Proposed new describes services provided under the MTP.

Transcription

1 CHAPTER 380. MEDICAL TRANSPORTATION PROGRAM The Texas Health and Human Services Commission (HHSC) proposes to amend , , , , , , , , , and concerning the Medical Transportation Program. HHSC also proposes new concerning Program Services. Background and Justification The Medical Transportation Program (MTP) provides nonemergency medical transportation services to Medicaid clients and those served by the Children with Special Health Care Needs services program and the Transportation for Indigent Cancer Patients program. MTP services are currently delivered across the state under two delivery models: a full risk broker (FRB) capitated rate model and a Transportation Service Area Provider (TSAP) fee-for-service model. Senate Bill (S.B.) 8, 83rd Legislature, Regular Session, 2013, added to the Government Code, which requires HHSC to provide MTP services on a regional basis through Managed Transportation Organizations (MTOs). The proposed new and amended rules define the term "managed transportation organization" and specify requirements of participation in the MTP as required by S.B. 8. In addition, the amended rules update references to agencies, delete obsolete citations and definitions, and update language to reflect current policies of the MTP. Section-by-Section Summary Proposed amended adds new definitions for: accident, covered health care service, demand response, long distance trip, managed transportation organization, nonemergency ambulance transportation services, performing provider, significant traditional provider, and transportation provider. The amendment also deletes obsolete definitions and clarifies existing definitions. Proposed amended clarifies that HHSC determines eligibility for the Transportation for Indigent Cancer Patients program and updates language. Proposed new describes services provided under the MTP. Proposed amended retitles the section "Program Requirements" and updates the rule to reflect current requirements in policy. Proposed amended updates the rule to update references, removes language relating to rates paid to Individual Transportation Participants (ITPs), clarifies existing reporting requirements related to accidents, and requires transportation providers to attempt to contract with significant traditional providers. Proposed amended updates language and clarifies the text to reflect current policy.

2 Proposed amended removes redundant language relating to individuals not eligible for MTP services, removes language relating to retroactive reimbursement, and removes language relating to program services which were moved and consolidated in , Program Services. Proposed amended clarifies language relating to client rights to appeal denial of services, and updates language relating to reimbursement of out-of-pocket expenses for meals and lodging when not prior authorized. Proposed amended retitles the section "Individual Transportation Participant Requirements", identifies situations in which Individual Transportation Participants may be required to complete validation processes, and updates language. Proposed amended retitles the subchapter "Regional Contracted Brokers or Managed Transportation Organizations", adds an MTO as an entity that must adhere to the standards for motor vehicles, and updates outdated language. Proposed amended updates language related to criminal records information of motor vehicle operators. The proposed amended rules include other technical corrections and non-substantive changes throughout to make the rule more understandable. Fiscal Note Greta Rymal, Deputy Executive Commissioner for Financial Services, has determined that during the first five-year period the proposed amendments and new rules are in effect, there will be a fiscal impact of cost savings to state government. The expected cost savings are $13,654,375 General Revenue (GR) ($32,588,007 All Funds (AF)) for State Fiscal Year (SFY) 2015, $14,341,766 GR ($34,187,761 AF) for SFY 2016, $15,038,923 GR ($35,849,639 AF) for SFY 2017, $15,802,450 GR ($37,669,725 AF) for SFY 2018 and $16,197,352 GR ($38,611,089 AF) for SFY There may be a fiscal impact on local governments. In S.B. 8, MTOs were defined to include rural or urban transit districts and public transportation providers. HHSC currently contracts with some such entities under the program, and may continue to contract with those or others under the new delivery model. The rate negotiated between the MTO and their contracted providers will not be within the scope of these rules. Therefore, HHSC lacks sufficient data to determine a fiscal impact to local governments at this time. Ms. Rymal has also determined that there are no anticipated costs to persons required to comply with these rules and there is no anticipated adverse impact on local employment. Small and Micro-business Impact Analysis Ms. Rymal has also determined that there will be no adverse effect on small businesses or microbusinesses as a result of enforcing or administering the proposed amendments and new rules.

3 HHSC currently contracts with transportation service area providers. The entities in turn subcontract with entities that may include small businesses or micro-businesses. Under the new capitated model, HHSC will contract with MTOs who may again in turn sub-contract with entities that may include small businesses or micro-businesses. The rate negotiated between the MTO and their contracted providers, if any, is not within the scope of these rules. Public Benefit Chris Traylor, Chief Deputy Commissioner, has determined that, for each year of the first five years the proposed amendments and new rules are in effect, the public will benefit from the adoption of the rules through the assurance of safe and efficient nonemergency medical transportation under the MTP. Regulatory Analysis HHSC has determined that this proposal is not a "major environmental rule" as defined by of the Texas Government Code. A "major environmental rule" is defined to mean a rule the specific intent of which is to protect the environment or reduce risk to human health from environmental exposure and that may adversely affect, in a material way, the economy, a sector of the economy, productivity, competition, jobs, the environment or the public health and safety of a state or a sector of the state. This proposal is not specifically intended to protect the environment or reduce risks to human health from environmental exposure Takings Impact Assessment HHSC has determined that this proposal does not restrict or limit an owner's right to his or her private real property that would otherwise exist in the absence of government action and, therefore, does not constitute a taking under of the Texas Government Code. Public Comment Written comments on the proposal may be submitted to Jimmy Charney, Manager of Policy Development, Medical Transportation Program, Texas Health and Human Services Commission, mail code M0209, P.O. Box , Austin, Texas 78703; by fax to (512) ; or by e- mail at jimmy.charney@hhsc.state.tx.us within 30 days of publication of this proposal in the Texas Register. Public Hearing A public hearing is scheduled for May 28, 2014, starting at 10 a.m. (central time) in the Public Hearing Room, Brown-Heatly State Office Building, 4900 North Lamar, Austin, Texas Persons requiring further information, special assistance, or accommodations should contact Sallie Allen at (512)

4 SUBCHAPTER A. PROGRAM OVERVIEW 1 TAC Statutory Authority The amendment is proposed under Texas Government Code , which provides the Executive Commissioner of HHSC with broad rulemaking authority; and Texas Human Resources Code and Texas Government Code (a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas. The proposed amendment affects Texas Human Resources Code Chapter 32 and Texas Government Code Chapter 531. No other statutes, articles, or codes are affected by this proposal Definitions of Terms. The following words and terms are applicable to this Chapter, Medical Transportation Program (MTP): [, when used in the Medical Transportation Program (MTP) rules, shall have the following meanings, unless the content clearly indicates otherwise.] (1) Abuse--The willful infliction of intimidation or injury resulting in physical harm, pain, or mental anguish. (2) Accident--An unexpected event or series of events causing loss or injury to person or property (e.g., automobile). (3) [(2)] Adjacent county(ies)--the county or counties that share a common county line or point with the client's [recipient's] county of residence. (4) [(3)] Advance funds--funds authorized [by the Health and Human Services Commission (HHSC)] in advance of travel and provided to the client [a recipient] or attendant to cover authorized transportation services (e.g., gas money, lodging, and/or meals) for travel to [for] a covered [medically-necessary] health care service. [(4) Ambulance service--a service paid through HHSC or its designee in an emergency, or nonemergency situation in which transportation in a vehicle other than an ambulance could endanger the recipient's health.] (5) Attendant-- (A) An adult required to accompany a prior authorized MTP client [recipient] under (4) of this chapter (relating to Program Limitations); [or] (B) an adult [or service animal] that accompanies a prior authorized MTP client [recipient ] to provide necessary mobility, personal or language assistance to the client [recipient] during the time that transportation [and health care] services are provided; [.]

5 (C) a service animal that accompanies a prior authorized MTP client to provide necessary mobility or personal assistance to the client during the time that transportation services are provided; or (D) an adult that accompanies a prior authorized MTP client because a health care provider has submitted a statement of need that the client requires an attendant. (6) Certification Period--A period of time for which a Transportation for Indigent Cancer Patient client [the recipient] is certified for service. (7) Children with Special Health Care Needs (CSHCN) services program--a program funded with general revenue and federal funds administered by the Department of State Health Services. Services for eligible children include early identification, diagnosis and evaluation, resulting in early health care intervention. (8) Covered health care service--a service included in the premium of the health care policy paid by or on behalf of an MTP client. (9) Demand Response--Transportation that involves using performing provider dispatched vehicles in response to requests from clients or shared one-way trips. [(8) Contractor--A for-profit business, a non-profit organization, or a governmental unit, including a regional contracted broker, that has entered into a legally binding contract with HHSC to provide authorized MTP transportation services, advance funds, meals and/or lodging to prior authorized MTP recipients.] [(9) Dependent care--necessary care for a child or and adult with a disability.] [(10) Destination--The place or point to which a recipient has been authorized by MTP to travel.] [(11) Door-to-door service--transportation from the door of the trip origin to the door of the trip destination as authorized by Regional MTP staff. This service includes providing assistance, as required, to passengers entering and exiting the vehicle.] [(12) Fraud--Deliberate misrepresentation or intentional concealment of information in order to obtain services or payment for services to which a person or contractor is not entitled.] (10) [(13)] Health and Human Services Commission (HHSC)--The state agency that operates the Medical Transportation Program. (11) [(14)] Health Care Provider's Statement of Need--MTP Form 3113 or equivalent submitted by a health care provider which documents the client's [recipient's] need for health care services and/or special transportation accommodations. (12) [(15)] Individual Transportation Participant (ITP)--An individual who has been approved [by HHSC] for mileage reimbursement at a rate prescribed by HHSC [prescribed rate] to provide

6 transportation for a prior authorized MTP client [recipient] to a covered [prior authorized] health care service. (13) [(16)] Limited Status--A Medicaid client's [recipient's] limitation to a designated provider, either a primary care provider or primary care pharmacy, under the lock-in provisions contained in Chapter 354, Subchapter K of this title (relating to Medicaid Recipient Utilization Review and Control). Clients [Recipients] are limited for specific periods of time as outlined in (c) of this title (relating to Utilization Control). (14) [(17)] Lodging [establishment ]--A commercial [An] establishment such as a hotel, motel, charitable home or hospital that provides overnight lodging. (15) Long Distance Trip--Transportation beyond a client's county of residence, county adjacent to client's county of residence, or Medicaid managed care service delivery area for the purpose of receiving covered health care services that are not available in the transportation area of the transportation provider where the client resides. (16) Managed Transportation Organization (MTO)-- (A) a rural or urban transit district created under Chapter 458, Transportation Code; (B) a public transportation provider defined by , Transportation Code; (C) a regional contracted broker defined by Government Code ; (D) a local private transportation provider approved by HHSC to provide MTP services; or (E) any other entity HHSC determines meets the requirements. (17) [(18)] Mass transit--public transportation by bus, rail, air, ferry, or intra-city bus either publicly or privately owned, which provides general or special service transportation to the public on a regular and continuing basis. Mass transit is intercity or intra-city transportation and also includes the use of commercial air service to transport clients to an authorized service. [Transportation that is subsidized by sales taxes or Federal Transit Administration funds and provided to the general public within a specified local area.] (18) [(19)] Medicaid--A health care program provided to eligible individuals under 42 U.S.C. 1396a et seq.; 42 C.F.R ; Texas Human Resources Code, Chapters 22 and 32. [(20) Medicaid-allowable service--a service covered under the State's Medicaid Plan or a Medicaid waiver. This includes health care services that are provided to the recipient by a charitable organization but not billed to Medicaid as well as value-added services provided by a Medicaid managed care plan to a Medicaid-enrolled member.] (19) [(21)] Medically necessary [Medically-necessary]--Services that are:

7 (A) reasonably necessary to: prevent illness(es) or medical condition(s); maintain function or to slow further functional deterioration; provide early screening, intervention, care, and/or provide care or treatment for eligible clients [recipients ] who have medical condition(s) that cause suffering or pain, physical deformity or limitations in function, or that threaten to cause or worsen a disability, illness or infirmity, or endanger life; (B) provided at appropriate locations and at the appropriate levels of care for the treatment of the medical condition(s); (C) consistent with health care practice guidelines and standards endorsed by professionally recognized health care organizations or governmental agencies; (D) consistent with the diagnosis(es) of the condition(s); [and] (E) no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency;[.] (F) not experimental or investigative; and (G) not primarily for the convenience of the client. (20) [(22)] Medical Transportation Program (MTP)--The [A] program that [ which] provides prior authorized nonemergency [non-emergency ] transportation services to and from covered health care services, based on medical necessity, for categorically eligible Medicaid clients [recipients] enrolled in Medicaid, and eligible clients [recipients] enrolled in CSHCN services program, or the Transportation for Indigent Cancer Patients [(TICP)] program who have no other means of transportation. (21) [(23)] Minor--An individual under 18 years of age who has never been married or emancipated by court ruling. (22) Nonemergency ambulance transportation services--transportation provided by ambulance in a nonemergency situation when all other means of transportation are not suitable for transporting the client to a covered health care service. Nonemergency ambulance transportation does not include any medical monitoring, medical aid, medical care, or medical treatment during transport. No flashing lights, sirens, or emergency equipment is required. (23) [(24)] Passenger assistance--transportation from curb at origin to curb at destination, including providing assistance, as required, to clients entering and exiting the vehicle. [Assistance which enables a recipient to walk, enter or exit a vehicle, or transfer from a wheelchair. This does not include lifting or carrying a person.] (24) Performing provider--an entity that arranges or provides transportation services to a prior authorized MTP client, including subcontractors, independent contractors, lodging and meal vendors, and intercity or intra-city bus services.

8 (25) Prior authorization--authorization or approval for the provision of transportation[, attendant, advance funds and meals and/or lodging] services obtained from MTP or a transportation provider [Regional MTP staff] before the services are rendered. (26) Prior authorized MTP client [recipient ]--A client [recipient] authorized by HHSC as eligible for Medicaid services under a specific category, or identified by either the CSHCN service program or the TICP program as eligible for program services, who has no other means of transportation to covered health care services. (27) Reasonable transportation--transportation using the most cost-effective transportation that meets the client's [recipient's] medical needs: (A) within a client's [recipient's] local community, county of residence, or county adjacent to a client's [recipient's] county of residence where the client [recipient] wishes to maintain an ongoing relationship or establish a relationship with a health care provider of his or her choice; or [(B) to and from a county beyond the county adjacent to the recipient's county of residence when determined by HHSC to be reasonably close to obtain medically necessary, health program allowable services from a specialist when appropriate medical services are not available as specified in subparagraph (A) of this paragraph; or] (B) [(C)] to a provider or facility within a designated Medicaid managed care service delivery area. (28) Regional contracted broker--an entity that contracts with HHSC to provide or arrange for the provision of nonemergency transportation services under the MTP, including a full risk broker as referenced at 45 C.F.R (4) (relating to nonemergency medical transportation brokerage program). (29) Routine medical transportation--prior authorized medical transportation trips [that do not have priority status] to and/or from a facility where covered health care services will be provided [health care needs will be met]. (30) Service animal--a trained guide dog, signal dog, or other animal to provide assistance to a specified MTP client [recipient] with a disability. (31) Sexual harassment--unwelcome sexual advances, requests for sexual favors, or other unwanted verbal or physical conduct of a sexual nature directed toward an individual by another individual during the provision of transportation [MTP] services. (32) Significant traditional provider--an individual or entity that has a documented record of providing transportation services for a minimum of two years.

9 [(32) Special medical transportation--medical transportation to and/or from a recipient's county of residence and beyond the adjacent county, where health care needs will be met and the appropriate health care service(s) are not available locally.] (33) Special needs--a transportation service that requires the use of a vehicle equipped with a ramp or a mechanical lift to provide the client [recipient] with a means of accessing the vehicle. (34) Transportation provider--a regional contracted broker or an MTO. (35) [(34)] Transportation for Indigent Cancer Patients (TICP) Program--A state-funded program that provides medical transportation services to individuals diagnosed with cancer or a cancerrelated illness and who meet [TICP] residency and financial criteria. The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt. Filed with the Office of the Secretary of State on April 21, TRD Jack Stick Chief Counsel Texas Health and Human Services Commission Earliest possible date of adoption: June 1, 2014 For further information, please call: (512) SUBCHAPTER B. ELIGIBILITY, PROGRAM SERVICES, PROCESSES, ADDITIONAL TRANSPORTATION CONNECTED WITH AN AUTHORIZED TRIP, LIMITATIONS, AND EXCLUSIONS 1 TAC , , , Statutory Authority The amendments and new rule are proposed under Texas Government Code , which provides the Executive Commissioner of HHSC with broad rulemaking authority; and Texas Human Resources Code and Texas Government Code (a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas.

10 The proposed amendments and new rule affect Texas Human Resources Code Chapter 32 and Texas Government Code Chapter 531. No other statutes, articles, or codes are affected by this proposal Eligibility. (a) The following prior authorized Medical Transportation Program (MTP) clients [recipients] are eligible to receive reasonable transportation to covered health care services if [medical necessity exists,] no other means of transportation are available, the mode of transportation is the most cost-effective mode available, [that does not endanger the recipient's health] and the facility is reasonably close and [to the prior authorized health care service that] meets the client's [recipient's] health care needs: (1) current Medicaid clients [recipients] authorized and identified by the Health and Human Services Commission (HHSC) as eligible for Medicaid services under a specific category; (2) Children with Special Health Care Needs (CSHCN) services program clients [recipients]; and (3) Transportation for Indigent Cancer Patients (TICP) Program clients [recipients]. (b) Eligibility [To be eligible] for participation in the TICP Program must be determined by HHSC. The[, the] individual: (1) must reside in Webb, Zapata, Starr, Jim Hogg, Hidalgo, Cameron, Willacy, or Nueces County and provide a copy of a federal or state ID (driver's license or identification card) and one of the following as proof of residency: (A) a copy of a utility bill under the applicant's name; or (B) if residing with a family member, a written verification from that family member stating that the applicant resides in the household and proof that the household is in an eligible county; (2) must not be eligible for Medicaid; (3) must not be eligible for CSHCN services program [-CIDC]; (4) must be [medically indigent (] at or below 100% of federal poverty guidelines[)]. Before program services are provided, the monthly household gross income shall be verified by: (A) financial information obtained through HHSC; (B) check stub or other written verification for each person in the household who is employed. This form must contain the name, address of employer, income and dates covered for each pay period; or

11 (C) award letter or other written verification of unearned income (such as Social Security, Worker's Compensation, Unemployment or Veteran's Administration benefits); (5) is permitted the following allowable deductions from the total monthly household gross income: (A) $120 standard deduction per person in household who is employed (the standard deduction per person will be the rate set by HHSC); and (B) dependent care: (i) up to $200 per child under two [2] years of age; or (ii) up to $175 per child two [2] years of age and older; (6) is not permitted to take deductions on unearned income; (7) if over the age of 18 and residing with a family member, the family member's household income is not considered. The applicant's gross income, less standard deductions, is used to determine the applicant's eligibility; (8) has zero income and shall therefore submit written verification from two family members or individuals who can attest that the household receives no monthly earned or unearned income. Unearned income refers to monetary assistance provided by family, friends, charitable organizations, and such given to the client [recipient] for household expenses; (9) must provide initial confirmation of cancer or cancer-related diagnosis by a licensed medical physician to HHSC. The following restrictions apply: (A) the applicant is eligible for up to four [4] diagnostic visits to a licensed medical physician to determine cancer or cancer-related diagnosis if HHSC is provided written verification that diagnostic visits are to rule out the possibility of cancer or cancer-related illness; and (B) confirmation of cancer or cancer-related diagnosis must be provided on or following the last diagnostic visit for transportation [MTP] services to continue; and (10) must be accepted for evaluation or treatment by a medical institution in Texas capable of providing quality cancer services Program Services. Transportation services prior authorized by the Medical Transportation Program (MTP) or transportation providers include: (1) Demand response transportation services provided when fixed route services are either unavailable or do not meet the health care needs of clients. Services must be timely and provided by qualified, courteous, knowledgeable, and trained personnel;

12 (2) Mass transit tickets when determined to be the appropriate mode of transportation for the client, ensuring the client does not live more than a quarter (1/4) mile from a public fixed route stop, the appointment is not more than a quarter (1/4) mile from a public fixed route stop, and that mass transit tickets are received by the client before the client's appointment; (3) Individual transportation participant services provided by volunteers who enter into an agreement and are reimbursed for mileage if they are prior authorized to drive a client to a covered health care service in a personal car; (4) Meal and lodging services for clients and an attendant when a covered health care service requires an overnight stay outside the client's county of residence or beyond adjacent counties. Clients and attendants must receive the same quality of services provided to other guests and the lodging services must be equivalent or better than those listed in the Office of the Texas Comptroller's State Travel Management Program; (5) Transportation to and from renal dialysis services for clients enrolled in the Medicaid program who are residing in a nursing facility, as required by the Human Resources Code; (6) Advance funds disbursed before the covered health care service to clients when a lack of transportation funds will prevent a child from traveling to the service. Advance funds are for clients through age 20 and Children with Special Health Care Needs services program clients 21 and over who have been diagnosed with cystic fibrosis. Advanced funds may be issued to cover meals, lodging, and/or mileage; (7) Out-of-state transport to contiguous counties or bordering counties in adjoining states (Louisiana, Arkansas, Oklahoma, and New Mexico) that are within 50 miles of the Texas border, if services are medically necessary and it is the customary or general practice of clients in a particular locality within Texas to obtain services from an out-of-state provider that is enrolled as a Texas Medicaid provider; (8) Commercial airline transportation services for a client and attendant to a covered health care service, when it is the most cost effective option or when necessary to meet the client's medical needs; and (9) Nonemergency ambulance transportation services, including a driver and an assistant, for clients who are in excess of 600 pounds, reclining position, or are non-ambulatory and cannot be transported in a taxicab or wheelchair van Program Requirements [Services]. [Medical] Transportation [Program (MTP)] services must be prior authorized by [Regional] the Medical Transportation Program (MTP) or transportation providers. Program requirements [staff. MTP services] include the following: (1) reasonable or long distance transportation of a prior authorized MTP client [recipient] to and/or from a covered health care service when: [prior authorized health care facility where

13 health care needs will be met, which includes transportation to and from renal dialysis services for recipients enrolled in the medical assistance program who are residing in a nursing facility;] [(2) special medical transportation to a health care facility when one of the following conditions is met:] [(A) the services are allowable and the health care provider will not bill Medicaid or another source for the cost of the services; or] (A) [(B)] the client [ recipient] provides [Regional MTP staff with] a Health Care Provider's Statement of Need or equivalent when required; or [for review and the service is determined reasonable;] (B) a provider will not bill Medicaid or another source for the cost of the services. This includes health care services that are provided to the client by a charitable organization but not billed to Medicaid. It does not include value-added services provided by a Medicaid managed care plan. (2) [(3)] transportation for an attendant(s) if necessary [the health care provider documents the need, the recipient is a minor, or a language or other barrier to communication or mobility exists that necessitates such assistance]; [(4) transportation for a service animal when accompanying a recipient; or] [(5) retroactive reimbursement for up to three months of reasonable transportation, meals and lodging if the recipient is a new recipient to MTP and was eligible under all program requirements. The retroactive reimbursement process will begin on the date of the request for retroactive reimbursement;] (3) [(6)] advance funds for an eligible child and attendant(s) when lack of transportation funds will prevent the child from traveling to a covered [receive ] health care service; and [services;] (4) [(7)] if a client is required to receive health care services outside their county of residence for six consecutive months, proof of residency may be required. [reimbursement or advanced funds for an eligible child and attendant(s) for meals and lodging when the health care service requires the child to remain overnight. If the child remains overnight for six consecutive months the recipient or responsible party must provide proof of residency by providing a copy of federal or state ID (driver's license or identification card); and] [(A) copy of a utility bill under the recipient's or responsible party's (if recipient is a child) name; or] [(B) if residing with a family member, written verification that the applicant resides in the household; and] [(8) partial reimbursement or advance funds for a prior authorized MTP recipient and attendant(s) for transportation beyond the approved destination. Partial reimbursement is limited

14 to the amount that would have been paid to the approved destination for transportation permitted under paragraph (1) of this section.] Program Processes. The following processes must be followed in order to ensure safe, efficient, and cost-effective delivery of transportation services: [To ensure transportation for prior authorized Medical transportation Program (MTP) recipients to a health care facility where health care needs will be met:] (1) a request for routine medical transportation must be received [by the Regional MTP staff] at least two working days in advance of the client's [recipient's] health care service appointment; (2) a request for a long distance trip or for nonemergency ambulance transportation services [special medical transportation] must be received [by the Regional MTP staff] at least five working days in advance of the client's [recipient's] health care service appointment; (3) exceptions to paragraphs (1) and (2) of this section may be granted [by the Regional MTP manager or designee] when the circumstances have been determined [by the Regional MTP manager or designee] to be beyond the client's [recipient's] control. The exception will be documented in the client's [recipient's] record; (4) clients [recipients] with recurring visits to a health care provider may receive multiple mass transit tickets or may have more than one transportation appointment authorized in advance; [(5) an individual transportation participant (ITP) may receive reimbursement that exceeds the amount paid to other transportation contractors in their area for transportation to a similar facility when determined by the Health and Human Services Commission as appropriate for the health care service required;] (5) [(6)] a certification period for Transportation for Indigent Cancer Patients Program (TICP) clients [certification period] may be retroactive to the date of the initial request for transportation [MTP ] services if all eligibility requirements are met, and all forms are completed and returned to HHSC. The duration of the certification period is a maximum of 12 consecutive months and minimum of 60 days; [and/or] (6) [(7)] specific certification periods apply to the following applicants of the TICP Program: (A) applicants on unearned fixed income such as Social Security, workers' compensation, unemployment or U.S. Department of Veterans Affairs benefits can be certified for a 12 month period if there are no anticipated changes in household income; (B) applicants with earned income can be certified up to an eight month [8-month] period if there are no anticipated changes in household income;

15 (C) applicants whose unearned or earned household income is within 10% of the federal poverty guideline can be certified up to a six month [6-month] period at a time if there are no anticipated changes in household income; or (D) applicants who have zero income can be certified up to two [2] months at a time. Zero income requires written verification from family members or advocates who can attest that the household receives no monthly earned or unearned income. (7) transportation providers must report any accidents with injuries to HHSC within one hour and must report any other accidents within 24 hours; and (8) transportation providers must attempt to contract with significant traditional providers Program Limitations. In the following circumstances clients [Recipients ] are not eligible to receive [medical] transportation services [under the following circumstances]: (1) transportation to and from a day activity, a personal care home or state institution, or a facility participating in another Title XIX program for which the reimbursement rate structure includes transportation funds[, except as specified in (1) of this subchapter (relating to Program Services)]; (2) the intended destination is a nursing facility, except as specified in (5) of this subchapter (relating to Program Services); (3) the client [recipient] is an inpatient in a health care facility, except as specified in (5) [ (1)] of this subchapter; (4) the client [recipient] is under 15 years of age and: (A) the client's [recipient's] parent, guardian, or another adult authorized by the parent or guardian does not accompany the client [recipient] as required by of this title (relating to Parental Accompaniment Requirement); and (B) the parent or guardian, if authorizing another adult to accompany the client [recipient], has not provided written authorization on a form prescribed by the Health and Human Services Commission, which will allow for the designation of one authorized adult and one alternate authorized adult; (5) the client [recipient] is 15 through 17 years of age and not accompanied, unless one of the following conditions exists: (A) the client [recipient] presents the parent's or legal guardian's signed, written consent for the transportation services to Medical Transportation Program staff, or a transportation provider [the Regional MTP office or the transportation contractor]; and/or

16 (B) the treatment to which the minor is being transported is such that the law extends confidentiality to the minor for this treatment; (6) the client [recipient] or another person or entity providing care for the client [recipient ] receives direct payment of worker's compensation benefits, U.S. Department of Veterans Affairs benefits, or other third-party resources for transportation to health care services on the client's [recipient's] behalf; (7) the client [recipient] is on limited status, unless the provider has made the referral or the client [recipient] requests family planning services; (8) TICP diagnostic visits and/or cancer or cancer-related treatments that are provided out-ofstate; (9) the client [recipient] and/or attendant intentionally, knowingly, or recklessly boards the vehicle carrying an illegal knife, a club, handgun or other weapon, as defined in Penal Code, 46.01, on or about his or her person; (10) a third-party, such as a lodging establishment, provides transportation, meals, and/or lodging at no charge for a client [recipient] and attendant, for a particular appointment; or (11) an attendant does not accompany the client [recipient] on the MTP-requested trip when a Health Care Provider's Statement of Need, Form 3113 or equivalent, is on file stating the client [recipient] requires an attendant(s) Program Exclusions. The following transportation services are not covered by the Medical Transportation Program (MTP): (1) transportation of deceased clients [recipients]; [(2) transportation of an individual who does not qualify for a state or federal medical assistance program served by the MTP, unless that individual is an authorized attendant;] [(3) transportation of individuals to services which are not covered by the applicable state or federal medical assistance program under which the recipient qualifies;] [(4) advance funds, meals, and/or lodging services to a recipient 21 years of age or older, unless the individual is a Children with Special Health Care Needs recipient diagnosed with cystic fibrosis;] (2) [(5)] reimbursement for additional travel costs when a client [recipient] elects to seek care at a more remote facility that is not supported on a Health Care Provider's Statement of Need, Form 3113 or equivalent [and prior authorized by Regional MTP staff];

17 (3) [(6)] medical care while clients [recipients] are being transported; (4) [(7)] emergency [or non-emergency] ambulance service; (5) [(8)] passenger assistance beyond that which is necessary to ensure that clients [recipients ] enter and leave vehicles safely[, unless the contractor's contract states that door-to-door service is provided]; and [(9) reimbursement for transportation services provided by an individual transportation participant (ITP) before the date that Regional MTP staff approved the initial request to provide services from the ITP, unless an exception for retroactive reimbursement has been made and is documented by the Regional MTP staff; and] (6) [(10)] transportation services for family members not previously authorized for the specific trip [by Regional MTP staff]. The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt. Filed with the Office of the Secretary of State on April 21, TRD Jack Stick Chief Counsel Texas Health and Human Services Commission Earliest possible date of adoption: June 1, 2014 For further information, please call: (512) SUBCHAPTER C. CLIENT RIGHTS 1 TAC Statutory Authority The amendment is proposed under Texas Government Code , which provides the Executive Commissioner of HHSC with broad rulemaking authority; and Texas Human Resources Code and Texas Government Code (a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas.

18 The proposed amendment affects Texas Human Resources Code Chapter 32 and Texas Government Code Chapter 531. No other statutes, articles, or codes are affected by this proposal Client Rights and Responsibilities. (a) Client [Recipient] Rights. (1) Nondiscrimination. The client [recipient ] has a right to receive services in compliance with Title VI of the Civil Rights Act of 1964, 42 U.S.C.A. 2000d, et seq.; 504 of the Rehabilitation Act of 1973, 29 U.S.C.A. 794; the Americans with Disabilities Act of 1990, 42 U.S.C.A , et seq;. and all amendments to each, and all requirements imposed by the regulations issued pursuant to these Acts, in particular 45 C.F.R. [CFR] Part 80 (relating to race, color, national origin), 45 C.F.R. [CFR] Part 84 (relating to handicap), 45 C.F.R. [CFR] Part 86 (relating to sex), and 45 C.F.R. [CFR] Part 91 (relating to age). (2) Abuse report. Clients [Recipients] should report verbal or physical abuse or sexual harassment committed by other clients, [recipients or] passengers, a transportation provider's employees [contractor employees], or Health and Human Services Commission (HHSC) staff to the Medical Transportation Program (MTP) or the transportation provider [Regional MTP staff or Regional Management staff] upon arrival at the client's [recipient's] destination. (3) Denial notification. If a service is denied, MTP or the transportation provider [Regional MTP staff] shall notify the client [recipient] in accordance with Chapter 357, Subchapter A of this title (relating to Uniform Fair Hearing Rules). This client [recipient] notification does not apply to transportation services under of this title (relating to Program Exclusions). (4) Appeal request. (A) For services that have been denied by a transportation provider, a client may request an internal review of the denied services to be conducted by the transportation provider, MTP, or both. (B) For services that have been denied by MTP, a client may request an administrative review to be conducted by the MTP Program Director. (C) At any time, a client may request a fair hearing for review of a service denial by an HHSC hearings officer. [A recipient whose services have been denied may request an administrative review by the Regional MTP Manager. A second administrative review may be conducted by the MTP Program Director. If the recipient is still dissatisfied, the recipient may appeal the administrative review decision or the service denial by requesting a fair hearing.] A request for a fair hearing must be in writing and mailed or hand-delivered to the MTP office in Austin [appropriate Regional MTP office]. (b) Client [Recipient] Responsibilities.

19 (1) When a client [recipient] or responsible adult requests transportation, he/she must provide [Regional MTP staff with] the following information: (A) client [recipient] name, address, and, if available, the telephone number; (B) Medicaid, Transportation for Indigent Cancer Patients Program or Children with Special Health Care Needs services program client [recipient] identification number (if applicable) or Social Security number, and date of birth; (C) name, address, and telephone number of health care provider and/or referring health-care provider; (D) purpose and date of trip and time of appointment; (E) affirmation that other means of transportation are unavailable; (F) special needs, including wheelchair lift or attendant(s); (G) medical necessity verified by the Health Care Provider's Statement of Need, if applicable; and (H) affirmation that advance funds are needed when a lack of transportation funds will prevent the child from traveling to a covered health care service, if applicable. [in order for the recipient to access health care services.] (2) Clients [Recipients] must reimburse HHSC for any advance funds, and any portion thereof, that: (A) are not used for the specific prior authorized service; or[.] (B) when a verification that client attended the covered health services is not submitted. (3) Clients [Recipients] must refrain from verbal and/or physical abuse or sexual harassment toward another client [recipient] or passenger, transportation provider or performing provider [contractor's] employees, or HHSC employees while requesting or receiving medical transportation services. (4) Clients [Recipients] must safeguard all bus tickets and/or tokens from loss and theft and must return unused tickets or tokens to the MTP or the transportation provider [Regional MTP office] issuing the tickets or tokens. (5) Clients [Recipients] who receive mass transit [mass-transit] bus tickets or tokens must complete a verification form. Clients [HHSC's Verification of Travel to Health Care Services by Mass Transit, Form Recipients] must return this verification form prior to their next request for tickets or tokens. A letter from the health care provider verifying delivery of services may be substituted for the disbursement of mass transit tickets or tokens verification form.

20 Exceptions to this documentation may be granted [by a Regional MTP Manager or supervisor] when circumstances occur that are beyond the client's [recipient's] control. Exceptions will be documented in the client's [recipient's] record. (6) Clients [Recipients] must not use authorized medical transportation for purposes other than travel to and from health care services. (7) If the client [recipient] does not need to use the authorized transportation services, the client [recipient] or the responsible adult should contact MTP or the transportation provider [the Regional MTP staff] to cancel the particular trip no less than four hours prior to the time of the authorized trip. (8) Clients [Recipients] who receive advance funds for meals, lodging, and/or travel must return written documentation from the health care provider verifying services were provided, prior to receiving future advance funds. (9) Clients [Recipients] must cancel requests for advance funds or lodging when not needed and must refund any disbursed advance funds to HHSC. (10) Clients [Recipients] must provide the following [appropriate receipts] when seeking reimbursement for lodging in situations where prior authorization could not be obtained in advance:[.] (A) original receipt from the lodging establishment showing its name and address, the client's name as an occupant, and specific services for which the occupant was charged (e.g., room rent, tax); (B) letter from the client or attendant requesting reimbursement for out-of-pocket expenses; and (C) copies of the client or attendant's Social Security card and valid state-issued identification. The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency's legal authority. Filed with the Office of the Secretary of State on April 21, TRD Jack Stick Chief Counsel Texas Health and Human Services Commission Earliest possible date of adoption: June 1, 2014

21 For further information, please call: (512) SUBCHAPTER D. INDIVIDUAL TRANSPORTATION PARTICIPATION 1 TAC Statutory Authority The amendment is proposed under Texas Government Code , which provides the Executive Commissioner of HHSC with broad rulemaking authority; and Texas Human Resources Code and Texas Government Code (a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas. The proposed amendment affects Texas Human Resources Code Chapter 32 and Texas Government Code Chapter 531. No other statutes, articles, or codes are affected by this proposal Individual Transportation Participant [Participation] Requirements. (a) To participate in the Medical Transportation Program (MTP), all individual transportation participants (ITP) must: (1) complete an ITP [enrollment] application with the Health and Human Services Commission (HHSC) or its designee to acquire participation status; and (2) have and maintain a current driver's license, current vehicle insurance, current vehicle inspection sticker and current vehicle license tags and meet all other participation requirements. (b) In addition to the requirements in subsection (a) of this section, ITPs applying to receive mileage reimbursement for transporting eligible MTP clients [recipients] other than themselves or their family members may be subject to additional validation processes, as specified in the transportation provider's contract, or be [are] subject to the requirements contained in Chapter 352 of this title (relating to Medicaid and the Children's Health Insurance Program Provider Enrollment) and Chapter 371 of this title (relating to Medicaid and Other Health and Human Services Fraud and Abuse Program Integrity), whichever is applicable. (c) HHSC may reject any application for participation as an ITP or terminate the participation status of any ITP at HHSC's sole discretion. (d) To receive mileage reimbursement for a trip, an ITP must return to HHSC or its designee a completed ITP service record (Form H3017) or its equivalent. (e) The ITP must refund to HHSC or its designee any funds to which the ITP is not entitled for any reason.