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DOH Medicaid Q&A

 

  

 

Abuse of Emergency Services

A couple is constantly calling for emergency transportation. They have taken approximately 50

emergency runs in the past year. When they arrive at the hospital, nothing is wrong with them.

Is there anything that can be done?

 

Response

We cannot restrict enrollees from using ambulance service, because the enrollee may actually

need ambulance transport someday. Ambulance companies are required to respond and transport

– the company is liable if a decision is made not to transport. Additionally, in the financial

sense, it is in the company’s interest to transport.

 

In this situation, you should have a discussion with the enrollees. It is a misdemeanor to call for

an emergency transport when there is no emergency. It is similar to calling the fire department

when there is no fire.

 

What are their medical needs? Discuss alternative transportation options. Tell the enrollees that

the ambulance should only be called when needed. Suggest their caseworker be called prior to

calling 911. Inform the enrollee that this service has been abused, and the matter may be referred to the district attorney’s office for further investigation if the behavior continues.

 

 

After-hours Transportation from Emergency Room

We are having a problem with two individuals. Between the two of them, they are visiting the

Emergency Room 50-80 upwards of times per month. They always seem to get there and then

need to return home after the bus system stops running. A cab is then needed to return them

home after being discharged.

 

Can we require them to wait in the ER until the bus starts running again in the morning? I'm

sure the hospital wouldn't appreciate it but we are unsure of our options.

 

We actually have tried counseling these individuals without much luck. Things will get better

for a while but then revert back to the status quo. Part of the problem is that these folks actually

alternate between the ER and our local Urgent Care facility, which closes at 10:00 and so the

option of sitting overnight is not available. Is it true that the ER could make a decision to just let

them wait it out overnight rather than sending them home in a cab? They will both refuse any

counseling referrals. We are in the process of connecting with the hospital to see if we can come

up with some sort of plan.

 

Response

Medicaid Transportation Policy Manual

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It appears some behavior modification program needs to be established with these two

individuals.

 

First, it is clear that the emergency room staff are not responding appropriately to the true needs

of these individuals. While some of the trips may be emergency in nature, the remaining

emergency department visits are all for non-urgent needs. I am unsure if the emergency

department staff have taken any steps to get viable treatment to these two individuals.

Your question is about transportation home. I do not think the availability of the ride home is

what is triggering their decision to go to the emergency department in the first instance. Perhaps

if they had to sit in uncomfortable chairs for six hours until the following morning, this

experience may lead them to reconsider going to the emergency department. Of course, perhaps

the long overnight wait will just help them to adjust the time of day they go to the emergency

department, so that they are discharged with plenty of time to spare to catch the afternoon bus

home. Also, if other Medicaid beneficiaries get the cab ride home after hours, then you have to

treat these two somewhat comparably.

 

How involved do you want to get into this matter with these two beneficiaries? It seems a bit of

counseling is needed to assess and gauge their medical problems and phobias, and offer some

steps and modifying behaviors so that they can expand their network of friends beyond the

emergency department staff. I am unsure how you would connect these individuals with a

willing counselor.

The ER should continue to arrange for taxi transportation after hours..

At this point, it appears Cortland County DSS is entering new territory--I do not have any answer

at this time, except to work with the emergency department and determine if some plan of care

can be developed that will keep them at home.

 

 

Ambulance Company Bills Enrollee

Mrs. Smith became the responsibility of the County on April 1. Previously, she was the fiscal

responsibility of another County. Apparently, she fell on March 13 and the family called an

ambulance.

 

Mrs. Smith recently received a bill from the ambulance company for $153.00. The ambulance

company said they transported to a hospital further away than the closest facility - at the

enrollee’s choice. This is the reason they are billing the enrollee, as the services are not covered

by Medicare or Medicaid.

 

Is Mrs. Smith liable for the $153?

 

Response

If an enrollee agrees ahead of time to pay the ambulance claim as a private pay individual, then

the enrollee is responsible for the bill. Otherwise, Medicaid pays for ambulance service, and no

bill should be sent to the enrollee.

Medicaid Transportation Policy Manual

Version 2010-1 October 2010 Page 21 of 63

In this situation, the enrollee did not agree to a private-pay arrangement, so Medicaid/Medicare

will pay the bill.

As a Medicare/Medicaid provider, the ambulance company has to accept Medicare’s and our

payment as payment in full.

There are no “non-covered” ambulance services that can be passed along to an

enrollee for payment!

 

 

Ambulance Trips for Hospital Inpatient

A child is admitted to a hospital and needs to be transferred to another facility for an MRI, and

then transported back to the original hospital. The original hospital is responsible for this

transportation expense, so we would not issue a PA, right?

 

Response

The hospital should pay for transportation in this circumstance. There is no additional

reimbursement for the hospital when they bill Medicaid.

Reference: October 2006 Medicaid Update article Who Pays for the Transportation of a Hospital Inpatient?

 

 

Attendant Lodging

A child needs to go to the Boston Children’s Hospital. The stay will be for several days now,

and at least one month following surgery. The family is asking for a 2-room hotel stay as the

parents and grandparent will be traveling and staying while the child is being cared for.

What reimbursement is Medicaid expected to cover?

 

Response

Typically, the Medicaid Program only covers the transportation costs of the enrollee to and from

medical appointments. However, in certain circumstances, the transportation, meals and lodging

costs of one attendant is permitted, as allowed in the Medicaid policy stated below:

Per regulation at 18 NYCRR 505.10(b):

(20) 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.

(21) Transportation services means:

(i) transportation by ambulance, ambulette or invalid coach, taxicab,

common carrier or other means appropriate to the enrollee’s medical

condition.

Medicaid Transportation Policy Manual

Version 2010-1 October 2010 Page 22 of 63

(ii) A transportation attendant to accompany the MA enrollee, 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 enrollee’s family.

 

 

Bariatric Surgery

Bariatric surgery is a Medicaid-covered service, but what about all of the evaluations and

screenings that occur before the surgery? For example, is transportation covered when an

enrollee needs to see the nutritionist?

 

We have no doctors in our common medical marketing area that perform this surgery so the

enrollee needs to take numerous trips at great distance for the surgery and the doctor wants the

enrollee to go to the same location for all the screenings and evaluations.

 

Response

In order for Medicaid to pay for bariatric surgery, an enrollee must meet several criteria; for

example, he or she must attend a series of counseling appointments and meetings for a specified

timeframe before the surgery.

 

Certainly, you can try to minimize these transportation costs by negotiating with the enrollee.

You know how much a trip at this distance will cost. You can offer the enrollee some lower

amount to obtain their own transportation, an amount that will entice the enrollee to accept your

offer while saving you money for the multiple trips needed.

 

 

Car in Household

A husband and wife have one vehicle. The husband is self-employed and is not on Medicaid.

The wife is on SSI/Medicaid and requires transportation five days per week for day treatment for

mental health issues.

 

We have repeatedly asked if the husband can assist in transports to and/or from these

appointments, and he always 1responds that he is self-employed and must be available to meet

with his customers when they need him. He will not commit to providing any transports. The

wife has a medical statement indicating she cannot drive at this time.

Often when our staff drivers go to pick up the wife or return her home, the family vehicle is

there, as well as the husband. What are our options?

 

Response

Depending on the circumstances, you must decide the appropriate response of the Medicaid

Program.

 

As I read your email, I sense your frustration. While the husband says he requires his vehicle for

his employment, he is often home at the time transports for his wife are needed. The husband

appears not to be fulfilling his role as a husband.

Medicaid Transportation Policy Manual

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Certainly, we cannot require a husband who uses his personal vehicle for employment to take

time off from that employment to transport his wife to her medical care. However, when one is

self-employed, and it appears that he has the flexibility in his schedule to assume some

transportation responsibility, you can require him to assume his role.

It may be difficult to require the husband to do all the transportation as it will take a significant

amount of time.

 

I suggest you consider requiring him to do the morning transport, and you get the enrollee home

each day. Or, consider requiring him to assume Monday and Tuesday transports, while you pick

up the rest of the week.

 

 

Chemical Dependence Program Inpatient Needs Mental Health

Treatment

The county received a request to transport a chemical dependency program inpatient to mental

health therapy appointments five times per week. Isn’t that the responsibility of the treatment

program where the person is an inpatient?

 

Response

Yes. The treatment program is responsible to provide necessary treatment essential to recovery.

 

 

Clarification: Private Practicing Podiatrist

Podiatry is covered and transportation to a private practicing podiatrist may be authorized for the

following Medicaid enrollees:

--children under the age of 21 who are eligible to receive services through the early and

periodic screening and diagnosis treatment program,

--TBI waiver participants, and

--Medicare/Medicaid dual eligibles identified as Qualified Medicare Beneficiaries

(QMBs).

Additionally, transportation to a clinic for podiatry services can be authorized, as the service

being provided is a clinic service (not a podiatry service), which is covered under Medicaid.

 

 

Clinical Trials

An enrollee is being evaluated for a clinical trial. Once he is in the study, the study pays for it,

and he will not be charged.

Should we provide transportation for someone in a clinical trial (the clinical trial is taking place

in a hospital)?

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Response

 

There are two types of clinical trials:

--One type is experimental, and is not covered as a medical service under Medicaid at this

time. In this instance, the costs of transportation should not be authorized.

--The second type is an attempt to determine if one treatment protocol has more efficacy that

another protocol. For example, asthma patients often are asked to be involved in treatment

using new inhalers. In these instances, the actual care (clinic care for asthma) is already a

covered service; thus, we can authorize transportation to this clinic.

 

You can ask the staff at the clinic, who is ordering the transportation, whether this treatment will

result in a claim to Medicaid. If it will not, you should not authorize payment for the transport.

 

 

Common Medical Marketing Area: Enrollee Choice

We have an enrollee who has been in our county for two months and has asked for transportation

to doctors around this area. But, he does not like to take the bus, so he has refused to seek other

providers within this area. He insists on seeing his former doctor in Waterloo.

Do we continue to transport him all the way to Waterloo for continued care with this doctor or do

we ask him to seek a provider in this area?

 

Response

Your responsibility is to assure transportation is available to a Medicaid covered service. You've

done that - the enrollee has been assigned the most appropriate mode of transportation to a doctor

in the area who performs the same service as the doctor in Waterloo.

 

The enrollee has chosen to go outside the CMMA simply because he doesn't want to ride the bus.

He has that right, but the LDSS need not approve transportation to services outside the CMMA.

 

 

Comprehensive Medicaid Case Management

A patient called for a ride to see a case manager because she is a psych patient. I asked the

facility accepts Medicaid and was told they must, because that is what the patient has.

Is this something that people can and/or should be transported to?

 

Response

Comprehensive Medicaid Case Management (CMCM) is where a case manager reaches out to an

enrollee to manage their care. CMCM is a service that is most often used by psychiatric patients.

The case manager reaches out to the enrollee, not vice versa.

Since the nature of the service is the case manager goes to the enrollee, transportation of an

enrollee to see a case manager is typically not allowed.

Medicaid Transportation Policy Manual

Version 2010-1 October 2010 Page 25 of 63

 

 

Child Not on Medicaid Needs Group Counseling

A non-Medicaid-covered child needs to attend group counseling. The mother is on Medicaid,

and they told her that she needed to bring her child to group counseling.

Will Medicaid pay for them to both go under her Medicaid?

 

Response

It is the child who requires the medical service (counseling), and thereby requires transportation

to the medical service.

 

Since Medicaid will only cover the costs of transporting a Medicaid enrollee, and the child is not

on Medicaid, then you should not provide any transportation.

Mom has to find another way to get her and her child to the counseling appointment, and any

other medical appointment the child needs.

 

 

Enrollee Freedom of Choice: Hospitals

An enrollee was transported by ambulance to the nearest hospital; then the enrollee decided she

wanted to be taken to another hospital. Do we pay for the second transport?

 

Response

The patient arrived at the first hospital, and for some reason, wanted to go to a second hospital. I

must assume that the patient was no longer in an emergency situation in order to request and

receive transportation to another hospital. So, the first trip was emergency, the second trip was

non-emergency.

 

Medicaid can reimburse the cost of transportation to the first hospital.

The second trip requires a prior authorization from you. No prior authorization was given, and

there appears to be no medical need that could not have been treated at the first hospital. You do

not need to authorize reimbursement for transport to the second hospital.

From the DOH Bureau of Emergency Services:

"It is the expressed policy of the Department that a patient, in need of emergency medical

care be taken to the nearest most appropriate health care facility capable of treating the

illness, disability or injury of the patient...

A patient's choice of hospital or other facility should be complied with unless

contraindicated by state, regional or system/service protocol or the assessment by a

certified EMS provider shows that complying with the patient's request would be

injurious or cause further harm to the patient..."

Questions regarding the DOH policy statement above should be referred to the Bureau of

Emergency Medical Services, (518) 402-0996.

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Collateral Therapy

A parent needs to sit in on the appointment for her child in a mental health situation. The

therapist has requested the parent be present during treatment for a specific appointment versus

the parent going along as a responsible party for the child.

 

Can the parent’s Medicaid be billed for transportation in this situation at the same time the

child’s Medicaid is being billed for transportation?

 

Response

Collateral therapy is a service offered to the parent/guardian/significant-other-person of the

Medicaid enrollee receiving counseling/psychiatric services. This service is needed in order for

the primary patient to progress in the therapy. For instance, the parent of a patient may need to

learn how to address potential inappropriate behavior of the patient once the patient is returned to

the home environment.

If a parent is needed to attend what is referred to as "collateral therapy," with or without the

primary patient, then the parent should only be transported if the parent receives Medicaid. The

charge for the trip is against the parent's Medicaid. There is only one charge: for the transport of

the enrollee receiving the medical care. Any children traveling with the parent go for free

(unless it is public transit, when each person can be covered for the costs of the token).

 

 

Common Medical Marketing Area vs. Freedom of Choice

How far can we push an enrollee to go within the common medical marketing area (CMMA) and

what do you consider the CMMA?

We have enrollees who have always gone to various health centers in our area, but we have

others who want to travel a greater distance because that is where their physician practices.

Would you consider this an issue that you should push the CMMA on or do you believe the

enrollee has the right to choose?

 

Response

The CMMA is not easy to pinpoint because there is no set geographic size, and the CMMA can

differ if you are talking about general practitioners versus specialists. The rule of thumb to use

is: where do you generally go to seek medical care? Where do you generally go to take your

children? Where do other family members tend to go? This begins to set the boundaries of your

CMMA.

In a rural county such as Washington County, when someone says they are "going down the

road," 25 miles is normal! In an urban area, “going down the street” could be 10 blocks!

However, the Medicaid enrollee does have to take some responsibility about one's transportation

when he/she leaves your county and travels 25 miles. One reality of living in a rural area, where

25 miles is "just down the road," is that transportation resources are scarce. Most individuals

who live in these rural areas have access to a personal vehicle to travel down the road.

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Now, you have two factors to consider--the CMMA and the availability of a transportation

provider. If your transportation resources are scarce, the reality is that you cannot assure

transportation to a site 25 miles away when the same practitioner type is within town. You

would provide the transportation, if it was available, but it just is not. This is the reality of rural

living. So, you end up assuring transportation only to where the closest practitioner is available,

because you are shepherding your transportation resources.

 

Bottom line, you do not have an easy job. But, you can manage your transportation program in

the manner you deem most appropriate, knowing where your enrollees live, your providers

practice, and the availability of your transportation resources.

 

The basic right enrollees have is the right to choose who will treat their medical condition.

Enrollees have the right to choose which (participating) doctor, hospital, clinic, laboratory they

want. So, an enrollee can go to the renowned Strong Memorial Hospital in Rochester or a simple

dental clinic in Brooklyn for their medical care. However, we do not have to provide

transportation to accommodate that choice, when that care is available closer to home.

 

 

Continuing Day Treatment

We have been paying transportation to mental health continuing day treatment-they provide a

van and we have paid a rate less than individual trip rates. We asked them if they or we should

be paying transport-they bill an hourly rate for time a patient is at the program.

Additionally, we now have a wheelchair person they want to attend daily. The van they have

does not accommodate wheelchairs. Do we arrange and pay? Is there any other way we should

check this out on who should pay? Do they decide frequency of attendance?

 

Response

Mental health continuing treatment programs, established when we deinstitutionalized the

psychiatric centers and moved to a community-based response to mental illness, do not have the

costs of transportation in their program rate. Hence, any transportation that is needed is fee-forservice,

including wheelchair user transportation.

The program decides how often a person needs to attend this program--they have medical staff to

review each person's needs. Hopefully, the need for continuing treatment will decrease based

upon the severity of the mental illness.

 

 

Court-Ordered MMTP

Must we transport to court-ordered MMTP?

It will be costly, we’re a rural county and the nearest MMTP Clinic is 60 miles away.

 

Response

Must you transport? No. Draw a line, when is this treatment considered medically necessary as

opposed to court-ordered?

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Most MMTP enrollees come into the system through the courts. However, think about it another

way: If the enrollee doesn’t attend their court-ordered MMTP, they go to jail. You’re still

paying, because now they are in the corrections system. It’s a give and take situation.

 

 

Court-Ordered Substance Abuse Treatment

We have a request to provide transportation to court-ordered substance abuse and mental health

services. The enrollee has been ordered to these services as an “Order and Condition of

Probation.”In 1992, we received a letter stating that “…when a court of law, as part of the judicial process, orders a person to a medical evaluation, transportation of that person to that medical evaluation is the responsibility of the person and the court. Your department should not authorize payment for transportation.”

Is this still the basic logic to follow?

 

Response

The policy above is still correct. For the evaluation, the cost can be borne by the court.

Once the person is evaluated, and a determination is made that this person is in need of this

medical service, it becomes a Medicaid issue, i.e., the person needs medical care covered under

Medicaid. Now, Medicaid transportation can be delivered for the necessary care and treatment.

 

 

Covered Service: Assessment for Eating Disorder

We have a client who has been referred to an eating disorder clinic in Elmira just for the

evaluation for an inpatient admission. She (and her doctor) is requesting we provide

transportation. The facility is a Medicaid provider, but do we have to provide transportation for

an “intake assessment”. Any help would be appreciated.

 

Response

This intake assessment will involve some medical evaluation, and examination, which can be

reimbursed under the Medicaid Program. Transportation to this assessment can be authorized.

However, are you questioning if similar assessment/hospitalization cannot be found in the local

area? I do not know what this disorder is, but I am aware of the wealth of hospitals in your area.

This type of treatment may be long term. If this is a question for you, ask for additional

information from the referring physician.

 

 

Covered Service: Botox Injections

We have received a request to set up transportation for an enrollee to go to Westchester Medical

Center for Botox injections to treat his blephanspasm. Is this procedure covered by Medicaid?

 

Response

Botox injections for cosmetic reasons is not covered under Medicaid.

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