OAR 410-141-3920: Transportation: NEMT General Requirements

(1) For definitions of terms used in 410-141-3920 to 410-141-3965, please see OAR 141-136-3000. (2) 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 (2) 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 (2)(b) and (2)(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) NEMT must not provide transportation services, including public transportation, mileage reimbursement or driver provided rides, to an emergency room or emergency department setting for medical services that are not pre-scheduled, including from urgent care clinics; (e) 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. (3) 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. (4) 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. (5) Transportation providers shall be considered “participating providers” for the purposes of OAR 410-141-3520 (Record Keeping and Use of Health Information Technology). (6) 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 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. (7) A CCO or brokerage must review a requested NEMT ride service authorization in the following manner: (a) When providing notification to the member or member representative of an approval, denial or cancellation of the member’s requested ride service it must occur by their preferred method of contact. (A) If approving the NEMT ride service request, notification of the applicable transportation arrangements shall occur prior to the time of the service or no less than 48 hours prior to the time of the service. This timeframe shall be reduced if the request for a ride service occurs close to the scheduled ride service time to ensure the member is informed of the approved requested service; (B) If denying a request for an NEMT ride service the CCO or NEMT brokerage must provide: (i) A secondary review by another employee with knowledge of NEMT service requirements, prior to determination of a denial; (ii) Notification to the member or member representative. Notification must occur prior to sending a notice of adverse benefit determination (NOABD) and at least 48 hours prior to the time of the requested ride service. This timeframe shall be reduced if the request for a ride service occurs close to the scheduled ride service time to ensure the member is informed of the denied requested service; (iii) The member with a mailed NOABD within 72 hours of denial determination; (C) If canceling a previously approved NEMT ride service request (e.g., due to adverse weather conditions), the CCO or NEMT brokerage must provide notification to the member or the member’s representative prior to the time that the ride service was to occur or as soon as practical. (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. (8) 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 three (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 24 hours of the scheduled ride time; or (ii) A previously scheduled NEMT Driver cancels the assigned ride within 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 15 minutes after the scheduled pick-up time.