Or. Admin. Code § 410-141-3920 - Transportation: NEMT General Requirements
(1) A Coordinated Care Organization (CCO)
shall provide all non-emergency medical transportation (NEMT) services for its
members. For purposes of OAR
410-141-3920 to
410-141-3965, references to a
"member" include any individual eligible for NEMT services under section (1) of
this rule unless context dictates otherwise:
(a) The CCO is responsible for NEMT services
for all of its members' health care services consistent with the covered
services described in OAR
410-141-3820 and the excluded
services and limitations described in OAR
410-141-3825 and (1)(b) and
(1)(c) of this rule;
(b) NEMT
services for those health care services that, based on the member's plan type,
are paid by the Authority's fee-for-service program and that, based on rule or
contract, are carved-out from or otherwise not covered by the CCO and provided
by the Authority.
(c) NEMT must not
be provided for HRSN Services;
(d)
For members enrolled in the Compact of Free Association (COFA) Dental Program
or the Veteran Dental Program, both of which are defined in OAR chapter 410,
division 200, the CCO is responsible only for NEMT services related to the
member's dental services.
(2) A CCO shall provide a toll-free call
center for members to request rides.
(a) The
CCO shall ensure that its call center operates, at a minimum, Monday through
Friday from 9:00 a.m. to 5:00 p.m. The CCO may close its call center on New
Year's Day, Memorial Day, July 4th, Labor Day, Thanksgiving, and Christmas. The
Authority may approve, in writing, additional days of closure if the CCO
requests the closure at least thirty (30) days in advance.
(b) Consistent with OAR
410-141-3505, a CCO may
subcontract the operation of its call center. If the CCO's subcontractor is
also contracted by the Authority as an NEMT brokerage for FFS members, the CCO
remains fully accountable for the performance of the subcontracted work related
to the CCO contract.
(3)
Neither a CCO nor any of its Subcontracted transportation providers may bill a
member for transport to or from covered medical services, even if the CCO or
its contracted transportation provider denied reimbursement for the
transportation services.
(4)
Transportation providers shall be considered "participating providers" for the
purposes of OAR 410-141-3520 (Record Keeping and
Use of Health Information Technology).
(5) A CCO shall have written policies and
procedures regarding its NEMT services. All policies and procedures must be
provided to all Members either in Contractor's Member Handbook or in a
stand-alone document referred to as a "NEMT rider guide" that meets the
delivery and content specifications as defined by the Authority. The CCO's
written policies and procedures regarding NEMT services shall provide, without
limitation, for the following:
(a) Allow
members or their representatives to schedule:
(A) NEMT services up to ninety (90) days in
advance;
(B) Multiple NEMT services
at one time for recurring appointments up to 90 days in advance; and
(C) Same-day NEMT services.
(b) Comply with the following
criteria for member drop-offs and pick-up protocols. Drivers are not permitted
to:
(A) Drop Members off at an appointment
more than 15 minutes prior to the office or other facility opening for business
unless requested by the member or, as applicable, the Member's guardian,
parent, or representative; and
(B)
Pick up Members from an appointment more than 15 minutes after the office or
facility closes for business unless the appointment is not reasonably expected
to end within 15 minutes after closing, or as requested by the member, or as
applicable, the Member's guardian, parent, or representative.
(c) Describe passenger rights and
responsibilities as set forth in
42 CFR §
438.210, and as set forth in OARs
410-141-3920 through
410-141-3960, and other state
and federal administrative statutes and rules relating to the rights and
responsibilities of Medicaid recipients such as the right to file a grievance
and request an appeal or reconsideration.
(6) A CCO must review a NEMT ride service
authorization request with the following modifications:
(a) Approving and scheduling, or denying, a
request for NEMT ride services (including all legs of the trip) within
twenty-four (24) hours of receiving the request. This timeframe shall be
reduced as necessary to ensure the member arrives in time for their
appointment:
(A) If approved, notify members
by their preferred method of contact of the applicable arrangements prior to
the date of the NEMT service;
(B)
If intending to deny the NEMT ride, the CCO must provide a secondary review by
another employee with knowledge of NEMT service requirements and mail the NOABD
within 72 hours of denial determination.
(b) Adhering to the grievance and appeal
processes and rights specified in OAR
410-141-3835 through
410-141-3915 available with
respect to NEMT services; and
(c)
The CCO shall mail, within 72 hours of denial, a notice of adverse benefit
determination to:
(A) A member denied a ride;
and
(B) CCOs shall provide a copy
of the NOABD to the provider with which the affected member was scheduled for
an appointment, when the provider is part of the CCO's provider network and
requested the transportation on the member's behalf, in a format that is
agreeable to the provider and provides sufficient documentation of
notification.
(7) This rule applies only to the Authority's
pilot project in effect for 2/16/2024 through 2/15/2025, which allows a CCO to
utilize a Transportation Network Company (TNC) to provide NEMT services to the
CCO's members.
(a) Transportation network
company (TNC) has the meaning found in ORS
742.520.
(b) A TNC must obtain a certification from
the Oregon Health Authority to participate in the TNC Pilot Program as an NEMT
provider. Certification for the TNC pilot program is obtained by submitting to
HSD.QualityAssurance@odhsoha.oregon.gov the following documents:
(A) A document that identifies the process or
policies the TNC follows and documents its compliance with the requirement that
each driver has a valid driver license. The TNC must maintain records of their
drivers participating in the TNC Pilot and share relevant information with OHA
when requested;
(B) A document that
identifies the processes or policies the TNC follows and documents its
compliance with the processes and policies, to ensure that proposed TNC pilot
program drivers, employees, agents and contractors are not, as described in
42 CFR §
438.610 (a) or (b):
Excluded, suspended, or debarred, or otherwise excluded from participating in
procurement or non-procurement activities under the Federal Acquisition
Regulations or federal Executive Order No. 12549 or the implementation
guidelines for federal Executive Order No. 12549; or Excluded from
participation in any federal health care program under section 1128 or 1128A of
the Social Security Act as described in
42 CFR
438.610;
(C) A document that identifies the process or
policies that the TNC follows and documents its compliance with the processes
and policies, to ensure that all TNC proposed pilot program drivers have not:
Committed more than tree (3) traffic violations under ORS
801.557 in the past three (3)
years; or Committed one (1) or more traffic crimes under ORS
801.545 within the past seven
(7) years; or Have been convicted of Driving Under the Influence of Intoxicants
under ORS 813.010 within the last seven
(7) years;
(D) The TNC's policy for
monitoring the driving records and criminal records of all of its proposed TNC
pilot program drivers, employees, agents, and contractors;
(E) The TNC's policy for compliance with
federal and state regulatory requirements to ensure all OHP member information
is protected in accordance with OAR
410-136-3280;
(F) Proof of insurance and policy compliant
with ORS 742.520(1)(b).
(c) Upon receipt of the documents
identified in subsection (b) of this rule, the application shall be reviewed
and if all requirements are met, then the Authority shall issue a certificate
of approval to participate in the TNC Pilot Program.
(A) Once certification is issued, a TNC
certified to participate in the TNC Pilot Program shall be eligible to provide
rides to OHP Members upon request from the Authority or a CCO;
(B) Rides authorized to be provided by a
driver employed by or contracted with a certified TNC Pilot Program may only be
utilized by a CCO or the Authority if:
(i) No
NEMT driver who meets the requirements identified in OAR
410-136-3040 (NEMT Driver)
accepts an NEMT brokerage request within twenty-four (24) hours of the
scheduled ride time; or
(ii) A
previously scheduled NEMT Driver cancels the assigned ride within twenty-four
(24) hours of the scheduled ride time and no other NEMT Driver accepts, within
a reasonable period of time, the brokerage's new request for another NEMT
Driver; or
(iii) The previously
scheduled NEMT Driver does not arrive at the pick-up location within fifteen
(15) minutes after the scheduled pick-up time.
Notes
Statutory/Other Authority: ORS 413.042 & ORS 414.625
Statutes/Other Implemented: ORS 414.625, 414.572, 414.605, 414.665 & 414.719
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