Source: http://www.wnylc.com/health/entry/143/
Timestamp: 2019-04-18 14:41:55+00:00

Document:
States are required under federal regulations (42 C.F.R. §431.53) to assure necessary transportation to Medicaid beneficiaries to and from medical services.
Non-emergency transportation was carved out of the Medicaid managed care benefit package as part of the Medicaid Redesign Team's Transportation Reform Initiative. The carve-out took place in 2012 and 2013. Enrollees in mainstream Medicaid managed care plans do not access transportation services through their plans, but directly through private contractors. Medical Answering Services, LLC, which until recently managed transportation in all counties statewide except Nassau, Suffolk, and New York City, was recently awarded the contract for New York City transportation.
Medical Answering Services, LLC is handling New York City transportation as of April 23, 2017. LogistiCare continues to be the contractor for Nassau and Suffolk Counties.
PLEASE NOTE: Transportation remains a plan benefit for Managed Long Term Care (MLTC). MLTC enrollees must arrange for non-emergency transportation through their plans.
18 NYCRR §505.10 is the regulation governing transportation for medical care and services. “Generally, payment will be made only upon prior authorization for transportation services provided to an eligible medical assistance recipient. Prior authorization will be granted by the prior authorization official only when payment for transportation expenses is essential in order for an eligible MA recipient to obtain necessary medical care and services which may be paid for under the medical assistance program.” 18 NYCRR §505.10(a).
Prior authorization generally must be obtained by the medical assistance recipient, his representative, or an ordering practitioner before the transportation expenses are incurred, but such authorization is not required for emergency ambulance transportation or Medicare approved transportation by an ambulance service under certain circumstances. 18 NYCRR §505.10(d)(1); 18 NYCRR §505.10(d)(2).
The request must be made in the manner required by the prior authorization official. 18 NYCRR §505.10(d)(3). A request for prior authorization for nonemergency ambulance transportation must be supported by the order of an ordering practitioner who is the medical assistance recipient’s attending physician, physician’s assistant, or nurse practitioner. 18 NYCRR §505.10(d)(4). The prior authorization official may approve or deny the request, or require additional information before doing so. 18 NYCRR §505.10(d)(6).
Prior authorization official is defined as the department, a social services district, or their designated agents. 18 NYCRR §505.10(b)(18).
The prior authorization official must use the following criteria to determine whether to authorize the payment of transportation expenses. 18 NYCRR §505.10(d)(7).
Prior authorization may be denied when the recipient can be transported to necessary medical care or services by use of a private vehicle or mass transportation which are used by the recipient for the usual activities of daily living. 18 NYCRR §505.10(d)(7)(i).
When the recipient requires multiple visits or treatments within a short period of time and would suffer undue financial hardship if required to make payment for the transportation to such visits or treatments, prior authorization for transportation expenses may be granted for a means of transportation ordinarily used by the recipient for the usual activities of daily living. 18 NYCRR §505.10(d)(7)(ii).
Prior authorization may be granted when the nature and severity of the recipient’s illness necessitates a mode of transportation other than that ordinarily used by the recipient. 18 NYCRR §505.10(d)(7)(iii).
Prior authorization for another mode of transportation may be granted when the nature and severity of the recipient’s illness necessitates a mode of transportation other than that ordinarily used by the recipient. 18 NYCRR §505.10(d)(7)(iv).
Prior authorization for the recipient’s usual mode of transportation may be granted when the distance to be travelled necessitates a large transportation expense and undue financial hardship to the recipient. 18 NYCRR §505.10(d)(7)(v).
Prior authorization for transportation expenses to medical care and services outside of the recipient’s common medical marketing area may be denied when the needed medical care and services are available within the common medical marketing area of the recipient’s community. 18 NYCRR §505.10(d)(7)(vi). (See Fair Hearing #6629770L below).
Common medical marketing area is the geographic area from which a community customarily receives its medical care and the medical marketing takes place. It is not a geographic boundary but rather depends on the service from county to county and enrollee to enrollee. (https://www.medanswering.com/page.taf?ID=70).
However, prior authorization for payment of transportation expenses for medical care and services outside the common medical marketing area may be granted when the need to continue a regimen of medical care or services with a special provider necessitates travel outside of the common medical marketing area, notwithstanding the fact that the medical care or service is available within the common medical marketing area. 18 NYCRR §505.10(d)(7)(vii).
Prior authorization for payment of transportation expenses may be granted when there are any circumstances which are unique to the recipient and which the prior authorization official determines to have an effect on the need for payment of transportation expenses. 18 NYCRR §505.10(d)(7)(viii).
Medicaid beneficiaries in New York City who are able to use mass transit can receive a pre-paid Metrocard for this purpose.
Currently, public transportation is only reimbursed through the PTAR system.
What if I am able to utilize mass transit but my provider does not take PTAR?
According to the regulation, prior authorization may be denied when the recipient can be transported to necessary medical care or services by use of a private vehicle or mass transportation which are used by the recipient for the usual activities of daily living. 18 NYCRR §505.10(d)(7)(i).
If the medical practitioner does not participate in PTAR, then the Medical Answering Services website states that the enrollee may request transportation from Medical Answering Services.
When LogistiCare managed transportation for New York City, advocates were unable to get clear answers from the company about coverage of public transportation to providers who do not participate in PTAR.
See Fair Hearing #6532143J described below.
All trips must be pre-arranged by an enrollee or medical practitioner and confirmed by Medical Answering for the first trip.
To order transportation by telephone, providers/enrollees should use the following telephone number: 1-844-666-6270.
To order transportation through the MAS website go to www.medanswering.com and select Secure User Login. You will need a user name and password to access the secure MAS portal.
For information regarding access to the website you can contact Medical Answering Services through your toll-free county number listed above or select Secure User Login and apply for a user name and password online.
Who cannot get a ride through Medical Answering Services?
Individuals who are not NYC Medicaid fee-for-service enrollees or who are not NYC Medicaid Managed Care enrollees.
Enrollees who live within 10 blocks of their medical practitioner and who can walk there.
Enrollees who are able to utilize mass transit and are visiting a medical practitioner who participates in the Public Transit Automated Reimbursement (PTAR) system should not request transportation services from Medical Answering Services.
All trips must be pre-arranged through LogistiCare. Rides must be booked 72 hours in advance. If enrollees need to arrange a ride with less than 72 hours notice, their provider must call to explain why the appointment is necessary.
Medical providers can call 1-844-678-1106 to request a ride for their patients.
If a ride is late, enrollees can call the “Where’s My Ride” line at 1-844-678-1104.
Provide as much documentation as possible and officially request reimbursement.
Appellant was in receipt of a Medical Assistance Authorization. Appellant required a MetroCard reimbursement for out of pocket transportation costs. Appellant claimed both Medicaid and Logisticare refused to reimburse the transportation expenses.
At the hearing, Appellant failed to establish or present documentation on how and when contact was made to request reimbursement. He stated that he had not made any requests for reimbursement because his requests were frustrated by people in the Medicaid office. Further, he had no documentation from his doctor’s visits.
Appellant failed to establish that the denial of transportation benefits was incorrect because no request had been made, and thus there was no denial by the agency. Accordingly, the Agency determination was sustained.
In order to obtain payment for transportation to medical providers outside the medical marketing area, the recipient must show (by submitting documentation) that it is either medically necessary to see such provider or that the same services cannot be conducted in the common marketing area.
Appellant received Medical Assistance and requested medical transportation for a mammogram appointment in Cooperstown, New York (which was out of the medical marketing area). The Agency denied the preapproval request on the ground that mammogram services are available locally.
The Agency contended that the request for the transportation was denied because it was outside the medical marketing area and appropriate medical care was available within Sullivan County or adjacent Orange County. Medical Answering Services is not approving out of county transportation for nonmedical reason such as patient preferences, as documented by Appellant’s medical provider.
Appellant had been going to the same doctor’s facility in Cooperstown to have her mammogram for 21 years, they have all of her medical records, and she had developed a relationship with the providers. It was during one of her annual exams there that her breast cancer was detected. Her hospital wanted her to continue having her mammogram at Cooperstown. However, Appellant acknowledged that she has not looked into local providers.
Appellant failed to submit any medical documentation to establish that she needed to have the mammogram in Cooperstown due to a medical necessity or that the same mammogram cannot be conducted in her common medical marketing area. Therefore, the Agency was correct in denying the Appellant’s request for medical transportation to have a mammogram in Cooperstown. Regulations state that when the medical care and services needed are available within the common medical marketing area of the recipient’s community, prior authorization for payment of transportation expenses to such medical care and services outside the common medical marketing area may be denied. Because Appellant failed to established that the mammograms cannot be provided within the Sullivan County area, the Agency’s determination was upheld.
Logisticare must inform Medicaid recipients of the need for prior authorization in order for transportation expenses to be paid and of the procedures for obtaining such prior authorization.
Appellant was in receipt of Medicaid Assistance authorization and had been receiving coverage of his necessary public transportation expenses to attend medical appointments from the Agency through Logisticare. The Agency informed Appellant that effective November 1, 2013, the Agency would discontinue coverage of necessary public transportation expenses to attend medical appointments, and the Appellant could begin to receive medical care from a group of about 206 Medicaid providers who would provide Appellant with round trip public transportation fare. However, if Appellant continued to receive care from the current medical practitioner, he would be required to cover the transportation at his own cost.
The regulations require Logisticare to inform Medicaid recipients of the need for prior authorization in order for transportation expenses to be paid and of the procedures for obtaining such prior authorization. Here, there was insufficient evidence to establish that Logisticare met that requirement in its determination.
Logisticare’s determination was held to be incorrect and they were directed to inform Appellant in writing of the information and documentation necessary for him to request prior approval and to afford him the opportunity to submit such information and documentation. Logisticare was then directed to make a new determination regarding the public transportation expenses.
To complain about transportation issues, contact the Department of Health at medtrans@health.ny.gov or (518) 473-2160.

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