Presentation on theme: "Gate Keeping for NET Providers"— Presentation transcript:
1 Gate Keeping for NET Providers Presenter: Mike Bolin, AHCA AdministratorBureau of Medicaid Services
2 What is Gate Keeping?Ensuring the transportation service is appropriate and medically necessary, while employing the most efficient and cost effective means available.
3 Eligibility Determination Determined by interview when Medicaid recipient requests servicesRule Out:-Alternate resources for transport-Available public transportationIs the trip Medicaid compensable?CTD Medicaid Beneficiary Intake Form on website:
4 Is This Trip Medicaid Compensable? Contact the medical service provider, or the local area Medicaid office and ask if the appointment is for a Medicaid compensable service; or, Verify with medical provider if the recipient has an appointment.
5 Gate Keeper Responsibilities Accept requests for Transportation ServicesDirectly from recipients;Adult family members on behalf of minor recipients;Guardians responsible for recipients; andProviders/Licensed Health Care Professionals on behalf of recipients.
6 Gate Keeper Responsibilities Determine if there is a reason why the recipient cannot utilize his/her own transportation (such as the vehicle needs repair, out of gas, etc.).If the recipient is unable to utilize his/her transportation, the CTC/STP may assist the recipient in utilizing his/her own means of transport (repair vehicle, supply gas, etc.).
7 Gate Keeper Responsibilities Determine if a member of the recipient’s household can reasonably (i.e., both willing and able) provide transportation.Services cannot be denied because transportation may be available from a source outside of the recipient’s household.Relatives or household members may not be reimbursed for recipient transportation.Exceptions will be made in the case of foster parents
8 Gate Keeper Responsibilities Use public transportation where available and when medically appropriate for recipients who are able to understand signs and directions.
9 Gate Keeper Responsibilities Nursing facilities, group homes, and personal care homes may have vehicle(s) intended to facilitate the general administration of the facility and not necessarily to provide for resident transportation.The availability of a vehicle for resident transportation must be determined on a case-by-case basis. If not available for resident transportation at the time required, as represented by the nursing facility administrator, such vehicles must be excluded as an alternate form of available transportation.
10 Gate Keeper Responsibilities Consider each request for NET services separately, regardless of any previous denials of service.
11 Out of State Transportation AHCA reviews all requests for out of state services to determine if the services are necessary (e.g., there is no one in Florida who can treat the recipient). CTC/STP will determine the most appropriate and cost effective means of transportation to and from.
12 Medicaid Compensable Trips It is not appropriate to reschedule a trip for the following types of treatment:Urgent Care;Dialysis;Chemotherapy;Wound Treatment;Behavioral Health Care;Prescribed Pediatric Extended Care centers (PPECs);Other trip that AHCA determines is in the best interests of the Medicaid recipient.