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Gate Keeping for NET Providers

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Presentation on theme: "Gate Keeping for NET Providers"— Presentation transcript:

1 Gate Keeping for NET Providers
Presenter: Mike Bolin, AHCA Administrator Bureau 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 services Rule Out:-Alternate resources for transport -Available public transportation Is 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 Services Directly from recipients; Adult family members on behalf of minor recipients; Guardians responsible for recipients; and Providers/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.

13 Medicaid Transportation Specialists 5/22/12
Escambia Franklin Dixie Gilchrist Union Bradford Pinellas Santa Rosa Okaloosa Walton Holmes Jackson Bay Gulf Washington Area 1 Area 2A Calhoun Liberty Gadsden Leon Wakulla Madison Taylor Jefferson Area 2B Hamilton Suwannee Columbia Lafayette Levy Alachua Putnam Marion Sumter Citrus Lake Hernando Area 3A Baker Nassau Duval Clay St. Johns Area 4 Flagler Volusia Area 5 Pasco Seminole Orange Osceola Brevard Area 7 Hillsborough Polk Manatee Hardee Sarasota Charlotte Collier Lee DeSoto Glades Hendry Indian River St. Lucie Palm Beach Monroe Area 10 Area 8 Area 9 Area 11 Area 6 Highlands Martin Dade Broward Okeechobee Area 4-DeWeece Ogden Jacksonville, FL Area 1-John Vinski Pensacola, FL Area 3B-Donna Mitchell Ocala, FL Area 3B Area 2A-Faye Basiri Panama City, FL Area 7-Benjamin Akinola Orlando, FL Area 2B-Faye Basiri Tallahassee, FL Area 9-Cindy Barnes W. Palm Beach, FL Area 3A-Alana McKay Alachua, FL Area 5-Jim Callaway St. Petersburg, FL Area 10-Karen Porter Ft. Lauderdale, FL Medicaid Transportation Specialists 5/22/12 Area 6-Donnette Waul Tampa, FL Area 11-Maria Hernandez Doral, FL Area 8-Joseph Martinez Fort Myers, FL

14 Questions? Thank You! Enjoy the Conference!

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