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

State of Rhode Island and Providence Plantations Executive Office of Health & Human Services Section 1360: Transportation Services December 2013 April 2016 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 for Medicaid & Non-Medicaid Beneficiaries Page Number 1360.01 Covered Services 1 1360.02 Transportation Requests 3 1360.03 Transportation Provider Participation 4 1360.04 Recertification Process 4 1360.05 Claims Billing Guidelines 5 1360.06 Non-Medicaid Elderly Transportation Program 5 1360.07 Non-Medicaid Elderly Transportation Program – Specific Services 6 1360.08 1360.09 Non-Medicaid Elderly Transportation Program Service Provision Guidelines Transportation for Recipients of Temporary Assistance to Needy Families (TANF) 7 9 1360.10 Complaint Process for Medicaid Beneficiaries, Persons Using the Non- Medicaid Elderly Transportation Program and TANF Recipients 9 1360.11 Severability 10 Addendum #1 11 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. 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. Unless otherwise noted, the provisions contained herein pertain to transportation services for Medicaid beneficiaries, clients of the Non-Medicaid Elderly Transportation Program, and Temporary Assistance to Needy Families (TANF) recipients. These regulations shall supersede all previous regulations related to transportation services promulgated by EOHHS and filed with the Rhode Island Secretary of State. 1 1360 Transportation Services for Medicaid Beneficiaries REV: April 2016 The Executive Office of Health and Humans Services recognizes that Medicaid beneficiaries 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 Medicaid program. Transportation can be provided by any of the following modes, as appropriate to the needs of the individual. Public transit (bus) is the preferred mode of non-emergency medical transportation (NEMT) when both the beneficiary and the provider are within one-half (½) mile of an established bus route.  Public transit (bus)  Private Car  Public Motor Vehicles  Multi-Passenger Van  Ambulance  Wheelchair Van. 1360.01 Covered Services REV: April 2016 Covered Services - The Medicaid Program covers emergency and non-emergency medical transportation (NEMT). Ground transportation is covered and provided for when the individual has Medicaid and is receiving a Medicaid-covered service from a Medicaid- participating provider. A) Non-Emergency Medical Transportation (NEMT) Non-emergency medical transportation (NEMT) is covered when the recipient has no other means of transportation, no other community resource exists (i.e., family, friends) and transportation by any other means would endanger the individual’s health or safety. NEMT may be provided by ambulance if this mode is medically necessary. Physician/clinician documentation or attestation will be required. To be eligible for NEMT services, Medicaid participants must be unable to find alternative transportation and require transportation services for medical/health visits that are part of a total patient plan of care supervised and ordered by a health care professional.  If medically justified and communicated during the reservation to the State’s transportation broker, an additional person can be permitted to accompany a beneficiary.  More than one beneficiary 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 number of passengers in the same vehicle. 2  Transportation to communities that closely border Rhode Island may be provided for Medicaid- covered services and as pre-authorized by the transportation broker subject to review and approval of the State, as needed. See Addendum “1” or a list of border communities. 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. When medical services are obtained at a hospital participating in the Medicaid program, it is the responsibility of the hospital or emergency department staff to provide and pay for appropriate transportation home if needed. For Medicaid Managed Care beneficiaries, emergency transportation is provided by the Managed Care Organization. Billing for this service is through the Managed Care Organization. For Medicaid Fee-For-Service beneficiaries, emergency transportation is provided by the Medicaid Fee-For-Service program. Billing for this service is through the Medicaid Fee-For-Service program. C) Out-of-State Non-Emergency Medical Transportation With the exception of transportation to communities that closely border Rhode Island, NEMT for out- of-state trips will only be considered for payment when the service is medically necessary and the Medicaid-covered service is either not available in Rhode Island or there are other extenuating medical circumstances. All out-of-state NEMT, with the exception of NEMT to border communities, requires prior authorization from the State’s transportation broker. D) Nursing Facility Residents An individual residing in a Nursing Facility whose condition precludes transportation by the facility vehicle to and from a 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 (including transportation by family or friends) whenever possible. 3 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 or safety. 1360.02 Transportation Requests REV: April 2016 All NEMT requests must be scheduled through the State’s transportation broker. Some requests may require a physician or clinician’s attestation and/or documentation. Information on how to contact the State’s transportation broker is available at: www.eohhs.ri.gov. A) Door-to-Door “Door-to-door transportation” is defined as transportation of the client from the outside door of his/her residence to the outside door of his/her destination, including the return trip. “Door-to-door” is further defined herein to mean the transport of the client from the ground level door of his/her residence to the ground level door of his/her destination, including the return trip. The dwelling should be accessible by means of an ADA-approved (Americans with Disabilities Act) ramp or client-provided assistance. When necessary, service shall include passenger assistance from the client's door to the vehicle and from the vehicle to the door of the destination and include the return trip. Each client case must be assessed on an individual basis as to need. Beneficiaries must request this service at the time of reservation to the State’s transportation broker. Transportation providers are not permitted to enter the client’s residence or the provider’s office. Beneficiaries who will require additional assistance in leaving their destination or upon arrival at their medical appointment may bring an escort with them. Beneficiaries must inform the transportation broker when they reserve transportation that an escort will accompany them. B) 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 State’s transportation broker at least twenty-four (24) hours prior to the scheduled trip. C) Passenger No-Shows Passengers who frequently (more than three (3) instances per month) do not cancel their regularly scheduled trip appointment at least twenty-four (24) hours in advance may be required to schedule each trip separately at least two (2) days in advance (i.e., will no longer be eligible for “standing order” pick-ups). Clients who frequently (more than three (3) instances per month) do not cancel other scheduled trips (e.g., scheduled physician visits) at least twenty-four (24) hours in advance may also be required to confirm scheduled trips the morning of or twenty-four (24) hours in advance. 4 D) Physician's/Clinician’s Attestation and/or Documentation All NEMT transportation requests that require an attestation and/or documentation statement by the recommending physician/clinician must include the specific reason/rationale why NEMT is required based upon a client’s functional ability and not only upon diagnosis. 1360.03 Transportation Provider Participation Guidelines REV: April 2016 Ambulance providers:  Must have a license issued through the Rhode Island Department of Health (DOH);  License is renewed annually; 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 PUC RIGL Title 39 chapter 14 Taxi Cab Statute 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 and Necessity B) Public Motor Vehicles – Certificate of Operating Authority NEMT To participate in the NEMT Program, a transportation provider must enter into a signed agreement with the State’s transportation broker. Providers must be in compliance with all applicable state and federal statutes and regulations. All providers will be recruited and retained by the State’s transportation broker. All required provider documents must be submitted to the State’s transportation broker. All providers must meet the requirements set forth by the State’s transportation broker. 1360.04 Recertification Process REV: April 2016 Ambulance providers shall be recertified annually by the Rhode Island Department of Health. Taxi Public Motor Vehicle Carriers and Providers shall be required to forward a copy of their license or recertification to the State’s transportation broker within thirty (30) days of renewal to also avoid interruption of program enrollment. 5 1360.05 Claims Billing Guidelines REV: April 2016 The State’s transportation broker is responsible for claims and billing for NEMT. Providers will bill the health plans for emergency transportation provided to Medicaid managed care beneficiaries. Providers will bill the Medicaid Fee-for-Service Program for emergency transportation provided to Medicaid beneficiaries enrolled in the State’s Fee-for-Service delivery system. 2) Medicare/Medicaid Crossover Claims A. Emergency Transportation Medicare is the primary payer for emergency transportation. The Medicaid FFS Program will not make any additional payment on claims where the Medicare payment is equal to or more than the Medicaid allowable amount. Payment of cross-over claims for Medicaid managed care recipients is handled and directed by the managed care plans. B. Non-Emergency Transportation Certain forms of non-emergency transportation may be covered by Medicare. This may include basic life support and advanced life support (both of which are provided by ambulance) as well as transportation provided to/from hospitals and dialysis centers. The transportation broker may be responsible for payment of Medicaid-covered NEMT services that were denied by Medicare, subject to prior approval and verification by the broker. 3) Patient Liability The NEMT payment is considered payment in full. The transportation provider is not permitted to seek further payment from the beneficiary in excess of any payment received from the State’s transportation broker. Transportation providers are not permitted to seek further payment from the participant in excess of any payment received for emergency transportation from either the health plan or the Medicaid FFS Program. 1360.06. Non-Medicaid Elderly Transportation Program REV: April 2016 The Non-Medicaid Elderly Transportation Program is for individuals age 60 years and older who are not Medicaid eligible and who are not getting transportation from the RIPTA Ride Program or from 6 the Americans with Disabilities Act (ADA) Program. The Elderly Transportation Program provides transportation to and from medical appointments, adult day care, meal sites, dialysis/cancer treatment and the “Insight Program.” The program requires a two dollar ($2.00) co-payment for each trip segment. The $2 co-payment is collected and retained by the transportation driver. Medicaid and “Costs Not Otherwise Matchable” (“CNOM”)-eligible co-pay individuals are exempt from this co- pay for transportation in Priorities #1 - #4 in section 1360.07 (below). The Non-Medicaid Elderly Transportation Program provides safe, quality transportation services to qualified elderly individuals. Emphasis is placed on priority categories of transportation services in relation to existing state funding, vehicle and passenger safety and sensitivity to the needs and concerns of elderly clients. 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. Eligible participants must be legal residents of the State of Rhode Island. As a condition of eligibility for transportation services, participants must provide the information noted below to the transportation broker. This may include, but is not limited to: 1. Date of birth; 2. Proof of residency (e.g., valid Rhode Island driver’s license and/or Rhode Island state identification card issued by the Rhode Island Division of Motor Vehicles; voter identification card; current utility bill for a residence within Rhode Island in the name of the individual requesting transportation services); 3. Social Security number; 4. Medical documentation as requested by the State’s transportation broker. 1360.07 Non-Medicaid Elderly Transportation Program – Specific Services REV: April 2016 The following transportation services may be provided to Rhode Island elders by the State’s transportation broker based on the following prioritization. Service provision is contingent upon available state funding. Special Medical Care (Priority 1) Special medical transportation includes transportation for the purpose of kidney dialysis or cancer treatments. Names of clients to be transported are to be provided to the State’s transportation broker by the medical treatment facility, family, friends, or the client themselves. The State reserves the right to limit special medical transportation based on funding constraints or other programmatic requirements. Adult Day Care (Priority 2) This category includes 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 7 and provided to the State’s transportation broker. The State reserves the right to limit transportation to Adult Day Care centers based on funding constraints or other programmatic requirements. General Medical Care (Priority 3) This category includes transportation for any medical/health services that are 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 and dental offices as well as all trips for tests and/or treatments ordered by a health care professional as part of a treatment plan. The State reserves the right to limit General Medical transportation based on funding constraints or other programmatic requirements. INSIGHT (Priority 4) This category includes transport to and from INSIGHT, at their INSIGHT service location(s). 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 the State and available during the same days and hours as General Medical trips. Trip requests must be forwarded to the State’s transportation broker at least forty-eight (48) hours in advance. The State reserves the right to limit transportation to INSIGHT based on funding constraints or other programmatic requirements. Senior Nutrition Transportation (Priority 5) This category includes transport to and from congregate meal sites for the elderly. The Senior Nutrition Project shall be responsible for securing names and addresses of individuals to be transported. This information shall be forwarded to the State’s transportation broker for scheduling. The Nutrition Site shall verify residence of all individuals in the geographic area. The State reserves the right to limit transportation to specific meal sites based on funding constraints or other programmatic requirements. 1360.08 Non-Medicaid Elderly Transportation Program Service Provision Guidelines REV: April 2016 Limitation on Transportation The State reserves the right to limit or restrict the availability of transportation due to funding constraints, service availability, weather, etc. (This provision applies to clients of the Non-Medicaid Elderly Transportation Program only). Door-to-Door “Door-to-door transportation” is defined as transportation of the client from the outside door of his/her residence to the outside door of his/her destination, including the return trip. “Door-to-door” is further defined herein to mean the transport of the client from the ground level door of his/her residence to the ground level door of his/her destination, including the return trip. The dwelling should be accessible by means of an ADA-approved (Americans with Disabilities Act) ramp or client-provided assistance. 8 When necessary, service shall include passenger assistance from the client's exterior door to the vehicle and from the vehicle to the exterior door of the destination and include the return trip. Each case must be assessed on an individual basis as to need. Participants must request this service at the time of reservation to the State’s transportation broker. Transportation providers are not permitted to enter the client’s residence or the provider’s office. Participants who will require additional assistance in leaving their destination or upon arrival at their medical appointment may bring an escort with them. Participants must inform the transportation broker when they reserve transportation that an escort will accompany them. Transport to Nearest Sites Transportation to meal sites, kidney dialysis, and cancer treatments shall be to the facility closest to the client's home, whenever possible. If not possible, the participant shall receive approval from his/her physician or primary care provider to receive such services at another site based on medical necessity. 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. This is also subject to the availability of transportation services to that center. General medical trips shall be to the nearest health care professional whenever possible unless the participant has received approval from his/her physician or primary care provider to receive such services at another site based on medical necessity. Days and Hours of Service Service days shall typically include Monday-Friday. Trips may also be scheduled on weekends and holidays when medically necessary. Trips for Senior Nutrition Transportation (Priority 5) must occur between 10:00 a.m. – 2:00 p.m. 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 State’s transportation broker at least twenty-four (24) hours prior to the scheduled trip. Passenger No-Shows Passengers who frequently (more than three (3) instances per month) do not cancel their regularly scheduled trip appointments at least twenty-four (24) hours in advance may be required to schedule each trip separately at least two (2) days in advance (i.e., will no longer be eligible for “standing order” pick-ups). Passengers who frequently (more than three (3) instances per month) do not cancel other scheduled trips (e.g., separate physician visits) at least twenty-four (24) hours in advance will also be required to confirm scheduled trips the morning of or twenty-four (24) hours in advance. After a sixty (60) day period, passengers may request reinstatement of eligibility for standing order and scheduled ride pick-ups without being required to confirm such trips in advance. Requests will be subject to EOHHS approval. 9 Passengers with a frequent pattern of no-shows will receive written notice from the State’s transportation broker that they will be subject to a change in their transportation benefit. (See section 1360.10 herein, “Complaint Process for Medicaid Beneficiaries and Persons Using the Non-Medicaid Elderly Transportation Program and TANF recipients”). 1360.09. Transportation for Recipients of Temporary Assistance to Needy Families (TANF) EFF: April 2016 Recipients of the State’s Temporary Assistance to Needy Families (TANF) Program are eligible to receive a monthly bus pass. To obtain a monthly bus pass, TANF recipients must call the State’s transportation broker to request a pass. Bus passes will be mailed to the recipient following the request. 1360.10 Complaint Process for Medicaid Beneficiaries and Persons Using the Non-Medicaid Elderly Transportation Program and TANF Recipients REV: April 2016 Individuals may file a complaint as follows:  Passengers or their family members may submit a formal written or verbal complaint to the State’s transportation broker at: 1-855-330-9131 or 1-866-288-3133 (for hearing impaired).  The State’s transportation broker will attempt to resolve the complaint with the individual or his/her family.  In the event transportation benefits are terminated or substantially altered, after due notice, and the complainant wishes to pursue his/her concerns further, the written complaint shall be forwarded to the State for a fair hearing. State fair hearings shall be conducted in accordance with the provisions of the Medicaid Code of Administrative Rules, Section #0110 “Complaints and Hearings” promulgated by EOHHS and available on the Secretary of State’s website: www.sos.ri.gov/rules.  In the event transportation benefits are terminated or substantially altered due to a lack of Program funding, formal appeal rights to a Medicaid fair hearing shall not be available.  Individuals who fail to show up at their scheduled pick up time will receive written notice from the transportation broker that they will be subject to a change in their transportation benefit if they fail to show up for four (4) or more rides. Individuals will receive a warning letter for each of three (3) failures to show up, followed by a fourth letter notifying them they are being moved to mass transit or gas mileage payment because they failed to show up for a scheduled ride four (4) or more times. Individuals will receive written notice on how to appeal this determination in accordance with the provisions of this section. 10 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. April 21, 2016 1360transfinalfinalapril2016 11 Addendum 1 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