Health and Human Services Commission Council. Shannon Pickett, Medical Transportation Program

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1 TO: Health and Human Services Commission Council DATE: May 23, 2014 FROM: Shannon Pickett, Medical Transportation Program SUBJECT: Agenda Item 5.d. - Delivery of Non-emergency Medical Transportation Services BACKGROUND: Federal Requirement Legislative Requirement Other The Health and Human Services Commission (HHSC) proposes to amend Title 1, Part 15, Chapter 380, Medical Transportation Program (MTP). 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) capitation model and a state-authorized Transportation Service Area Provider fee-for-service model (TSAP). The FRB model operates in the greater Dallas / Ft. Worth and greater Houston areas; the TSAP model operates in the remainder of the state. Senate Bill (S.B.) 8, 83rd Legislature, Regular Session, 2013, added Section to the Government Code, which requires HHSC to provide MTP services on a regional basis through managed transportation organizations (MTOs). The proposed amendments and new 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 policy for the MTP. ISSUES AND ALTERNATIVES: There are no issues or alternatives for consideration. STAKEHOLDER INVOLVEMENT: Stakeholders will have an opportunity to comment during the MCAC meeting, the HHSC Council meeting on May 23, 2014, a public hearing on May 28, 2014, and during the 30-day public comment period that ends on June 1,

2 FISCAL IMPACT: None (if no, delete the table below) Yes (if yes, complete the table below) Cost Savings: SFY 2015 SFY 2016 SFY 2017 SFY 2018 SFY 2019 State $13,654,375 $14,341,766 $15,038,923 $15,802,450 $16,197,352 Federal $18,933,632 $19,845,995 $20,810,716 $21,867,275 $22,413,737 Total $32,588,007 $34,187,761 $35,849,639 $37,669,725 $38,611,089 SERVICES IMPACT STATEMENT: Describe the proposed rule s impact on the HHSC client population. None RULE DEVELOPMENT SCHEDULE: May 2, 2014 May 8, 2014 May 23, 2014 May 28, 2014 August 1, 2014 September 1, 2014 Publish proposed rules in the Texas Register Present to MCAC Present to HHSC Council Public hearing Publish adopted rules in the Texas Register Effective date REQUESTED ACTION: Information Only 2

3 TITLE 1 PART 15 CHAPTER 380 SUBCHAPTER A RULE SUBCHAPTER B RULE RULE RULE RULE RULE RULE SUBCHAPTER C RULE SUBCHAPTER D RULE SUBCHAPTER E RULE RULE ADMINISTRATION TEXAS HEALTH AND HUMAN SERVICES COMMISSION MEDICAL TRANSPORTATION PROGRAM PROGRAM OVERVIEW Definitions of Terms ELIGIBILITY, PROGRAM SERVICES, PROCESSES, ADDITIONAL TRANSPORTATION CONNECTED WITH AN AUTHORIZED TRIP, LIMITATIONS, AND EXCLUSIONS Eligibility Program Services Program Requirements [Services] Program Processes Program Limitations Program Exclusions CLIENT RIGHTS Client Rights and Responsibilities INDIVIDUAL TRANSPORTATION PARTICIPATION Individual Transportation Participant [Participation] Requirements REGIONAL CONTRACTED BROKERS AND MANAGED TRANSPORTATION ORGANIZATIONS Standards for Motor Vehicles Standards for Motor Vehicle Operators PROPOSED PREAMBLE 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 Section 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. 3

4 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 amended 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. 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 5-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 4

5 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. 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. 5

6 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 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) Statutory Authority These amendments 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. The proposed amendments affect Texas Human Resources Code Chapter 32 and Texas Government Code Chapter 531. No other statutes, articles, or codes are affected by this proposal. This agency hereby certifies that this proposal has been reviewed and approved by legal counsel and found to be within the agency s legal authority to adopt. 6

7 Legend: Single Underline = Proposed new language [Strikethrough and brackets] = Current language proposed for deletion Regular print = Current language (No change.) = No changes are being considered for the designated subdivision. TITLE 1 PART 15 CHAPTER 380 SUBCHAPTER A RULE ADMINISTRATION TEXAS HEALTH AND HUMAN SERVICES COMMISSION MEDICAL TRANSPORTATION PROGRAM PROGRAM OVERVIEW 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 non-emergency 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; [.] (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 7

8 (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 [a 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) 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.] (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. [(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.] (10 [11]) 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 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 8

9 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 [An] commercial 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 Section , Transportation Code; (C) a regional contracted broker defined by Government Code Section ; or (D) a local private transportation provider approved by HHSC to provide MTP services; (E) any other entity HHSC determines meets the requirements. (17) 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: (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; 9

10 (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. (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 10

11 service program or [of] 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 (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. [(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. 11

12 (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 cancer-related illness and who meet [TICP] residency and financial criteria. 12

13 TITLE 1 PART 15 CHAPTER 380 SUBCHAPTER B RULE ADMINISTRATION TEXAS HEALTH AND HUMAN SERVICES COMMISSION MEDICAL TRANSPORTATION PROGRAM ELIGIBILITY, PROGRAM SERVICES, PROCESSES, ADDITIONAL TRANSPORTATION CONNECTED WITH AN AUTHORIZED TRIP, LIMITATIONS, AND EXCLUSIONS 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; 13

14 (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 (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 (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. 14

15 TITLE 1 PART 15 CHAPTER 380 SUBCHAPTER B RULE ADMINISTRATION TEXAS HEALTH AND HUMAN SERVICES COMMISSION MEDICAL TRANSPORTATION PROGRAM ELIGIBILITY, PROGRAM SERVICES, PROCESSES, ADDITIONAL TRANSPORTATION CONNECTED WITH AN AUTHORIZED TRIP, LIMITATIONS, AND EXCLUSIONS 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; (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; 15

16 (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. 16

17 TITLE 1 PART 15 CHAPTER 380 SUBCHAPTER B RULE ADMINISTRATION TEXAS HEALTH AND HUMAN SERVICES COMMISSION MEDICAL TRANSPORTATION PROGRAM ELIGIBILITY, PROGRAM SERVICES, PROCESSES, ADDITIONAL TRANSPORTATION CONNECTED WITH AN AUTHORIZED TRIP, LIMITATIONS, AND EXCLUSIONS Program Requirements [Services] [Medical] Transportation [Program (MTP)] services must be prior authorized by [Regional] the Medical Transportation Program (MTP) [staff] or transportation providers. [MTP] Program requirements [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 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 [for review and the service is determined reasonable]; or (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;] 17

18 (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[s]; and (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 to the amount that would have been paid to the approved destination for transportation permitted under paragraph (1) of this section.] 18

19 TITLE 1 PART 15 CHAPTER 380 SUBCHAPTER B RULE ADMINISTRATION TEXAS HEALTH AND HUMAN SERVICES COMMISSION MEDICAL TRANSPORTATION PROGRAM ELIGIBILITY, PROGRAM SERVICES, PROCESSES, ADDITIONAL TRANSPORTATION CONNECTED WITH AN AUTHORIZED TRIP, LIMITATIONS, AND EXCLUSIONS 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; 19

20 (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; (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. 20