or home-based care. The remainder were primarily 
(Louisville,  classified as either needing care within a day or more or needing only routine care.  
Kentucky and Fort    Despite these numbers, across all age groups, only slight more than a third of calls were safely triaged to 
Worth, Texas)  lower acuity settings; the remainder were sent an ambulance.  
  Another analysis of these two programs over different periods of operations indicated that 25% of 
participating callers to the medical triage line ultimately pursued care in settings other than the ED with 
$1,700 in savings per avoided ED visit.33 
  The Fort Worth program indicates that since June 2012, of the 9,836 low-acuity callers referred to this 
program, roughly one third did not use an ambulance to the emergency department, resulting in $3.8 
million savings from avoided ambulance transport and emergency department expenditures ($1,165 per 
enrolled patient).34 
                                                           
31 Both programs directly connected patients to care and provided non-ambulance transport. For more information on the Louisville program see: Richmond, N. J. (2014, August 21). The Front Door to 
Care: EMS in Louisville Grows Beyond Simple 9-1-1 Response. EMS World. For more information on the Ft. Worth program see: Fact Sheet   
32 Fivaz, M. C., McQueen, J., Barron, T., Clawson, J., Scott, G., & Gardett, M. I. (2015). The distribution of recommended care levels by age, gender, and trauma vs medical classification within the 
emergency communication nurse system. Ann Emerg Dispatch Response, 3(1), 14-20. 
33 Gardett, I., Scott, et al. (2015). 911 Emergency communication nurse triage reduces EMS patient costs and directs patients to high-satisfaction alternative point of care. Ann Emerg Dispatch 
Response, 3, 8-13. 
34 Mobile Healthcare Programs  Overview. Medstar911. http://www.medstar911.org/mobile-healthcare-programs