Transportation Services for Medi-Cal Recipients

Publications
#F120.01

This tells you how to get transportation to medical appointments from your Medi-Cal managed care plan. Managed care is a way to provide and pay for health care. You receive most of your health care from a managed care plan. A managed care plan is an organized network of health care providers that focuses on primary and preventive care. The pub also tells you how to get transportation services if you have fee for service or traditional Medi-Cal.

This fact sheet explains how to obtain transportation to your medical appointments from your Medi-Cal Managed Care Plan (MCP). The end of this publication discusses how to obtain transportation services if you have Fee-For-Service (FFS) Medi-Cal.

BACKGROUND

Non-Emergency Medical Transportation (NEMT) has long been recognized as a covered Medi-Cal benefit. Effective July 1, 2017, all MCPs must also provide Non-Medical Transportation (NMT) to obtain medically necessary, MCP-covered carved in services AND for carved out services that are not covered under the MCP contract. (See WIC Section 14132(ad)). Services that are not provided through the MCP are said to be “carved out” of managed care. A service is “medically necessary” when it is reasonable and necessary to protect life, prevent significant illness or significant disability, or alleviate severe pain. (WIC Section 14059.5.)

NMT services include transportation to and from a doctor’s visit, the pharmacy or medical supplier to pick up prescriptions, medical equipment or devices, attend to a sick baby in the Neonatal Intensive Care Unit (NICU), or to receive any other Medi-Cal covered service, including mental health and dental services.  (See Medi-Cal's Non-Medical Transportation Benefit.)

As of October 1, 2017, MCPs must also provide NMT for Medi-Cal services that are not covered under the MCP contract (“carved out services”) including, but not limited to, specialty mental health, substance use disorder, dental, and any other services delivered through the Medi-Cal FFS delivery system. (See All-Plan Letter 17-010 Non-Emergency Medical and Non-Medical Transportation Services.)

I. Non-Emergency Medical Transportation (NEMT)

NEMT is a covered Medi-Cal benefit when a member needs to obtain medically necessary services and when prescribed in writing by a physician, dentist, podiatrist, mental health, or substance use disorder provider.

a. How do I know if I qualify for NEMT?

If your medical or physical condition prevents you from using ordinary methods of public or private transportation and transportation is required for obtaining medically necessary services, MCPs are required to provide you medically appropriate NEMT services. (22 CCR Sections 51323(a), (b)(2)(C)). MCPs must provide NEMT for members who cannot reasonably ambulate or are unable to stand or walk without assistance (such as those using a walker or crutches) and ensure door-to-door assistance. At a minimum, MCPs must authorize the lowest cost type of NEMT that meets your medical needs. NEMT services are subject to prior authorization, except for those transferred from an inpatient stay at the acute level of care to an acute care hospital, skilled nursing facility (SNF), or licensed intermediate care facility. (22 CCR Section 51323(b)(2)(C)).

b. What if I need services that are NOT covered by my MCP’s contract?

For Medi-Cal services outside of the MCP contract, the MCP must make its best effort to refer for and coordinate NEMT. MCPs must ensure that there are no limits to receiving NEMT as long as your services are medically necessary and you obtained prior authorization for the NEMT.

c. What if the MCP member is a minor?

If the member is a minor, MCPs must also provide transportation for a parent or guardian. MCPs may arrange NEMT for an unaccompanied minor with the written consent of the minor’s parent or guardian, unless the minor is seeking Minor Consent Medi-Cal services like reproductive care. Before arranging transportation for unaccompanied minors, the MCP must make sure it has received all necessary written consent forms.  Parental consent is NOT required for Minor Consent Medi-Cal services.

d. What types of NEMT services are available to me?

If your medical or physical condition prevents you from using ordinary means of public or private transport and the transportation is required for you to obtain needed medical care, MCPs must provide the following four modes of NEMT transportation:

i. NEMT Ambulance Services for:

  • Transfers between facilities for members who require continuous intravenous (IV) medication, medical monitoring, or observation
  • Transfers from an acute care facility to another acute care facility
  • Transport for members who have recently been placed on oxygen (does not apply to members with chronic emphysema who carry their own oxygen for continuous use)
  • Transport for members with chronic conditions who require oxygen if monitoring is required

ii. Litter Van Services

A litter van is a modified vehicle that is used for the purpose of providing NEMT for passengers with stable medical conditions who require the use of a litter or gurney, and which is not routinely equipped with the medical equipment or personnel required for the specialized care provided in an ambulance. MCPs must provide litter van services if your medical and physical condition does NOT meet the need for NEMT ambulance services, but meets both of the following:

  • Requires that the member be transported in a prone or supine position because he/she is unable to sit for the duration of the transport; AND
  • Requires specialized safety equipment above and beyond what is normally available in passenger cars, taxicabs, or other forms of public transportation. (22 CCR Section 51323(2)(A)(1), (B).)

iii. Wheelchair Van Services

MCPs must provide wheelchair van services when your medical and physical condition does NOT meet the need for litter van services, but meets any of the following:

  • You cannot sit in a private vehicle, taxi, or other form of public transportation for the period of time needed to transport; OR
  • You must be transported in a wheelchair or assisted to and from a residence, vehicle, and place of treatment due to a disabling physical or mental limitation; OR
  • Requires specialized safety equipment above what is typically available in passenger cars, taxis, or other forms of transportation (22 CCR Sections 51323(3)(A)-(C))

You can qualify for wheelchair van transport if you have any of the following conditions AND your doctor submits a signed Physician Certification Statement form (discussed further below):

  • Severe mental confusion
  • Paraplegia
  • Dialysis recipients
  • You have a chronic condition that requires oxygen but do not require monitoring

iv. NEMT by Air

MCPs must provide NEMT by air when it is necessary because of your medical condition or because ground transportation is not practical. Your doctor, dentist, podiatrist, mental health, or substance use disorder provider must submit a written order explaining why air transportation is necessary.

e. NEMT Physician Certification Statement (PCS) Forms

Each MCP has its own PCS form. You can request a form from your doctor by telephone, electronically, in person, or another method established by your MCP. Once your doctor prescribes the form of transportation, the MCP cannot modify the authorization. At a minimum, your doctor must include the following information:

  • Functional Limitations Justification: Your doctor must document your limitations and provide specific physical and medical limitations that prevent you from reasonably ambulating without assistance or transporting by public or private vehicles.
  • Dates of Service Needed: Provide start and end dates for NEMT services up to a maximum of 12 months.
  • Mode of Transportation Needed: Ambulance, litter van, wheelchair van, or air transport.
  • Certification Statement: Your physician must certify that medical necessity was used to determine the type of transportation you need.

II. Non-Medical Transportation (NMT)

MCPs must provide NMT for all Medi-Cal services, including those NOT covered by the MCP contract. Services not covered under the MCP contract include, but are not limited to, specialty mental health, substance use disorder, dental, and any other benefits delivered through FFS.

a. How do I know if I need NMT or NEMT?

NMT does not include transporting those who must be transported by ambulance, litter van, wheelchair van, or air transport. For example, your doctor can prescribe NMT if you currently use a wheelchair but you can ambulate without assistance from the driver. Like NEMT, the request NMT must be the least costly method of transportation that meets your needs.

b. What NMT services are available to me?

  • Round trip transportation by passenger car, taxicab, or any other form of public or private vehicle, including mileage reimbursement for medical purposes when transport is in a private vehicle and arranged by the member and not through a transportation broker, bus passes, taxi vouchers, or train tickets
  • Round trip NMT is available for the following:
    • Medically necessary covered services
    • Picking up drug prescriptions that cannot be mailed directly to you
    • Picking up medical supplies, prosthetics, orthotics, and other medical equipment
  • MCPs must provide NMT in a manner that is physically and geographically accessible to you and consistent with applicable state and federal disability rights laws

c. How do I obtain authorization for NMT services?

MCPs must use the prior authorization process for approving NMT services and reauthorize services every 12 months when necessary. NMT coverage includes transportation costs for you and one attendant to accompany you, subject to prior authorization at the time of the initial NMT request. Like NEMT, MCPs can arrange for NMT for an unaccompanied minor with the parent or guardian’s written consent.

MCPs are obligated to meet timely access standards for health care services. (22 CCR Section 1300.51(d)(H)). This means that there are limits on how long you have to wait to obtain services and any delays because of NEMT or NMT do not make those limits longer. MCPs that have a Knox-Keene license are also required to meet timely access standards contained in 28 CCR Section 1300.67.2.2. For more information on timely access care standards, see publication #5610.01 Medi-Cal Managed Care Time and Distance Standards for Providers, available online: Medi-Cal Managed Care Time and Distance Standards for Providers

d. What services are NOT covered by NMT?

NMT does NOT cover trips to a non-medical location or appointments that are not medically necessary.

e. What are the requirements to authorize NMT by private vehicle?

Your MCP must authorize the use of private vehicle when no other transportation method is reasonably available or provided by the MCP. Before applying for private vehicle use, you must exhaust all other reasonable transportation options and confirm that no other method is available either in person, electronically, or via telephone to your MCP. This can include verifying that you do not have a valid driver’s license or working vehicle available; cannot travel or wait for medical or dental services alone; or you have a physical, cognitive, mental, or developmental limitation.

What can I do if my MCP denies my request for NEMT or NMT?

If your MCP denies your NEMT or NMT request based on medical necessity, level of transportation requested, or refuses to pay for transportation, you can appeal the decision with your MCP. An appeal is a review by your MCP of the denial. (42 CFR Section 438.400(b)). You must file your appeal within 60 days after you receive notice of the denial. For more information on filing an appeal with your MCP, see publication #5606.01 Medi-Cal Managed Care: Appeals and Grievances, available online. Click here to read more about Medi-Cal Managed Care: Appeals and Grievances  In addition, helpful answers to frequently asked questions regarding NEMT and NMT services is available online. Click here for more information on DHCS Transportation Workgroup Frequently Asked Questions (FAQs)

I have FFS Medi-Cal.  Can I still obtain transportation services?

Beginning July 1, 2018, full-scope FFS recipients and pregnant women (during pregnancy and for 60 days postpartum) can access NMT services to and from Medi-Cal covered medical, mental health, substance use disorder, or dental services.  (WIC Section 14132(ad)(1)). Transportation is also covered for one person to go with the Medi-Cal beneficiary when necessary, such as an attendant to accompany an elderly person or for a parent to take their child to the doctor.

To access NMT, call or email the transportation contact from your county. A complete list of county contacts is available online. Click here for a list of NMT County Contacts 1

If you are still unable to access NMT services through your county contact above, send all inquiries to DHCS-Benefits@dhcs.ca.gov with a CC to Raquel.Sanchez@dhcs.ca.gov.  You can also call the San Diego Field Office contact info ((916) 688-6131) for FFS NEMT requests (even if you are not a San Diego County resident).

Finally, if you are still unable to obtain NMT through your county and the DHCS contact above, you have the right to ask for a state hearing. You must file your hearing request within 90 days of receiving a Notice of Action (NOA) denying your transportation. You may request a hearing by phone by calling the State Hearings Division at (800) 743-8525, or in writing by completing the “Request for State Hearing” on the back of your NOA or writing your request on a separate piece of paper. You must include your full name, address, telephone number, the name of the county that denied your transportation request, and a detailed reason why you disagree and want a state hearing. Submit your written request in one of the following ways:

  1. By mail or in person to the county welfare department at the address shown on your NOA.
  2. By mail to the California Department of Social Services – State Hearings Division, P.O. Box 944243, Mail Station 9-17-37, Sacramento, CA 94244-2430.
  3. By fax to (916) 651-2789 or (916) 651-5210.

 

1 Note that this document should be titled NMT not NEMT as it lists information for NMT. – (Return to main document)

 

 

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