HEALTH CARE AUTHORITY

(Washington Apple Health)

(1) The ((department)) medicaid agency covers nonemergency nonambulance transportation to and from covered health care services, as provided by the Code of Federal Regulations (42 C.F.R. 431.53 and 42 C.F.R. 440.170) subject to the limitations and requirements under WAC ((388-546-5000)) 182-546-5000 through ((388-546-6200)) 182-546-6200. See WAC ((388-546-1000)) 182-546-1000 for nonemergency ground ambulance transportation.

(2) The ((department)) agency pays for nonemergency transportation for clients covered under state-funded medical programs subject to funding appropriated by the legislature.

(3) Clients may not select the transportation provider(((s))) or the mode of transportation.

The following definitions and those found in ((WAC 388-500-0005)) chapter 182-500 WAC apply to nonemergency medical brokered transportation. Unless otherwise defined in WAC ((388-546-5200)) 182-546-5200 through ((388-546-6000)) 182-546-6000, medical terms are used as commonly defined within the scope of professional medical practice in the state of Washington.

"Ambulance" - See WAC ((388-546-0001)) 182-546-0001.

"Broker" - An organization or entity contracted with the ((department)) medicaid agency to arrange nonemergency transportation services for ((department)) clients.

"Drop off point" - The location authorized by the transportation broker for the client's trip to end.

"Escort" - A person authorized by the transportation broker to accompany and be transported with a client to a health care service. An escort's transportation may be authorized depending on the client's age, mental state or capacity, safety requirements, mobility skills, communication skills, or cultural issues.

"Extended stay" - A period of time spanning seven consecutive days or longer for which a client receives health care services outside of his or her local community and for which he or she may request assistance with meals and/or lodging.

"Guardian" - A person who is legally responsible for a client and who may be required to be present when a client is receiving health care services.

"Local community" - The client's city or town of residence or nearest location to residence.

"Local provider" - A provider, as defined in WAC ((388-500-0005)) 182-500-0085, who delivers covered health care service within the client's local community, and the treatment facility where the services are delivered are also within the client's local community.

"Lodging and meals" - Temporary housing and meals in support of a client's out-of-area medical stay.

"Mode" - A method of transportation assistance used by the general public that an individual client can use in a specific situation. Methods that may be considered include:

• Air transport;

• Bus fares;

• Ferries/water taxis;

• Gas vouchers;

• Grouped or shared-ride vehicles;

• Mileage reimbursement;

• Parking;

• Stretcher vans or cars;

• Taxi;

• Tickets;

• Tolls;

• Volunteer drivers;

• Walking or other personal conveyance; and

• Wheelchair vans.

"Noncompliance or noncompliant" - When a client:

• Fails to appear at the ((pick-up)) pickup point of the trip at the scheduled ((pick-up)) pickup time;

• Misuses or abuses ((department-paid)) agency-paid medical, transportation, or other services;

• Fails to comply with the rules, procedures, ((and/or)) or policies of the ((department and/or)) agency or those of the ((department's)) agency's transportation brokers, the brokers' subcontracted transportation providers, ((and)) or health care service providers;

• Poses a direct threat to the health ((and/or)) or safety of self or others; or

• Engages in violent, seriously disruptive, or illegal conduct.

"Pickup point" - The location authorized by the ((department's)) agency's transportation broker for the client's trip to begin.

"Return trip" - The return of the client to the client's residence, or another authorized drop-off point, from the location where a covered health care service has occurred.

"Short stay" - A period of time spanning one to six days for which a client receives health care services outside of his or her local community and for which he or she may request assistance with meals and/or lodging.

"Stretcher car or van" - A vehicle that can legally transport a client in a prone or supine position when the client does not require medical attention en route.

"Stretcher trip" - A transportation service that requires a client to be transported in a prone or supine position without medical attention during the trip. This may be by stretcher, board, gurney, or other appropriate device. Medical or safety requirements must be the basis for transporting a client in the prone or supine position.

"Transportation provider" - An individual or company under contract with a broker, for the provision of trips.

"Urgent care" - An unplanned appointment for a covered medical service with verification from an attending physician or facility that the client must be seen that day or the following day.

(1) The ((department)) medicaid agency requires:

(a) Brokers and subcontracted transportation providers to be licensed, equipped, and operated in accordance with applicable federal, state, and local laws, and the terms specified in their contracts;

(b) Brokers to:

(i) Screen their employees and subcontracted transportation providers and employees prior to hiring or contracting, and on an ongoing basis thereafter, to assure that employees and contractors are not excluded from receiving federal funds as required by 42 U.S.C. 1320a-7 and 42 U.S.C. 1320c-5; and

(ii) Report immediately to the ((department)) agency any information discovered regarding an employee's or contractor's exclusion from receiving federal funds in accordance with 42 U.S.C. 1320a-7 and 42 U.S.C. 1320c-5.

(c) Drivers and passengers to comply with all applicable federal, state, and local laws and regulations during transport.

(2) Brokers:

(a) Must determine the level of assistance needed by the client (e.g., curb-to-curb, door-to-door, door-through-door, hand-to-hand) and the mode of transportation to be used for each authorized trip;

(b) Must select the lowest cost available mode or alternative that is both accessible to the client and appropriate to the client's medical condition and personal capabilities;

(c) Must have subcontracts with transportation providers in order for the providers to be paid by the broker;

(d) Must provide transportation services comparable to those available to the general public in the local community;

(e) May subcontract with licensed ambulance providers for nonemergency trips in licensed ground ambulance vehicles; and

(f) May contract with a federally recognized tribe within the broker's service region to provide transportation services when requested by that tribe. When the ((department)) agency approves the request of a tribe or a tribal agency to administer or provide transportation services under WAC ((388-546-5100)) 182-546-5100 through ((388-546-6200)) 182-546-6200, tribal members may obtain their transportation services from the tribe or tribal agency with coordination from and payment through the transportation broker.

(3) If the broker is not open for business and is unavailable to give advance approval for transportation to an urgent care appointment or after a hospital discharge, the subcontracted transportation provider must either:

(a) Provide the transportation in accordance with the broker's instructions and request a retroactive authorization from the broker within two business days of the transport; or

(b) Deny the transportation, if the requirements of this section cannot be met.

(4) If the subcontracted transportation provider provides transportation as described in subsection (3)(a) of this section, the broker may ((agree to)) grant retroactive authorization and must document the reason in the client's trip record.

(1) Clients must comply with applicable state, local, and federal laws during transport.

(2) Clients must comply with the rules, procedures ((and/or)) and policies of the ((department)) medicaid agency, brokers, the brokers' subcontracted transportation providers, and health care service providers.

(3) A client who is noncompliant may have limited transportation mode options available.

(4) Clients must request, arrange, and obtain authorization for transportation at least two business days before a health care appointment, except when the request is for an urgent care appointment or a hospital discharge.

(1) The ((department)) medicaid agency covers nonemergency transportation for medical assistance clients to and from health care services when all of the following apply:

(a) The health care services are:

(i) Within the scope of coverage of the eligible client's benefit services package; ((and))

(ii) Covered as defined in WAC ((388-501-0050)) 182-501-0050 through ((388-501-0065)) 182-501-0065 and the specific program rules; and

(iii) Authorized, when required within specific program rules.

(b) The health care service is medically necessary as defined in WAC ((388-500-0005)) 182-500-0070;

(c) The health care service is being provided as follows (see subsection (3) of this section for exceptions):

(i) Under fee-for-service, by ((a department-contracted)) an agency-contracted provider;

(ii) Through ((a department-contract)) an agency-contracted managed care organization (MCO), by an MCO provider; ((or))

(iii) Through a regional support network (RSN), by an RSN contractor; or

(C) A provider performing services paid for by the Veteran's Administration, charitable program, or other voluntary program (Shriners, etc.).

(d) The trip is to a local provider as defined in WAC ((388-546-5100)) 182-546-5100 (see WAC ((388-546-5700)) 182-546-5700(3) for local provider exceptions);

(e) The transportation is the lowest cost available mode or alternative that is both accessible to the client and appropriate to the client's medical condition and personal capabilities;

(f) The trip is authorized by the broker ((in advance of)) before a client's travel; and

(g) The trip is a minimum of three-quarters of a mile from pick-up point to the drop-off point (see WAC ((388-546-6200)) 182-546-6200(7) for exceptions to the minimum distance requirement).

(2) Coverage for nonemergency medical transportation is limited to one roundtrip per day, with the exception of multiple medical appointments which cannot be accessed in one roundtrip.

(1) The following service categories ((cited)) listed in WAC ((388-501-0060)) 182-501-0060 are subject to the following exclusions and limitations:

(a) Adult day health (ADH) - Nonemergency transportation for ADH services is not provided through the brokers. ADH providers are responsible for arranging or providing transportation to ADH services.

(b) Ambulance - Nonemergency ambulance transportation is not provided through the brokers except as specified in WAC ((388-546-5200 (1)(d))) 182-546-5200 (2)(e).

(c) ((Family planning services - Nonemergency transportation is not provided through the brokers for clients that are enrolled only in TAKE CHARGE or family planning only services.

(d))) Hospice services - Nonemergency transportation is not provided through the brokers when the health care service is related to a client's hospice diagnosis. See WAC ((388-551-1210)) 182-551-1210.

(((e))) (d) Medical equipment, durable (DME) - Nonemergency transportation is not provided through the brokers for DME services, ((with the exception of)) except for complex rehabilitation technology (CRT) and DME equipment that needs to be fitted to the client.

(((f))) (e) Medical nutrition services - Nonemergency transportation is not provided through the brokers to pick up medical nutrition products.

(((g))) (f) Medical supplies/equipment, nondurable (MSE) - Nonemergency transportation is not provided through the brokers for MSE services.

(((h))) (g) Mental health services:

(i) Nonemergency transportation brokers generally provide one round trip per day to or from a mental health service. Additional trips for off-site activities, such as a visit to a recreational park, are the responsibility of the provider/facility.

(ii) Nonemergency transportation of an involuntarily detained person((s)) under the Involuntary Treatment Act (ITA) is not a service provided or authorized by transportation brokers. Involuntary transportation is a service provided by an ambulance or a designated ITA transportation provider. See WAC ((388-546-4000)) 182-546-4000.

(j))) (h) Chemical dependency services - Nonemergency transportation is not provided through the brokers to or from the following:

(i) Residential treatment, intensive inpatient, or long-term treatment at certified facilities which are institutes for mental diseases (IMDs). Transportation may be provided to these services which are identified by the agency as non-IMDs, and therefore eligible to receive medicaid funds (refer to the catalog of federal domestic assistance (CFDA) program number 93.778);

(ii) ((Intensive inpatient;)) Recovery house; and

(iii) ((Recovery house;

(C) Emergency service patrol.)) Information and assistance services which include:

(2) The ((following medical assistance programs have limitations on trips:

(a))) state-funded medical care services (MCS) program ((for clients covered by the disability lifeline program and the Alcohol and Drug Addiction Treatment and Support Act (ADATSA) -)) has a limitation on trips. Nonemergency transportation for mental health services and substance abuse services is not provided through the brokers. The ((department)) medicaid agency does pay for nonemergency transportation to and from medical services ((as specified)) listed in WAC ((388-501-0060)) 182-501-0060, excluding mental health services and substance abuse services, and subject to any other limitations in this chapter or other program rules.

(((b) Transitional bridge waiver for clients covered by the disability lifeline program and the Alcohol and Drug Addiction Treatment and Support Act (ADATSA) - Nonemergency transportation for mental health services and substance abuse services is not provided through the brokers. The department does pay for nonemergency transportation to and from medical services as covered in the transitional bridge waiver approved by the Centers for Medicare and Medicaid Services, excluding mental health services and substance abuse services, and subject to any other limitations in this chapter or other program rules.)) (3) The following programs do not have a benefit for brokered nonemergency transportation through the agency:

(1) The ((department)) medicaid agency does not pay for any costs related to intermediate stops or delays that are not directly related to the original approved trip, including trips that would, or did, result in additional transportation costs due to client convenience.

(2) Brokers may authorize intermediate stops or delays for clients if the broker determines that the intermediate stop is:

(a) Directly related to the original approved trip; or

(b) Likely to limit or eliminate the need for supplemental covered trips.

(3) The ((department)) agency considers the following reasons to be related to the original trip:

(a) Transportation of the client to and from an immediate subsequent medical referral/appointment; or

(b) Transportation of the client to a pharmacy to obtain one or more prescriptions when in route to or from the covered service and the pharmacy is within a reasonable distance of the usual route to the medical appointment. The agency does not pay for transportation of the client to a pharmacy to obtain medicare Part D prescriptions.

(1) Clients receiving services provided under fee-for-service and/or through a ((department)) medicaid agency-contracted managed care organization (MCO) are transported to a local provider only.

(a) A local provider's medical specialty may vary as long as the provider is capable of providing medically necessary care that is the subject of the appointment or treatment;

(b) A provider's acceptance of the ((departments')) agency's clients may determine if the provider may be considered as an available local provider, along with whether ((managed care)) MCO, primary care case management, or third party participation is involved.

(2) Brokers are responsible for considering and authorizing exceptions. See subsection (3) of this section for exceptions.

(3) A broker may transport a client to a provider outside the client's local community for covered health care services when any of the following apply:

(a) The health care service is not available within the client's local community.

(i) If requested by the broker, the client or the client's provider must provide documentation from the client's primary care provider (PCP), specialist, or other appropriate provider verifying the medical necessity for the client to be served by a health care provider outside of the client's local community.

(ii) If the service is not available in the client's local community, the broker may authorize transportation ((may be authorized)) to the nearest provider where the service may be obtained((.));

(b) The transportation to a provider outside the client's local community is required for continuity of care.

(i) If requested by the broker, the client or ((their)) the client's provider must submit documentation from the client's PCP, specialist, or other appropriate provider verifying the existence of ongoing treatment for medically necessary care by the provider and the medical necessity for the client to continue to be served by the health care provider.

(ii) If the broker authorizes transportation to a provider outside the client's local community based on continuity of care, this authorization is for a limited period of time for completion of ongoing care for a specific medical condition. Each transport must be related to the ongoing treatment of the specific condition that requires continuity of care.

(iii) Ongoing treatment of medical conditions that may qualify for transportation based on continuity of care, include but are not limited to:

(A) Active cancer treatment;

(B) Recent transplant (within the last twelve months);

(C) Scheduled surgery (within the next sixty days);

(D) Major surgery (within the previous ((sixty)) ninety days); or

(E) Third trimester of pregnancy((.));

(c) The health care service is paid by a third payer who requires or refers the client to a specific provider within their network;

(d) The total cost to the ((department)) agency, including transportation costs, is lower when the health care service is obtained outside of the client's local community; and

(e) A provider outside the client's local community has been issued a global payment by the ((department)) agency for services the client will receive and the broker determines it to be cost effective to provide transportation for the client to complete treatment with this provider.

(4) Brokers determine whether an exception should be granted based on documentation from the client's health care providers and program rules. Brokers may refer requests to transport a client to a provider outside the client's local community for health care services to the ((department's)) agency's medical director or the medical director's designee for review and/or authorization.

(5) When a client or a provider moves to a new community, the existence of a provider-client relationship, independent of other factors, does not constitute a medical need for the broker to authorize and pay for transportation to the previous provider.

(6) The health care service must be provided in the state of Washington or a designated border city, unless the ((department)) agency specifically authorizes transportation to an out-of-state provider in accordance with WAC ((388-546-5800)) 182-546-5800.

(7) ((The department does not authorize and pay for nonemergency transportation to providers outside the client's local community if the client's noncompliance is the reason a local health care provider or service is not available.)) If local Washington apple health providers refuse to see a client due to the client's noncompliance, the agency does not authorize or pay more for nonemergency transportation to a provider outside the client's local community.

(1) The ((department)) medicaid agency reviews requests for out-of-state nonemergency transportation in accordance with regulations for covered health care services, including WAC ((388-501-0180, 388-501-0182 and 388-501-0184)) 182-501-0180, 182-501-0182 and 182-501-0184.

(2) The agency does not pay for nonemergency transportation ((is not provided)) to or from locations outside of the United States and U.S. territories, except ((for the limitations)) as allowed under WAC 182-501-0184 for British Columbia, Canada((, identified in WAC 388-501-0184)).

(1) The ((department)) medicaid agency may pay for meals and lodging for clients who must be transported to health care services outside of the client's local community. The ((department's)) agency's transportation brokers determine when meals and lodging are necessary based on a client's individual need.

(2) Brokers may authorize payment for meals and lodging for up to one calendar month. Extensions beyond the initial calendar month must be prior authorized by the broker on a month-to-month, week-to-week, or as-needed basis.

(3) Brokers follow the ((department's)) agency's guidelines in determining the reasonable costs of meals and lodging. The ((department's)) agency's guidelines are:

(a) The reasonable cost of lodging for short and extended stays is measured against state per diem rates.

(b) For short stays, the cost of meals is measured against the state per diem rate.

(c) For extended stays, the reasonable cost of meals is measured against the state's basic food program. The maximum monthly allowable meal cost for extended stays is not to exceed the client's calculated monthly food benefit or state per diem rates.

(4) The ((department)) agency pays for the transportation of an authorized escort, including meals and lodging, when all of the following apply:

(a) The client is present, ((with the exception of)) except as stated in subsection (5) of this section; and

(b) The broker determines the transportation costs of an escort((s are)) is necessary based upon the client's age, mental state or capacity, safety requirements, mobility requirements, communication or translation requirements, or cultural issues.

(5) The ((department)) agency may authorize and pay for the transportation of an authorized escort or guardian, with or without the presence of the client, if the broker determines, and documents, that the presence of the authorized escort or guardian is necessary to ensure that the client has access to medically necessary care.

(6) Lodging and meals for all out-of-state nonemergency transportation must be prior authorized by the ((department)) agency. Border areas as defined by WAC ((388-501-0175)) 182-501-0175 are considered in-state under this section and subsequent sections.

(1) The ((department)) medicaid agency contracts with brokers to authorize or deny requests for transportation services.

(2) Brokers may refer requests to transport a client to a provider to the ((department's)) agency's medical director or designee for a review ((and/or)) or authorization.

(3) Nonemergency medical transportation, other than ambulance, must be prior authorized by the broker. See WAC ((388-546-5200)) 182-546-5200 (3) and (4) and ((388-546-6200)) 182-546-6200(4) for granting retroactive authorization.

(4) The broker mails a written notice of denial to each client who is denied authorization of transportation.

(5) A client who is denied nonemergency transportation under this chapter may request an administrative hearing, if one is available under state and federal law.

(6) If the ((department)) agency approves a medical service under exception to rule (ETR), the authorization requirements of this section apply to transportation services related to the ETR service.

(1) The ((department)) medicaid agency does not cover ((any)) nonemergency transportation that is not specifically addressed in WAC ((388-546-5000)) 182-546-5000 through ((388-546-6200)) 182-546-6200.

(2) Brokers do not provide nonemergency transportation for admissions under the Involuntary Treatment Act (ITA), as defined in WAC ((388-546-4000)) 182-546-4000.

(3) The ((department)) agency does not provide escorts or cover the cost of wages of escorts.

(4) The ((department)) agency does not cover the purchase or repair of equipment for privately owned vehicles or modifications of privately owned vehicles under the nonemergency transportation program. The purchase or repair of equipment for a privately owned vehicle or modification of a privately owned vehicle is not a health care service. Exception to rule (ETR) as described in WAC ((388-501-0160)) 182-501-0160 is not available for ((this nonhealth)) equipment that is not a health care service.

(1) To be reimbursed for trips, meals, ((and)) or lodging, the requestor must receive prior authorization from the broker at least ((forty-eight hours)) two business days in advance of the client's travel.

(2) A client must request reimbursement of preauthorized expenditures for trips, meals, ((and)) or lodging within thirty days after his or her medical appointment(((s))). The broker may consider reimbursement requests beyond thirty days if a client shows good cause as defined in WAC 388-02-0020 for having not requested reimbursement within thirty days.

(3) To be reimbursed for mileage, ((fuel/gas)) fuel, parking, bridge tolls, ((and)) or ferry fees, the requestor must provide the broker with legible copies of:

(a) Receipt(s);

(b) The operator's ((driver)) valid driver's license;

(c) ((Current)) Valid vehicle registration; and

(d) Proof of insurance for the vehicle/operator at the time of the trip.

(4) The ((department)) medicaid agency or the broker may retroactively authorize and reimburse for transportation costs, including meals and lodging when:

(a) A client is approved for a delayed certification period as defined in WAC 182-500-0025, or for a retroactive eligibility period as defined in WAC 182-500-0095, or is ((approved for a delayed certification period)) retroactively eligible for a medically needy program which requires a spenddown as defined in WAC ((388-500-0005)) 182-500-0100;

(b) The transportation costs were not used to meet a client spenddown liability in accordance with WAC ((388-519-0110)) 182-519-0110;

(c) The transportation costs for which retroactive reimbursement is requested falls within the period of retroactive eligibility or delayed certification;

(d) The client received medically necessary services that were covered by ((their)) the client's medical program for the date(s) of service for which retroactive reimbursement is requested; and

(e) The request for retroactive reimbursement is made within sixty days from the date of eligibility notification (award letter), not to exceed eight months from the date(s) of service for which reimbursement is requested.

(5) When transportation cost(s) are retroactively authorized, the reimbursement amount must not exceed the reimbursement amount that would have been authorized prior to the date(s) of service.

(6) To be paid by the broker for nonemergency transportation services:

(a) Ambulance providers must be subcontracted with the broker in accordance with WAC ((388-546-5200 (1)(d))) 182-546-5200.

(b) Nonambulance providers must be subcontracted with the broker in accordance with WAC ((388-546-5200 (1)(c))) 182-546-5200.

(7) The ((department)) agency, through its contracted brokers, does not pay for nonemergency transportation when:

(a) The health care service the client is requesting transportation to or from is not a service covered by the client's medical program((.));

(b) The covered health care service is within three-quarters of a mile from the pick-up point, except when:

(i) The client's documented and verifiable medical condition and personal capabilities demonstrates that the client is not able to walk three-quarters mile distance;

(ii) The trip involves an area that the broker determines is not physically accessible to the client; or

(iii) The trip involves an area that the ((department's)) agency's broker considers to be unsafe for the client, other riders, or the driver.

(c) The client has personal or informal transportation resources that are available and appropriate to the clients' needs;

(d) Fixed-route public transportation service is available to the client within three-quarters of a mile walking distance. Exceptions to this rule may be granted by the transportation broker when the need for more specialized transportation is documented. Examples of such a need may be the client's use of a portable ventilator, a walker, or a quad cane; or

(e) The mode of transport that the client requests is not necessary, suitable, or appropriate to the client's medical condition.