Current through 2024-38, September 18, 2024
113.06-1
Broker Agreements
A. Broker(s)
are required to have a current executed MaineCare Provider Agreement with the
Department.
B. Broker(s) are
required to have a current executed Business Associate Agreement with the
Department.
C. Brokers are
required to have a current executed contract for NET services with the
Department.
113.06-2
Transportation Network
A.
Service Agreements. Each Brokermust have signed Service Agreements with
agencies providing transportation services. Service Agreements are not required
for volunteers, family and friends, Public Transportation, taxis, or other
ad-hoc transportation use. All Service Agreements shall be submitted to the
Department for review. The Department shall notify the Broker if the Service
Agreement is not approved and include the reasons why it is not approved. The
Broker must provide the Department with copies of all fully executed Service
Agreements.
B. EachBrokermust
establish a network of Transporters to deliver NET services to eligible Members
who live in its regions which is sufficient to provide adequate access to all
covered services. The Broker must secure sufficient Transporter resources
(numbers and types of vehicles, drivers, and Attendants including requirements
for wheelchair accessibility) under Service Agreements so that the failure of
any Transporter to perform will not impede the ability of the Broker to provide
NET services.
C. Each Brokermust
insure adequate transportation at all times, including holidays.
D. Each Brokermust notify the Department (or
its agent) within 24 hours of knowledge of a termination of a Service
Agreement. Within 72 hours of any such termination, the Broker shall have a
plan for replacement of coverage for Members served pursuant to that Service
Agreement.
113.06-3
Assignment of Members to Brokers
The Department will notify Members by written notice of
the name, address, phone number, and other contact information regarding the
Broker that has been assigned to them.
113.06-4
Verification of Member
Eligibility
A. As set forth in
Section 113.02, the Broker will be responsible for receiving and processing
requests for NET services from MaineCare Members who reside in its assigned
region(s). Any Members who must reside out of state due to medical reasons, as
approved by the Department, will be assigned to the Broker in the region most
geographically proximate to their physical residences. The Broker is
responsible for verifying Member MaineCare eligibility. The Broker may use one
(1) of four (4) options available to verify Member eligibility:
1. Access this information via the MaineCare
web portal;
2. Use automated
telephone verification;
3.
Reference the eligibility file provided by the Department; or
4. Additionally, if necessary, the Broker may
contact a Departmental provider services agent to verify eligibility. The
Broker must ensure that it can verify eligibility at all
times.
B. Specific
service eligibility: Each Brokerwill be responsible for verifying the service
eligibility of the Member for the MaineCare service to which the Member is
being transported. Some Members may have restrictions on the type and amount of
covered MaineCare services they may receive (e.g. a visit cap on a particular
type of medical appointment).
Additionally, Members have varying levels of eligibility
for services. In some cases the Broker may need to determine the type of
eligibility a Member has (e.g. full MaineCare benefit, Home and Community Based
Services (HCBS) benefits, etc.) to verify that the requested trip is to an
authorized service for that Member.
113.06-5
Authorization and
Verification of NET Services
A. The
Broker will assess the Member's eligibility for transportation services. This
assessment will include ensuring:
1. That the
transportation is to and/or from a MaineCare covered service. This may include
transportation to non-medical services as indicated on an approved plan of care
for HCBS waiver Members;
2. That
the Member has no other appropriate means of transportation available. Members
are considered to have no other appropriate means of transportation if they are
unable to safely rely on themselves, a household member, friend, public transit
or other means to access MaineCare-covered services, without undue financial
hardship and/or substantial interference with family or friends' work or other
obligations; and
3. That the
transportation is to and/or from the nearest appropriate provider of care or
meets one of the listed exceptions.
B. Validity of Information
Except for these required verifications, the Broker will
accept as valid the information provided verbally by the Member, or person
speaking on behalf of the Member when determining the need for NET services,
unless the Brokers have cause to doubt the validity of said information.
If the Broker has cause to doubt the validity of the
information provided by or on behalf of the Member, the Broker may require
documentation to confirm the information as necessary.
If the Member refuses to cooperate in determining status
of MaineCare eligibility, or refuses to provide the documentation requested to
determine eligibility for NET services, the Member can be denied
services.
C. Residence in
NET Service Region
The Broker is responsible for ensuring that NET services
are provided to MaineCare Members who require medical or HCBS waiver services,
reside within the Broker's region and have no other means of accessing those
services. The Broker is not responsible for arranging MaineCare NET services
for MaineCare Members who reside outside the region for which the Broker holds
a valid contract unless the Member resides out of state for medical reasons. In
that case the Member will be assigned to the Broker in the region most
geographically proximate to the Member's residence. The Broker will arrange
travel to and from medically necessary services in other regions when the
eligible MaineCare Member who is being transported resides within the Broker's
region.
D. Transportation
Services to HCBS Waiver Services
When HCBS waiver Members or their authorized
representatives request transportation to HCBS waiver services, the Broker must
verify that the Member is authorized to receive transportation under the HCBS
waiver, and that the HCBS waiver service to which the Member is requesting
transportation is a MaineCare-covered service (e.g., employment specialist
services, adult day health services, etc.).
1. For Members with Intellectual Disabilities
and Autism Spectrum Disorders receiving Home and Community or Support Benefits
under Sections 21 or 29 of the MaineCare Benefits Manual, the Broker will
contact the Member's assigned case manager to confirm that the service or
activity to which the Member is requesting transportation is a covered HCBS
waiver service under the Member's plan of care.
2. For elderly Members and those with
physical disabilities, the Broker will contact the designated Service
Coordination Agency to confirm that the service or activity to which the Member
is requesting transportation is a covered HCBS waiver service under the
Member's plan of care. See MaineCare Benefits Manual, Chapter II, Section
19.
3. For Waiver Services for
Children with Intellectual Disabilities or Pervasive Developmental Disorders
(MBM Chapter II, Section 32), the Broker will contact the Member's assigned
case manager to confirm that the service or activity to which the Member is
requesting transportation is a covered HCBS waiver service under the Member's
plan of care.
4. For Members with
Other Related Conditions receiving Home and Community Benefits under Section 20
of the MaineCare Benefits Manual or for Members with Brain Injury receiving
Home and Community Benefits under Section 18 of the MaineCare Benefits Manual,
the Broker will contact the Member's assigned care coordinator to confirm that
the service or activity to which the Member is requesting transportation is a
covered HCBS waiver service under the Member's plan of care.
5. Additional waiver services may be
initiated by the Department during the course of the NET contract. The Broker
will be given specific instructions for verifying eligibility and covered
services at the time the waiver is initiated.
113.06-6
Determination of Mode of
Transportation
The Broker may arrange for non-emergency transportation
by:
A. Negotiating Service Agreements
with qualified Transporters;
B.
Entering into Service Agreements with federally funded and/or fixed route
transit;
C. Providing tokens,
vouchers or passes to Members, and to Escorts when requested, to cover the fare
for federally funded, established public, or private transit service which is
available when the Member has the capacity to use such service;
D. Providing mileage reimbursement to
Members, family and/or friends to transport MaineCare Members;
E. Entering into Service Agreements with
commercial taxi services to supplement the Broker's NET services;
F. Use of commercial taxis; and
G. Other methods, including utilizing family,
friends, and volunteers, if permitted by federal and state law.
In all cases, the Broker determines the mode of
transportation used that meets the Member's needs.
113.06-7
Nearest Appropriate
HealthCare or Waiver Service Provider
NET is generally limited to transporting the Member to
MaineCare providers that are geographically proximate to the Member. It is
neither efficient nor economical to transport a Member a lengthy distance to a
MaineCare provider when there are qualified and appropriate providers located
closer to the Member. Each Broker shall develop procedures ensuring that
transportation is provided to medical or waiver service providers that are
geographically proximate to the Member.
A. A MaineCare provider will be considered a
nearest appropriate provider if the distance between the Member's residence and
the provider location is less than or equal to:
1. 30 Miles for non-pharmacy or waiver
service providers in Urban areas.
2. 50 Miles for non-pharmacy medical or
waiver service providers in Rural areas.
3. 15 Miles for pharmacies in Urban
areas.
4. 30 Miles for pharmacies
in Rural areas.
B. For
all non-urgent care, regardless of the provider's geographic proximity to the
Member, Members must call or contact the Broker at least two (2) business days
in advance of their appointment to receive transportation services.
For an urgent trip or for other good cause, there is no
waiting period.
C. The
Broker(s) shall arrange for transportation beyond these mileage limits when any
of the following conditions exist:
1. The
Member does not have access to an appropriate provider within the mileage
limits;
2. The Member's Primary Care
Provider has referred the Member to a specific provider whose location is
beyond the mileage limit;
3. A
specific medical or waiver service provider is designated in the Member's Plan
of Care for HCBS services whose location is beyond the mileage limit;
4. The Member requests NET to a medical or
waiver service provider with whom the Member has had an ongoing relationship
for at least one (1) year and a change of provider would be detrimental to the
Member's care. Such determination is made by the Member's MaineCare
provider.
D. These
mileage limits may be extended if necessary; but in no case may they be
reduced.
E. All requests for
transportation to out of state destinations must be prior authorized by the
Department.
113.06-8
Limit on Self-Referral and Certain Relationships
The Broker may operate as a Transporter and Broker.
However, a Broker who also operates as a Transporter may not show preference
towards itself in the scheduling of trips and may act as a Transporter only
when it is the most cost effective means of appropriate transportation
available. No more than 25% of trips shall be self-referred unless approved in
advance by the Department. Such approval shall be contingent on demonstrating
insufficient network adequacy if the limit is not exceeded.
A. A trip is considered self-referred when
the vehicle used to transport the Member is owned and/or operated by the Broker
or if the same company that owns and operates the vehicle has an ownership
interest in the Broker. The self-referral rate is calculated monthly.
B. In addition, the Broker shall
not knowingly have a relationship with the following:
1. An individual who is debarred, suspended,
or otherwise excluded from participating in procurement activities under the
Federal Acquisition Regulation, 48 C.F.R. 1 et seq. or from participating in
non-procurement activities under regulations issued under Executive Order
No.12549 or under guidelines implementing Executive Order No. 12549.
2. An individual who is an affiliate, as
defined in the Federal Acquisition Regulation, of an individual who is
debarred, suspended, or otherwise excluded from participating in procurement
activities under the Federal Acquisition Regulation, 48 C.F.R. 1 et seq. or
from participating in non-procurement activities under regulations issued under
Executive Order No.12549 or under guidelines implementing Executive Order No.
12549.
3. For purposes of Section
113.06-8(B), "relationship" is described as follows:
a. A director, officer, or partner of the
Broker;
b. A person with beneficial
ownership of five percent or more of the Broker's equity; or
c. A person with an employment, consulting,
or other arrangement with the Broker obligations under its contract with the
State.
113.06-9
Timely Access
Requirements
A. The Broker(s) must meet
the following minimum timely access to service delivery standards:
1. The Broker must make NET services
available for Members 24 hours a day, 7 days a week, when transportation to a
MaineCare covered service is medically necessary;
2. The Broker must establish mechanisms to
ensure that its network of Transporters complies with the timely access
requirements;
3. The Broker must
regularly monitor its network to determine compliance with timely
access;
4. The Broker must take
corrective action if there is a failure to comply with timely access and notify
the Department of any corrective action undertaken;
5. If the Broker's network is unable to
provide transportation to MaineCare covered services to an eligible Member, the
Broker must adequately and timely provide transportation utilizing Transporters
outside of the Broker's network for as long as the Broker's network is unable
to provide the needed transportation;
6. In the event that a trip pickup will not
be made On Time, the Broker, or its designated representative, must contact and
inform the Member. Making such contact does not negate the pickup being
considered Late; and
7. Drivers
must wait no less than 10 minutes beyond the scheduled pickup time if the
Member is not at the scheduled Point of Origin prior to service. The driver
must contact the Broker, or Broker's designated representative, if a Member has
not presented within 10 minutes of the scheduled pickup time before the driver
may leave the Point of Origin.
113.06-10
Urgent Trips
Brokers must provide same day trips for Members who have
urgent medical needs that do not require emergency treatment. This
includes:
A. Urgent care, defined as a
need, as assessed by the medical provider, for the Member to be seen within 48
hours;
B. Post-surgical and/or
medical follow-up care specified by a health care provider to occur in fewer
than forty eight hours;
C. Imminent
availability of an appointment with a specialist when the next available
appointment would require a delay of two weeks or more;
D. Trips to acquire prescription medication,
when defined as urgent by the medical provider;
E. The result of administrative or technical
delay caused by the Broker and requiring that an appointment be rescheduled;
and
F. Hospital
discharges.
113.06-11
Standing Orders
A. Standing
Orders may be put in place for recurring or repetitive trips that occur one (1)
or more days a week with the same Point of Origin, destination and return.
Examples of services treated as Standing Orders include, but are not limited
to: trips to dialysis, methadone treatment, adult day health care, day support,
and supported employment.
B. The
necessity for a Standing Order for a Member must be re-affirmed by the Member's
Broker at least once every 90 days.
113.06-12
Transporting MaineCare
Members With Non-MaineCare Passengers
Unless otherwise specified in this Section,
non-MaineCare Members may share rides with Members only if the fare or rate
paid to the Transporter for non-Member riders is not less than the amount paid
for Members. Medicaid shall not supplement or supplant other funding sources.
If there is no funding/payment to pay for the non-Member's ride, the individual
shall not be permitted to share a ride with a Member.
113.06-13
Escorts and Attendants
The Broker(s) must allow, without charge to the Escort,
Member, or the Department, one (1) Escort to accompany a Member or group of
Members who are blind, deaf, have an intellectual disability, have Autism
Spectrum Disorder, have a brain injury, are less than 21 years of age, or as
otherwise determined by the Department staff as needing an Escort, to a covered
service.
The Broker must arrange with the Transporter for the
provision of one Attendant during transport when, in the judgment of the
Broker, considering all known factors or as required by the licensed MaineCare
provider, it is necessary to have an adult aide on a trip to assure the safety
of all passengers. Neither the Member nor the Department may be charged for the
use of attendants.
113.06-14
Transport of Minors
A. Unaccompanied Minors
Children under the age of sixteen (16) shall not be
transported without an adult Escort, except when:
1. The Broker is in possession of a consent
form, signed by the legal parent or guardian of the child, authorizing the
Broker to provide transportation to the unaccompanied minor. The consent form
shall be valid for a period of up to twelve months; or until revoked by the
legal parent or guardian; or
2. The
minor requests transportation to a service deliverable without parental
consent, only if allowed by state and/or federal law.
B. Children Under the Age of 12
For children under the age of twelve (12), parental
consent must include specific approval for the type of transportation utilized
to convey the child. In providing transportation to children under the age of
12, in addition to the general requirements for unaccompanied minors set forth
above, the following requirements apply:
1. At the time of scheduling, the Brokermust
confirm that an adult at the drop off location will be available to take
responsibility for the minor. It is sufficient to note that an employee,
volunteer, or other associate of the medical or waiver service provider will be
available; a specific named employee is not required.
2. Upon reaching the destination, the driver
shall consider all circumstances in determining if the driver will accompany
the minor into the drop off location. Under no circumstances shall the driver
leave the vehicle unattended if:
a. There are
other riders who would remain in the vehicle; or
b. Leaving the vehicle unattended would
create a risk to public safety.
3. Should the driver determine it unsafe to
leave the vehicle, the driver, Transporter, or Broker shall contact the medical
or waiver service provider requesting that an authorized adult come to the
vehicle to take responsibility for the child.
4. Whether the driver accompanies the child
into the building, or an employee, volunteer, or other associate comes to the
vehicle, the driver shall confirm that the person is authorized to take
responsibility for the minor and agrees to do so. It is not sufficient to
inform a receptionist that the child is present without confirming that the
medical service provider and/or its staff are taking responsibility for the
child. If the driver cannot verify that any person is authorized to take
responsibility, the driver shall not leave the child with that individual.
5. In the event that no verified
and authorized adult is available to take responsibility for the child; the
Broker and Transporter will arrange for safe transportation of the child to a
parent or guardian.
6. The Broker
and Transporter may create additional policies and procedures to ensure the
safe transportation of unaccompanied minors.
113.06-15
Related Travel
Expenses
Brokers must reimburse Related Travel Expenses, such as
overnight lodging and meals, at the current State rates and under the current
State limitations as addressed in section 10.90.20 of the State Administrative
and Accounting Manual (SAAM) for the State of Maine, except in any exceptional
circumstances where adherence to the maximum limits would effectively prohibit
the Member from being able to access MaineCare-covered services. The Department
shall not be responsible for providing reimbursement to the Brokers for Related
Travel Expenses.
113.06-16
Maine Federally Recognized Native Tribes Requirements
Brokers are required to enter into Service Agreements
with any Federally Recognized Native Tribe that resides within the Brokers'
regions, would like to be a Transporter, and that meets the driver and vehicle
requirements and all other applicable requirements set forth in the Brokers'
contracts with the Department. The Department will work with the Tribe and the
Broker to ensure that the agreed upon, negotiated rates are adequate and
reasonable given other area rates and the cultural expertise offered by the
Tribe. Brokers must pay Tribal Transporters rates that are not less than the
level and amount of payment that would be made if the Transporters were not
Tribal Transporters.
113.06-17
Requirements for Drivers and
Attendants
EachBroker shall establish a written oversight procedure
that ensures all drivers and Attendants operating under a Service Agreement
with the Broker:
A. Have a current
valid driver's license to operate the transportation vehicle to which they are
assigned;
B. Are competent in their
driving habits (if a driver);
C.
Have no more than two (2) chargeable accidents or moving violations in the
previous three (3) years;
D. Have
not had their driver's license suspended or revoked within the last five (5)
years. This excludes individuals whose cause for license suspension is for
non-payment of child support (once the courts release the individual and such
release can be verified and the individual remains in good standing for a
minimum of ninety (90) days). At any point should the individual's status
change and he or she be in arrears of child support payment(s), said driver's
approval would be revoked permanently;
E. Cannot be convicted of two (2) moving
violations and/or accidents related to NET services, during the course of the
Service Agreement, where the driver was at fault.
F. Attend training in patient assistance
techniques such as the Community Transportation Association's PASS program,
defensive driving, customer service, and cultural & disability sensitivity.
Training shall be provided to all drivers and Attendants who are not currently
certified in any curriculum. Training must be conducted within 30 days of the
Transporter beginning service under a Service Agreement and within 30 days of
hiring for drivers and Attendants hired during the term of the Service
Agreement;
G. Are prohibited from
wearing headphones or earpieces, except that a driver may wear a single
earpiece if it is part of the Transporter's two way communication system;
H. Are prohibited from using
hand-held cellular devices or texting while driving. All cellular use is
prohibited while the vehicle is in motion unless the driver is using a headset
and communicating with the Broker, Transporter, or calling emergency
services;
I. Must wear
identification badges that are easily visible and legible. These badges must
identify the name of the Transporter as well as the name of the driver or
Attendant;
J. Are certified in
First Aid and CPR. Such certification must be achieved by the driver or
Attendant within 60 days of the first date of operations under the Service
Agreement;
K. Are courteous,
patient, and helpful to all passengers;
L. Are neat and clean in
appearance;
M. Do not engage in any
behavior or practices that may subject the Broker to charges of discrimination
against protected groups;
N. Are
not known abusers of alcohol or known consumers of narcotics or
drugs/medications that would endanger the safety of Members. If the Transporter
or Broker suspects a driver of driving under the influence of alcohol,
narcotics, or drugs/medications that would endanger the safety of Members, the
Transporter or Broker shall immediately remove the driver from providing
service to Members;
O. Do not smoke
in any vehicle used to provide NET services. Drivers and Attendants shall not
smoke at any time when they are in the presence of any Member;
P. Ensure that all passengers are secured
with the proper restraints (seatbelts, wheelchair restraints and tie downs,
child safety seats, etc.) and assist Members as needed prior to putting the
vehicle in motion;
Q. Assist
Members, including with the movement, securing, and storage of mobility
assistance devices. The driver will ensure all such devices are properly
secured before putting the vehicle in motion;
R. Meet the following requirements regarding
previous criminal convictions:
1. If a person
has been convicted of a Class A, B, or C crime under Maine law, or has been
convicted of a felony or its equivalent under another state or under federal
law, and that conviction was for a violent crime or a crime of a sexual nature,
that person shall not be allowed to provide services under a Service Agreement
for a minimum of ten (10) years after the completion of that person's sentence.
After 10 years, in the event that the individual reapplies to provide services
under a Service Agreement, the Transporter shall notify the Broker regarding
same and obtain its approval prior to hiring the individual.
2. If a person has been convicted of a Class
A, B, or C crime under Maine law, or has been convicted of a felony or its
equivalent under another state or under federal law, and that conviction was
for a crime related to drugs, that person is prohibited from operating a
vehicle being used to transport Members and from having unsupervised contact
with a Member for a minimum of seven (7) years after the completion of that
individual's sentence. After 7 years, in the event that the individual
reapplies to provide services under a Service Agreement, the Transporter shall
notify the Broker regarding same and obtain its approval prior to hiring the
individual.
3. If a person has been
convicted of a Class A, B, or C crime under Maine law, or has been convicted of
a felony or its equivalent under another state or federal law within the
previous five (5) years, and that conviction was not for a crime related to
drugs, a violent crime, or a crime of a sexual nature, that person is not
prohibited from operating a vehicle being used to transport Members, nor from
having unsupervised contact with Members, so long as the Broker approves.
4. If a person has been convicted
of a Class D or E crime under Maine law, or has been convicted of a misdemeanor
or its equivalent under another state or federal law, and the conviction was
for a violent crime, a crime related to drugs, or crime of a sexual nature,
that person shall be allowed to serve in a position with unsupervised contact
with Members only with the approval of the Broker.
113.06-18
Monitoring and Enforcement of Driver and Attendant Requirements
EachBroker must have written oversight procedures for
ensuring that any Transporters utilized meet all driver and vehicle Attendant
requirements as stated in the NET contract between the Broker and the
Department. The Broker is not responsible for enforcing these requirements for
drivers of Public Transportation or commercial taxis used on an ad hoc basis
operating outside of a Service Agreement with the Broker as stated in contract
with the Department.
The Broker may establish additional qualifications, which
will be approved by the Department prior to implementation.
The Broker must have procedures in place to verify and
document that Transporters meet the requirements as stated in the NET contract
with the Department.
113.06-19
Wheelchairs
Vehicles used to transport wheelchair passengers must
meet ADA requirements, including but not limited to, the following:
A. Maintain a floor-to-ceiling height
clearance of at least fifty-six (56) inches in the passenger compartment.
B. Must have wheelchair lift or
manual ramp. A hydraulically or electro-mechanically powered wheelchair lift
mounted so as not to impair the structural integrity of the vehicle or a secure
ramp will satisfy this requirement so long as the Member is capable of
utilizing such a lift or ramp.
C.
For vehicles equipped with a powered wheelchair lift, the vehicle must have an
engine-wheelchair lift interlock system which requires that the vehicle's
transmission be placed in park and the emergency brake engaged to prevent
vehicle movement when the lift is deployed.
D. Wheelchair Restraint System: For each
wheelchair position, the vehicle shall be equipped with a wheelchair securement
device (i.e. "tie-down") that complies with applicable ADA standards.
E. The vehicle utilized may accommodate
scooter-type wheelchairs. Passengers utilizing these devices may be requested
to dismount from the device and be seated in a passenger seat. Alternately, the
rider may remain on the device, with the device secured with tie-downs and the
rider secured with a separate floor seatbelt.
113.06-20
Telephone Call Centers
Each Broker must each establish and maintain a callcenter
so that Members may conveniently schedule needed transportation andcontact the
Broker regarding potential problems, Complaints, and questions as necessary.
Detailed information regarding call center services, hours of operation,
telephone numbers, questions and Complaints can be obtained by contacting the
Broker assigned to each region.
