Rule 5160-15-10 | Transportation: non-emergency services through a CDJFS.
(A) Pursuant to 42 C.F.R. 431.53, the Ohio department of medicaid (ODM) is obligated to ensure necessary transportation for medicaid-eligible individuals to and from providers of covered healthcare services. ODM fulfills this obligation in large measure through three-way subgrant agreements with the Ohio department of job and family services (ODJFS) and with each county department of job and family services (CDJFS). This rule sets forth the responsibilities and expectations placed by ODM on each CDJFS in the administration of this medicaid-funded non-emergency transportation assistance benefit. In signing a subgrant agreement, a CDJFS agrees to be bound by this rule and by any other applicable provision of the Administrative Code.
(B) For each individual to whom non-emergency transportation assistance is provided, a CDJFS is expected to select the type of assistance that is most cost-effective, is suitable to the individual's needs and circumstances, and enables timely access. If one type of assistance proves infeasible, a CDJFS may select another type.
(1) A CDJFS may decline to provide medicaid-funded non-emergency transportation assistance to a medicaid-eligible individual under this rule if either of the following criteria is met:
(a) The associated healthcare service is not part of the individual's medicaid benefit package; or
(b) The requested non-emergency transportation assistance is not necessary for any of the following reasons:
(i) A medicaid managed care organization (MCO) is obligated to furnish transportation to the individual under its provider agreement with ODM;
(ii) The individual is a resident of a long-term care facility (nursing facility, skilled nursing facility, or intermediate care facility for individuals with intellectual disabilities), for whom transportation is provided in accordance with Chapter 5160-3 or Chapter 5123:2-7 of the Administrative Code;
(iii) A medicaid hospice provider is obligated to provide or arrange transportation that is necessary for the individual to receive care related to a terminal illness;
(iv) Suitable transportation is available free of charge to the general public; or
(v) Failure to provide the requested assistance will have no effect on the individual's ability to obtain the healthcare service.
(2) A request made on behalf of a minor child for non-emergency transportation assistance entails additional considerations.
(a) Responsibility for transporting a child normally falls to a parent or guardian. In reviewing a request, a CDJFS should take into account the impact, if any, of the following factors:
(i) Whether a family member or friend is available to provide transportation;
(ii) Whether the family has ready access to a reliable vehicle;
(iii) Whether the family has sufficient financial resources (including any adoption or foster care subsidy); and
(iv) Whether another entity such as a school system is or should be involved.
(b) A request for non-emergency transportation assistance to enable another person, such as a parent, to be with a child in a healthcare facility may be approved if two criteria are met:
(i) The presence of the other person is needed for an identifiable healthcare purpose that will benefit the child; and
(ii) The other person lacks the resources necessary to make the trip (or trips).
(3) A CDJFS may temporarily restrict or suspend a particular type of non-emergency transportation assistance or non-emergency transportation assistance in general for an individual for reasons including but not limited to the following examples:
(a) Misuse by the individual, as determined by the CDJFS;
(b) Dangerous, threatening, or disruptive behavior on the part of the individual; or
(c) Presence in the individual of a communicable disease or condition (other than a mild endemic illness such as the common cold) that constitutes a danger to public health.
(4) A CDJFS is to provide a notice of state hearing rights whenever it proposes to withhold, reduce, suspend, or terminate the medicaid-funded non-emergency transportation assistance benefit or whenever a medicaid-eligible individual formally expresses disagreement with an action or lack of action taken by the CDJFS on a request for non-emergency transportation assistance. The following examples, however, do not constitute restrictions by the CDJFS of the medicaid benefit and are not subject to state hearing:
(a) The refusal of a request for a specific trip, particularly because of factors beyond the control of the CDJFS such as a scheduling conflict, lack of sufficient advance notice, or adverse weather conditions; and
(b) Failure to provide further non-emergency transportation assistance when all options have been exhausted.
(C) The community service area of a CDJFS is the geographical area within which medicaid-eligible individuals and the general population in the county routinely access healthcare services.
(1) The community service area comprises at least the county or counties served by the CDJFS, and it may also include specific locations in contiguous Ohio counties, non-contiguous Ohio counties, and bordering states.
(2) It is expected that medicaid-eligible individuals will access covered healthcare services within the community service area. If a covered healthcare service can be obtained only outside the community service area, the CDJFS may choose to provide assistance sufficient to enable travel only to or from the nearest location, unless a documented consideration other than distance overrides such a limitation.
(D) Every CDJFS may offer a variety of transportation assistance options.
(1) These options include the following examples:
(a) Contracted livery service;
(b) Payment for fixed-route or demand-response transportation;
(c) Vouchers for fuel at participating service stations;
(d) Prepayment of fares;
(e) Prepayment for fuel;
(f) Transportation by a CDJFS staff member in a CDJFS vehicle;
(g) Payment of mileage reimbursement;
(h) Reimbursement for travel-related expenses that represent a necessary out-of-pocket cost to a medicaid-eligible individual;
(i) Transportation, or payment for transportation, of a parent or legal guardian accompanying a medicaid-eligible individual who is younger than twenty-one years of age; and
(j) Other services approved in advance by ODM.
(2) The types of non-emergency transportation assistance offered by a CDJFS generally reflect the resources available within its community service area. In a large metropolitan area with an extensive public transit system and numerous taxicab and transportation network companies, for example, the CDJFS may choose to offer rides rather than payment of vehicle costs; in a very rural area with no public transit and few livery options, the CDJFS may choose to offer fuel subsidy as its main form of assistance. Every CDJFS, however, regardless of community service area, is expected to develop a process for identifying transportation sources and to make a good-faith effort to secure rides for individuals who need actual transportation.
(E) Each CDJFS shares basic information about its administration of the transportation assistance benefit by submitting form ODM 10241, "Medicaid County Transportation Profile" (rev. 4/2021), to ODM and revising the document whenever changes are made but not less often than every twelve months.
(F) Of all the records created in the course of administering medicaid-funded non-emergency transportation assistance, ODM expects a CDJFS to collect the following types for purposes of data analysis and program integrity:
(1) Documentation of each request for non-emergency transportation assistance, maintained in such a manner that ODM can readily verify the following information:
(a) The individual's medicaid identification number;
(b) The date on which the request for transportation assistance was made;
(c) The identity and location of the healthcare provider where the individual planned to obtain a covered service;
(d) The trip date or dates requested;
(e) The number of one-way trips involved;
(f) The type of transportation assistance provided or the reason why transportation assistance was not provided;
(g) The name of the transportation vendor, when applicable;
(h) The scheduled pick-up and drop-off times and the actual pick-up and drop-off times, when applicable; and
(i) The name of the medicaid program area (such as pregnancy-related services, healthchek/EPSDT, or general non-emergency transportation) to which the cost should be allocated;
(2) Results of criminal background checks and database searches conducted in accordance with rule 5160-15-14 of the Administrative Code; and
(3) Complaints and suggestions received from passengers and, if applicable, from vendors.
Last updated July 1, 2021 at 11:01 AM
Supplemental Information