Date of Adoption: March 2, 2001.

Purpose: The department has consolidated and clarified rules regarding nonambulance transportation services in a new chapter. The proposed rules reflect long-standing department policy, are more readable, and comply with the Governor's Executive Order 97-02 on regulatory reform.

     New Transportation service -- Nonambulance transportation, WAC 388-546-5000, 388-546-5100, 388-546-5200, 388-546-5300, 388-546-5400, and 388-546-5500.

Citation of Existing Rules Affected by this Order: Repealing WAC 388-86-085 and 388-87-035; WAC 388-86-100 had been proposed for amendment but was withdrawn on December 26, 2000.

Statutory Authority for Adoption: RCW 74.08.090 and 74.09.500.

Other Authority: RCW 74.04.050, 74.04.055, and 74.04.057.

Adopted under notice filed as WSR 00-17-096 on August 15, 2000.

Changes Other than Editing from Proposed to Adopted Version: Changes to the proposed rule text for chapter 388-546 WAC are detailed below.

     WAC 388-546-5000 Nonemergency transportation program definitions.

     "Local provider of type" means the medical provider who is closest to the client's residence and within the client's local community who fulfills the requirements of the medical appointment. The provider may vary by medical specialty, the provider's acceptance of MAA's clients, and whether managed care, primary care case management or third party participation is involved.

     "Noncompliance" means a client: (1) Engages in violent, seriously disruptive, or illegal conduct; (2) poses a direct threat to the health and/or safety of self or others; or (3) fails to be present at the pick-up point of the trip.

     "Return trip" means the return of the client to the client's home, or another authorized return point, from the location where a covered medical service has occurred.

     "Trip" means transportation one-way from the pick-up point by an authorized transportation provider to the drop-off point by an authorized transportation provider.

     "Urgent care" means an unplanned appointment for a covered medical service with verification from an attending physician or facility that the client must be seen that day.

     WAC 388-546-5100 Nonemergency transportation program scope of coverage.

     (2) Licensed ambulance companies providers, who contract with MAA's transportation brokers, may be reimbursed for nonemergency transportation services under WAC 388-546-5200 as administrative services.

     (4) Prior authorization by MAA is required for all out-of-state nonemergency medical transportation. Border areas...

     (5) MAA requires all medical nonemergency transportation to and from eligible covered medical services to meet the following:

     (a) Be The covered service must be medically necessary as defined in WAC 388-500-0005;

     (b) It must Bbe the lowest--cost transportation available that is both appropriate and accessible to the client's medical need condition and personal capabilities; and

     (c) Be limited to the local provider of type as follows:

     (i) Clients who are served receiving services provided under MAA's fee-for-service program may be transported only to the local provider of type. MAA's transportation broker is responsible for considering and authorizing exceptions.

     (ii) Clients under enrolled in MAA's managed care (healthy options) program may be transported to a any provider as determined necessary supported by the client's managed care plan. Clients may be enrolled in a managed care plan but are obtaining a specific service not covered under the plan. The requirements in (5)(c)(i) apply to these fee-for-service services.

     (6) MAA does not cover nonemergency transportation services if the covered medical services are within three-quarters of a mile walking distance from the client's residence. Exceptions to this rule may be granted by MAA's transportation broker based on the client's documented medical condition or personal capabilities, or based on safety or physical accessibility concerns, as described in WAC 388-546-5400(1).

     (7) A client must use personal or informal transportation alternatives if they are available and appropriate to the client's needs.

     (8) If a fixed-route public transportation service is available to the client within three-quarters of a mile walking distance, the broker may require the client to use the fixed-route public transportation system unless the need for more specialized transportation is present and documented. Examples of such a need are the client's use of a portable ventilator, a walker or a quad cane.

     WAC 388-546-5200 Nonemergency transportation program broker and provider requirements.

     (1) MAA requires that all nonambulance transportation providers serving MAA clients be under subcontracted with the department's primary contracted transportation brokers contractors. In addition, MAA's transportation brokers may choose to subcontract with willing ambulance providers in order to provide for nonemergency trips in licensed ground ambulance vehicles as an administrative services. rather than as a medical service sSee WAC 388-546-5100(2).

     (2) MAA requires all contracted and subcontracted transportation providers under this chapter to be licensed, equipped, and operated in accordance with applicable federal, state and local statures, regulations, and ordinances laws.

     (3) MAA's contracted transportation brokers determine the level of transportation service needed by the client and the mode of transportation to be used for each authorized trip.

     (4) MAA's contracted transportation brokers must comply with the terms specified in their contracts.

     (5) MAA's transportation brokers may require up to forty-eight hours advance notice of a requested trip (see WAC 388-546-5300(2)) with the exception of hospital discharge requests or urgent care trips. MAA allows its transportation brokers...

     (6) If MAA's transportation broker is not open for business and unavailable to give advance approval for a hospital discharge or urgent care request as described in subsection (5), the sub-contracted transportation provider must either:

     (a) Provide the transportation...

     (8) MAA, through its contracted transportation brokers, limits its payment does not pay for transportation according to under the following conditions:

     (a) Clients are not eligible for transportation services when medical services are within reasonable walking distance (normally three-quarters of a mile actual travelling distance), taking into account the client's documented medical condition and personal capabilities (see WAC 388-546-5100(6));

     (b) Clients must use personal or informal transportation alternatives if they are available and appropriate to the clients' needs (see WAC 388-546-5100(7));

     (c) If a fixed-route public transportation service is available to the client within three-quarters of a mile walking distance, the broker may require the client to use the fixed route public transportation system unless a higher need is both present and documented (e.g., portable ventilator, use of a walker or quad cane) under the terms of WAC 388-546-5100(8);

     (d) MAA or MAA's contracted transportation broker may deny transportation services requested if the request is not necessary, suitable, or appropriate to the client's medical condition (see WAC 388-546-5100 (1) and (5)(a));

     (e) The medical services requiring transportation must be services that are covered by the client's medical program (see WAC 388-545-5100(1)); and or

     (f) The transportation selected by the broker for the client must be the lowest cost available alternative that is both appropriate and accessible to the client's medical condition and personal capabilities, considering all cost factors (e.g., the impact on MAA of third party coverage, the costs of meals and lodging).

     (9) The transportation broker mails a written notice of denial to each client who is denied coverage of transportation within three business days of the denial.

     WAC 388-546-5300 Nonemergency transportation program client requirements.

     (1) Clients must cooperate comply with MAA's contracted transportation brokers, the brokers' subcontracted transportation providers, and MAA's medical services providers. A client who refuses to cooperate does not comply may be suspended or terminated from access to nonemergency transportation services have limited in the transportation service mode options available to him/her. See the definition of noncompliance in this chapter. The broker mails the client a written notice of limited transportation service mode options within three business days of the broker's decision that transportation service mode options are limited.

     (2) Clients must request, arrange and obtain authorization for medical transportation forty-eight hours in advance of a medical appointment. Exceptions to the forty-eight-hour advance arrangements are described in WAC 388-546-5200 (5) and (6).

     (3) If MAA's contracted broker is not open for business at the time nonemergency transportation is needed, the client must follow the transportation broker's instructions to obtain a medically necessary transportation service.

     (4) Clients must use the closest available medical care MAA will cover a client's transportation to medically necessary covered services with local providers of type that can meet the client's medical needs. Exceptions are Transportation services will be covered to non-local providers of type in the following circumstances:...

     (6) If local medical services are not available to a client because of the client's behavior or the client's lack of cooperation noncompliance with MAA's transportation brokers, the brokers' subcontracted transportation providers, or MAA's medical services providers, MAA does not cover nonemergency transportation to out-of-area medical services for the client. MAA's contracted broker notify a mails a written notice to the client, in writing, if the broker determines within three business days of the broker's determination that the client's documented behavior noncompliance results in a denial of out-of-area transportation services.

     WAC 388-546-5400 Nonemergency transportation program general reimbursement limitations.

     (1) To be reimbursed, MAA requires that a trip be a minimum of three-quarters of a mile from pick-up point to drop off point (see WAC 388-546-5100(6)). MAA's transportation broker may grant exceptions to the minimum distance requirement for any of the following conditions:...

     (2) MAA reimburses for return trips from eligible covered medical services if the return trips are directly related to the original trips. MAA, through its transportation broker, may deny...

     (4) The MAA's transportation broker may authorize intermediate stops that are directly related to the original approved trip if the broker determines that the intermediate stop is likely to limit or eliminate the need for supplemental covered trips. MAA considers the following reasons to be related to the original trip:

     (a) Transportation to and from an immediate subsequent medical referral; and or

     (b) Transportation to a pharmacy...

     (5) MAA may pay the costs of meals and lodging for clients who must be transported to out-of-area medical services. MAA's contracted transportation brokers make the determination...

     (6) MAA may pay transportation costs, including meals and lodging, for authorized escorts. MAA's contracted transportation brokers make the determination...

     WAC 388-546-5500 Modifications of privately owned vehicles.

     (1) MAA may cover...

     (a) The requested item is medically necessary for the client's transportation to medically necessary MAA covered services as defined under WAC 388-500-0005; and

     (b) The client owns a vehicle...

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 6, Amended 0, Repealed 2.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 6, Amended 0, Repealed 2.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 6, Amended 0, Repealed 2. Effective Date of Rule: Thirty-one days after filing.

February 28, 2001

Bonita H. Jacques, Chief

Office of Legal Affairs

     "Broker" means an organization or entity contracted with the department of social and health services (DSHS)/medical assistance administration (MAA) to arrange nonemergency transportation services for MAA's clients.

     "Drop-off point" means the place authorized by the transportation broker for the client's trip to end.

     "Escort" means a person authorized by the broker to be transported with a client to a medical service. An escort may be authorized depending on the client's age, mental state or capacity, safety requirements, mobility requirements, communication or translation requirements, or cultural issues.

     "Guardian" means a person who is legally responsible for a client and who may be required to be present when a client is receiving medical services.

     "Local provider of type" means the medical provider within the client's local community who fulfills the requirements of the medical appointment. The provider may vary by medical specialty, the provider's acceptance of MAA's clients, and whether managed care, primary care case management or third party participation is involved.

     "Noncompliance" means a client:

     (1) Engages in violent, seriously disruptive, or illegal conduct;

     (2) Poses a direct threat to the health and/or safety of self or others; or

     (3) Fails to be present at the pick-up point of the trip.

     "Pick-up point" means the place authorized by MAA's transportation broker for the client's trip to begin.

     "Return trip" means the return of the client to the client's home, or another authorized return point, from the location where a covered medical service has occurred.

     "Service mode" means the method of transportation the transportation broker selects to use for an MAA client.

     "Stretcher trip" means a transportation service that requires a client to be transported in a prone or supine position. This may be by stretcher, board or gurney (reclined and with feet elevated). Medical or safety requirements must be the basis for transporting a client in the prone or supine position.

     "Trip" means transportation one-way from the pick-up point to the drop-off point by an authorized transportation provider.

     "Urgent care" means an unplanned appointment for a covered medical service with verification from an attending physician or facility that the client must be seen that day.

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     (2) Licensed ambulance providers, who contract with MAA's transportation brokers, may be reimbursed for nonemergency transportation services under WAC 388-546-5200 as administrative services.

     (3) MAA covers nonemergency transportation under WAC 388-546-5000 through 388-546-5500 as an administrative service as provided by the Code of Federal Regulations (42 CFR 431.53 and 42 CFR 440.170 (a)(2). As a result, clients may not select the transportation provider(s) or the mode of transportation (service mode).

     (4) Prior authorization by MAA is required for all out-of-state nonemergency transportation. Border areas as defined by WAC 388-501-0175 are considered in-state under this section and subsequent sections.

     (5) MAA requires all nonemergency transportation to and from covered services to meet the following:

     (a) The covered service must be medically necessary as defined in WAC 388-500-0005;

     (b) It must be the lowest cost available service mode that is both appropriate and accessible to the client's medical condition and personal capabilities; and

     (c) Be limited to the local provider of type as follows:

     (i) Clients receiving services provided under MAA's fee-for-service program may be transported only to the local provider of type. MAA's transportation broker is responsible for considering and authorizing exceptions.

     (ii) Clients enrolled in MAA's managed care (healthy options) program may be transported to any provider supported by the client's managed care plan. Clients may be enrolled in a managed care plan but are obtaining a specific service not covered under the plan. The requirements in subsection (5)(c)(i) apply to these fee-for-service services.

     (6) MAA does not cover nonemergency transportation services if the covered medical services are within three-quarters of a mile walking distance from the client's residence. Exceptions to this rule may be granted by MAA's transportation broker based on the client's documented medical condition or personal capabilities, or based on safety or physical accessibility concerns, as described in WAC 388-546-5400(1).

     (7) A client must use personal or informal transportation alternatives if they are available and appropriate to the client's needs.

     (8) If a fixed-route public transportation service is available to the client within three-quarters of a mile walking distance, the broker may require the client to use the fixed-route public transportation system unless the need for more specialized transportation is present and documented. Examples of such a need are the client's use of a portable ventilator, a walker or a quad cane.

     (9) MAA does not cover any nonemergency transportation service that is not addressed in WAC 388-546-1000 or in 388-546-5000 through 388-546-5500. See WAC 388-501-0160 for information about obtaining approval for noncovered transportation services, known as exception to rule (ETR).

     (10) If a medical service is approved by ETR, both the broker and MAA must separately prior approve transportation to that service.

     (11) MAA may exempt members of federally recognized Indian tribes from the brokered transportation program. Where MAA approves the request of a tribe or a tribal agency to administer or provide transportation services under WAC 388-546-5000 through 388-546-5400, tribal members obtain their transportation services as provided by the tribe or tribal agency.

     (12) A client who is denied service under this chapter may request a fair hearing per chapter 388-02 WAC.

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     (2) MAA requires all contracted and subcontracted transportation providers under this chapter to be licensed, equipped, and operated in accordance with applicable federal, state, and local laws.

     (3) MAA's transportation brokers determine the level of transportation service needed by the client and the mode of transportation to be used for each authorized trip.

     (4) MAA's transportation brokers must comply with the terms specified in their contracts.

     (5) MAA's transportation brokers may require up to forty-eight hours advance notice of a requested trip (see WAC 388-546-5300(2)) with the exception of hospital requests or urgent care trips. MAA allows its transportation brokers to accommodate requests that provide less than forty-eight hours advance notice, within the limits of the resources available to a broker at the time of the request.

     (6) If MAA's transportation broker is not open for business and unavailable to give advance approval for a hospital discharge or urgent care request as described in subsection (5), the sub-contracted transportation provider must either:

     (a) Provide the transportation in accordance with the broker's instructions and request an after-the-fact authorization from the transportation broker within seventy-two hours of the transport; or

     (b) Deny the transportation, if the requirements of this section cannot be met.

     (7) If the sub-contracted transportation provider provides transportation as described in subsection (6), the broker may agree to grant retroactive authorization as provided in WAC 388-546-5300(3). Such retroactive authorization must be:

     (a) Documented as to the reasons retroactive authorization is needed; and

     (b) Agreed to by the broker within seventy-two hours after the transportation to a medical appointment.

     (8) MAA, through its transportation brokers, does not pay for transportation under the following conditions:

     (a) Clients are not eligible for transportation services when medical services are within reasonable walking distance (normally three-quarters of a mile actual traveling distance), taking into account the client's documented medical condition and personal capabilities (see WAC 388-546-5100(6));

     (b) Clients must use personal or informal transportation alternatives if they are available and appropriate to the clients' needs (see WAC 388-546-5100(7));

     (c) If a fixed-route public transportation service is available to the client within three-quarters of a mile walking distance, the broker may require the client to use the fixed route public transportation under the terms of WAC 388-546-5100(8);

     (d) MAA or MAA's transportation broker may deny transportation services requested if the request is not necessary, suitable, or appropriate to the client's medical condition (see WAC 388-546-5100 (1) and (5)(a));

     (e) The medical services requiring transportation must be services that are covered by the client's medical program (see WAC 488-546-5100(1)); or

     (f) The transportation selected by the broker for the client must be the lowest cost available alternative that is both appropriate and accessible to the client's medical condition and personal capabilities.

     (9) The transportation broker mails a written notice of denial to each client who is denied coverage of transportation within three business days of the denial.

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     (2) Clients must request, arrange and obtain authorization for transportation forty-eight hours in advance of a medical appointment. Exceptions to the forty-eight-hour advance arrangements are described in subsection (3) of this section and in WAC 388-546-5200 (5) and (6).

     (3) If MAA's contracted broker is not open for business at the time nonemergency transportation is needed, the client must follow the transportation broker's instructions to obtain transportation service.

     (4) MAA will cover a clients transportation to medically necessary covered services with local providers of type. Transportation services will be covered to nonlocal providers of type in the following circumstances:

     (a) The client is enrolled in a healthy options managed health care plan and the client's primary care provider (PCP) or a PCP referred provider is not the closest available provider;

     (b) The client's service is covered by a third party payer and the payer requires or refers the client to a specific provider;

     (c) A charitable or other voluntary program (e.g., Shriners) is paying for the client's medical service;

     (d) The medical service required by the client is not available within the local healthcare service area;

     (e) The total cost to MAA is lower when the services are obtained outside of the local healthcare service area; or

     (f) The out-of-area service is required to provide continuity of care for the client's ongoing care as:

     (i) Documented by the client's primary care provider; and

     (ii) Agreed to by MAA's contracted transportation broker.

     (5) MAA may require transportation brokers to refer any of the exception categories listed in subsection (4) to MAA's medical director or the medical director's designee for review and/or prior authorization of the medical service.

     (6) If local medical services are not available to a client because of noncompliance with MAA's transportation brokers, the brokers' subcontracted transportation providers, or MAA's medical services providers, MAA does not cover nonemergency transportation to out-of-area medical services for the client. MAA's contracted broker mails a written notice to the client within three business days of the broker's determination that the client's documented noncompliance results in a denial to out-of-area transportation services.

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     (a) When there is medical justification for a shorter trip;

     (b) When the trip involves an area that MAA's contracted broker considers to be unsafe for the client, other riders, or the driver; or

     (c) When the trip involves an area that the broker determines is not physically accessible to the client.

     (2) MAA reimburses for return trips from covered medical services if the return trips are directly related to the original trips. MAA, through its transportation broker, may deny coverage of a return trip if any delays in the return trip are for reasons not directly related to the original trip.

     (3) MAA does not reimburse any costs related to intermediate stops that are not directly related to the original approved trip.

     (4) MAA's transportation broker may authorize intermediate stops that are directly related to the original approved trip if the broker determines that the intermediate stop is likely to limit or eliminate the need for supplemental covered trips. MAA considers the following reasons to be related to the original trip:

     (a) Transportation to and from an immediate subsequent medical referral; or

     (b) Transportation to a pharmacy to obtain one or more prescriptions when the pharmacy is within a reasonable distance of the original medical appointment route.

     (5) MAA may pay the costs of meals and lodging for clients who must be transported to out-of-area medical services. MAA's transportation brokers make the determination that meals and lodging are necessary based on client need and the reasonableness of costs (as measured against state per diem rates).

     (6) MAA may pay transportation costs, including meals and lodging, for authorized escorts. MAA's transportation brokers make the determination that the costs of escorts are necessary based on client need and reasonableness of costs (as measured against state per diem rates).

     (7) MAA does not provide escorts or pay the wages of escorts. MAA does not pay for the transportation of an escort when the client is not present unless the broker documents exceptional circumstances causing the broker to determine that the service is necessary to ensure that the client has access to medically necessary care.

     (8) MAA may reimburse for the transportation of a guardian with or without the presence of the client if the broker documents its determination that such a service is necessary to ensure that the client has access to medically necessary care.

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     (a) The requested item is necessary for the client's transportation to medically necessary MAA-covered services; and

     (b) The client owns a vehicle that MAA determines is suitable for modification; and

     (c) Medical transportation provided under WAC 388-546-5000 through 388-546-5400 cannot meet the client's need for transportation to and from medically necessary covered services at a lower total cost to the department (including anticipated costs); and

     (d) Prior approval from MAA is obtained.

     (2) Any vehicle driving controls, vehicle wheelchair lift conversion or vehicle wheelchair lift purchased by MAA under this section becomes the property of the client on whose behalf the purchase is made. MAA assumes no continuing liability associated with the ownership or use of the device.

     (3) MAA limits the purchase of vehicle driving control(s), vehicle wheelchair lift conversion or vehicle wheelchair lift to one purchase per client. If a device purchased under this section becomes inoperable due to wear or breakage and the cost of repair is more than the cost of replacement, MAA will consider an additional purchase under this section as long as the criteria in subsection (1) of this section are met.

     (4) MAA must remain the payer of last resort under this section.

     (5) MAA does not cover the purchase of any new or used vehicle under this section or under this chapter.

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     The following sections of the Washington Administrative Code are repealed:

WAC 388-86-085	Transportation (other than ambulance).
WAC 388-87-035	Payment -- Transportation (other than ambulance).

© Washington State Code Reviser's Office