Current through Register 1531, September 27, 2024
(A)
Covered
Services. The MassHealth agency pays for transportation services
that meet the requirements of 130 CMR 407.000 only when such services are
covered under the member's MassHealth coverage type and only when members are
traveling to obtain medical services covered under the member's coverage type
(see 130 CMR 450.105: Coverage Types').
(1) In the case of public transportation, the
MassHealth agency determines those medical services that are covered by
MassHealth.
(2) In the case of
fee-for-service ambulance and wheelchair van transportation, it is the
responsibility of the transportation provider to judge which medical services
are covered by MassHealth and to advise the member in cases where
transportation is requested to a service that, in the provider's judgment, may
not be or is not covered by MassHealth. If a member is in doubt as to whether
or not a medical service is covered by MassHealth, the member should contact
the MassHealth agency.
(3) In the
case of brokered transportation, the MassHealth agency determines those
services that are covered by MassHealth.
(B)
Noncovered
Services. The following are examples of transportation services
that are not covered by MassHealth:
(1)
transportation to child day-care centers and nurseries;
(2) transportation of persons who are elderly
or disabled to adult day health programs, except when arranged by special
contract with the MassHealth Adult Day Health Program;
(3) transportation to schools, summer camps,
and recreational programs (for example, swimming classes);
(4) transportation of family members to visit
a hospitalized or institutionalized member;
(5) transportation to a medical facility or
physician's office for the sole purpose of obtaining a medical recommendation
for homemaker/chore services;
(6)
transportation to government-agency offices;
(7) transportation to visit a child in
foster-care placement or in group-care placement;
(8) transportation to a medical service that
is within 0.75 miles of the member's home or other MassHealth agency-approved
point of origin, when the member is able to ambulate freely with or without an
escort;
(9) transportation to
pharmacies to obtain medications; and
(10) transportation to obtain computerized
axial tomography (CAT) scans at a facility other than one that has been issued
a Certificate of Need by the Massachusetts Department of Public
Health.
(C)
Locality Restrictions. The MassHealth agency pays for
an eligible member to be transported to sources of medical care only within the
member's locality, unless otherwise authorized by the MassHealth agency.
However, when necessary medical services are unavailable in the member's
locality, transportation to the nearest medical facility in which treatment is
available is covered by MassHealth. Medical transportation originates from the
member's home or other appropriate location, such as the office of another
provider, and proceeds to the location of the medical appointment.
(D)
Institutionalized
Members. When specialized equipment required for medical treatment
for an institutionalized member is not available at a facility, the member may
be transported to the site of such specialized equipment. Medical services that
may require specialized equipment include X-ray services, cast removal, fitting
for artificial limbs, and radiation therapy.
(E)
Nonemergency Community-based
Transportation.
(1) Members
should use public or personal transportation resources, including family or
friends, whenever possible.
(2)
Subject to meeting the requirements of 130 CMR 407.000, the MassHealth agency
pays transportation brokers or fee-for-service transportation providers to
furnish transportation services to eligible MassHealth members only when public
transportation is not available as determined in accordance with 130 CMR
407.411(E)(3).
(3) Public
transportation is considered available if all of the following criteria are
met.
(a) Public transportation is accessible
and suitable to the member's medical condition and circumstances as determined
by the MassHealth agency.
(b)
Public transportation is operated in the member's locality on a regularly
scheduled basis. A wait of up to one hour for a regularly scheduled ride and up
to two transfers in transit is considered reasonable.
(c) The public transportation stop
(i.e., bus or trolley stop, subway, or commuter rail station)
is
1. within 0.75 mile from the member's
residence or other authorized point of origin; and
2. within 0.75 mile from the destination
address.
(4)
Public transportation information may be obtained by contacting the local
public transit authority in the member's community.
(F)
Shared Ride.
When two or more members are traveling to the same locality at the same time,
they must share transportation when such arrangements are made by the
MassHealth agency, transportation provider, transportation broker, or medical
provider.
(G)
Members
Traveling with Escorts. If a member is ambulatory but must be
accompanied by an escort whose mobility is limited, the escort's medical
condition determines the appropriate mode of transportation.
