Part 1.
TEXAS DEPARTMENT OF HEALTH
Chapter 40.
MEDICAL TRANSPORTATION
The Texas Department of Health (department) adopts amendments to §§40.1,
40.101-40.103, 40.105-40.106, and 40.201, the repeal of §§40.104,
40.301-40.304, 40.401-40.405, 40.501-40.502, 40.601-40.603 and new §40.301
concerning the Medical Transportation Program (MTP). Sections 40.1, 40.101-40.103,
40.105 and 40.201 are adopted with changes to the proposed text as published
in the November 22, 2002 issue of the
Texas Register
(27 TexReg 10882). The amendment to §40.106, new §40.301,
and the repeals of §§40.104, 40.301-40.304, 40.401-40.405, 40.501-40.502,
and 40.601-40.603 are adopted without changes and those sections will not
be republished.
Specifically, the amendments, repeals and new section are required to add
new definitions, correct terms, clarify language and delete references to
information already contained in contract documents.
An amendment to §40.1 changes the term client(s) to recipient(s),
eligible MTP client to prior authorized MTP recipient and individual contractor
to individual volunteer contractor, changes references to the Chronically
Ill and Disabled Children (CIDC) program to the Children with Special Health
Care Needs (CSHCN) program, adds additional definitions, expands on definitions
and deletes definitions contained in contract documents.
The amendments to §§40.101-40.103, and 40.105 expand on language,
change the term client(s) to recipient(s) and change references to the Chronically
Ill and Disabled Children (CIDC) program to the Children with Special Health
Care Needs (CSHCN) program, add language pertaining to partial reimbursement
or advance funds and clarify services to nursing facilities.
An amendment to §40.106 changes the term client to recipient, changes
references to the Chronically Ill and Disabled Children (CIDC) program to
the Children with Special Health Care Needs (CSHCN) program, and adds additional
requirements not covered by the MTP.
An amendment to §40.201 changes the term client(s) to recipient(s),
changes references to the Chronically Ill and Disabled Children (CIDC) program
to the Children with Special Health Care Needs (CSHCN) program, clarifies
language in that if a service is denied, then the recipient shall be notified
in accordance with Medicaid Uniform Fair Hearings Procedures by the MTP and
adds an additional requirement to the recipients responsibilities.
New §40.301 pertains to individual volunteer contractors participation
requirements and includes language from repealed §40.301.
The department is also making minor changes due to staff comments to clarify
the intent and improve the accuracy of the sections.
Change: Concerning §40.1(4), "Texas Medicaid Program's Claims Administrator"
has been changed to "Health and Human Services Commission (HHSC) or its designee".
Change: Concerning §40.1(20), the word "health care" has been inserted
to clarify the type of providers.
Change: Concerning §40.1(34) and proposed §40.1(37), the hyphen
in "prior-authorized" has been removed in order to be consistent with the
remainder of the text.
Change: Concerning proposed §40.1(36), the definition for "Rescheduled
authorized trips" has been deleted as contractors are not allowed to reschedule
authorized trips. Therefore, proposed §40.1(37)-(44) have been renumbered
as §40.1(36)-(43).
Change: Concerning §40.101(1), the word "Current" has been replaced
with "current".
Change: Concerning §40.101(b), the word "recipient" has been replaced
with "individual" to conform with proposed §40.1(44), renumbered as §40.1(43).
Change: Concerning §40.102(1), the word "an" has been replaced with
"a".
Change: Concerning §40.103(1), §40.103(2), §40.103(5), and §40.201(b)(5),
the words "prior authorized" have been deleted from these rules as "prior
authorized" refers to the service and not the medical appointment.
Change: Concerning §40.105(5), the words "prior authorized" have been
replaced with "health care".
Change: Concerning §40.201(a)(3), the words "not covered" have been
deleted.
The following comments were received concerning the rules during the comment
period and at the Public Hearing held on December 6, 2002.
Comment: Concerning §40.1(5), one commenter suggested that the definition
be changed to read "An adult or a service animal that accompanies a prior
authorized recipient to provide necessary mobility, personal or language assistance
to the recipient during the time that transportation and health care services
are provided". The commenter stated that this language could prevent discrimination
against younger married people or people emancipated by court ruling.
Response: The department agrees. The rule has been amended to reflect this
change.
Comment: Concerning §40.1(7), a commenter suggested that the words
"to a Regional MTP staff" be inserted in order to eliminate confusion.
Response: The department agrees that the current language may cause confusion.
The rule has been amended to add language that will eliminate confusion.
Comment: Concerning §40.1(12), a commenter suggested that the word
"contractor" be inserted in order to identify the dispatched vehicles.
Response: The department agrees. The rule has been amended to reflect this
change.
Comment: Concerning §40.1(20), a commenter suggested that the department
limit the number of trips for a recipient.
Response: The department disagrees. The department has inserted language
that will clarify that the recipient's choice of providers is limited and
not the number of trips in accordance with federal law.
Comment: Concerning §40.1(26), a commenter suggested that the definition
be changed to read "A program which provides prior authorization for non-emergency
transportation services to covered health care services, based on medical
necessity, for categorically eligible Medicaid recipients, Children with Special
Health Care Needs (CSHCN) or Transportation for Indigent Cancer Patients Program
(TICP). Eligible recipient must have no other means of transportation."
Response: The department agrees. The rule has been amended to reflect this
change.
Comment: Concerning §40.1(32), one commenter suggested that the definition
be changed to read "Authorization or approval by designated Texas Department
of Health Medical Transportation staff, for the delivery of services before
the services are rendered." The commenter stated that this is clearer in that
the other version could be easily misinterpreted that the department is providing
the services directly.
Response: The department agrees that clarification on who authorizes services
should be added. The rule has been amended to reflect this change.
Comment: Concerning §40.1(32), a second commenter suggested the definition
be changed to read "Authorization or approval for the provision of transportation,
attendant, advance funds or meals and/or lodging services obtained from the
department before the services are rendered." The commenter stated that it
might be good to list all of the services that must be prior authorized.
Response: The department agrees. The rule has been amended to reflect this
change.
Comment: Concerning §40.1(33), one commenter suggested the definition
be changed to read "A recipient, as authorized by the department, who has
been identified by the Texas Department of Human Services (DHS) as eligible
for Medicaid services under a specific category, or identified by either the
Children with Special Health Care Needs (CSHCN) or the Transportation for
Indigent Cancer Patients (TICP) Program as eligible for program services."
The commenter stated that omitting the words "or identified by either" could
lead to misinterpretation that DHS determines eligibility for CSHCN or TICP.
Response: The department agrees. The rule has been amended to reflect this
change.
Comment: Concerning §40.1(33), a second commenter suggested that the
words "who have" be replaced with "who has".
Response: The department agrees. The rule has been amended to reflect this
change.
Comment: Concerning §40.1(35), the commenter suggested "to delete
subparagraphs (A), (B) and (C) and replace with "Reasonable transportation
- The MTP is responsible for ensuring that necessary non-ambulance transportation
services are provided in a manner that is similar in scope and duration; consistent
with the best interest of recipients; appropriate to available services, geographic
location and limitation of clients prompt; cost-effective; and efficient."
The commenter stated this is based on the federal regulations for the state
program and also the basis for the federal match.
Response: The department disagrees because the suggested change would not
be in accordance with federal law. The language proposed in the rule expands
on the definition and is clarified. No changes were made as a result of this
comment.
Comment: Concerning proposed §40.1(37), now renumbered as §40.1(36),
a commenter asked if retroactive payments are actually provided by the department.
Response: The department has determined that the current language proposed
requires clarification. The rule has been amended to reflect this change.
Comment: Concerning proposed §40.1(38), now renumbered as §40.1(37),
a commenter stated that the definition should be deleted since the rule is
no longer enforced and reasonable transportation is allowed to any physician
within a recipient's county of residence or a county adjacent to that county.
Response: The department disagrees with the comment to delete the rule
in its entirety. The department does agree to delete the word "the nearest"
from the rule text. The rule has been amended to reflect this change.
Comment: Concerning proposed §40.1(40), now renumbered as §40.1(39),
the commenter suggested the definition be changed to read "A trained guide
dog, signal dog or other animal to provide assistance to a specified MTP recipient
with a disability". The commenter stated that the suggested changes include
that the person with the service animal must be an MTP recipient.
Response: The department agrees. The rule has been amended to reflect this
change.
Comment: Concerning proposed §40.1(42), now renumbered as §40.1(41),
a commenter suggested the definition be changed to read "When appropriate
health care services are not available closer, medical transportation is prior
authorized to and/or from a recipient's county of residence to health care
services beyond the adjacent county where the recipient's health care needs
will be met." The commenter stated that the words "health care service" instead
of "facility" would be more clear.
Response: The department agrees that changes to this rule are required.
The rule has been amended to reflect changes.
Comment: Concerning proposed §40.1(43), now renumbered as §40.1(42),
one commenter suggested changing the word "Special needs" to "Wheelchair needs".
Response: The department disagrees. The term "special needs" is a broader
term and refers to recipients in wheelchairs and other recipients unable to
access transportation in regular vehicles. No changes were made as a result
of the comment.
Comment: Concerning proposed §40.1(43), now renumbered as §40.1(42),
a second commenter suggested the definition be changed to read "Some MTP recipients
have disabilities that require prior authorized transportation services to
be provided by vehicles equipped with a ramp or a mechanical lift". The commenter
stated that the wording proposed in the rule seems to place more emphasis
on recipients than requests.
Response: The department disagrees to change the rule in its entirety.
The department agrees to delete the word "request" which places the emphasis
on recipients and not the request for services. The rule has been amended
to reflect this change.
Comment: Concerning proposed §40.1(44), now renumbered as §40.1(43),
a commenter suggested replacing the words "recipients" with "individuals"
and "certain" with "TICP". The commenter stated that by using the acronym
"TICP" instead of the word "certain" identifies the criteria and the individuals
probably are not TICP recipients when diagnosed.
Response: The department agrees. The rule has been amended to reflect this
change.
Comment: Concerning §40.101(a), one commenter suggested that the department
replace subsection (a) with "The following prior authorized MTP recipients
are eligible to receive reasonable transportation to medically necessary health
care services; when no other means of transportation is available, and the
transportation made is the least expensive method, suitable to the recipient's
medical needs, and transportation is available only to get individuals to
qualified providers of their choice who are generally available and used by
other residents of the community." The commenter stated that this wording
is from the program guidelines in the federal Medicaid Assistance Manual-Part
6 General Program Administration 6-20-00 Transportation of Recipients.
Response: The department disagrees. The department believes the proposed
language is clearer and better understood by the public. No changes were made
as a result of the comments.
Comment: Concerning §40.101(a), a second commenter suggested the word
"medical" be replaced with "health care" and add the words "if medical necessity
exists and". The commenter also suggested that the word "facility" be replaced
with another word that would make the paragraph clearer.
Response: The department agrees with replacing the word "medical" with
"health care" and adding the words "if medical necessity exists". The rule
has been amended to reflect these changes. The department disagrees with replacing
the word "facility" because the word "facility" identifies the location of
the medical appointment. No change was made as a result of this comment.
Comment: Concerning §40.101(a)(2), the commenter suggested that the
program name "CSHCN" be spelled out.
Response: The department disagrees. The program name is spelled out in
the definition in §40.1(9). No changes were made as a result of this
comment.
Comment: Concerning §40.101(a)(3), the commenter suggested that the
program name "TICP" be spelled out.
Response: The department disagrees. The program name is spelled out in
the definition in §40.1(43). No changes were made as a result of this
comment.
Comment: Concerning §40.102(2)(B), one commenter suggested that the
section be changed to read "The recipient provides Regional MTP staff with
a Health Care Provider's Statement of Need or equivalent for review and the
service is determined reasonable." The commenter stated that this sentence
seems to have the same meaning and is more concise.
Response: The department agrees. The rule has been amended to reflect the
change.
Comment: Concerning §40.102(5), one commenter suggested that the section
be changed to read "retroactive reimbursement for up to three months of reasonable
transportation, meals and lodging if the recipient is a new recipient to MTP
and was eligible under all program requirements. The retroactive reimbursement
process will begin on the date of the request for retroactive reimbursement".
The commenter stated that if we are dealing with the past, the word "is" needs
to be changed to "was" since reimbursement probably would not begin on the
date of request.
Response: The department agrees. The rule has been amended to reflect the
change.
Comment: Concerning §40.102(5), a second commenter asked who the retroactive
reimbursement would apply to.
Response: The department believes that the incorporation of the changes
requested by the first commenter on this rule will clarify this commenter's
question.
Comment: Concerning §40.103(1), a commenter suggested the word "routine"
be replaced with "reasonable". The commenter stated that the word "reasonable"
in this paragraph seems to fit the definitions in §40.1(35)(A) and (B).
Response: The department disagrees. The term "routine" describes the type
of transportation request. No changes were made as a result of this comment.
Comment: Concerning §40.103(4), a commenter stated that allowing recipients
to receive multiple mass transit tickets will only open the door for abuse.
Response: The department disagrees. This service provides recipients who
have multiple health care appointments access to health care services more
efficiently and without delay. No changes were made as a result of this comment.
Comment: Concerning §40.103(5), a commenter suggested inserting the
word "not" between the words "may receive". The commenter stated he believes
the word "not" was omitted.
Response: The department disagrees. Individual contractors "may" receive
reimbursement that exceeds the amount paid to other transportation contractors
in their area. No changes were made as a result of this comment.
Comment: Concerning §40.105(1), a commenter stated that he believes
"health care services (DAHS) center" may have been omitted.
Response: The department disagrees. The term "day activity" identifies
a Day Activity and Health Services (DAHS). No changes were made as a result
of this comment.
Comment: Concerning §40.105(4)(A), a commenter stated that the wording
is such that if someone read the exception literally, they could make an argument
that a six year old in a head start program going to see a clinical therapist
does not need an adult caretaker because the "treatment" is confidential by
law.
Response: The department agrees. The term "or" has been replaced with "and/or".
Comment: Concerning §40.105(10), a commenter stated that the contractor
should not be penalized if an attendant does not accompany a recipient on
an authorized trip.
Response: The department believes this is a training issue that should
be addressed at training sessions provided to vendors. No change was made
as a result of the comment.
Comment: Concerning §40.201(a), a commenter asked why the word "client"
is stated in the rule text instead of "recipient".
Response: The word "client" has been replaced with "recipient" in 42 Code
of Federal Regulations (CFR) relating to Medicaid. No change was made as result
of the comment.
Comment: Concerning §40.201(b)(6), the commenter stated that recipients
do not call to cancel a particular trip and therefore believes that "this
rule is not enforced".
Response: The department intends to continue providing program education
to recipients to address this issue. No changes were made as a result of this
comment as this comment does not require a change in the rules.
Comments received during the comment period consisted of requests for clarifying
language, adding new definitions, rewording sentences for clarity, correcting
and changing references. Comments were received from two former department
MTP employees, one regional MTP manager and one MTP transportation contractor.
Subchapter A. PROGRAM OVERVIEW
25 TAC §40.1
The amendment is adopted under the Texas Human Resources Code,
Chapter 22 and Chapter 32; and Texas Health and Safety Code, §12.001,
which provides the board with the authority to adopt rules for its procedure
and for the performance of each duty imposed by law on the board, the department,
or the commissioner of health.
§40.1.Definitions of Terms.
The following words and terms, when used in the Medical Transportation
Program (MTP) rules, shall have the following meanings, unless the content
clearly indicates otherwise.
(1)
Abuse--The willful infliction of intimidation or injury
resulting in physical harm, pain, or mental anguish.
(2)
Adjacent county(ies)--The county or counties that share
a common county line or point with the recipient's county of residence.
(3)
Advance funds--Funds authorized by Regional MTP staff in
advance of travel and provided to a recipient or attendant for a medically-necessary
health care service.
(4)
Ambulance service--A service paid through the Health and
Human Services Commission (HHSC) or its designee in an emergency, or non-emergency
situation in which transportation in a vehicle other than an ambulance could
endanger the recipient's health.
(5)
Attendant--An adult or service animal that accompanies
a prior authorized MTP recipient to provide necessary mobility, personal or
language assistance to the recipient during the time that transportation and
health care services are provided.
(6)
Batch--A group of mass-transit tickets or tokens with one
unique confirmation number.
(7)
Cancellation--Verbal notification from a recipient or a
recipient's advocate using the MTP toll free number prior to the scheduled
medical transportation service which indicates that the particular service
is not needed.
(8)
Certification Period--A period of time for which the recipient
is certified for service.
(9)
Children with Special Health Care Needs (CSHCN)--A department
program funded with general revenue and federal funds. Services for eligible
children include early identification, diagnosis and evaluation, resulting
in early health care intervention.
(10)
Contractor--A for-profit business, a non-profit organization,
or a governmental unit that has entered into a legally binding contract with
the department to provide authorized MTP transportation services, advance
funds, meals and/or lodging to prior authorized MTP recipients.
(11)
Curb-to-curb service--Transportation from curb at origin
to curb at destination. This service includes providing assistance, as required,
to passengers entering and exiting the vehicle.
(12)
Demand-response--Transportation that involves using contractor
dispatched vehicles in response to requests for individual or shared one-way
trips.
(13)
Department--Texas Department of Health. The State agency
that operates the Medical Transportation Program.
(14)
Dependent care--Necessary care for a child or disabled
adult.
(15)
Destination--The place or point to which a recipient has
been authorized by MTP to travel.
(16)
Door-to-door service--Transportation from the door of
the trip origin to the door of the trip destination as authorized by Regional
MTP staff. This service includes providing assistance, as required, to passengers
entering and exiting the vehicle.
(17)
Fraud--Deliberate misrepresentation or intentional concealment
of information in order to obtain services or payment for services to which
a person or contractor is not entitled.
(18)
Health Care Provider's Statement of Need--MTP Form 3113
or equivalent submitted by a health care provider which documents the recipient's
need for health care services and/or special transportation accommodations.
(19)
Individual Volunteer Contractor (IVC)--An individual who
has an approved service agreement with the department for mileage reimbursement
at a prescribed rate to provide transportation for a prior authorized MTP
recipient to a prior authorized health care service.
(20)
Limited--An action taken by the Texas Department of Human
Services (TDHS) to limit a Medicaid recipient's choice of health care providers.
(21)
Lodging establishment--An establishment such as a hotel,
motel, charitable home or hospital that provides overnight lodging.
(22)
Mass transit--Transportation that is subsidized by sales
taxes or Federal Transit Administration funds and provided to the general
public within a specified local area.
(23)
Medicaid--A health care program provided to eligible individuals
under 42 U.S.C. §1396a
et seq.
; 42 C.F.R. §431.53;
Texas Human Resources Code, Chapters 22 and 32.
(24)
Medicaid-allowable service--A service covered under the
State's Medicaid Plan. This includes health care services that are provided
to the recipient by a charitable organization but not billed to Medicaid as
well as value-added services provided by a Medicaid managed care plan to a
Medicaid-enrolled member.
(25)
Medically-necessary--Services that are:
(A)
reasonably necessary to: prevent illness(es) or medical
condition(s); maintain function or to slow further functional deterioration;
provide early screening, intervention, care, and/or provide care or treatment
for eligible recipients who have medical condition(s) that cause suffering
or pain, physical deformity or limitations in function, or that threaten to
cause or worsen a disability, illness or infirmity, or endanger life;
(B)
provided at appropriate locations and at the appropriate
levels of care for the treatment of the medical condition(s);
(C)
consistent with health care practice guidelines and standards
endorsed by professionally recognized health care organizations or governmental
agencies;
(D)
consistent with the diagnosis(es) of the condition(s);
and
(E)
no more intrusive or restrictive than necessary to provide
a proper balance of safety, effectiveness, and efficiency.
(26)
Medical Transportation Program (MTP)--A program which
provides prior authorization for non-emergency transportation services to
and from covered health care services, based on medical necessity, for categorically
eligible Medicaid recipients enrolled in Medicaid, and eligible recipients
enrolled in CSHCN, or TICP who have no other means of transportation.
(27)
Minor--An individual under 18 years of age who has never
been married or emancipated by court ruling.
(28)
No show--
(A)
a recipient who does not respond within ten minutes of
the time the contractor arrives at the designated pick-up point and scheduled
time and announces its presence; or
(B)
a contractor who fails to arrive at the designated pick-up
point and time.
(29)
One-way trip--Transportation of a passenger from point-of-origin
to destination.
(30)
Origin--The location at which the contractor is authorized
to pick up the recipient.
(31)
Passenger assistance--Assistance which enables a recipient
to walk, enter or exit a vehicle, or transfer from a wheelchair. This does
not include lifting or carrying a person.
(32)
Prior authorization--Authorization or approval for the
provision of transportation, attendant, advance funds and meals and/or lodging
services obtained from Regional MTP staff before the services are rendered.
(33)
Prior authorized MTP recipient--A recipient, as authorized
by the department, who has been identified by the Texas Department of Human
Services (TDHS) as eligible for Medicaid services under a specific category,
or identified by either the Children with Special Health Care Needs (CSHCN)
or the Transportation for Indigent Cancer Patients (TICP) program, as eligible
for program services who has no other means of transportation to health care
services.
(34)
Priority Trips--Prior authorized trips that must be provided
on the original authorized date and time.
(35)
Reasonable transportation--Transportation using the most
cost-effective transportation that meets the recipient's medical needs:
(A)
within a recipient's local community, county of residence,
or county adjacent to a recipient's county of residence where the recipient
wishes to maintain an ongoing relationship or establish a relationship with
a health care provider of his or her choice;
(B)
to and from a county beyond the county adjacent to the
recipient's county of residence when determined by the department to be reasonably
close to obtain medically necessary, health program allowable services from
a specialist when appropriate medical services are not available as specified
in subparagraph (A) of this paragraph; or
(C)
to a provider or facility within a designated Medicaid
managed care service delivery area.
(36)
Retroactive authorizations--Authorizations provided to
eligible recipients and lodging establishments for eligible services which
would have been authorized had they been requested prior to the service.
(37)
Routine medical transportation--Prior authorized medical
transportation trips that do not have priority status to and/or from a facility
where health care needs will be met.
(38)
Same-day service--An urgent request prior authorized by
MTP staff.
(39)
Service animal--A trained guide dog, signal dog, or other
animal to provide assistance to a specified MTP recipient with a disability.
(40)
Sexual harassment--Unwelcome sexual advances, requests
for sexual favors, or other unwanted verbal or physical conduct of a sexual
nature directed toward an individual by another individual during the provision
of MTP services.
(41)
Special medical transportation--Medical transportation
to and/or from a recipient's county of residence and beyond the adjacent county,
where health care needs will be met and the appropriate health care service(s)
are not available locally.
(42)
Special needs--A transportation service that requires
the use of a vehicle equipped with a ramp or a mechanical lift to provide
the recipient with a means of accessing the vehicle.
(43)
Transportation for Indigent Cancer Patients (TICP) Program--A
state-funded program that provides medical transportation services to individuals
diagnosed with cancer or a cancer-related illness and who meet TICP residency
and financial criteria.
This agency hereby certifies that the adoption has been
reviewed by legal counsel and found to be a valid exercise of the agency's
legal authority.
Filed with the Office of
the Secretary of State on April 21, 2003.
TRD-200302578
Susan K. Steeg
General Counsel
Texas Department of Health
Effective date: May 11, 2003
Proposal publication date: November 22, 2002
For further information, please call: (512) 458-7236
25 TAC §§40.101 - 40.103, 40.105, 40.106
The amendments are adopted under the Texas Human Resources
Code, Chapter 22 and Chapter 32; and Texas Health and Safety Code, §12.001,
which provides the board with the authority to adopt rules for its procedure
and for the performance of each duty imposed by law on the board, the department,
or the commissioner of health.
§40.101.Eligibility.
(a)
The following prior authorized MTP recipients are eligible
to receive reasonable transportation to health care services if medical necessity
exists, no other means of transportation are available, the mode of transportation
is the most cost-effective mode available that does not endanger the recipient's
health and the facility is reasonably close to the prior authorized health
care service that meets the recipient's health care needs:
(1)
current Medicaid recipients authorized by the department
and identified by the Texas Department of Human Services (TDHS) as eligible
for Medicaid services under a specific category;
(2)
CSHCN recipients; and
(3)
TICP recipients.
(b)
Transportation for Indigent Cancer Patients (TICP) - To
be eligible for participation in the TICP Program, the individual:
(1)
must reside in Webb, Zapata, Starr, Jim Hogg, Hidalgo,
Cameron, Willacy, or Nueces County and provide one of the following as proof
of residency:
(A)
copy of federal or state ID (driver's license or identification
card); or
(B)
copy of utility bill under the applicant's name.
(2)
if residing with a family member, shall obtain from the
family member, written verification that the applicant resides in the household
and provide proof that household is in an eligible county;
(3)
must not be eligible for Medicaid;
(4)
must not be eligible for CSHCN-CIDC;
(5)
must be medically indigent (at or below 100% of federal
poverty guidelines). Before program services are provided, the monthly household
gross income shall be verified by:
(A)
financial information obtained through the Texas Department
of Human Services;
(B)
check stub or other written verification for each person
in the household who is employed. This form must contain the name, address
of employer, income and dates covered for each pay period; or
(C)
award letter or other written verification of unearned
income (such as Social Security, Worker's Compensation, Unemployment or Veteran's
Administration benefits);
(6)
is permitted the following allowable deductions from the
total household gross income:
(A)
$120 standard deduction per person in household who is
employed (the standard deduction per person will be the rate set by the Texas
Department of Human Services);
(B)
dependent care:
(i)
up to $200 per child under 2 years of age; or
(ii)
up to $175 per child 2 years of age and older.
(7)
is not permitted to take deductions on unearned income;
(8)
if over the age of 18 and residing with a family member,
the family member's household income is not considered. The applicant's gross
income, less standard deductions, is used to determine the applicant's eligibility;
(9)
has zero income and shall therefore submit written verification
from two family members or individuals who can attest that the household receives
no monthly earned or unearned income. Unearned income refers to monetary assistance
provided by family, friends, charitable organizations, and such given to the
recipient for household expenses;
(10)
must provide initial confirmation of cancer or cancer-related
diagnosis by a licensed medical physician. The following restrictions apply:
(A)
the applicant is eligible for up to 4 diagnostic visits
to a licensed medical physician to determine cancer or cancer-related diagnosis
if the department is provided written verification that diagnostic visits
are to rule out the possibility of cancer or cancer-related illness;
(B)
confirmation of cancer or cancer-related diagnosis must
be provided on or following the last diagnostic visit for MTP services to
continue;
(11)
must be accepted for evaluation or treatment by a medical
institution in Texas capable of providing quality cancer services.
§40.102.Program Services.
Medical Transportation Program (MTP) services must be prior authorized
by Regional MTP staff. MTP services include the following:
(1)
reasonable transportation of a prior authorized MTP recipient
to and/or from a prior authorized health care facility where health care needs
will be met;
(2)
special medical transportation to a health care facility
when one of the following conditions is met:
(A)
the services are allowable and the health care provider
will not bill Medicaid or another source for the cost of the services; or
(B)
the recipient provides Regional MTP staff with a Health
Care Provider's Statement of Need or equivalent for review and the service
is determined reasonable.
(3)
transportation for an attendant(s); if the health care
provider documents the need, the recipient is a minor, or a language or other
barrier to communication or mobility exists that necessitates such assistance;
(4)
transportation for a service animal when accompanying a
recipient;
(5)
retroactive reimbursement for up to three months of reasonable
transportation, meals and lodging if the recipient is a new recipient to MTP
and was eligible under all program requirements. The retroactive reimbursement
process will begin on the date of the request for retroactive reimbursement;
(6)
advance funds for an eligible child and attendant(s) when
lack of transportation funds will prevent the child from traveling to receive
health care services; and
(7)
reimbursement or advance funds for an eligible child and
attendant(s) for meals and lodging when the health care service requires the
child to remain overnight. If the child remains overnight for six consecutive
months, the recipient or responsible party must provide proof of residency
by providing:
(A)
copy of federal or state ID (driver's license or identification
card); and
(B)
copy of a utility bill under the recipient's or responsible
party's (if recipient is a child) name; or
(C)
if residing with a family member, written verification
that the applicant resides in the household.
(8)
partial reimbursement or advance funds for a prior authorized
MTP recipient and attendant(s) for transportation beyond the approved destination.
Partial reimbursement is limited to the amount that would have been paid to
the approved destination for transportation permitted under paragraph (1)
of this section.
§40.103.Program Processes.
To ensure transportation for prior authorized MTP recipients to a health
care facility where health care needs will be met:
(1)
a request for routine medical transportation must be received
by the Regional MTP staff at least two working days in advance of the recipient's
health care service appointment;
(2)
a request for special medical transportation must be received
by the Regional MTP staff at least five working days in advance of the recipient's
health care service appointment;
(3)
exceptions to paragraphs (1) and (2) of this section may
be granted by the Regional MTP manager or designee when the circumstances
have been determined by the Regional MTP manager or designee to be beyond
the recipient's control. The exception will be documented in the recipient's
record;
(4)
recipients with recurring visits to a health care provider
may receive multiple mass transit tickets or may have more than one transportation
appointment authorized in advance;
(5)
an individual volunteer contractor(s) may receive reimbursement
that exceeds the amount paid to other transportation contractors in their
area for transportation to a similar facility when determined by the department
as appropriate for the health care service required;
(6)
a TICP certification period may be retroactive to the date
of the initial request for MTP services if all eligibility requirements are
met, and all forms are completed and returned. The duration of the certification
period is a maximum of 12 consecutive months and minimum of 60 days; and/or
(7)
specific certification periods apply to the following applicants:
(A)
applicants on unearned fixed income such as Social Security,
worker's compensation, unemployment or U.S. Department of Veterans Affairs
benefits can be certified for a 12 month period if there are no anticipated
changes in household income;
(B)
applicants with earned income can be certified up to an
8-month period if there are no anticipated changes in household income;
(C)
applicants whose unearned or earned household income is
within 10% of the federal poverty guideline can be certified up to a 6-month
period at a time if there are no anticipated changes in household income;
or
(D)
applicants who have zero income can be certified up to
2 months at a time. Zero income requires written verification from family
members or advocates who can attest that the household receives no monthly
earned or unearned income.
§40.105.Program Limitations.
To ensure transportation for prior authorized MTP recipients to a health
care facility where health care needs will be met:
(1)
to and from a day activity, a personal care home or state
institution, or a facility participating in another Title XIX program for
which the reimbursement rate structure includes transportation funds;
(2)
the intended destination is a nursing facility;
(3)
the recipient is an inpatient in a health care facility;
(4)
the recipient is under 18 years of age and not accompanied
by a parent or legal guardian, unless one of the following conditions exists:
(A)
the recipient is aged 15 through 17 years of age and presents
the parent's or legal guardian's signed, written consent for the transportation
services to the Regional MTP office or the transportation contractor; and/or
(B)
the treatment to which the minor is being transported is
such that the law extends confidentiality to the minor for this treatment;
(5)
the recipient or another person or entity providing care
for the recipient receives direct payment of worker's compensation benefits,
U. S. Department of Veterans Affairs benefits, or other third-party resources
for transportation to health care services on the recipient's behalf;
(6)
the recipient is on limited status, unless the provider
has made the referral or the recipient requests family planning services;
(7)
TICP diagnostic visits and/or cancer or cancer-related
treatments that are provided out-of-state;
(8)
the recipient and/or attendant intentionally, knowingly,
or recklessly boards the vehicle carrying an illegal knife, a club, handgun
or other weapon, as defined in Penal Code, §46.01, on or about his or
her person;
(9)
a third-party, such as a lodging establishment, provides
transportation, meals, and/or lodging at no charge for a recipient and attendant,
for a particular appointment; or
(10)
an attendant does not accompany the recipient on the MTP-requested
trip when a Health Care Provider's Statement of Need, Form 3113 or equivalent,
is on file stating the recipient requires an attendant(s).
This agency hereby certifies that the adoption has been
reviewed by legal counsel and found to be a valid exercise of the agency's
legal authority.
Filed
with the Office of the Secretary of State on April 21, 2003.
TRD-200302570
Susan K. Steeg
General Counsel
Texas Department of Health
Effective date: May 11, 2003
Proposal publication date: November 22, 2002
For further information, please call: (512) 458-7236
25 TAC §40.104
The repeal is adopted under the Texas Human Resources Code,
Chapter 22 and Chapter 32; and Texas Health and Safety Code, §12.001,
which provides the board with the authority to adopt rules for its procedure
and for the performance of each duty imposed by law on the board, the department,
or the commissioner of health.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on April 21, 2003.
TRD-200302571
Susan K. Steeg
General Counsel
Texas Department of Health
Effective date: May 11, 2003
Proposal publication date: November 22, 2002
For further information, please call: (512) 458-7236
25 TAC §40.201
The amendment is adopted under the Texas Human Resources Code,
Chapter 22 and Chapter 32; and Texas Health and Safety Code, §12.001,
which provides the board with the authority to adopt rules for its procedure
and for the performance of each duty imposed by law on the board, the department,
or the commissioner of health.
§40.201.Recipient Rights and Responsibilities.
(a)
Recipient Rights.
(1)
Nondiscrimination. The recipient has a right to receive
services in compliance with Title VI of the Civil Rights Act of 1964, 42 U.S.C.A. §§2000d,
(2)
Abuse report. Recipients should report verbal or physical
abuse or sexual harassment committed by other recipients or passengers, contractor
employees, or department staff to Regional MTP staff or Regional Management
staff upon arrival at the recipient's destination.
(3)
Denial notification. If a service is denied, Regional MTP
staff shall notify the recipient in accordance with Chapter 1, Subchapter
C, §1.41 of this title (relating to Medicaid Uniform Fair Hearings Procedures).
This recipient notification does not apply to transportation services under §40.106
of this title (relating to Program Exclusions).
(4)
Appeal request. A recipient whose services have been denied
may request an administrative review by the Regional MTP Manager. A second
administrative review may be conducted by the MTP Program Director. If the
recipient is still dissatisfied, the recipient may appeal the administrative
review decision or the service denial by requesting a fair hearing. A request
for a fair hearing must be in writing and mailed or hand-delivered to the
appropriate Regional MTP office.
(b)
Recipient Responsibilities.
(1)
When a recipient or responsible adult requests transportation,
he/she must provide Regional MTP staff with the following information:
(A)
recipient name, address, and, if available, the telephone
number;
(B)
Medicaid, TICP or CSHCN recipient identification number
(if applicable) or Social Security number, and date of birth;
(C)
name, address, and telephone number of health care provider
and/or referring health-care provider;
(D)
purpose and date of trip and time of appointment;
(E)
affirmation that other means of transportation are unavailable;
(F)
special needs, including wheelchair lift or attendant(s);
(G)
medical necessity verified by the Health Care Provider's
Statement of Need, if applicable; and
(H)
affirmation that advance funds are needed in order for
the recipient to access health care services;
(I)
recipient must reimburse the department for any advance
funds, and any portion thereof, that are not used for the specific prior authorized
service.
(2)
Recipients must refrain from verbal and/or physical abuse
or sexual harassment toward another recipient or passenger, contractor's employees,
or department employees while requesting or receiving medical transportation
services.
(3)
Recipients must safeguard all bus tickets and/or tokens
from loss and theft and must return unused tickets or tokens to the Regional
MTP office issuing the tickets or tokens.
(4)
Recipients who receive mass-transit bus tickets or tokens
must complete the department's Verification of Travel to Health Care Services
by Mass Transit, Form 3111. Recipients must return this verification form
prior to their next request for tickets or tokens. A letter from the health
care provider verifying delivery of services may be substituted for the disbursement
of mass transit tickets or tokens verification form. Exceptions to this documentation
may be granted by a Regional MTP Manager or supervisor when circumstances
occur that are beyond the recipient's control. Exceptions will be documented
in the recipient's record.
(5)
Recipients must not use authorized medical transportation
for purposes other than travel to and from health care services.
(6)
If the recipient does not need to use the authorized transportation
services, the recipient or the responsible adult should contact the Regional
MTP staff to cancel the particular trip no less than four hours prior to the
time of the authorized trip.
(7)
Recipients who receive advance funds for meals, lodging,
and/or travel must return a completed Individual Volunteer Contractor (IVC)
Service Record verifying services were provided, prior to receiving future
advance funds or reimbursements.
(8)
Recipients must cancel requests for advance funds or lodging
when not needed and must refund any disbursed advance funds to the department.
(9)
Recipients must provide appropriate receipts when seeking
reimbursement for lodging.
This agency hereby certifies that the adoption has been
reviewed by legal counsel and found to be a valid exercise of the agency's
legal authority.
Filed
with the Office of the Secretary of State on April 21, 2003.
TRD-200302572
Susan K. Steeg
General Counsel
Texas Department of Health
Effective date: May 11, 2003
Proposal publication date: November 22, 2002
For further information, please call: (512) 458-7236
25 TAC §§40.301 - 40.304
The repeals are adopted under the Texas Human Resources Code,
Chapter 22 and Chapter 32; and Texas Health and Safety Code, §12.001,
which provides the board with the authority to adopt rules for its procedure
and for the performance of each duty imposed by law on the board, the department,
or the commissioner of health.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on April 21, 2003.
TRD-200302573
Susan K. Steeg
General Counsel
Texas Department of Health
Effective date: May 11, 2003
Proposal publication date: November 22, 2002
For further information, please call: (512) 458-7236
25 TAC §40.301
The new section is adopted under the Texas Human Resources
Code, Chapter 22 and Chapter 32; and Texas Health and Safety Code, §12.001,
which provides the board with the authority to adopt rules for its procedure
and for the performance of each duty imposed by law on the board, the department,
or the commissioner of health.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on April 21, 2003.
TRD-200302574
Susan K. Steeg
General Counsel
Texas Department of Health
Effective date: May 11, 2003
Proposal publication date: November 22, 2002
For further information, please call: (512) 458-7236
25 TAC §40.401 - 40.405
The repeals are adopted under the Texas Human Resources Code,
Chapter 22 and Chapter 32; and Texas Health and Safety Code, §12.001,
which provides the board with the authority to adopt rules for its procedure
and for the performance of each duty imposed by law on the board, the department,
or the commissioner of health.
This agency hereby certifies that the adoption has been reviewed
by legal counsel and found to be a valid exercise of the agency's legal authority.
Filed
with the Office of the Secretary of State on April 21, 2003.
TRD-200302575
Susan K. Steeg
General Counsel
Texas Department of Health
Effective date: May 11, 2003
Proposal publication date: November 22, 2002
For further information, please call: (512) 458-7236
Subchapter B. ELIGIBILITY, PROGRAM SERVICES, PROCESSES, ADDITIONAL TRANSPORTATION CONNECTED WITH AN AUTHORIZED TRIP, LIMITATIONS, AND EXCLUSIONS
Subchapter C. CLIENT RIGHTS
Subchapter D. CONTRACTOR PARTICIPATION
Subchapter E. PAYMENT PROCEDURES AND RECORDKEEPING
Subchapter F. MONITORING AND EVALUATION