Oklahoma Health Care Authority

Transcription

1 Oklahoma Health Care Authority It is very important that you provide your comments regarding the proposed rule change by the comment due date. Comments are directed to Oklahoma Health Care Authority (OHCA) Health Policy Unit OHCA COMMENT DUE DATE: February 16, 2015 The proposed policy is a Permanent Rule. This proposal is scheduled to be presented to the Medical Advisory Committee (MAC) on March 12, 2015 and the (OHCA) Board of Directors on March 26, Reference: APA WF A&B SUMMARY: SoonerRide Non-emergency transportation rules are revised to clarify eligibility and coverage criterion. LEGAL AUTHORITY The Oklahoma Health Care Authority Board; The Oklahoma Health Care Authority Act, Section 5003 through 5016 of Title 63 of Oklahoma Statutes; 42 CFR RULE IMPACT STATEMENT: STATE OF OKLAHOMA OKLAHOMA HEALTH CARE AUTHORITY TO: FROM: Tywanda Cox Health Policy Demetria Bennett Health Policy SUBJECT: Rule Impact Statement APA WF # A&B A. Brief description of the purpose of the rule: Rules remove mention to inpatient under the exclusion group as this is not considered an eligibility standard. Rules also remove coverage for non-emergency transport to VA facilities as these facilities are not contracted with the Oklahoma Health Care Authority. Rules also clarify coverage guidelines for escorts, and rules remove mention of the My Life, My Choice group as the waiver is set to expire. 1

2 B. A description of the classes of persons who most likely will be affected by the proposed rule, including classes that will bear the cost of the proposed rule, and any information on cost impacts received by the agency from any private or public entities: SoonerCare member receiving SoonerRide services will be impacted by the rule change. C. A description of the classes of persons who will benefit from the proposed rule: There are no classes of persons who will benefit from the proposed rule. D. A description of the probable economic impact of the proposed rule upon the affected classes of persons or political subdivisions, including a listing of all fee changes and, whenever possible, a separate justification for each fee change: There is no probable economic impact of the proposed rules upon the affected classes of persons or political subdivisions. E. The probable costs and benefits to the agency and to any other agency of the implementation and enforcement of the proposed rule, the source of revenue to be used for implementation and enforcement of the proposed rule, and any anticipated effect on state revenues, including a projected net loss or gain in such revenues if it can be projected by the agency: The rule change may result in a minimal savings to the agency. F. A determination of whether implementation of the proposed rule will have an economic impact on any political subdivisions or require their cooperation in implementing or enforcing the rule: The proposed rule will not have an economic impact on any political subdivision or require their cooperation in implementing or enforcing the rule. G. A determination of whether implementation of the proposed rule will have an adverse effect on small business as provided by the Oklahoma Small Business Regulatory Flexibility Act: The proposed rule will not have an adverse effect on small businesses as provided by the Oklahoma Small Business Regulatory Flexibility Act. H. An explanation of the measures the agency has taken to minimize 2

3 compliance costs and a determination of whether there are less costly or non-regulatory methods or less intrusive methods for achieving the purpose of the proposed rule: The agency has taken measures to determine that there is no less costly or non-regulatory method or less intrusive method for achieving the purpose of the proposed rule. I. A determination of the effect of the proposed rule on the public health, safety and environment and, if the proposed rule is designed to reduce significant risks to the public health, safety and environment, an explanation of the nature of the risk and to what extent the proposed rule will reduce the risk: The proposed rule should have no effect on the public health, safety, and environment. J. A determination of any detrimental effect on the public health, safety and environment if the proposed rule is not implemented: OHCA does not believe there is a detrimental effect on the public health and safety if the rule is not passed. K. The date the rule impact statement was prepared and if modified, the date modified: The rule impact statement was prepared December 16, RULE TEXT TITLE 317. OKLAHOMA HEALTH CARE AUTHORITY CHAPTER 35. MEDICAL ASSISTANCE FOR ADULTS AND CHILDREN-ELIGIBILITY SUBCHAPTER 3. COVERAGE AND EXCLUSIONS 317: SoonerCare transportation and subsistence (a) The Oklahoma Health Care Authority (OHCA) is responsible for assuring that necessary transportation is available to all eligible SoonerCare members who are in need of SoonerCare medical services in accordance with 42 CFR The agency contracts with a broker to provide statewide curb to curb coverage for non-emergency transportation under the SoonerRide program. The broker provides the most appropriate and least costly mode of transportation necessary to meet the individual needs of SoonerCare members. As the Medicaid Agency, OHCA is the payer of last resort, with few exceptions. When other resources are available, those resources must first be utilized. Exceptions to this policy are those receiving medical treatment through Indian Health Services and those eligible for the Crime Victims Compensation Act. The agency contracts directly with ambulance and air providers for all other 3

4 transportation needs for eligible members not provided by SoonerRide. SoonerRide excludes those individuals who are categorized as: (1) Qualified Medicare Beneficiaries(QMB)when SoonerCare pays only the Medicare premium, deductible, and co-pay; (2) Specified Low Income Medicare Beneficiaries (SLMB)only; (3) Qualifying Individuals-1; (4) individuals who are in an institution for mental disease (IMD); (5) inpatient; (6)(5) institutionalized(i.e. long-term care facility); (7)(6) Home and Community Based Waiver members with the exception of the In-home Supports Waiver for Children, the ADvantage Waiver, the Living Choice demonstration, the Sooner Seniors Waiver, the My Life; My Choice Waiver and the Medically Fragile Waiver. (b) Members seeking medically necessary non-emergency transportation will be required to contact the SoonerRide reservation center. Contact will be made via a toll-free phone number which is answered Monday through Saturday, 8 a.m. to 6 p.m. Whenever possible, the member is required to notify SoonerRide at least 72 hours prior to the appointment. The member is asked to furnish the SoonerRide reservation center their SoonerCare member number, home address, the time and date of the medical appointment, the address and phone number of the medical provider, and any physical/mental limitations which will impact the type of transportation needed. SoonerRide makes arrangements for the most appropriate, least costly transportation. SoonerRide verifies appointments when appropriate. If the member disagrees with the transportation arranged or denied by SoonerRide, an appeal must be filed with OHCA according to OAC 317: The appropriateness of transportation may be appealed only to the extent that the transportation does not meet the medical needs of the member. Dissatisfaction with the use of public transportation, shared rides, type of vehicle, etc., is not appropriate grounds for appeal. The Oklahoma Health Care Authority's decision is final. (1) Authorization for transportation by private vehicle or bus. Transportation by private vehicle or bus is administered through the broker when it is necessary for an eligible member to receive medical services. (2) Authorization for transportation by taxi. Taxi service may be authorized at the discretion of the broker. (3) Transportation by ambulance (ground, air ambulance or helicopter). Transportation by ambulance is compensable for individuals eligible for SoonerCare benefits when other available transportation does not meet the medical needs of the individual. Payment is made for ambulance transportation to and/or from a medical facility for medical care compensable under SoonerCare. (4) Transportation by airplane. When an individual's medical 4

5 condition is such that transportation out-of-state by a commercial airline is required, approval for airfare must be secured by telephoning the OHCA who will make the necessary flight arrangements. (5) Subsistence (lodging and meals). Payment for lodging and/or meals assistance for an eligible member and/or an approved medical escort is provided only when medically necessary in connection with transportation to and from SoonerCare compensable services. The member and/or medical escort must make a reasonable effort to secure lodging at a hospital or nonprofit organization. The Oklahoma Health Care Authority (OHCA) has discretion and final authority to approve or deny any lodging and/or meal services. (A) Lodging and/or meals are reimbursable when prior approved. Payment for lodging and/or meals is limited to a period of up to 24 hours prior to the start of the member's medical services and up to 24 hours after the services end. Lodging is approved for the member and/or one approved medical escort. The following factors may be considered by OHCA when approving reimbursement for a member and/or one medical escort: (i) travel is to obtain specialty care; and (ii) the trip cannot be completed during SoonerRide operating hours; (iii) the trip is 100 miles or more from the member's residence, as listed in the OHCA system, to the medical facility; and/or (iv) the member's medical treatment requires an overnight stay, or the condition of the member discourages traveling. (B) When a member is not required to have a PCP or when a PCP referral is not required to obtain a SoonerCare covered service, a member may go to any provider they choose but SoonerCare will not reimburse for transportation, lodging, or meals if the distance is beyond what is considered the nearest appropriate facility. (C) Meals will be reimbursed only if an overnight stay occurs and the stay meets the lodging criteria is met.meals will be reimbursed if lodging criteria is met, and duration of trip is or exceeds 18 hours. (D) Reimbursement for meals is based on a daily per diem and may be used for breakfast, lunch or dinner, or all three meals, whichever is required. (E) During inpatient or outpatient medical stays, lodging and/or meals services are reimbursed for a period of up to 14 days without prior approval; stays exceeding the 14 day period must be prior approved. A member may not receive reimbursement for lodging and/or meals services for days the member is an inpatient in a hospital or medical facility. (F) For eligible members in the Neonatal Intensive Care Unit 5

6 (NICU) a minimum visitation of 6 hours per day for the medical escort is required for reimbursement of lodging and/or meals services. (G) Lodging must be with a SoonerCare contracted Room and Board provider, when available, before direct reimbursement to a member and/or medical escort can be approved. If the lodging provider provides meals the member and/or medical escort is not eligible for separate reimbursement and may not seek assistance for meals obtained outside of the contracted Room and Board provider facility. If lodging and/or meal assistance with contracted Room and Board providers is not available, the member and/or medical escort may request reimbursement assistance by submitting the appropriate travel reimbursement forms. The travel reimbursement forms may be obtained by contacting SoonerCare Care Management division. Any lodging and/or meal expenses claimed on the travel reimbursement forms must be documented with the required receipts and medical records to document the lodging and/or meals criteria have been met. Reimbursement will not exceed established state per diem amounts. The OHCA has discretion and the final authority to approve or deny lodging and/or meals reimbursement. (6) Escort assistance required. Payment for transportation and lodging and/or meals of one medical escort may be approved if the service is required. If the Oklahoma Department of Human Services (OKDHS) removes a child from his/her home, a court must appoint a temporary guardian. During this time the temporary guardian is eligible for escort related lodging and/or meals services. The custodial parent, if under investigation, is not eligible. It is the responsibility of the OHCA to determine this necessity. The decision should be based on the following circumstances: (A) when the individual's health or disability does not permit traveling alone; and (B) when the individual seeking medical services is a minor child. 6