New York Codes, Rules and Regulations › Title 18 - DEPARTMENT OF SOCIAL SERVICES › Chapter II - Regulations of the Department of Social Services › Subchapter E - Medical Care › Article 3 - Policies and Standards Governing Provision of Medical and Dental Care › Part 505 - Charges For Professional Health Services › Section 505.10 - Transportation for medical care and services

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Scope and purpose. This section describes
			 the department's policy concerning payment for transportation services provided
			 to medical assistance (MA) recipients, the standards to be used in determining
			 when the MA program will pay for transportation, and the prior authorization
			 process required for obtaining such payment. Generally, payment will be made
			 only upon prior authorization for transportation services provided to an
			 eligible MA 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 MA program.
(b) Definitions.
(1) Ambulance means a motor vehicle,
			 aircraft, boat or other form of transportation designed and equipped to provide
			 emergency medical services during transit.
(2) Ambulance service means any entity, as
			 defined in section 3001  of the Public Health Law, which is
			 engaged in the provision of emergency medical services and the transportation
			 of sick, disabled or injured persons by motor vehicle, aircraft, boat or other
			 form of transportation to or from facilities providing hospital services and
			 which is currently certified or registered by the Department of Health as an
			 ambulance service.
(3) Ambulette or
			 paratransit vehicle means a special-purpose vehicle, designed and equipped to
			 provide nonemergency transport, that has wheelchair-carrying capacity,
			 stretcher-carrying capacity, or the ability to carry disabled
			 individuals.
(4) Ambulette service
			 means an individual, partnership, association, corporation, or any other legal
			 entity which transports disabled individuals by ambulette to or from facilities
			 which provide medical care. An ambulette service provides disabled individuals
			 with personal assistance as defined in this subdivision.
(5) Common medical marketing area means the
			 geographic area from which a community customarily obtains its medical care and
			 services.
(6) Community means
			 either the State, a portion of the State, a city or a particular classification
			 of the population, such as all persons 65 years of age and older.
(7) Conditional liability means that the
			 prior authorization official is responsible for making payment only for
			 transportation services which are provided to MA-eligible individuals in
			 accordance with the requirements of this Title.
(8) Day treatment program or continuing
			 treatment program means a planned combination of diagnostic, treatment and
			 rehabilitative services certified by the Office for People with Developmental
			 Disabilities or the Office of Mental Health.
(9) Department established fee means the fee
			 for any given mode of transportation which the department has determined will
			 ensure the efficient provision of appropriate transportation to MA recipients
			 in order for the recipients to obtain necessary medical care or
			 services.
(10) Emergency ambulance
			 transportation means the provision of ambulance transportation for the purpose
			 of obtaining hospital services for an MA recipient who suffers from severe,
			 life threatening or potentially disabling conditions which require the
			 provision of emergency medical services while the recipient is being
			 transported.
(11) Emergency medical
			 services means the provision of initial urgent medical care including, but not
			 limited to, the treatment of trauma, burns, and respiratory, circulatory and
			 obstetrical emergencies.
(12)
			 Emergency triage, treat and transport (ET3) model means an innovative payment
			 and service delivery model established by the United States Department of
			 Health and Human Services to lower costs and improve quality of care to
			 Medicare beneficiaries by requiring ambulance service suppliers selected by the
			 Center for Medicare and Medicaid Innovation (CMMI), or successor agency or
			 office, to partner with qualified health care practitioners to deliver
			 treatment in place and/or transport to alternative destination sites, such as
			 primary care physician offices or urgent care clinics.
(13) Locally prevailing fee means a fee for a
			 given mode of transportation which is established by a transit or
			 transportation authority or commission empowered to establish fees for public
			 transportation, a municipality, or a third-party payor, and which is charged to
			 all persons using that mode of transportation in a given community.
(14) Nonemergency ambulance transportation
			 means the provision of ambulance transportation for the purpose of obtaining
			 necessary medical care or services to an MA recipient whose medical condition
			 requires transportation by an ambulance service.
(15) New York State Medicaid payment system
			 means an automated system, such as eMedNY, used to process Medicaid
			 fee-for-service claims submitted by Medicaid enrolled providers for services
			 provided to Medicaid beneficiaries.
(16) Ordering practitioner means the MA
			 recipient's attending physician or other medical practitioner who has not been
			 excluded from enrollment in the MA program and who is requesting transportation
			 on behalf of the MA recipient in order that the MA recipient may obtain medical
			 care or services which are covered under the MA program. The ordering
			 practitioner is responsible for initially determining when a specific mode of
			 transportation to a particular medical care or service is medically
			 necessary.
(17) Personal assistance
			 means the provision of physical assistance by a provider of transportation
			 services to an MA recipient for the purpose of assuring safe access to and from
			 the recipient's place of residence, vehicle and MA covered health service
			 provider's place of business. Personal assistance is the rendering of physical
			 assistance to the recipient in walking, climbing or descending stairs, ramps,
			 curbs or other obstacles; opening or closing doors; accessing a vehicle; and
			 the moving of wheelchairs or other items of medical equipment and the removal
			 of obstacles as necessary to assure the safe movement of the recipient. In
			 providing personal assistance, the provider or the provider's employee will
			 physically assist the recipient which shall include touching, or, if the
			 recipient prefers not to be touched, guiding the recipient in such close
			 proximity that the provider of services will be able to prevent any potential
			 injury due to a sudden loss of steadiness or balance. A recipient who can walk
			 to and from a vehicle, his or her home, and a place of medical services without
			 such assistance is deemed not to require personal assistance.
(18) Prior authorization means a prior
			 authorization official's determination that payment for a specific mode of
			 transportation is essential in order for an MA recipient to obtain necessary
			 medical care and services and that the prior authorization official accepts
			 conditional liability for payment of the recipient's transportation
			 costs.
(19) Prior authorization
			 official means the department, the transportation manager or the transportation
			 management broker, or such other entity under contract with, or specifically
			 permitted by, the Department of Health, as applicable.
(20) Service Agreement means an agreement
			 between a vendor and a transportation management broker that includes, but is
			 not limited to, vendor service standards and fees to be established and paid by
			 the transportation management broker for the provision of nonemergency
			 transportation services to MA recipients.
(21) Transportation attendant means any
			 individual authorized by the prior authorization official to assist the MA
			 recipient in receiving safe transportation.
(22) Transportation expenses means:
(i) the costs of transportation services;
			 and
(ii) the costs of outside meals
			 and lodging incurred when going to and returning from a provider of medical
			 care and services when distance and travel time require these costs.
(23) Transportation management
			 broker or brokers means the entity or entities with which the commissioner
			 contracts to cost-effectively administer non-emergency transportation services
			 to MA recipients in accordance with Social Services Law section
			 365-h(4)(b).
(24) Transportation
			 manager or managers means the entity or entities with which the commissioner
			 contracts to manage transportation services provided to MA recipients in
			 accordance with Social Services Law section 365-h(4)(a).
(25) Transportation services means:
(i) transportation by ambulance, ambulette or
			 paratransit vehicle, taxicab/livery, transportation network
			 company/high-volume for-hire services vehicle (TNC), common carrier or other
			 means appropriate to the MA recipient's medical condition; and
(ii) a transportation attendant to accompany
			 the MA recipient, if necessary. Such services may include the transportation
			 attendant's transportation, meals, lodging and salary; however, no salary will
			 be paid to a transportation attendant who is a member of the MA recipient's
			 family.
(26) Undue
			 financial hardship means transportation expenses which the MA recipient cannot
			 be expected to meet from monthly income or from available resources. Such
			 transportation expenses may include those of a recurring nature or major
			 one-time costs.
(27) Value-based
			 payment means an additional fee for certain transportation services determined
			 by the department that may be paid to vendors that achieve certain quality
			 and/or efficiency targets established by the department or a transportation
			 management broker.
(28) Vendor
			 means a lawfully authorized provider of transportation services who is enrolled
			 in the MA program pursuant to Part 504 of this Title and authorized to receive
			 payment for transportation services directly from the New York State Medicaid
			 payment system or pursuant to a service agreement with a transportation
			 management broker, as applicable . The term vendor does not mean an MA
			 recipient or other individual who transports an MA recipient by means of a
			 private vehicle.