Medicaid Payments and Providers: Transportation Services (210-RICR-20-00-2)

A.These rules and regulations related to the Executive Office of Health and Human Services’ (EOHHS) Non-Emergency Medical Transportation (NEMT) Program are promulgated pursuant to the authority conferred under:

1.42 C.F.R. § 431.53 “Assurance of Transportation”;

2.42 C.F.R. § 440 “Medicaid Program; State Option to Establish Non-Emergency Medical Transportation Program”;

3.Section 1902(a)(70) of the Social Security Act (“Deficit Reduction Act of 2005”);

4.R.I. Gen. Laws § 42-66-4(8) “Duties of the Department”;

5.R.I. Gen. Laws § 42-12-1.3 “Transfer of Functions from the Department of Elderly Affairs”; and

6.R.I. Gen. Laws § 31-36-20(a) “Motor Fuel Tax Disposition of Proceeds.”

B.Federal 42 C.F.R. § 431.53 requires the Medicaid agency:

1.to ensure necessary transportation for beneficiaries to/from health care providers; and

2.to describe the methods used to provide such transportation services.

The purpose of this regulation is to set forth methods and requirements for the Non-Emergency Medical Transportation (NEMT) Program, the Elderly Transportation Program (ETP), and the transportation for recipients of Temporary Assistance to Needy Families (TANF).

A.Wherever used in these rules and regulations, the following terms shall be construed as follows:

1.“Border communities” means the list of locations contained in § 2.20 of this Part.

2.“Curb-to-curb” means transportation of the beneficiary from the curb in front of his/her residence to the curb in front of the destination, including the return trip. The driver may assist the individual to get in and out of the vehicle.

3.“Door-to-door” means transportation of the beneficiary 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 beneficiary from the ground level door of his/her residence to the ground level door of his/her destination, including the return trip.

4.“Elderly”, as used herein, means persons aged 60 and older.

5.“Emergency transportation” means transportation 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 must be provided by ambulance.

6.“Executive Office of Health and Human Services” or “EOHHS” means the state agency that is designated under the Medicaid State Plan as the single state agency responsible for the administration of the Title XIX Medicaid Program.

7."Limited public motor vehicle" or "LPMV" means and includes every motor vehicle for hire, other than a jitney, as defined in R.I. Gen. Laws § 39-13-1, or a taxicab equipped with a taximeter used for transporting members of the general public for compensation only from a designated location on private property to such points as may be directed by the passenger.

8.“Medicaid-covered service” means the full scope of services and supports authorized by the Medicaid State Plan and the Section 1115 demonstration waiver. Although there is variation in benefits by coverage group, in general, Medicaid health coverage includes the benefits set forth in Part 10-00-1 of this Title, “Overview of the Rhode Island Medicaid and Children’s Health Insurance Program.”

9.“Medically necessary” means and includes medical/health visits that are part of a total patient plan of care supervised and ordered by a health care professional.

10.“Ride share program” means a transportation service provided through a Transportation Network Company (TNC) regulated by the Rhode Island Division of Public Utilities and Carriers under R.I. Gen. Laws Chapter 39-14.2.

11."R.I. Gen. Laws" means the Rhode Island General Laws, as amended.

12.“Transportation management authority” means an entity that provides, or arranges to provide, transportation services to EOHHS beneficiaries and elderly non-Medicaid riders, as provided herein.

13.“Transportation provider” means an entity that transports EOHHS beneficiaries and elderly non-Medicaid riders, as provided herein, via public transit (bus), taxi, LPMV, ride share program, public motor vehicles, multi-passenger van, ambulance, or wheelchair van.

A.EOHHS recognizes that Medicaid beneficiaries need available and appropriate transportation in order to access medical care, and assures the provision of such transportation when required to obtain medically necessary services covered by the Medicaid program.

B.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 NEMT when both the beneficiary and the provider are within one-half (½) mile of an established bus stop and the beneficiary is able to walk or transport her/himself to the bus stop.

1.Public transit (bus)

2.Taxi or Limited Public Motor Vehicle (LPMV)

3.Ride Share Program

4.Public Motor Vehicles

5.Multi-Passenger Van

6.Ambulance

7.Wheelchair Van.

8.Mileage Reimbursement.

Covered Services - The Medicaid Program covers emergency and NEMT. Ground transportation is covered and provided for when the individual is a Medicaid beneficiary and is receiving a Medicaid-covered service.

2.5.1Emergency Transportation

A.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.

B.For Medicaid managed care beneficiaries, emergency transportation is provided by the managed care organization. Billing for this service is through the managed care organization.

C.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.

2.5.2Non-Emergency Medical Transportation (NEMT)

A.NEMT is provided when the Medicaid beneficiary has no other means of transportation, no other community resource exists, such as family and 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. A physician/clinician written statement or attestation will be required.

B.To be eligible for NEMT services, Medicaid beneficiaries 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.

1.Escorts

a.If medically justified and communicated during the reservation to the State’s transportation management authority, an additional person can be permitted to accompany a beneficiary.

b.An escort must accompany all children under the age of 18 years.

c.Adult beneficiaries who need transportation to their own medical appointments may have a child accompany them.

2.More than one beneficiary may be transported by the same vehicle on the same trip, provided:

a.Adequate seating and safety restraints are available for all passengers.

b.The health and safety of any of the passengers is not compromised.

c.Passengers must not have their trip lengthened by more than 30 minutes due to increasing the number of passengers in the same vehicle.

2.5.3Out-of-State Non-Emergency Medical Transportation

A.Transportation to communities that closely border Rhode Island may be provided for Medicaid-covered services and as pre-authorized by the transportation management authority subject to review and approval of the State, as needed. See § 2.20 of this Part for a list of border communities.

B.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.

C.All out-of-state NEMT, with the exception of NEMT to border communities, requires prior authorization from the State’s transportation management authority.

2.5.4Nursing Facility Residents

A.NEMT: 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:

1.Patient cannot be transported by any other means through the facility; and

2.Required medical service cannot be provided within the facility, such as portable x-ray services provided in a facility setting; and

3.Facility has exhausted all other alternative means (including transportation by family or friends) whenever possible.

B.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.

All NEMT requests must be scheduled through the State’s transportation management authority. Some requests may require a physician or clinician’s attestation and/or documentation. Information on how to contact the State’s transportation management authority is available at: www.eohhs.ri.gov.

2.6.1Standing Order Requests

Regularly recurring appointments for which the beneficiary requires NEMT transportation may be scheduled with the State’s transportation management authority. A licensed medical/behavioral health provider must request or modify the standing order.

A.Curb-to-curb

B.Door-to-door

C.Wheelchair van: This service is for beneficiaries who are permanently confined to a wheelchair and cannot transfer out of it. Wheelchair-dependent beneficiaries must provide their own wheelchair. A Hoyer Lift or two-person lift will be used to transfer the beneficiary. Beneficiaries must request this service at the time of reservation to the state’s transportation management authority. Transportation providers are not permitted to enter the beneficiary’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 management authority when they reserve transportation that an escort will accompany them.

D.Stretcher: A beneficiary who is confined to a bed, cannot walk, and cannot sit in a wheelchair may be transported by stretcher. The beneficiary must not require medical assistance during transport. The driver must enter residence and a clear, accessible path to the beneficiary must be available.

E.Basic Life Support (BLS) and Advanced Life Support (ALS): Transportation of a beneficiary who is confined to a bed, cannot walk, and cannot sit in a wheelchair requires medical assistance during transport. The driver must enter residence and a clear, accessible path to the beneficiary must be available.

F.Mileage Reimbursement

1.Personal vehicle mileage reimbursement is a payment to a friend, family member or volunteer who transports the recipient in his/her own vehicle. The reimbursement must be pre-approved by the State’s transportation management authority and will be paid at the approved reimbursement rate which is the federal transportation mileage reimbursement rate.

2.Personal vehicle mileage reimbursement is available to transport an eligible Medicaid beneficiary to and from a Medicaid-covered service.

3. Trips will be validated by the State’s transportation management authority.

A.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 management authority at least twenty-four (24) hours prior to the scheduled trip.

B.If a medical appointment is cancelled the same day, or there are other unforeseen circumstances, the beneficiary should contact the State's transportation management authority as soon as possible.

A.Standing Orders

1.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 and will no longer be eligible for “standing order” pick-ups.

2.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.

3.Passengers who frequently (more than three (3) instances per month) do not cancel other scheduled trips, such as 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.Passengers with a frequent pattern of no-shows will receive written notice from the State’s transportation management authority that they will be subject to a change in their transportation benefit. (See § 2.18 of this Part, “Complaint Process for Medicaid Beneficiaries and Persons Using the Non-Medicaid Elderly Transportation Program and TANF recipients”).

All NEMT transportation requests that require an attestation and/or written 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.

A.To participate in the NEMT Program, a transportation provider must enter into a signed agreement with the State’s transportation management authority. 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 management authority. All required provider documents must be submitted to the State’s transportation management authority. All providers must meet the requirements set forth by the State’s transportation management authority.

B.Drivers must treat beneficiaries with courtesy and respect.

2.11.1Ambulance Providers:

A.Must have a license issued through the Rhode Island Department of Health (DOH);

B.License must be renewed annually;

C.Must have proof of insurance.

2.11.2 Taxi, Limited Public Motor Vehicles, and Public Motor Vehicles:

A.Must have a license issued through the Rhode Island Division of Public Utilities and Carriers (DPUC) validating proof of authority to engage granted by the DPUC. R.I. Gen. Laws Chapter 39-14 (Taxicabs and Limited Public Motor Vehicles) and R.I. Gen. Laws Chapter 39-14.1 (Public Motor Vehicles).

1.Taxis and Limited Public Motor Vehicles – Public Certificate for Convenience and Necessity

2.Public Motor Vehicles – Certificate of Operating Authority.

B.Providers are required to maintain and ensure drivers have a valid Hackney License (Blue Card).

C.All licenses must be renewed annually through the Division of Public Utilities and Carriers (DPUC).

2.11.3Ride-Share Vehicles

Drivers and vehicles must be in compliance with ride-share company standards.

2.11.4 Personal Vehicles

A.Vehicles used to provide transportation to a beneficiary must be in good condition, safe for transport, and have current and valid:

1.Registration

2.State Inspection and

3.Proof of Insurance.

B.The driver must have a valid, unrestricted driver’s license and the driver must have completed any and all training required by the transportation management authority.

A.Ambulance providers shall be recertified annually by the Rhode Island Department of Health.

B.Taxi and Public Motor Vehicle Carriers and providers shall be required to forward a copy of their license or recertification with the DPUC to the State’s transportation management authority within thirty (30) days of renewal to avoid interruption of program enrollment.

C.Ride share companies must also provide a copy of their annual recertification permit as a Transportation Network Company to the State’s transportation management authority to avoid interruption in program enrollment.

A.NEMT: The State’s transportation management authority is responsible for claims and billing for NEMT.

B.Emergency Transportation: 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.

2.13.1Medicare/Medicaid Crossover Claims

A.Emergency Transportation

1.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.

2.Payment of cross-over claims for Medicaid managed care recipients is handled and directed by the managed care plans.

B.Non-Emergency Transportation

1.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 management authority may be responsible for payment of Medicaid-covered NEMT services that were denied by Medicare, subject to prior approval and verification by the broker.

2.13.2Patient Liability

A.The NEMT payment is considered payment in full. The transportation provider is not permitted to seek further payment from the Medicaid beneficiary in excess of any payment received from the State’s transportation management authority.

B.Emergency Transportation: 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.

A.The Non-Medicaid Elderly Transportation Program (ETP) 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 the Americans with Disabilities Act (ADA) Program.

B.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.

C.The ETP provides transportation to and from medical appointments, adult day care, meal sites, dialysis/cancer treatment and the “INSIGHT Program.”

D.The program requires a co-payment for each trip segment. The co-payment amount is determined by EOHHS. The co-payment is collected and retained by the transportation driver. Medicaid and “Costs Not Otherwise Matchable” (“CNOM”)-eligible individuals are exempt from this co-pay for transportation in Priorities #1 - #4 in § 2.15 of this Part (below).

E.The ETP 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, and consistent assignment of preferred transportation providers to the maximum extent possible.

F.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 management authority. This may include, but is not limited to:

1.Date of birth;

2.Proof of residency, including but not limited to, 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 management authority.

The following transportation services may be provided to Rhode Island elders by the State’s transportation management authority based on the following prioritization. Service provision is contingent upon available state funding.

2.15.1Special 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 management authority 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.

2.15.2Adult 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 and provided to the State’s transportation management authority. The State reserves the right to limit transportation to adult day care centers based on funding constraints or other programmatic requirements.

2.15.3General 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.

2.15.4INSIGHT (Priority 4)

A.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.

B.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 management authority 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.

2.15.5Senior 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 management authority 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.

2.16.1Limitation on Transportation

Subject to state and federal law, EOHHS reserves the right to limit, restrict, or terminate the availability of transportation due to funding constraints, programmatic requirements, service availability, weather, etc. (This provision applies to clients of the ETP only).

2.16.2Service Models

A.Curb-to-curb

B.Door-to-door

C.Wheelchair van: Wheelchair dependent beneficiaries must provide their own wheelchair. Beneficiaries must request this service at the time of reservation to the State’s transportation management authority. 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 management authority when they reserve transportation that an escort will accompany them.

2.16.3Transport to Nearest Sites

A.Transportation to kidney dialysis, cancer treatments and general medical trips shall be to the facility closest to the client's home, unless transportation to another facility is more appropriate. The facility closest to the client’s home may be in a bordering town listed in § 2.20 of this Part.

B.Transportation to adult day care facilities and meal sites 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. The facility closest to the client’s home may be in a bordering town listed in § 2.20 of this Part.

2.16.4Days 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.

2.16.5 Passenger Cancellations

A.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 management authority at least twenty-four (24) hours prior to the scheduled trip.

B.If a medical appointment is cancelled the same day, or there are other unforeseen circumstances, the beneficiary should contact the State’s transportation management authority as soon as possible.

2.16.6Passenger No-Shows

A.Standing Orders

1.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, and will no longer be eligible for “standing order” pick-ups.

2.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.

B.Passengers who frequently (more than three (3) instances per month) do not cancel other scheduled trips, such as separate physician visits, at least twenty-four (24) hours in advance will be required to confirm scheduled trips the morning of or twenty-four (24) hours in advance.

C.Passengers with a frequent pattern of no-shows will receive written notice from the State’s transportation management authority that they will be subject to a change in their transportation benefit. Individuals will receive written notice on how to appeal this determination. (See § 2.18 of this Part, “Complaint Process for Medicaid Beneficiaries and Persons Using the Non-Medicaid Elderly Transportation Program and TANF recipients”).

A.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 management authority to request a pass.

B.Bus passes will be mailed to the recipient following the request.

A.Individuals may file a complaint as follows:

1.Passengers or their family members may submit a formal written or verbal complaint to the State’s transportation management authority. Contact information is available at www.eohhs.ri.gov.

2.The State’s transportation management authority will attempt to resolve the complaint with the individual and/or his/her family.

3.In the event transportation benefits are terminated or substantially altered, after due notice, and the complainant wishes to pursue his/her concerns further, a written complaint shall be forwarded to the State for a fair hearing. State fair hearings shall be conducted in accordance with the provisions of Part 10-05-2 of this Title, Appeals Process and Procedures for EOHHS Agencies and Programs, promulgated by EOHHS and available on the Secretary of State’s website.

4.In the event ETP transportation benefits are terminated or altered due to a lack of Program funding, formal appeal rights to a fair hearing shall not be available.

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.

A.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: