210-RICR-20-00-2. Medicaid Payments and Providers: Transportation Services (version Adoption, 12/31/2013 to 05/17/2016)

State of Rhode Island and Providence Plantations Executive Office of Health & Human Services Section 1360: Transportation Services December 2013 i Rhode Island Executive Office of Health and Human Services Rules and Regulations Section 1360 Transportation Services TABLE OF CONTENTS Section Number Section Name 1360: Transportation Services Page Number 1360.01 Covered Services 1 1360.02 Authorization Process 2 1360.03 Provider Participation Licensing Guidelines 3 1360.04 Recertification Process 4 1360.05 Claims Billing Guidelines 4 1360.06 Specialized Transportation Program for Elders 5 1360.07 Categories of State and Federally Funded Services 6 1360.08 Service Provision Guidelines 7 1360.09 Client Complaint Process 8 1360.10 Client Contribution 8 1360.11 Severability 8 Addendum #1 9 ii Introduction These rules related to Transportation Services, Section 1360 of the Medicaid Code of Administrative Rules, are promulgated pursuant to the authority set forth in Rhode Island General Laws Chapter 40-8 (Medical Assistance), as amended, and Title XIX of the Social Security Act. These rules supersede the transportation services sections #0300.20.05.30 et. seq. (contained in section #0300 of the Medicaid Code of Administrative Rules entitled “Medical Assistance Program”) last amended on February 27, 2013. Pursuant to the provisions of §42-35-3(a)(3) and §42-35.1-4 of the General Laws of Rhode Island, as amended, consideration was given to: (1) alternative approaches to the regulations; (2) duplication or overlap with other state regulations; and (3) significant economic impact on small business. Based on the available information, no known alternative approach, duplication or overlap was identified and these regulations are promulgated in the best interest of the health, safety, and welfare of the public. 1 1360. Transportation Services The Executive Office of Health and Humans Services recognizes that Medical Assistance Recipients need available and appropriate transportation in order to access medical care, and assure the provision of such transportation when required to obtain medically necessary services covered by the Medical Assistance program. 1360.01. Covered Services Covered Services-The Medical Assistance Program covers emergency and non-emergency medical transportation (NEMT). Ground transportation is covered/provided for when the individual has Medicaid, is receiving a Medicaid covered service from a Medicaid participating provider. • Maximum of (4) one-way non-emergency medical trips can be provided to a patient in one day. • An additional staff to accompany a patient can be permitted if medically justified and prior approval is received. • More than one recipient may be transported by the same vehicle on the same trip, provided there are adequate seating and safety restraints for all passengers and at no time the health and safety of any of the other passengers are compromised. • Passengers must not have their trip lengthened by more than 30 minutes due to increasing the capacity of the passengers in the same vehicle. • Emergency round trips by ambulance can be approved only if the patient is transported out of state and back. A) Non-Emergency Medical Transportation Non-emergency medical transportation is covered when the recipient has no other means of transportation, no other community resource exists (i.e., family, friends, bus pass) and transportation by any other means would endanger the individual’s health and safety. Non-emergency transportation can be provided by ambulance but will require a physician’s statement to justify this mode of transportation. (See authorization process, physician’s statement). B) Emergency Transportation Emergency Transportation means transportation to a medical treatment when required to obtain emergency health care services for unforeseen circumstances which demand immediate attention at a hospital to prevent serious impairment or loss of life. Medically necessary emergency transportation is provided by ambulance. 2 When medical services are obtained at a hospital participating in the Medical Assistance program, it is the responsibility of the hospital or emergency department staff to provide and pay for appropriate transportation home if needed. C) Out of State Non-Emergency Medical Transportation Non-emergency medical transportation for out-of-state trips will only be considered for payment on the basis of medical necessity if the Medicaid covered service is not available in Rhode Island or there are other extenuating medical circumstances. Refer to Section 200-30 of the Provider Manual for authorization guidelines and procedures. The patient’s current primary care physician must provide written medical documentation to the State for review. The State will require ten business days for the review to be completed. Providers must maintain a confidential area to maintain all requests, for auditing and review purposes. Mileage is reimbursable for wheelchair, Basic Life Support (BLS), Advanced Life Support (ALS) and out-of-state ambulatory transportation services. There is no mileage reimbursement for in-state ambulatory trips. The maximum mileage allowed for each trip will be predetermined by the State or its designee during the authorization process. Waiting time is reimbursed for out-of-state trips up to a maximum of two hours. In-state waiting time is included in the base rate and not a separate billing item. D) Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF) Residents An individual residing in a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF) whose condition precludes transportation by the facility automobile to and from physician’s office, medical laboratory, hospitals, etc., may be transported for non-emergency medical services when: • Patient cannot be transported by any other means through the facility; • Required medical service cannot be provided within the facility. (i.e., portable x-ray services provided in a facility setting); • Facility has exhausted all other alternative means whenever possible; Emergency medical transportation services can only be provided when a patient is severely ill or injured and transportation by any other means would endanger the individual’s health and safety. 3 1360.02. Authorization Process All transportation requests must be authorized before being scheduled. Authorizations are to be requested from the transportation scheduler. Some requests will require a physician’s statement. A) Physician's Statement Non-emergency medical transportation that requires a written statement by the recommending physician must include the following: • Recipient’s medical condition that prevents them from taking public transportation; • Specific reason/rationale why non-emergency medical transportation is required based on client’s functional ability and not only on diagnosis. The individual’s physician must provide written medical documentation to the State’s Office of Health and Human Services for review. All correspondences are to be faxed to the following: Executive Office of Health and Human Services Office of Transportation Fax # 401-462-6352 The state will require ten business days for the review to be completed. Providers must maintain a confidential area to maintain all requests, for auditing and review purposes. If the non- emergency transportation is on-going (such as for kidney dialysis), one physician statement can be used for a period of up to one year. A new physician statement will be needed each year. All non-emergency procedure codes (excludes non-emergency stretcher transports) require authorization. Additional attendant (s) also requires authorization. 1360.03. Provider Participation Licensing Guidelines To participate in the Medical Assistance Program, a provider must have an office(s) and perform services in Rhode Island or in a state-approved border community (see Addendum I). Consideration will be given to out-of-state providers if the covered service is not available in Rhode Island, the recipient is currently residing in another state or if the covered service was performed as an emergency service while the recipient was traveling through another state. Ambulance providers: • Must have a license issued through the Rhode Island Department of Health (DOH); 4 • License is renewed annually; • Must attach a copy of each of their vehicles licenses with their application when enrolling the Medical Assistance Program. Taxi and Public Motor Vehicles: • Must have a license issued through the Rhode Island Division of Public Utilities and Carriers (PUC) validating proof of authority to engage granted by the by PUC RIGL Title 39 chapter 14 Taxi Cab Statue and Title 39 chapter 14.1 Public Motor Vehicles. • Providers are required to maintain and ensure drivers have a valid Hackney License (Blue Card). • A license is renewed annually through the Division of Public Utilities and Carriers. PUC License Types: A) Taxi – Public Certificate for Convenience & Necessity B) Public Motor Vehicles – Certificate of Operating Authority 1360.04 Recertification Process Ambulance providers: • Recertified annually by the Rhode Island Department of Health; • The license expiration date is December 31; • Once a license renewal is obtained, a copy of the renewal documentation is forwarded to Hewlett Packard Enterprise Services (HPES) within thirty days to avoid interruption of program enrollment. Taxi Public Motor Vehicle Carriers and Providers: • Required to forward a copy of their license or recertification to HPES within thirty days of renewal to also avoid interruption of program enrollment. 5 1360.05. Claims Billing Guidelines A) Instructions for completing the CMS 1500 claim form are located on the Executive Office of Health and Human Services (EOHHS) website at: http://www.dhs.ri.gov/ForProvidersVendors/MedicalAssistanceProviders/FormsApplications/t abid/164/Default. aspx B) Reimbursable Emergency and Non-Emergency Medical Transportation Procedure Codes; Reimbursable emergency and non-emergency medical transportation procedure codes and the corresponding reimbursement rates can be found on the EOHHS website at: http://www.dhs.ri.gov/ForProvidersVendors/MedicalAssistanceProviders/FormsApplications/ tabid/164/Default. aspx C) Reimbursement Guidelines The reimbursement rates for transportation providers are listed on the EOHHS website at: http://www.dhs.ri.gov/ForProvidersVendors/MedicalAssistanceProviders/FeeSchedules/tabi d/170/Default.aspx Providers must bill the Medical Assistance Program for their usual and customary rate (UCR) as charged to the general public. Payments to providers can not exceed the maximum reimbursement rate of the Medical Assistance Program. 1) Payment is not authorized for any of the following reasons: • For transportation which is ordinarily made available to other persons in the community without charge; • For care or services that are not covered under the Medical Assistance program; • To non-participating service providers; or • When the Medicaid recipient is not actually transported in the vehicle. 2) Medicare/Medicaid Crossover The Medical Assistance Program payment for crossover claims is always capped by the established Medical Assistance allowed amount, regardless of coinsurance or deductible amounts. The standard calculation for crossover payments is as follows: • Medical Assistance will pay the lesser of the difference between the Medical Assistance allowed amount and the Medicare Payment (Medical Assistance allowed minus Medicare paid); 6 • Or the Medicare coinsurance and deductible up to the Medical Assistance allowed amount, calculated as follows: Medicare coinsurance/deductible + Medicare paid - Medical Assistance allowed. 3) Patient Liability The Medical Assistance Program payment is considered payment in full. The provider is not permitted to seek further payment from the recipient in excess of the Medical Assistance Program rate. 4) Origin/Destination Modifiers Claims must include a two-letter origin-destination modifier indicating the following: • Beginning and ending destinations of the trip to include town codes; • Number of miles for the trip; • Emergency or non-emergency transportation services (i.e., non-emergency stretcher, emergency Basic Life Support (BLS) or Advanced Life Support (ALS)). 1360.06. Specialized Transportation Program for Elders The Specialized Transportation Services Program for Rhode Island elders and persons with disabilities is administered by the Rhode Island Executive Office of Heath and Human Services EOHHS. The program provides quality, safe and self-sufficient transportation services to qualified elderly individuals and persons with disabilities. Specifically, emphasis is placed on priority categories of transport services in relation to existing state funding, vehicle and passenger safety and sensitivity to the needs and concerns of the elderly and disabled clients. DHS contracts with RIPTA for transportation services for the elderly and persons with disabilities. Transportation funds available for this program are specifically allocated for services to be provided for Rhode Island residents sixty- (60) years of age and older and Rhode Island Department of Human Services (DHS) Medicaid clients. Individuals who meet certain eligibility criteria may receive transportation services through the RIde program ("RIde Participants") and other transportation providers as appropriate. Eligible participants must be legal residents of the State of Rhode Island who meet the following criteria: 1. Age sixty- (60) or over; or 2. Eligible for services under the Rhode Island EOHHS Medicaid Program; or 7 As a condition of eligibility for transportation services, applicants and members must provide documentation which includes, but is not limited to, one (1) or more of the following original and valid documents: 1. Birth certificate (original); 2. United States Passport (valid); 3. Rhode Island driver’s license and/or Rhode Island state identification card issued by the Rhode Island Division of Motor Vehicles (valid); 4. Social Security card; 5. Utility bill for a residence within Rhode Island in the name of the individual requesting RIde services; or 6. Medical documentation as requested by DHS or RIPTA’s RIde Program regarding mobility capacity and disability. Medicaid client eligibility for RIde Program services is determined through the DHS. To be eligible for Medicaid transportation services participants must meet the following criteria: 1. Unable to find alternative transportation; 2. Have medical needs that require door-to-door level of service and be unable to take a fixed route bus; 3. Requires transportation services for medical/health visits that are part of a total patient plan of care supervised and ordered by a health care professional; 4. Meets transportation service categories of State and Federally-funded transportation defined below in Section V of these Regulations. 1360.07. Categories of State and Federally Funded Services The following transportation services are provided: Special Medicals (Priority 1) Special medical transportation that shall include transportation for the purpose of kidney dialysis or cancer treatments. Names of clients to be transported are to be provided to the RIde Program by the medical treatment facility, family, friends, or the client themselves. DHS or its representative will 8 insure that clients will spend the least amount of time reasonably possible in transport. DHS reserves the right to limit transportation to special medicals based on funding constraints or other programmatic requirements. Adult Day Care (Priority 2) Transport to and from Adult Day Care Centers that are licensed by the Department of Health (DOH). Residences of clients shall be verified by the Adult Day Care Center and provided to the RIde Program. DHS shall maintain a listing of all transportation approved Adult Day Care Centers. DHS reserves the right to limit transportation to Adult Day Care centers based on funding constraints or other programmatic requirements. General Medicals (Priority 3) Transportation for any medical/health services that is part of a total patient plan of care supervised by a health care professional. Trips eligible under this service category include visits to physicians' offices as well as all trips for tests and/or treatments ordered by a health care professional as part of a treatment plan. DHS reserves the right to limit transportation to General Medicals based on funding constraints or other programmatic requirements. INSIGHT (Priority 4) Transport to and from INSIGHT, 43 Jefferson Boulevard, Warwick, RI. Riders must be sixty-five (65) years of age or over, have a sight impaired condition and/or presently registered with the INSIGHT agency. Transportation shall be at the discretion of DHS and available during the same days and hours as General Medical trips. Trip requests must be forwarded to the RIde Program at least one (1)week in advance. DHS reserves the right to limit transportation to Insight based on funding constraints or other programmatic requirements. Senior Nutrition Transportation (Priority 5) Transport to and from congregate meal sites for the elderly. The Senior Nutrition Project shall be responsible for securing names and addresses of clients to be transported. This information shall be forwarded to the RIde Program for necessary scheduling. The Nutrition Site shall verify residence of all clients in the geographic area. DHS reserved the right to limit transportation to specific meal sites based on funding constraints or other programmatic requirements. Meal sites not on the list are not approved for DHS- funded transportation. 1360.08. Service Provision Guidelines Limitation on Transportation The Department of Human Services reserves the right to limit or restrict the availability of transportation due to funding constraints, service availability, weather, etc. 9 Door to Door Transportation of the client from the outside door of his/her residence to the outside door of his/ her destination. Door to door is defined in this instance as transport of the client from the ground level door of his/ her residence to the ground level door of his/her destination. The dwelling should be accessible by means of a ramp, or client provided assistance. Service shall include passenger assistance from the client's door to the van and from the van to the door of the destination when necessary. Each client case must be assessed on an individual basis as to need. Transport to Nearest Sites Transportation to meal sites, kidney dialysis, and cancer treatments shall be to the facility closest to the client's home. Transportation to adult day care facilities shall be to the facility closest to the client's home unless transportation to another center is more appropriate and subject to the availability of transportation services to that center. General medical trips shall be to the nearest health care professional whenever possible. Days and Hours of Service Service days shall include Monday-Friday. State holidays are not included as service days. Trips must occur between 10am-2pm for all categories of DHS-funded services except Special Medical trips (Priority 1) and Adult Day Care (Priority 2). Passenger Cancellations Passengers must make every effort to keep their scheduled trip appointments. If unable to keep an appointment, notification must be provided to the RIde Program at least twenty-four (24) hours prior to the scheduled trip. 1360.09. Client Complaint Process Clients may file a complaint as follows: • Passengers or their family members may submit a formal written complaint to the RIde Program. • The Ride Program will attempt to resolve the complaint with the individual or his/her family, the RIde shall contact and work with DHS. • If the complainant wishes to pursue his/client her concerns further, the written complaint shall be forwarded to DHS who may consult and involve the EOHHS for follow up and resolution. 10 1360.10. Client Contribution Participating clients who are not exempt will contribute a co-pay fee of $2.00 per one-way trip which is paid to the transportation vendor. Medicaid and CNOM-eligible/Co-Pay individuals are exempt from this co-pay. 1360.11. Severability If any provisions of these Regulations or the application thereof to any person or circumstance shall be held invalid, such invalidity shall not affect the provisions or application of these Regulations which can be given effect, and to this end the provisions of these Regulations are declared to be severable. 11 Addendum I Border Communities Border Communities include cities and town that border Rhode Island and are considered for the purpose of the Rhode Island Medical Assistance Program, in-state providers. Out-of-state service restrictions and prior authorization requirements are not imposed on providers in the following communities: Connecticut Massachusetts Danielson Attleboro Groton Bellingham Moosup Blackstone Mystic Dartmouth New London Fall River North Stonington Foxboro Pawcatcuk Milford Putnam New Bedford Stonington North Attleboro Thompson North Dartmouth Waterford Rehoboth Seekonk Somerset South Attleboro Swansea Taunton Uxbridge Webster Westport Whitinsville