DHCS issued an All Plan Letter to clarify what transportation services plans must provide in non-emergency situations.
Subject to prior authorization, non-emergency medical transportation (NEMT) is a covered benefit when a member needs to obtain medically necessary services and when it is prescribed in writing by a provider. Plans are required to authorize at minimum the lowest cost type of NEMT that is adequate for the member’s medical needs with no limits as long as the medical services are medically necessary and authorized.
NEMT is required when the member cannot take ordinary public or private means due to medical and physical condition and when transportation is required for obtaining medically necessary services. Plans must ensure door-to-door assistance for members receiving NEMT services, and plans must provide transportation for a parent or guardian is the member is minor. The letter discusses when plans must provide NEMT ambulance services, litter van services, wheelchair van services, and NEMT by air. NEMT requests require a Physician Certification Statement that includes functional limitations justification, dates of service and mode of transportation needed, and a certification statement.
Effective July 1, 2017, non-medical transportation (NMT) expands from EPSDT to a managed care benefit for all members to obtain medically necessary services covered by the managed care plan. This expands to cover NMT for all Medi-Cal services, including carved out services, starting October 1, 2017. NMT requested must be the least costly method of transportation that meets the member’s needs. NMT services must include round trip transportation for a member to obtain covered services, as well as mileage reimbursement when the member arranges for a private vehicle to get to an appointment. The round trip is available for covered services, picking up prescriptions, and picking up medical equipment and supplies. The provided NMT must be in a form and manner that is accessible for the member.
NMT services must be authorized prior to use. Coverage includes the transportation costs for the member and one attendant, subject to authorization. The member must attest to the plan that other transportation resources have been reasonably exhausted.
Plans are still required to meet timely access standards, either contractually or through Knox-Keene licensing. The member’s need for NEMT or NMT services do not relieve the MCPs from complying with these obligations.
DHCS APL 17-010 (June 29, 2017)
