Or. Admin. Code § 410-136-3000 - Responsibility for Providing Non-emergent Medical Transportation
(1) The Authority
shall provide non-emergent medical transportation (NEMT) for eligible clients
who receive their Oregon Health Plan (OHP) covered medical services on a
fee-for-service basis or are clients enrolled in coordinated care organizations
(CCO), and for eligible clients who receive Reproductive Health Access Fund
(RHAF) covered services. The Authority shall discontinue providing this service
to a client enrolled in a CCO after the date the client is enrolled in a CCO.
The CCO shall provide and coordinate the service to their enrollees on and
after the date of the client's enrollment in the CCO pursuant to section (2) of
this rule.
(2) When a CCO begins
providing NEMT services for its enrollees, the Authority shall provide NEMT
services in the CCO's service area only to clients not enrolled in a CCO:
(a) The Authority may not pay for services
covered by a CCO. Reimbursement is a matter between the CCO and its
transportation brokerage and subcontractor. Reimbursement is a matter between
the CCO and its contracted brokerage and transportation providers;
(b) For clients enrolled in a CCO the
transportation provider must coordinate all transportation services with the
client's transportation brokerage or CCO prior to providing services.
(3) The requirements in OAR
410-136-3000-410-136-3360 apply to NEMT
services for which the Authority is responsible pursuant to this
rule.
(4) Brokerages shall, and
must ensure subcontractors, have access to culturally and linguistically
appropriate tools available to provide clients accessing NEMT services:
(a) of free written translations, oral
interpretation, certified and qualified spoken and sign language interpreters,
alternative formats, and auxiliary aids and services, for the client to be able
to understand NEMT services information provided;
(b) Alternative formats or languages,
including interpretation during phone calls, shall be provided upon request at
no cost to the client.
(5) Language access services for NEMT
services also applies to client representatives, family members and caregivers
with hearing impairments or Limited English Proficiency (LEP) who need to
understand the client's condition and care. For OHP members, see Oregon Health
Plan (OHP) program OAR
410-120-0001 Interpreter
Services requirements for Medicaid members with Limited English Proficiency
services. For RHAF clients, see Certification Requirements for RHCare Clinics
Version 3, Certification Requirements for CCare Clinics Version 2, or
Certification Requirements for AbortionCare Clinics Version 3 for language
access requirements adopted in in OAR
333-004-3030, which are
incorporated by reference in this section.
(6) A brokerage may request that the
Authority delay responsibility for reimbursement to clients pursuant to OAR
410-136-3240, Client Reimbursed
Mileage, Meals and Lodging, until a CCO in the brokerage's service area assumes
NEMT services for the CCO's enrolled client. Any delay of responsibility must
not exceed fourteen (14) days and must be prior approved by the Authority. The
delay of the brokerage's responsibility also includes reimbursing clients in
the fee-for-service delivery system.
(7) OAR
410-136-3040, Vehicle Equipment
and Subcontractor Standards and OAR
410-136-3120, Secured Transports
do not apply to ambulance providers, ambulance vehicles, or ambulance personnel
that are licensed and regulated by ORS Chapter 682 and OAR chapter 333,
divisions 250, 255, 260 and 265, whether providing ambulance or stretcher
transports.
(8) The following
definitions specifically apply to OAR 410, division 136. This rule does not
include an exhaustive list of Division acronyms and definitions. For more
information of any terms not defined in this rule, see Oregon Health Plan (OHP)
program OAR 410-141-3500 Acronyms and
Definitions; OAR 410-120-0000 Acronyms and
Definitions; OAR 309-032-0860; OAR
410-200-0015 General
Definitions; and any appropriate governing acronyms and definitions in the
Department of Human Services (Department) chapter 411, 413, or 461
administrative rules; or contact the Division. For purposes of the rules OAR
410-136-3000 through
410-136-3360:
(a) "Attendant" means an individual at least
18 years of age to accompany the client. An attendant may also be a behavioral
health personal care attendant allowed to accompany the client in accordance
with OAR 410-172-0780;
(b) "Brokerage" means a governmental
transportation brokerage (local unit of government), or other entity, enrolled
by and contracted with the Authority to arrange rides and pay subcontractors
for NEMT services;
(c) "Client"
means an individual eligible to receive OHP or RHAF health services on the date
of service and who resides in the Service Area;
(d) "Contractor" means a transportation
brokerage, or other entity, enrolled as an OHP provider by and contracted with
the Authority to arrange rides brokerages pay subcontractors for NEMT
services;
(e) "Covered service"
means medically necessary and appropriate health services and items described
in ORS Chapter 414 and applicable administrative rules and the Prioritized List
of Health Services above the funding line set by the legislature, consistent
with OAR Chapter 410 division 120, or services as described in OAR
333-004-3070;
(f) "Electronic Data Interchange (EDI)" means
the exchange of business documents from application to application in a
federally mandated format or, if no federal standard has been promulgated,
using bulk transmission processes and other formats as the Authority designates
for EDI transactions consistent with OAR Chapter 410 division 120;
(g) "Local area" means an area within the
accepted community standard and includes the client's metropolitan area, city,
or town of residence;
(h) "Member"
means an Oregon Health Plan (OHP) client enrolled with a coordinated care
organization (CCO);
(i)
"Non-Emergent Medical Transportation Services (NEMT)" means transportation to
or from a source of covered service, that does not involve a sudden, unexpected
occurrence which creates a medical crisis requiring emergency medical services
as defined in OAR 410-120-0000 and requiring
immediate transportation to a site, usually a hospital, where appropriate
emergency medical care is available;
(j) "Provider" means a public Agency,
non-profit company, for-profit company, or an individual with whom a brokerage
subcontracts with to provide rides;
(k) "RHAF" means Reproductive Health Access
Fund, a source of coverage for reproductive health services as defined in OAR
333-004-3070 provided to
individuals who complete the RH Access Fund Enrollment Form and are deemed
eligible ("RHAF client").
(l) "RH
Access Fund Eligibility Database" means the centralized, web-based data system
operated by the RH Program to house information about enrollees.
(m) "Ride" means to drive the client to and
from Oregon Health Plan (OHP) covered services or RHAF covered
services;
(n) "Secure transport"
means NEMT services for the involuntary transport of clients who are in danger
of harming themselves or other individuals;
(o) "Service area" means the geographic area
within which the Regional Brokerage agreed under contract with the Authority to
provide Rides as a service through the contractor's Call Center;
(p) "Subcontractor" means the provider,
individual or entity, with which the brokerage executes a contract to drive the
client to and from Oregon Health Plan (OHP) covered services;
(q) "The Authority" means the Oregon Health
Authority (OHA);
(r) "Volunteer"
(for the purposes of NEMT) means an individual selected, trained and under the
supervision of the ODHS who is providing services on behalf of the ODHS in a
non-paid capacity except for incidental expense reimbursement under the ODHS
Volunteer Program authorized by ORS
409.360.
Notes
Statutory/Other Authority: ORS 413.042
Statutes/Other Implemented: ORS 414.065
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