States are required under federal regulations (42 C.F.R. §431.53) to assure necessary transportation to Medicaid beneficiaries to and from medical services.
When travelling to medical appointments, a Medicaid beneficiary is expected to use the same mode of transportation as the beneficiary would use to carry out the activities of daily life. Generally, this mode is public transit or a personal vehicle. However, for some Medicaid beneficiaries, their medical condition necessitates another form of transportation, such as an ambulette. In these circumstances, Medicaid will pay for the most medically appropriate and cost-effective level of transportation to and from services covered by the Medicaid Program. All non-emergency transportation must be authorized prior to payment and only emergency ambulance transportation can be reimbursed without a prior authorization. (https://www.medanswering.com/page.taf?ID=10)
To implement the Medicaid Redesign Team's Transportation Reform Initiative, the New York State Department of Health phased in a Medicaid fee-for-service non-emergency medical transportation (NEMT) management program under which transportation services are carved out of the Medicaid managed care benefit package. The first NEMT program for managed care enrollees was implemented in the Hudson Valley Region in January 2012, and additional counties in the Region moved to the NEMT program in March and September of 2012. New York City was implemented in January of 2013.
New York City’s services are now handled by the contractor LogistiCare, and most counties in the rest of the state are handled by Medical Answering Services, LLC.
Prior Authorization for Non-Emergency Transportation (New York City)
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).
LogistiCare Procedures (for New York City)
- In New York City, Medicaid transportation services are managed by Logisticare. The following procedures apply to mainstream managed care plans and HIV Special Needs plans in New York City:
- All trips must be pre-arranged by an enrollee or medical practitioner and confirmed by LogistiCare.
- Consumers who are unable to utilize mass transit must ask their medical practitioner to request their transportation from Logisticare for the first trip.
- Some Medicaid facilities and practitioners participate in a program called Public Transportation Automated Reimbursement (PTAR). Participating facilities and practitioners purchase MetroCards from the Metropolitan Transit Authority (MTA) and provides the cards to Medicaid recipients using public transportation. Before transportation benefits were carved out the benefit package, Medicaid recipients would get their MetroCards directly from their managed care plans.
- Consumers using public transportation and visiting a provider who participates in the Public Transportation Automated Reimbursement (PTAR) System will continue to receive their Metrocards directly from the medical facility. Consumers using public transportation to other providers will not be reimbursed by PTAR.
- If the medical practitioner does not participate in PTAR, then the Logisticare website states that the enrollee may request transportation from LogistiCare. (See below for more information on this).
- Enrollees who are medically unable to utilize mass transit must ask their medical practitioner to request their transportation from LogistiCare for their first trip. Trip requests for a mode of transportation other than mass transit require that the medical practitioner fill out and sign a Medical Necessity Form. (http://www.nycmedicaidride.net/en-us/more/orderingguidelines.aspx) For a copy of the form click here: http://www.nycmedicaidride.net/Portals/0/Users/030/30/30/SR%20159737%20REVISED%202015%20FORM%20Medical%20Justification.pdf.
Who cannot get a ride through Logisticare?
- Enrollees in a Managed Long Term Care plan.
- 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 LogistiCare.
LogistiCare Contact Information (for New York City)
- Reservation number: (877) 564-5922
- This is limited to enrollees and their caregivers. This number is available to request NEMT services Monday through Friday 7 a.m. to 6 p.m.
- Deaf and Hearing Impaired: (866)-288-3133
- Where is my ride: (877) 564-5923
- This number is for enrollees or their caregivers to call when the enrollee is ready to be picked up or if there is a service issue or complaint.
- Hospital Discharges: (877) 564-5926
- Website: http://www.nycmedicaidride.net/
Public Transportation Automated Reimbursement System (PTAR)
- Medicaid enrolled facilities and practitioners may voluntarily participate in a web-based application established by the Department of Health called PTAR. Facilities and practitioners participating in PTAR purchase MetroCards directly from the MTA and when a patient enrolled in Medicaid uses public transportation to travel to a medical appointment covered by Medicaid, the participating facility or practitioner will distribute a pre-paid MetroCard to the enrollee. The facility or practitioner is then reimbursed by the State. (https://www.emedny.org/ProviderManuals/Transportation/PDFS/Ordering_Guidelines_Manual.pdf)
- In New York City, consumers using public transportation and visiting a provider who participates in the Public Transportation Automated Reimbursement System (PTAR) will continue to receive their Metrocards directly from the medical facility (PTAR participating providers are those who dispense Metrocards at their medical site). PTAR will reimburse participating facilities the cost of public transportation. 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).
- Medicaid expects that New York City Medicaid enrollees will use public transit if their appointment is within ten (10) city blocks of a bus or subway stop, so long as their medical condition permits this. (https://www.emedny.org/providermanuals/transportation/pdfs/transportation_pa_guidelines.pdf.)
- Logisticare stated by phone that they will not provide rides to recipients when public transportation is available and able to be utilized. However, it is unclear what the recipient should do if he or she can utilize public transportation but does not see a PTAR provider. The Legal Aid Society has been trying to determine if there is a way to get this cost reimbursed.
- The Legal Aid Society called Logisticare on March 25, 2015 and on March 30, 2015 to try to gain clarity on this issue and was unable to obtain an answer. We are still exploring this issue and will continue to update this article.
- Also see Fair Hearing #6532143J described below.
Medical Answering Services Procedures:
For the majority of counties in New York State, Medicaid Transportation is handled by Medical Answering Services. The following is a list of all counties covered: https://www.medanswering.com/page.taf?ID=12
- Transportation can be ordered by phone, fax or through the website.
- When ordering transportation the medical provider or enrollee should be prepared with the following information:
- Date of birth
- Contact number
- Medical reason for transportation
- Level of transportation required
- Name of ordering physician and name of physician that will be seen
- Date and time of appointment
- Location of appointment
- Preferred transportation vendor
- Any other special instructions
New York State Medicaid Transportation Contact Information
The following is a contact list for transportation service in all of New York State:
Fair Hearing Advice:
- Provide as much documentation as possible and officially request reimbursement.
- Fair Hearing #6629770L
- 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.
- Fair Hearing #6522862M
- 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.
- Fair Hearing #6532143J:
- 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.
- New York State Medicaid Program Transportation Contact List:
- Medical Answering Services:
- New York City Human Resources Administration Medicaid Alert:
- New York City Human Resources Administration Transportation:
- New York State Department of Health Medicaid Update:
- Medicaid Transportation Management Initiative- New York City Funding Availability Solicitation:
- Medical Insurance and Community Services Administration Medicaid Alert:
- United Fund Hospital, Medicaid Transportation in New York: Background and Options: