Current through all regulations passed and filed through September 16, 2024
(A)
Pursuant to
42 C.F.R.
431.53, the Ohio department of medicaid (ODM)
is obligated to ensure necessary transportation for medicaid-eligible
individuals to and from providers of covered healthcare services. ODM fulfills
this obligation in large measure through three-way subgrant agreements with the
Ohio department of job and family services (ODJFS) and with each county
department of job and family services (CDJFS). This rule sets forth the
responsibilities and expectations placed by ODM on each CDJFS in the
administration of this medicaid-funded non-emergency transportation assistance
benefit. In signing a subgrant agreement, a CDJFS agrees to be bound by this
rule and by any other applicable provision of the Administrative
Code.
(B)
For each individual to whom non-emergency
transportation assistance is provided, a CDJFS is expected to select the type
of assistance that is most cost-effective, is suitable to the individual's
needs and circumstances, and enables timely access. If one type of assistance
proves infeasible, a CDJFS may select another type.
(1)
A CDJFS may
decline to provide medicaid-funded non-emergency transportation assistance to a
medicaid-eligible individual under this rule if either of the following
criteria is met:
(a)
The associated healthcare service is not part of the
individual's medicaid benefit package; or
(b)
The requested
non-emergency transportation assistance is not necessary for any of the
following reasons:
(i)
A medicaid managed care organization (MCO) is obligated
to furnish transportation to the individual under its provider agreement with
ODM;
(ii)
The individual is a resident of a long-term care
facility (nursing facility, skilled nursing facility, or intermediate care
facility for individuals with intellectual disabilities), for whom
transportation is provided in accordance with Chapter 5160-3 or Chapter
5123:2-7 of the Administrative Code;
(iii)
A medicaid
hospice provider is obligated to provide or arrange transportation that is
necessary for the individual to receive care related to a terminal
illness;
(iv)
Suitable transportation is available free of charge to
the general public; or
(v)
Failure to provide the requested assistance will have
no effect on the individual's ability to obtain the healthcare
service.
(2)
A request made on
behalf of a minor child for non-emergency transportation assistance entails
additional considerations.
(a)
Responsibility for transporting a child normally falls
to a parent or guardian. In reviewing a request, a CDJFS should take into
account the impact, if any, of the following factors:
(i)
Whether a family
member or friend is available to provide transportation;
(ii)
Whether the
family has ready access to a reliable vehicle;
(iii)
Whether the
family has sufficient financial resources (including any adoption or foster
care subsidy); and
(iv)
Whether another entity such as a school system is or
should be involved.
(b)
A request for
non-emergency transportation assistance to enable another person, such as a
parent, to be with a child in a healthcare facility may be approved if two
criteria are met:
(i)
The presence of the other person is needed for an
identifiable healthcare purpose that will benefit the child;
and
(ii)
The other person lacks the resources necessary to make
the trip (or trips).
(3)
A CDJFS may
temporarily restrict or suspend a particular type of non-emergency
transportation assistance or non-emergency transportation assistance in general
for an individual for reasons including but not limited to the following
examples:
(a)
Misuse by the individual, as determined by the
CDJFS;
(b)
Dangerous, threatening, or disruptive behavior on the
part of the individual; or
(c)
Presence in the
individual of a communicable disease or condition (other than a mild endemic
illness such as the common cold) that constitutes a danger to public
health.
(4)
A CDJFS is to provide a notice of state hearing rights
whenever it proposes to withhold, reduce, suspend, or terminate the
medicaid-funded non-emergency transportation assistance benefit or whenever a
medicaid-eligible individual formally expresses disagreement with an action or
lack of action taken by the CDJFS on a request for non-emergency transportation
assistance. The following examples, however, do not constitute restrictions by
the CDJFS of the medicaid benefit and are not subject to state hearing:
(a)
The refusal of a
request for a specific trip, particularly because of factors beyond the control
of the CDJFS such as a scheduling conflict, lack of sufficient advance notice,
or adverse weather conditions; and
(b)
Failure to
provide further non-emergency transportation assistance when all options have
been exhausted.
(C)
The community
service area of a CDJFS is the geographical area within which medicaid-eligible
individuals and the general population in the county routinely access
healthcare services.
(1)
The community service area comprises at least the
county or counties served by the CDJFS, and it may also include specific
locations in contiguous Ohio counties, non-contiguous Ohio counties, and
bordering states.
(2)
It is expected that medicaid-eligible individuals will
access covered healthcare services within the community service area. If a
covered healthcare service can be obtained only outside the community service
area, the CDJFS may choose to provide assistance sufficient to enable travel
only to or from the nearest location, unless a documented consideration other
than distance overrides such a limitation.
(D)
Every CDJFS may
offer a variety of transportation assistance options.
(1)
These options
include the following examples:
(a)
Contracted livery service;
(b)
Payment for
fixed-route or demand-response transportation;
(c)
Vouchers for fuel
at participating service stations;
(d)
Prepayment of
fares;
(e)
Prepayment for fuel;
(f)
Transportation by
a CDJFS staff member in a CDJFS vehicle;
(g)
Payment of
mileage reimbursement;
(h)
Reimbursement for travel-related expenses that
represent a necessary out-of-pocket cost to a medicaid-eligible
individual;
(i)
Transportation, or payment for transportation, of a
parent or legal guardian accompanying a medicaid-eligible individual who is
younger than twenty-one years of age; and
(j)
Other services
approved in advance by ODM.
(2)
The types of
non-emergency transportation assistance offered by a CDJFS generally reflect
the resources available within its community service area. In a large
metropolitan area with an extensive public transit system and numerous taxicab
and transportation network companies, for example, the CDJFS may choose to
offer rides rather than payment of vehicle costs; in a very rural area with no
public transit and few livery options, the CDJFS may choose to offer fuel
subsidy as its main form of assistance. Every CDJFS, however, regardless of
community service area, is expected to develop a process for identifying
transportation sources and to make a good-faith effort to secure rides for
individuals who need actual transportation.
(E)
Each CDJFS shares
basic information about its administration of the transportation assistance
benefit by submitting form ODM 10241, "Medicaid County Transportation Profile"
(rev. 4/2021), to ODM and revising the document whenever changes are made but
not less often than every twelve months.
(F)
Of all the
records created in the course of administering medicaid-funded nonemergency
transportation assistance, ODM expects a CDJFS to collect the following types
for purposes of data analysis and program integrity:
(1)
Documentation of
each request for non-emergency transportation assistance, maintained in such a
manner that ODM can readily verify the following information:
(a)
The individual's
medicaid identification number;
(b)
The date on which
the request for transportation assistance was made;
(c)
The identity and
location of the healthcare provider where the individual planned to obtain a
covered service;
(d)
The trip date or dates requested;
(e)
The number of
one-way trips involved;
(f)
The type of transportation assistance provided or the
reason why transportation assistance was not provided;
(g)
The name of the
transportation vendor, when applicable;
(h)
The scheduled
pick-up and drop-off times and the actual pick-up and dropoff times, when
applicable; and
(i)
The name of the medicaid program area (such as
pregnancy-related services, healthchek/EPSDT, or general non-emergency
transportation) to which the cost should be allocated;
(2)
Results of criminal background checks and database searches
conducted in accordance with rule
5160-15-14 of the Administrative
Code; and
(3)
Complaints and suggestions received from passengers
and, if applicable, from vendors.
Replaces: 5160-15-11, 5160-15-12, 5160-15-13
