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Medicaid Transportation in NYS

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Views: 182083
Posted: 17 Nov, 2010
by Valerie Bogart (New York Legal Assistance Group)
Updated: 08 Mar, 2024
by Valerie Bogart (New York Legal Assistance Group)

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.  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.  

See IMPORTANT WEBSITES and WHERE TO COMPLAIN HERE. 

Starting March 1, 2024 -- All Managed Care, MLTC, and Medicaid Advantage Plus Members obtain Transportation from Medical Answering Services - the State's  Contractor - NO LONGER through their plan

Enrollees in MLTC plans, Medicaid Advantage Plus plans along with mainstream Medicaid managed care plans do not access transportation services through their plans, but directly through private contractors - Medical Answering Services, LLC,  See this article on the NYS Dept. of Health website.

  • Members of Medicaid Managed Care Plans  -Transportation "carved out" from managed care benefits since 2013

Non-emergency transportation was carved out of the Medicaid managed care benefit package as part of the 2011 Medicaid Redesign Team's Transportation Reform Initiative. The carve-out took place in 2012 and 2013.  Medical Answering Services, LLC, gradually became the statewide contractor.   

  • Managed Long Term Care (MLTC) Members - Big change Started March 1,  2024

Through February 2024, transportation remained a plan benefit for Managed Long Term Care (MLTC) and Medicaid Advantage Plus (MAP) , requiring MLTC and MAP enrollees  to arrange for non-emergency transportation through their plans.  HOWEVER, as of March 1, 2024  this service is "carved out" and handled by a State contractor centrally. The carve out was postponed since Oct. 2021, but is now happening effective March 1, 2024.   

Temporary Exemption for MLTC Members who use Transportation to get to Social Adult Day Care

MLTC members who use non-emergency transportation to get to Social Adult Day Care should still arrange this transportation through their plan for the time being, after March 1, 2024.. This benefit will be transitioned at a later date that has not yet been announced. 

USING Medical Answering Services (MAS) for Transportation to Medical Appointments

These two websites have information on how to schedule transportation, where to file complaints, where to download manuals and see updates:

You can schedule transportation by phone or by creating an online account. Here are the contact numbers to request transportation (from the websites above)_

  • Downstate: 844-666-6270 - NYC, Long Island, Westcheter, Putnam County
  • Upstate: 866-932-7740 - all other counties

  • You can also schedule transportation by creating an online account on the MAS website: https://www.medanswering.com.

  • Medical Providers can file online requests - using an online version of Form 2015 or fax a completed Form 2015   to: (315)299-2786.  Providers hotline 1(866) 371-3881

  • If trip is outside the "Common Medical Marketing Area" - see here for extra form required. 

When to request: The  MAS website says you should request transportation for routine appointments at least 72 hours in advance, but can request urgent care on the same day.

Medical providers or enrollees should be prepared with the following information when requesting transportation:

  • Name, Address, Contact number
  • Birth Date
  • Medical Reason for Transportation
  • Level of transportation required
  • Name of ordering physician and name of physician to be seen
  • Date and time of the appointment
  • Location of the medical appointment
  • Transportation vendor with whom you prefer to ride
  • Any other special instructions needed for the trip

NYS DOH Travel Reimbursement & Long-Distance Travel Policy Manual (eff Jan. 1, 2021)

Prior Authorization for Non-Emergency Transportation - General Rules

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).

  • SEE NYS Medicaid Program: Transportation Manual Policy Guidelines  (updated 8/5/2023)

Common Medical Marketing Area  - Form 2020-U Required for Trips Outside CMMA

  • Consumers must receive prior authorization for transportation outside the common medical marketing area (CMMA). Providers should submit Common Medical Marketing Area Form 2020-U  to MAS in order to qualify.

  • 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. For instance, in NYC, the CMMA generally spans the five boroughs. 

  • Prior authorization for transportation outside the CMMA will be granted ONLY when one of the following conditions are met:

    • When the requested medical care/services are not available within consumer's CMMA

    • When the medical need to continue a specialized regimen of care or service with a specific provider necessitates travel outside the CMMA even though the medical care or service is available within the CMMA

    • When there are any other circumstances which are unique to the enrollee and the transportation manager and/or the New York State Department determines that travel outside the CMMA is appropriate.

    • Common Medical Marketing Area  2020 Policy and Procedure and form:   

    • 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).

  • 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).

Coverage of Public Transportation in New York City and elsewhere - see this link.

  • NYS has a Public Transportation Automated Reimbursement System (PTAR) - see PTAR webpageMedicaid beneficiaries who are able to use mass transit can receive a pre-paid Metro Card for this purpose or  from their provider.   If they request the transportation from MAS at least 5 days before the appointment, they will receive a pre-paid card in the mail.  

  • 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.  

  • Medicaid enrolled facilities and practitioners may voluntarily participate in a web-based application established by the Department of Health called PTAR.

  • See this NYS eMedNY PTAR webpage for providers, including a user manual, instructions for providers to enroll, etc. Facilities and practitioners participating in PTAR purchase MetroCards directly from the Metropolitan Transit Authority (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.

  • SEE eMedny Medicaid Transportation Ordering Guidelines - NYS  

  • 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.
    • See Fair Hearing #6532143J described below.

Who cannot get a ride through Medical Answering Services?

  • 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.

  • EMERGENCY needs - call 911 not MAS. 

  • MLTC members who use non-emergency transportation to get to Social Adult Day Care should continue to use that transportation through their MLTC plan.. until further notice.

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.

Fair Hearing #8045907Z

  • Appellant requested transportation to Syracuse (outside CMMA) to see multiple providers treating her for cerebral palsy
  • Agency denied the request, stating the services are available locally.
  • Appellant testified she had been seeing the providers in Syracuse for over 4 years. She further testified that she previously saw local providers who did not provide correct treatment. 
  • Agency failed to provide a list of providers within the CMMA that could provide appropriate care or were willing to accept appellant as a new patient. 
  • Because agency failed to establish there was alternative care available within CMMA and appellant detailed the need to continue care with current providers, the Agency's determination was overturned. 
  • See also: Fair Hearing#8142970H, #7631916N, #6846058R

Contractor 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.

 

Complaints and Links

Attached files
item MAS transportation.pdf (191 kb) Download

Also read
item Medicaid Managed Care

Also listed in
folder Medicaid -> Medicaid Managed Care

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