WSR 11-10-070

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medicaid Purchasing Administration)

[ Filed May 3, 2011, 7:32 a.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 09-04-073.

Title of Rule and Other Identifying Information: Amending WAC 388-546-5000 Nonemergency transportation program definitions, 388-546-5100 Nonemergency transportation program scope of coverage, 388-546-5200 Nonemergency transportation program broker and provider requirements, 388-546-5300 Nonemergency transportation program client requirements, 388-546-5400 Nonemergency transportation program general reimbursement limitations and 388-546-5500 Modifications of privately owned vehicles -- Noncovered; and new sections WAC 388-546-5550 Nonemergency transportation -- Exclusions and limitations, 388-546-5600 Nonemergency transportation -- Intermediate stops or delays, 388-546-5700 Nonemergency transportation -- Local provider and trips outside client's local community, 388-546-5800 Nonemergency transportation -- Trips out-of-state/out-of-country, 388-546-5900 Nonemergency transportation -- Meals, lodging, escort/guardian, 388-546-6000 Nonemergency transportation -- Authorization, 388-546-6100 Nonemergency transportation -- Noncovered, and 388-546-6200 Nonemergency transportation -- Reimbursement.

Hearing Location(s): Office Building 2, Auditorium, DSHS Headquarters, 1115 Washington, Olympia, WA 98504 (public parking at 11th and Jefferson. A map is available at http://www1.dshs.wa.gov/msa/rpau/RPAU-OB-2directions.html or by calling (360) 664-6094), on June 21, 2011, at 10:00 a.m.

Date of Intended Adoption: Not sooner than June 22, 2011.

Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504-5850, delivery Office Building 2, DSHS Headquarters, 1115 Washington, Olympia, WA 98504, e-mail DSHSRPAURulesCoordinator@dshs.wa.gov, fax (360) 664-6185, by 5 p.m. on June 21, 2011.

Assistance for Persons with Disabilities: Contact Jennisha Johnson, DSHS rules consultant, by May 24, 2011, TTY (360) 664-6178 or (360) 664-6094 or by e-mail at jennisha.johnson@dshs.wa.gov.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The department of social and health services' medicaid purchasing administration (MPA) is proposing [changes] to WAC 388-546-5000 through 388-546-6200, Nonemergency medical transportation. The department reorganized the sections, added/removed/updated definitions, included a section on "covered trips," added a section for "exclusions and limitations," included a section for "intermediate stops or delays," added a new section regarding local provider and trips outside the client's local community, further clarified meals/lodging/escort/guardian, and expanded the section on reimbursement.

Reasons Supporting Proposal: These rule amendments are necessary to support the requirements for contracted nonemergency transportation brokers. Contracted brokers are responsible for the management of overall day-to-day operations necessary for the delivery of cost-efficient, appropriate medical transportation services, the maintenance of appropriate records, and meeting the requirements of these proposed rules. These rules also protect the health and safety of DSHS clients and further ensure program integrity.

Statutory Authority for Adoption: RCW 74.04.057, 74.08.090, 74.09.500.

Statute Being Implemented: RCW 74.08.090.

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: DSHS, MPA, governmental.

Name of Agency Personnel Responsible for Drafting: Wendy L. Boedigheimer, P.O. Box 45504, Olympia, WA 98504-5504, (360) 725-1306; Implementation and Enforcement: Walter Neal, P.O. Box 45530, Olympia, WA 98504-5506 [98504-5530], (360) 725-1703.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the proposed rule amendments and determined that there are no new costs associated with these changes and they do not impose disproportionate costs on small businesses.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Walter Neal, P.O. Box 45530, Olympia, WA 98504-5530, phone (360) 725-1703, fax (360) 586-9727, e-mail Nealw@dshs.wa.gov.

April 28, 2011

Katherine I. Vasquez

Rules Coordinator

4296.2
AMENDATORY SECTION(Amending WSR 01-06-029, filed 3/2/01, effective 4/2/01)

WAC 388-546-5000   Nonemergency transportation ((program definitions))--General.   ((The following terms apply to WAC 388-546-5000, 388-546-5100, 388-546-5200, 388-546-5300, 388-546-5400, and 388-546-5500:

"Broker" means an organization or entity contracted with the department of social and health services (DSHS)/medical assistance administration (MAA) to arrange nonemergency transportation services for MAA's clients.

"Drop off point" means the place authorized by the transportation broker for the client's trip to end.

"Escort" means a person authorized by the broker to be transported with a client to a medical service. An escort may be authorized depending on the client's age, mental state or capacity, safety requirements, mobility requirements, communication or translation requirements, or cultural issues.

"Guardian" means a person who is legally responsible for a client and who may be required to be present when a client is receiving medical services.

"Local provider of type" means the medical provider within the client's local community who fulfills the requirements of the medical appointment. The provider may vary by medical specialty, the provider's acceptance of MAA's clients, and whether managed care, primary care case management or third party participation is involved.

"Noncompliance" means a client:

(1) Engages in violent, seriously disruptive, or illegal conduct;

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

(3) Fails to be present at the pickup point of the trip.

"Pickup point" means the place authorized by MAA's transportation broker for the client's trip to begin.

"Return trip" means the return of the client to the client's home, or another authorized return point, from the location where a covered medical service has occurred.

"Service mode" means the method of transportation the transportation broker selects to use for an MAA client.

"Stretcher trip" means a transportation service that requires a client to be transported in a prone or supine position. This may be by stretcher, board or gurney (reclined and with feet elevated). Medical or safety requirements must be the basis for transporting a client in the prone or supine position.

"Trip" means transportation one-way from the pickup point to the drop off point by an authorized transportation provider.

"Urgent care" means an unplanned appointment for a covered medical service with verification from an attending physician or facility that the client must be seen that day)) (1) The department covers nonemergency nonambulance transportation to and from covered healthcare services, as provided by the Code of Federal Regulations (42 CFR 431.53 and 42 CFR 440.170) subject to the limitations and requirements under WAC 388-546-5000 through 388-546-6200. See WAC 388-546-1000 for nonemergency ground ambulance transportation.

(2) The department 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.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. 01-06-029, 388-546-5000, filed 3/2/01, effective 4/2/01.]


AMENDATORY SECTION(Amending WSR 08-08-064, filed 3/31/08, effective 5/1/08)

WAC 388-546-5100   Nonemergency transportation ((program scope of coverage))--Definitions.   (((1) The department's health and recovery services administration (HRSA) covers transportation that is necessary for its clients to receive medically necessary HRSA covered services. See WAC 388-546-0100 through 388-546-1000 for Ambulance transportation that covers emergency ambulance transportation and limited nonemergency ground ambulance transportation as medical services.

(2) Licensed ambulance providers, who contract with HRSA's transportation brokers, may be reimbursed for nonemergency transportation services under WAC 388-546-5200 as administrative services.

(3) HRSA covers nonemergency transportation under WAC 388-546-5000 through 388-546-5500 as an administrative service as provided by the Code of Federal Regulations (42 CFR 431.53 and 42 CFR 440.170 (a)(2)). As a result, clients may not select the transportation provider(s) or the mode of transportation (service mode).

(4) Prior authorization by HRSA is required for all out-of-state nonemergency transportation. Border areas as defined by WAC 388-501-0175 are considered in-state under this section and subsequent sections.

(a) HRSA reviews requests for out-of-state nonemergency transportation in accordance with regulations for covered healthcare services, including WAC 388-501-0180, 388-501-0182 and 388-501-0184.

(b) Nonemergency transportation is not provided to or from locations outside of the United States and U.S. territories, except for the limitations for British Columbia, Canada, identified in WAC 388-501-0184.

(5) HRSA requires all nonemergency transportation to and from covered services to meet the following:

(a) The covered service must be medically necessary as defined in WAC 388-500-0005;

(b) It must be the lowest cost available service mode that is both appropriate and accessible to the client's medical condition and personal capabilities; and

(c) Be limited to the local provider of type as follows:

(i) Clients receiving services provided under HRSA's fee-for-service program may be transported only to the local provider of type. HRSA's transportation broker is responsible for considering and authorizing exceptions.

(ii) Clients enrolled in HRSA's managed care (healthy options) program may be transported to any provider supported by the client's managed care plan. Clients may be enrolled in a managed care plan but are obtaining a specific service not covered under the plan. The requirements in subsection (5)(c)(i) apply to these fee-for-service services.

(6) HRSA does not cover nonemergency transportation services if the covered medical services are within three-quarters of a mile walking distance from the client's residence. Exceptions to this rule may be granted by HRSA's transportation broker based on the client's documented medical condition or personal capabilities, or based on safety or physical accessibility concerns, as described in WAC 388-546-5400(1).

(7) A client must use personal or informal transportation alternatives if they are available and appropriate to the client's needs.

(8) If a fixed-route public transportation service is available to the client within three-quarters of a mile walking distance, the broker may require the client to use the fixed-route public transportation system unless the need for more specialized transportation is present and documented. Examples of such a need are the client's use of a portable ventilator, a walker or a quad cane.

(9) HRSA does not cover any nonemergency transportation service that is not addressed in WAC 388-546-1000 or in 388-546-5000 through 388-546-5500. See WAC 388-501-0160 for information about obtaining approval for noncovered transportation services, known as exception to rule (ETR).

(10) If a medical service is approved by ETR, both the broker and MAA must separately prior approve transportation to that service.

(11) HRSA may exempt members of federally recognized Indian tribes from the brokered transportation program. Where HRSA approves the request of a tribe or a tribal agency to administer or provide transportation services under WAC 388-546-5000 through 388-546-5400, tribal members obtain their transportation services as provided by the tribe or tribal agency.

(12) A client who is denied service under this chapter may request a fair hearing per chapter 388-02 WAC)) The following definitions and those found in WAC 388-500-0005 apply to nonemergency medical brokered transportation. Unless otherwise defined in WAC 388-546-5200 through 388-546-6000, 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.

"Broker" - An organization or entity contracted with the department 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 healthcare 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 healthcare 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 healthcare 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, who delivers covered healthcare 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 point of the trip at the scheduled pick-up time;

Misuses or abuses department-paid medical, transportation, or other services;

Fails to comply with the rules, procedures, and/or policies of the department and/or those of the department's transportation brokers, the brokers' subcontracted transportation providers, and healthcare service providers;

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

Engages in violent, seriously disruptive, or illegal conduct.

"Pickup point" - The location authorized by the department'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 healthcare service has occurred.

"Short stay" - A period of time spanning one to six days for which a client receives healthcare 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.

"Trip" - Transportation one-way from the pickup point to the drop off point by an authorized transportation provider.

"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.

[Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 74.09.035. 08-08-064, 388-546-5100, filed 3/31/08, effective 5/1/08. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. 01-06-029, 388-546-5100, filed 3/2/01, effective 4/2/01.]


AMENDATORY SECTION(Amending WSR 01-06-029, filed 3/2/01, effective 4/2/01)

WAC 388-546-5200   Nonemergency transportation ((program)) broker and provider requirements.   (1) ((MAA requires that all nonambulance transportation providers serving MAA clients be under subcontract with the department's contracted transportation broker. MAA's transportation brokers may subcontract with ambulance providers for nonemergency trips in licensed ground ambulance vehicles as administrative services. See WAC 388-546-5100(2).

(2) MAA requires all contracted and subcontracted transportation providers under this chapter to be licensed, equipped, and operated in accordance with applicable federal, state, and local laws.

(3) MAA's transportation brokers determine the level of transportation service needed by the client and the mode of transportation to be used for each authorized trip.

(4) MAA's transportation brokers must comply with the terms specified in their contracts.

(5) MAA's transportation brokers may require up to forty-eight hours advance notice of a requested trip (see WAC 388-546-5300(2)) with the exception of hospital requests or urgent care trips. MAA allows its transportation brokers to accommodate requests that provide less than forty-eight hours advance notice, within the limits of the resources available to a broker at the time of the request.

(6) If MAA's transportation broker is not open for business and unavailable to give advance approval for a hospital discharge or urgent care request as described in subsection (5), the subcontracted transportation provider must either:

(a) Provide the transportation in accordance with the broker's instructions and request an after-the-fact authorization from the transportation broker within seventy-two hours of the transport; or

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

(7) If the subcontracted transportation provider provides transportation as described in subsection (6), the broker may agree to grant retroactive authorization as provided in WAC 388-546-5300(3). Such retroactive authorization must be:

(a) Documented as to the reasons retroactive authorization is needed; and

(b) Agreed to by the broker within seventy-two hours after the transportation to a medical appointment.

(8) MAA, through its transportation brokers, does not pay for transportation under the following conditions:

(a) Clients are not eligible for transportation services when medical services are within reasonable walking distance (normally three-quarters of a mile actual traveling distance), taking into account the client's documented medical condition and personal capabilities (see WAC 388-546-5100(6));

(b) Clients must use personal or informal transportation alternatives if they are available and appropriate to the clients' needs (see WAC 388-546-5100(7));

(c) If a fixed-route public transportation service is available to the client within three-quarters of a mile walking distance, the broker may require the client to use the fixed route public transportation under the terms of WAC 388-546-5100(8);

(d) MAA or MAA's transportation broker may deny transportation services requested if the request is not necessary, suitable, or appropriate to the client's medical condition (see WAC 388-546-5100 (1) and (5)(a));

(e) The medical services requiring transportation must be services that are covered by the client's medical program (see WAC 488-546-5100(1)); or

(f) The transportation selected by the broker for the client must be the lowest cost available alternative that is both appropriate and accessible to the client's medical condition and personal capabilities.

(9) The transportation broker mails a written notice of denial to each client who is denied coverage of transportation within three business days of the denial)) (1) The department requires:

(a) Brokers and subcontracted transportation providers to be licensed, equipped, and operated in accordance with applicable federal, state, 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 USC 1320a-7 and 42 USC 1320c-5; and

(ii) Report immediately to the department any information discovered regarding an employee's or contractor's exclusion from receiving federal funds in accordance with 42 USC 1320a-7 and 42 USC 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 approves the request of a tribe or a tribal agency to administer or provide transportation services under WAC 388-546-5100 through 388-546-6200, 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.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. 01-06-029, 388-546-5200, filed 3/2/01, effective 4/2/01.]


AMENDATORY SECTION(Amending WSR 01-06-029, filed 3/2/01, effective 4/2/01)

WAC 388-546-5300   Nonemergency transportation ((program)) --Client ((requirements)) eligibility.   (1) ((Clients must be compliant with MAA's transportation brokers, the brokers' subcontracted transportation providers, and MAA's medical services providers. A client who is in noncompliance may have limited transportation service mode options available. The broker mails the client a written notice of limited transportation service mode options within three business days of the broker's decision that transportation service mode options are limited.

(2) Clients must request, arrange and obtain authorization for transportation forty-eight hours in advance of a medical appointment. Exceptions to the forty-eight-hour advance arrangements are described in subsection (3) of this section and in WAC 388-546-5200 (5) and (6).

(3) If MAA's contracted broker is not open for business at the time nonemergency transportation is needed, the client must follow the transportation broker's instructions to obtain transportation service.

(4) MAA will cover a clients transportation to medically necessary covered services with local providers of type. Transportation services will be covered to nonlocal providers of type in the following circumstances:

(a) The client is enrolled in a healthy options managed health care plan and the client's primary care provider (PCP) or a PCP referred provider is not the closest available provider;

(b) The client's service is covered by a third party payer and the payer requires or refers the client to a specific provider;

(c) A charitable or other voluntary program (e.g., Shriners) is paying for the client's medical service;

(d) The medical service required by the client is not available within the local healthcare service area;

(e) The total cost to MAA is lower when the services are obtained outside of the local healthcare service area; or

(f) The out-of-area service is required to provide continuity of care for the client's ongoing care as:

(i) Documented by the client's primary care provider; and

(ii) Agreed to by MAA's contracted transportation broker.

(5) MAA may require transportation brokers to refer any of the exception categories listed in subsection (4) to MAA's medical director or the medical director's designee for review and/or prior authorization of the medical service.

(6) If local medical services are not available to a client because of noncompliance with MAA's transportation brokers, the brokers' subcontracted transportation providers, or MAA's medical services providers, MAA does not cover nonemergency transportation to out-of-area medical services for the client. MAA's contracted broker mails a written notice to the client within three business days of the broker's determination that the client's documented noncompliance results in a denial to out-of-area transportation services)) The department pays for nonemergency transportation for medical assistance clients, including clients enrolled in a department-contracted managed care organization (MCO), to and from healthcare services when the healthcare service(s) meets the requirements in WAC 388-546-5500.

(2) Clients assigned to the patient review and coordination (PRC) program according to WAC 388-501-0135 may be restricted to certain providers.

(a) Brokers may authorize transportation of a PRC client to only those providers to whom the client is assigned or referred by their primary care provider (PCP), or for covered services which do not require referrals.

(b) If a client assigned to PRC chooses to receive service from a provider, pharmacy, and/or hospital that is not in the client's local community, the client's transportation is limited per WAC 388-546-5700.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. 01-06-029, 388-546-5300, filed 3/2/01, effective 4/2/01.]


AMENDATORY SECTION(Amending WSR 01-06-029, filed 3/2/01, effective 4/2/01)

WAC 388-546-5400   Nonemergency transportation ((program general reimbursement limitations))--Client responsibility.   (1) ((To be reimbursed, MAA requires that a trip be a minimum of three-quarters of a mile from pick-up point to drop off point (see WAC 388-546-5100(6)). MAA's transportation broker may grant exceptions to the minimum distance requirement for any of the following conditions:

(a) When there is medical justification for a shorter trip;

(b) When the trip involves an area that MAA's contracted broker considers to be unsafe for the client, other riders, or the driver; or

(c) When the trip involves an area that the broker determines is not physically accessible to the client.

(2) MAA reimburses for return trips from covered medical services if the return trips are directly related to the original trips. MAA, through its transportation broker, may deny coverage of a return trip if any delays in the return trip are for reasons not directly related to the original trip.

(3) MAA does not reimburse any costs related to intermediate stops that are not directly related to the original approved trip.

(4) MAA's transportation broker may authorize intermediate stops that are directly related to the original approved trip if the broker determines that the intermediate stop is likely to limit or eliminate the need for supplemental covered trips. MAA considers the following reasons to be related to the original trip:

(a) Transportation to and from an immediate subsequent medical referral; or

(b) Transportation to a pharmacy to obtain one or more prescriptions when the pharmacy is within a reasonable distance of the original medical appointment route.

(5) MAA may pay the costs of meals and lodging for clients who must be transported to out-of-area medical services. MAA's transportation brokers make the determination that meals and lodging are necessary based on client need and the reasonableness of costs (as measured against state per diem rates).

(6) MAA may pay transportation costs, including meals and lodging, for authorized escorts. MAA's transportation brokers make the determination that the costs of escorts are necessary based on client need and reasonableness of costs (as measured against state per diem rates).

(7) MAA does not provide escorts or pay the wages of escorts. MAA does not pay for the transportation of an escort when the client is not present unless the broker documents exceptional circumstances causing the broker to determine that the service is necessary to ensure that the client has access to medically necessary care.

(8) MAA may reimburse for the transportation of a guardian with or without the presence of the client if the broker documents its determination that such a service is necessary to ensure that the client has access to medically necessary care)) Clients must comply with applicable state, local, and federal laws during transport.

(2) Clients must comply with the rules, procedures and/or policies of the department, brokers, the brokers' subcontracted transportation providers and healthcare 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 healthcare appointment, except when the request is for an urgent care appointment or a hospital discharge.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. 01-06-029, 388-546-5400, filed 3/2/01, effective 4/2/01.]


AMENDATORY SECTION(Amending WSR 10-05-079, filed 2/15/10, effective 3/18/10)

WAC 388-546-5500   ((Modifications of privately owned vehicles -- Noncovered)) Nonemergency transportation--Covered trips.   (1) The department ((does not cover the purchase or repair of equipment for privately owned vehicles or modifications of privately owned vehicles under the nonemergency transportation program.

(2) The purchase or repair of equipment for privately owned vehicles or modifications of privately owned vehicles is not a healthcare service. Exception to rule (ETR) as described in WAC 388-501-0160 is not available for this nonhealthcare service)) covers nonemergency transportation for medical assistance clients to and from healthcare services when all of the following apply:

(a) The healthcare services is:

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

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

(b) The healthcare service is medically necessary as defined in WAC 388-500-0005;

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

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

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

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

(d) The trip is to the local provider as defined in WAC 388-546-5100 (see WAC 388-546-5700(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 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(6) 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.

(3) Subsection (1)(c) of this section does not apply if the covered healthcare services is paid for or provided by medicare, a third party insurance, Veteran's Administration, charitable or other voluntary program (Shriners, etc.).

[Statutory Authority: RCW 74.08.090 and 42 C.F.R. Part 440. 10-05-079, 388-546-5500, filed 2/15/10, effective 3/18/10. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. 01-06-029, 388-546-5500, filed 3/2/01, effective 4/2/01.]


NEW SECTION
WAC 388-546-5550   Nonemergency transportation--Exclusions and limitations.   (1) The following service categories cited in WAC 388-501-0060 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).

(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 healthcare service is related to a client's hospice diagnosis. See WAC 388-551-1210.

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

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

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

(h) 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 involuntarily detained persons 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.

(i) Substance abuse services - Nonemergency transportation is not provided through the brokers for substance abuse services for clients under the state-funded medical programs (medical care services program (MCS)). See WAC 388-546-5200(2).

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

(i) Residential treatment;

(ii) Intensive inpatient;

(iii) Recovery house;

(iv) Long-term treatment;

(v) Information and assistance services, which include:

(A) Alcohol and drug information school;

(B) Information and crisis services; and

(C) Emergency service patrol.

(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) - 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 specified in WAC 388-501-0060, 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.

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NEW SECTION
WAC 388-546-5600   Nonemergency transportation--Intermediate stops or delays.   (1) The department 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 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 the pharmacy is within a reasonable distance of the usual route to the medical appointment.

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NEW SECTION
WAC 388-546-5700   Nonemergency transportation--Local provider and trips outside client's local community.   (1) Clients receiving services provided under fee-for-service and/or through a department contracted managed care organization 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' clients may determine if the provider may be considered as an available local provider, along with whether managed care, 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 healthcare services when any the following apply:

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

(i) If requested by the broker, the client 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 healthcare provider outside of the client's local community.

(ii) If the service is not available locally, 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 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 healthcare 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 the following medical conditions may qualify for transportation based on continuity of care:

(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 days); or

(E) Third trimester of pregnancy.

(c) The healthcare 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, including transportation costs, is lower when the healthcare 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 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 healthcare providers and program rules. Brokers may refer requests to transport a client to a provider outside the client's local community for healthcare services to the department'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 healthcare service must be provided in the state of Washington or a designated border city, unless the department specifically authorizes transportation to an out of state provider in accordance with WAC 388-546-5800.

(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 healthcare provider or service is not available.

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NEW SECTION
WAC 388-546-5800   Nonemergency transportation--Trips out-of-state/out-of-country.   (1) The department reviews requests for out-of-state nonemergency transportation in accordance with regulations for covered healthcare services, including WAC 388-501-0180, 388-501-0182 and 388-501-0184.

(2) Nonemergency transportation is not provided to or from locations outside of the United States and U.S. territories, except for the limitations for British Columbia, Canada, identified in WAC 388-501-0184.

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NEW SECTION
WAC 388-546-5900   Nonemergency transportation--Meals, lodging, escort/guardian.   (1) The department may pay for meals and lodging for clients who must be transported to healthcare services outside of the client's local community. The department'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 guidelines in determining the reasonable costs of meals and lodging. The department'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 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 subsection (5) of this section; and

(b) The broker determines the transportation costs of escorts are 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 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 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. Border areas as defined by WAC 388-501-0175 are considered in-state under this section and subsequent sections.

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NEW SECTION
WAC 388-546-6000   Nonemergency transportation--Authorization.   (1) The department 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 medical director or designee for a review and/or authorization.

(3) Nonemergency medical transportation, other than ambulance, must be prior authorized by the broker. See WAC 388-546-5200 (3) and (4) and WAC 388-546-6200(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 approves a medical service under exception to rule (ETR), the authorization requirements of this section apply to transportation services related to the ETR service.

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NEW SECTION
WAC 388-546-6100   Nonemergency transportation--Noncovered.   (1) The department does not cover any nonemergency transportation that is not specifically addressed in WAC 388-546-5000 through 388-546-6200.

(2) Brokers do not provide nonemergency transportation for admissions under the involuntary treatment act (ITA), as defined in WAC 388-546-4000.

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

(4) The department 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 healthcare service. Exception to rule (ETR) as described in WAC 388-501-0160 is not available for this nonhealthcare service.

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NEW SECTION
WAC 388-546-6200   Nonemergency transportation--Reimbursement.   (1) To be reimbursed for trips, meals, and lodging, the requestor must receive prior authorization from the broker at least forty-eight hours in advance of the client's travel.

(2) A client must request reimbursement of preauthorized expenditures for trips, meals, and 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, parking, bridge tolls, and ferry fees, the requestor must provide the broker with legible copies of:

(a) Receipt(s);

(b) The operator's driver license;

(c) Current vehicle registration; and

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

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

(a) A client is approved for a retroactive eligibility period, or is approved for a delayed certification period as defined in WAC 388-500-0005;

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

(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 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).

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

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

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

(b) The covered healthcare 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.

(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.

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Washington State Code Reviser's Office