TITLE 8 SOCIAL SERVICES

CHAPTER 301 MEDICAID GENERAL BENEFIT DESCRIPTION

PART 6 CLIENT MEDICAL TRANSPORTATION SERVICES

8.301.6.1 ISSUING AGENCY: New Mexico Human Services Department (HSD).

[2/1/95; 8.301.6.1 NMAC - Rn, 8 NMAC 4.MAD.000.1 & A, 3/1/11]

8.301.6.2 SCOPE: The rule applies to the general public.

[2/1/95; 8.301.6.2 NMAC - Rn, 8 NMAC 4.MAD.000.2, 3/1/11]

8.301.6.3 STATUTORY AUTHORITY: The New Mexico medicaid and other health care programs are administered pursuant to regulations promulgated by the federal department of health and human services under the Social Security Act as amended or by state statute. See NMSA 1978, Section 27-1-12 et seq.

[2/1/95; 8.301.6.3 NMAC - Rn, 8 NMAC 4.MAD.000.3 & A, 3/1/11]

8.301.6.4 DURATION: Permanent

[2/1/95; 8.301.6.4 NMAC - Rn, 8 NMAC 4.MAD.000.4, 3/1/11]

8.301.6.5 EFFECTIVE DATE: February 1, 1995, unless a later date is cited at the end of a section.

[2/1/95; 8.301.6.5 NMAC - Rn, 8 NMAC 4.MAD.000.5 & A, 3/1/11]

8.301.6.6 OBJECTIVE: The objective of this rule is to provide instruction for the service portion of the New Mexico medical assistance programs.

[2/1/95; 8.301.6.6 NMAC - Rn, 8 NMAC 4.MAD.000.6 & A, 3/1/11]

8.301.6.7 DEFINITIONS: [RESERVED]

8.301.6.8 MISSION STATEMENT: To reduce the impact of poverty on the people living in New Mexico and to assure low income and individuals with disabilities in New Mexico equal participation in the life of their communities.

[2/1/95; 8.301.6.8 NMAC - Rn, 8 NMAC 4.MAD.002 & A, 3/1/11]

8.301.6.9 CLIENT MEDICAL TRANSPORTATION SERVICES: The medical assistance division (MAD) covers expenses for transportation, meals and lodging it determines are necessary to secure MAD covered medical examination and treatment for eligible recipients in or out of their home community [42 CFR 440.170]. Travel expenses include the cost of transportation by long distance common carrier, taxicab, handivan, and ground or air ambulance, all as appropriate to the situation and location of the eligible recipient. When medically necessary, MAD covers similar expenses for an attendant who accompanies the eligible recipient to the medical examination or treatment.

[2/28/98; 8.301.6.9 NMAC - Rn, 8 NMAC 4.MAD.605 & A, 3/1/11]

8.301.6.10 COVERED SERVICES AND SERVICE LIMITATIONS: MAD reimburses eligible recipients or transportation providers for medically necessary transportation subject to the following:

A. Free alternatives: Alternative transportation services which may be provided free of charge, include volunteers, relatives or transportation services provided by nursing facilities or other residential centers. An eligible recipient must certify in writing that they do not have access to free alternatives.

B. Least costly alternatives: MAD covers the most appropriate and least costly transportation alternatives suitable for the eligible recipient’s medical condition. If an eligible recipient can use private vehicles or public transportation, those alternatives must be used before the eligible recipient can use more expensive transportation alternatives.

C. Non-emergency transportation service: MAD covers non-emergency transportation services for an eligible recipient who does not have primary transportation and who is unable to access a less costly form of public transportation.

D. Long distance common carriers: MAD covers long distance services furnished by a common carrier if the eligible recipient must leave their home community to receive medical services. Authorization forms for direct payment to long distance bus common carriers by MAD are available through the eligible recipient’s local county income support division (ISD) office.

E. Ground ambulance services: MAD covers services provided by ground ambulances when:

(1) an emergency which requires ambulance service is certified by a physician or is documented in the provider’s records as meeting emergency medical necessity as defined as:

(a) an emergency condition that is a medical or behavioral health condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to body function or serious dysfunction of any bodily organ or part; and

(b) “medical necessity” for ambulance services is established if the eligible recipient’s condition is such that the use of any other method of transportation is contraindicated and would endanger the eligible recipient’s health;

(2) scheduled, non-emergency ambulance services are ordered by a physician who certifies that the use of any other method of non-emergency transportation is contraindicated by the eligible recipient’s medical condition; and

(3) MAD covers non-reusable items and oxygen required during transportation; coverage for these items are included in the base rate reimbursement for ground ambulance.

F. Air ambulance services: MAD covers services provided by air ambulances, including private airplanes, if an emergency exists and the medical necessity for the service is certified by the physician.

(1) An emergency condition is a medical or behavioral health condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to body function or serious dysfunction of any bodily organ or part.

(2) MAD covers the following services for air ambulances:

(a) non-reusable items and oxygen required during transportation;

(b) professional attendants required during transportation; and

(c) detention time or standby time up to one hour without physician documentation; if the detention or standby time is more than one hour, a statement from the attending physician or flight nurse justifying the additional time is required.

G. Lodging services: MAD covers lodging services if recipients are required to travel to receive medical services more than four hours one way and an overnight stay is required due to medical necessity or cost considerations. If medically justified and approved, lodging is initially set for up to five continuous days. For a longer stay, the need for lodging must be re-evaluated by the fifth day to authorize up to an additional 15 days. Re-evaluation must be made every 15 days for extended stays, prior to the expiration of the existing authorization. Approval of lodging is based on the medical provider’s statement of need. Authorization forms for direct payment to medicaid lodging providers by MAD are available through local county income support division (ISD) offices.

H. Meal services: Medicaid covers meals if a recipient is required to leave their home community for eight hours or more to receive medical services. Authorization forms for direct payment to medicaid meal providers by MAD are available through local county ISD offices.

I. Coverage for attendants: MAD covers transportation, meals and lodging in the same manner as for an eligible recipient, for one attendant if the medical necessity for the attendant is certified in writing by the eligible recipient’s medical provider or the eligible recipient who is receiving medical service is under 18 years of age. If the medical appointment is for an adult recipient, MAD does not cover transportation services or related expenses of children under 18 years of age traveling with the adult recipient.

J. Coverage for medicaid waiver recipients: Transportation of a medicaid waiver recipient to a provider of a waiver service is only covered when the service is occupational therapy, physical therapy, speech therapy and behavioral therapy services.

K. Medicaid family planning waiver eligible recipients: MAD does not cover transportation service for recipients eligible for medicaid family planning waiver services.

[2/28/98; 8.301.6.10 NMAC - Rn, 8 NMAC 4.MAD.605.1 & A, 3/1/11]

8.301.6.11 NONCOVERED SERVICES: Transportation services are subject to the same limitations and coverage restrictions which exist for other services. A payment for transportation to a MAD non-covered service is subject to retroactive recoupment. MAD does not cover the following services or related costs of travel:

A. attendants where there is not required certification from the eligible recipient’s medical provider;

B. minor aged children of the eligible recipient that are simply accompanying the eligible recipient to medical services;

C. transportation to a non-covered MAD service;

D. transportation to a pharmacy provider. See Subsection F of 8.324.14.18 NMAC, transportation services. See Section 8.301.3 NMAC, General Noncovered Services.

[2/28/98; 8.301.6.11 NMAC - Rn, 8 NMAC 4.MAD.605.2 & A, 3/1/11]

8.301.6.12 OUT-OF-STATE TRANSPORTATION AND RELATED EXPENSES: All out-of-state transportation, meals and lodging must be prior approved by MAD. Out-of-state transportation is approved only if the out-of-state medical service is approved. Documentation must be available to the reviewer to justify the out-of-state travel and verify that treatment is not available in the state of New Mexico.

A. Requests for out-of-state transportation must be coordinated through the MAD client services bureau or MAD’s designated contractor.

B. Authorization for lodging and meal services by out-of-state providers can be granted for up to 30 calendar days by MAD. Re-evaluation authorizations are completed prior to expiration and every 30 days, thereafter.

C. Transportation to border cities, those cities within 100 miles of the New Mexico border (Mexico excluded), are treated as in-state provider service. An eligible recipient who receives MAD reimbursable services from a border area provider is eligible for transportation services to that provider. See 8.302.4 NMAC, Out of State and Border Area Providers, to determine when a provider is considered an out-of-state provider or a border area provider.

[2/28/98; 8.301.6.12 NMAC - Rn, 8 NMAC 4.MAD.605.3 & A, 3/1/11]

8.301.6.13 CLIENT MEDICAL TRANSPORTATION FUND: In non-emergency situations, an eligible recipient can request reimbursement from the client medical transportation (CMT) fund through their local county ISD office for money they spend on transportation, meals and lodging. For reimbursement from the CMT fund, an eligible recipient must apply for reimbursement within 30-calendar days after the appointment.

A. Information requirements: The following information must be furnished to the ISD CMT fund custodian within 30-calendar days of the provider visit to receive reimbursement:

(1) submit a letter on the provider’s stationary which indicates that the eligible recipient kept the appointment(s) for which the CMT fund reimbursement is requested; for medical services, written receipts confirming the dates of service must be given to the eligible recipient for submission to the local county ISD office;

(2) proper referral with original signatures and documentation stating that the services are not available within the community from the designated MAD medical management provider or MAD primary care provider, when a referral is necessary;

(3) verification of current eligibility for a MAD service for the month the appointment and travel are made;

(4) certification that free alternative transportation services are not available and that the recipient is not enrolled in a managed care organization;

(5) verification of mileage; and

(6) documentation justifying a medical attendant.

B. Fund advances in emergency situations: Money from the CMT fund is advanced for travel only if an emergency exists. “Emergency” is defined in this instance as a non-routine, unforeseen accident, injury or acute illness demanding immediate action and for which transportation arrangements could not be made five calendar days in advance of the visit to the provider. Advance funds must be requested and disbursed prior to the medical appointment.

(1) The ISD CMT fund custodian or a MAD fee-for-service coordinated service contractor or the appropriate utilization contractor verifies that the recipient is eligible for a MAD service and has a medical appointment prior to advancing money from the CMT fund and that the recipient is not enrolled in a managed care organization.

(2) Written referral for out of community service must be received by the CMT fund custodian or a MAD fee-for-service coordinated service contractor or the appropriate utilization contractor no later than 30-calendar days from the date of the medical appointment for which the advance funds were requested. If an eligible recipient fails to provide supporting documentation, recoupment proceedings are initiated. See Section OIG-900, Restitutions.

[2/28/98; 8.301.6.13 NMAC - Rn, 8 NMAC 4.MAD.605.4 & A, 3/1/11]

8.301.6.14 CMT REIMBURSEMENT RATES: Reimbursement for lodging and meal expenses is based on the MAD allowable fee schedule. The CMT fund reimbursement rate for transportation services and related expenses are:

A. private automobile use is reimbursed by the mile, based on the established MAD reimbursement schedule;

B. meals are reimbursed at the rate established by MAD; authorization forms used for direct payment to medicaid meal providers by MAD are available through the recipient’s local county ISD office;

C. lodging is reimbursed at the rate established by MAD; authorization forms for direct payment to medicaid lodging providers by MAD are available through the recipient’s local county ISD office; and

D. the CMT fund reimbursement rate for transportation services is at the established MAD reimbursement schedule per mile when a private automobile is used.

[2/28/98; 8.301.6.14 NMAC - Rn, 8 NMAC 4.MAD.605.5 & A, 3/1/11]

HISTORY OF 8.301.6 NMAC: [RESERVED]