C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-113, subsec. 144-101-II-113.06

Current through 2024-51, December 18, 2024

Subsection 144-101-II-113.06 - POLICIES AND PROCEDURES

113.06-1Broker Agreements

A. Broker(s) are required to have a current executed MaineCare Provider Agreement with the Department.

B. Broker(s) are required to have a current executed Business Associate Agreement with the Department.

C. Brokers are required to have a current executed contract for NET services with the Department.

113.06-2Transportation Network

A. Service Agreements. Each Brokermust have signed Service Agreements with agencies providing transportation services. Service Agreements are not required for volunteers, family and friends, Public Transportation, taxis, or other ad-hoc transportation use. All Service Agreements shall be submitted to the Department for review. The Department shall notify the Broker if the Service Agreement is not approved and include the reasons why it is not approved. The Broker must provide the Department with copies of all fully executed Service Agreements.

B. EachBrokermust establish a network of Transporters to deliver NET services to eligible Members who live in its regions which is sufficient to provide adequate access to all covered services. The Broker must secure sufficient Transporter resources (numbers and types of vehicles, drivers, and Attendants including requirements for wheelchair accessibility) under Service Agreements so that the failure of any Transporter to perform will not impede the ability of the Broker to provide NET services.

C. Each Brokermust insure adequate transportation at all times, including holidays.

D. Each Brokermust notify the Department (or its agent) within 24 hours of knowledge of a termination of a Service Agreement. Within 72 hours of any such termination, the Broker shall have a plan for replacement of coverage for Members served pursuant to that Service Agreement.

113.06-3 Assignment of Members to Brokers

The Department will notify Members by written notice of the name, address, phone number, and other contact information regarding the Broker that has been assigned to them.

113.06-4 Verification of Member Eligibility

A. As set forth in Section 113.02, the Broker will be responsible for receiving and processing requests for NET services from MaineCare Members who reside in its assigned region(s). Any Members who must reside out of state due to medical reasons, as approved by the Department, will be assigned to the Broker in the region most geographically proximate to their physical residences. The Broker is responsible for verifying Member MaineCare eligibility. The Broker may use one (1) of four (4) options available to verify Member eligibility:

1. Access this information via the MaineCare web portal;

2. Use automated telephone verification;

3. Reference the eligibility file provided by the Department; or

4. Additionally, if necessary, the Broker may contact a Departmental provider services agent to verify eligibility. The Broker must ensure that it can verify eligibility at all times.

B. Specific service eligibility: Each Brokerwill be responsible for verifying the service eligibility of the Member for the MaineCare service to which the Member is being transported. Some Members may have restrictions on the type and amount of covered MaineCare services they may receive (e.g. a visit cap on a particular type of medical appointment).

Additionally, Members have varying levels of eligibility for services. In some cases the Broker may need to determine the type of eligibility a Member has (e.g. full MaineCare benefit, Home and Community Based Services (HCBS) benefits, etc.) to verify that the requested trip is to an authorized service for that Member.

113.06-5 Authorization and Verification of NET Services

A. The Broker will assess the Member's eligibility for transportation services. This assessment will include ensuring:

1. That the transportation is to and/or from a MaineCare covered service. This may include transportation to non-medical services as indicated on an approved plan of care for HCBS waiver Members;

2. That the Member has no other appropriate means of transportation available. Members are considered to have no other appropriate means of transportation if they are unable to safely rely on themselves, a household member, friend, public transit or other means to access MaineCare-covered services, without undue financial hardship and/or substantial interference with family or friends' work or other obligations; and

3. That the transportation is to and/or from the nearest appropriate provider of care or meets one of the listed exceptions.

B. Validity of Information

Except for these required verifications, the Broker will accept as valid the information provided verbally by the Member, or person speaking on behalf of the Member when determining the need for NET services, unless the Brokers have cause to doubt the validity of said information.

If the Broker has cause to doubt the validity of the information provided by or on behalf of the Member, the Broker may require documentation to confirm the information as necessary.

If the Member refuses to cooperate in determining status of MaineCare eligibility, or refuses to provide the documentation requested to determine eligibility for NET services, the Member can be denied services.

C. Residence in NET Service Region

The Broker is responsible for ensuring that NET services are provided to MaineCare Members who require medical or HCBS waiver services, reside within the Broker's region and have no other means of accessing those services. The Broker is not responsible for arranging MaineCare NET services for MaineCare Members who reside outside the region for which the Broker holds a valid contract unless the Member resides out of state for medical reasons. In that case the Member will be assigned to the Broker in the region most geographically proximate to the Member's residence. The Broker will arrange travel to and from medically necessary services in other regions when the eligible MaineCare Member who is being transported resides within the Broker's region.

D. Transportation Services to HCBS Waiver Services

When HCBS waiver Members or their authorized representatives request transportation to HCBS waiver services, the Broker must verify that the Member is authorized to receive transportation under the HCBS waiver, and that the HCBS waiver service to which the Member is requesting transportation is a MaineCare-covered service (e.g., employment specialist services, adult day health services, etc.).

1. For Members with Intellectual Disabilities and Autism Spectrum Disorders receiving Home and Community or Support Benefits under Sections 21 or 29 of the MaineCare Benefits Manual, the Broker will contact the Member's assigned case manager to confirm that the service or activity to which the Member is requesting transportation is a covered HCBS waiver service under the Member's plan of care.

2. For elderly Members and those with physical disabilities, the Broker will contact the designated Service Coordination Agency to confirm that the service or activity to which the Member is requesting transportation is a covered HCBS waiver service under the Member's plan of care. See MaineCare Benefits Manual, Chapter II, Section 19.

3. For Waiver Services for Children with Intellectual Disabilities or Pervasive Developmental Disorders (MBM Chapter II, Section 32), the Broker will contact the Member's assigned case manager to confirm that the service or activity to which the Member is requesting transportation is a covered HCBS waiver service under the Member's plan of care.

4. For Members with Other Related Conditions receiving Home and Community Benefits under Section 20 of the MaineCare Benefits Manual or for Members with Brain Injury receiving Home and Community Benefits under Section 18 of the MaineCare Benefits Manual, the Broker will contact the Member's assigned care coordinator to confirm that the service or activity to which the Member is requesting transportation is a covered HCBS waiver service under the Member's plan of care.

5. Additional waiver services may be initiated by the Department during the course of the NET contract. The Broker will be given specific instructions for verifying eligibility and covered services at the time the waiver is initiated.

113.06-6 Determination of Mode of Transportation

The Broker may arrange for non-emergency transportation by:

A. Negotiating Service Agreements with qualified Transporters;

B. Entering into Service Agreements with federally funded and/or fixed route transit;

C. Providing tokens, vouchers or passes to Members, and to Escorts when requested, to cover the fare for federally funded, established public, or private transit service which is available when the Member has the capacity to use such service;

D. Providing mileage reimbursement to Members, family and/or friends to transport MaineCare Members;

E. Entering into Service Agreements with commercial taxi services to supplement the Broker's NET services;

F. Use of commercial taxis; and

G. Other methods, including utilizing family, friends, and volunteers, if permitted by federal and state law.

In all cases, the Broker determines the mode of transportation used that meets the Member's needs.

113.06-7 Nearest Appropriate HealthCare or Waiver Service Provider

NET is generally limited to transporting the Member to MaineCare providers that are geographically proximate to the Member. It is neither efficient nor economical to transport a Member a lengthy distance to a MaineCare provider when there are qualified and appropriate providers located closer to the Member. Each Broker shall develop procedures ensuring that transportation is provided to medical or waiver service providers that are geographically proximate to the Member.

A. A MaineCare provider will be considered a nearest appropriate provider if the distance between the Member's residence and the provider location is less than or equal to:

1. 30 Miles for non-pharmacy or waiver service providers in Urban areas.

2. 50 Miles for non-pharmacy medical or waiver service providers in Rural areas.

3. 15 Miles for pharmacies in Urban areas.

4. 30 Miles for pharmacies in Rural areas.

B. For all non-urgent care, regardless of the provider's geographic proximity to the Member, Members must call or contact the Broker at least two (2) business days in advance of their appointment to receive transportation services.

For an urgent trip or for other good cause, there is no waiting period.

C. The Broker(s) shall arrange for transportation beyond these mileage limits when any of the following conditions exist:

1. The Member does not have access to an appropriate provider within the mileage limits;

2. The Member's Primary Care Provider has referred the Member to a specific provider whose location is beyond the mileage limit;

3. A specific medical or waiver service provider is designated in the Member's Plan of Care for HCBS services whose location is beyond the mileage limit;

4. The Member requests NET to a medical or waiver service provider with whom the Member has had an ongoing relationship for at least one (1) year and a change of provider would be detrimental to the Member's care. Such determination is made by the Member's MaineCare provider.

D. These mileage limits may be extended if necessary; but in no case may they be reduced.

E. All requests for transportation to out of state destinations must be prior authorized by the Department.

113.06-8 Limit on Self-Referral and Certain Relationships

The Broker may operate as a Transporter and Broker. However, a Broker who also operates as a Transporter may not show preference towards itself in the scheduling of trips and may act as a Transporter only when it is the most cost effective means of appropriate transportation available. No more than 25% of trips shall be self-referred unless approved in advance by the Department. Such approval shall be contingent on demonstrating insufficient network adequacy if the limit is not exceeded.

A. A trip is considered self-referred when the vehicle used to transport the Member is owned and/or operated by the Broker or if the same company that owns and operates the vehicle has an ownership interest in the Broker. The self-referral rate is calculated monthly.

B. In addition, the Broker shall not knowingly have a relationship with the following:

1. An individual who is debarred, suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation, 48 C.F.R. 1 et seq. or from participating in non-procurement activities under regulations issued under Executive Order No.12549 or under guidelines implementing Executive Order No. 12549.

2. An individual who is an affiliate, as defined in the Federal Acquisition Regulation, of an individual who is debarred, suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation, 48 C.F.R. 1 et seq. or from participating in non-procurement activities under regulations issued under Executive Order No.12549 or under guidelines implementing Executive Order No. 12549.

3. For purposes of Section 113.06-8(B), "relationship" is described as follows:

a. A director, officer, or partner of the Broker;

b. A person with beneficial ownership of five percent or more of the Broker's equity; or

c. A person with an employment, consulting, or other arrangement with the Broker obligations under its contract with the State.

113.06-9 Timely Access Requirements

A. The Broker(s) must meet the following minimum timely access to service delivery standards:

1. The Broker must make NET services available for Members 24 hours a day, 7 days a week, when transportation to a MaineCare covered service is medically necessary;

2. The Broker must establish mechanisms to ensure that its network of Transporters complies with the timely access requirements;

3. The Broker must regularly monitor its network to determine compliance with timely access;

4. The Broker must take corrective action if there is a failure to comply with timely access and notify the Department of any corrective action undertaken;

5. If the Broker's network is unable to provide transportation to MaineCare covered services to an eligible Member, the Broker must adequately and timely provide transportation utilizing Transporters outside of the Broker's network for as long as the Broker's network is unable to provide the needed transportation;

6. In the event that a trip pickup will not be made On Time, the Broker, or its designated representative, must contact and inform the Member. Making such contact does not negate the pickup being considered Late; and

7. Drivers must wait no less than 10 minutes beyond the scheduled pickup time if the Member is not at the scheduled Point of Origin prior to service. The driver must contact the Broker, or Broker's designated representative, if a Member has not presented within 10 minutes of the scheduled pickup time before the driver may leave the Point of Origin.

113.06-10 Urgent Trips

Brokers must provide same day trips for Members who have urgent medical needs that do not require emergency treatment. This includes:

A. Urgent care, defined as a need, as assessed by the medical provider, for the Member to be seen within 48 hours;

B. Post-surgical and/or medical follow-up care specified by a health care provider to occur in fewer than forty eight hours;

C. Imminent availability of an appointment with a specialist when the next available appointment would require a delay of two weeks or more;

D. Trips to acquire prescription medication, when defined as urgent by the medical provider;

E. The result of administrative or technical delay caused by the Broker and requiring that an appointment be rescheduled; and

F. Hospital discharges.

113.06-11 Standing Orders

A. Standing Orders may be put in place for recurring or repetitive trips that occur one (1) or more days a week with the same Point of Origin, destination and return. Examples of services treated as Standing Orders include, but are not limited to: trips to dialysis, methadone treatment, adult day health care, day support, and supported employment.

B. The necessity for a Standing Order for a Member must be re-affirmed by the Member's Broker at least once every 90 days.

113.06-12 Transporting MaineCare Members With Non-MaineCare Passengers

Unless otherwise specified in this Section, non-MaineCare Members may share rides with Members only if the fare or rate paid to the Transporter for non-Member riders is not less than the amount paid for Members. Medicaid shall not supplement or supplant other funding sources. If there is no funding/payment to pay for the non-Member's ride, the individual shall not be permitted to share a ride with a Member.

113.06-13Escorts and Attendants

The Broker(s) must allow, without charge to the Escort, Member, or the Department, one (1) Escort to accompany a Member or group of Members who are blind, deaf, have an intellectual disability, have Autism Spectrum Disorder, have a brain injury, are less than 21 years of age, or as otherwise determined by the Department staff as needing an Escort, to a covered service.

The Broker must arrange with the Transporter for the provision of one Attendant during transport when, in the judgment of the Broker, considering all known factors or as required by the licensed MaineCare provider, it is necessary to have an adult aide on a trip to assure the safety of all passengers. Neither the Member nor the Department may be charged for the use of attendants.

113.06-14Transport of Minors

A. Unaccompanied Minors

Children under the age of sixteen (16) shall not be transported without an adult Escort, except when:

1. The Broker is in possession of a consent form, signed by the legal parent or guardian of the child, authorizing the Broker to provide transportation to the unaccompanied minor. The consent form shall be valid for a period of up to twelve months; or until revoked by the legal parent or guardian; or

2. The minor requests transportation to a service deliverable without parental consent, only if allowed by state and/or federal law.

B. Children Under the Age of 12

For children under the age of twelve (12), parental consent must include specific approval for the type of transportation utilized to convey the child. In providing transportation to children under the age of 12, in addition to the general requirements for unaccompanied minors set forth above, the following requirements apply:

1. At the time of scheduling, the Brokermust confirm that an adult at the drop off location will be available to take responsibility for the minor. It is sufficient to note that an employee, volunteer, or other associate of the medical or waiver service provider will be available; a specific named employee is not required.

2. Upon reaching the destination, the driver shall consider all circumstances in determining if the driver will accompany the minor into the drop off location. Under no circumstances shall the driver leave the vehicle unattended if:

a. There are other riders who would remain in the vehicle; or

b. Leaving the vehicle unattended would create a risk to public safety.

3. Should the driver determine it unsafe to leave the vehicle, the driver, Transporter, or Broker shall contact the medical or waiver service provider requesting that an authorized adult come to the vehicle to take responsibility for the child.

4. Whether the driver accompanies the child into the building, or an employee, volunteer, or other associate comes to the vehicle, the driver shall confirm that the person is authorized to take responsibility for the minor and agrees to do so. It is not sufficient to inform a receptionist that the child is present without confirming that the medical service provider and/or its staff are taking responsibility for the child. If the driver cannot verify that any person is authorized to take responsibility, the driver shall not leave the child with that individual.

5. In the event that no verified and authorized adult is available to take responsibility for the child; the Broker and Transporter will arrange for safe transportation of the child to a parent or guardian.

6. The Broker and Transporter may create additional policies and procedures to ensure the safe transportation of unaccompanied minors.

113.06-15Related Travel Expenses

Brokers must reimburse Related Travel Expenses, such as overnight lodging and meals, at the current State rates and under the current State limitations as addressed in section 10.90.20 of the State Administrative and Accounting Manual (SAAM) for the State of Maine, except in any exceptional circumstances where adherence to the maximum limits would effectively prohibit the Member from being able to access MaineCare-covered services. The Department shall not be responsible for providing reimbursement to the Brokers for Related Travel Expenses.

113.06-16Maine Federally Recognized Native Tribes Requirements

Brokers are required to enter into Service Agreements with any Federally Recognized Native Tribe that resides within the Brokers' regions, would like to be a Transporter, and that meets the driver and vehicle requirements and all other applicable requirements set forth in the Brokers' contracts with the Department. The Department will work with the Tribe and the Broker to ensure that the agreed upon, negotiated rates are adequate and reasonable given other area rates and the cultural expertise offered by the Tribe. Brokers must pay Tribal Transporters rates that are not less than the level and amount of payment that would be made if the Transporters were not Tribal Transporters.

113.06-17Requirements for Drivers and Attendants

EachBroker shall establish a written oversight procedure that ensures all drivers and Attendants operating under a Service Agreement with the Broker:

A. Have a current valid driver's license to operate the transportation vehicle to which they are assigned;

B. Are competent in their driving habits (if a driver);

C. Have no more than two (2) chargeable accidents or moving violations in the previous three (3) years;

D. Have not had their driver's license suspended or revoked within the last five (5) years. This excludes individuals whose cause for license suspension is for non-payment of child support (once the courts release the individual and such release can be verified and the individual remains in good standing for a minimum of ninety (90) days). At any point should the individual's status change and he or she be in arrears of child support payment(s), said driver's approval would be revoked permanently;

E. Cannot be convicted of two (2) moving violations and/or accidents related to NET services, during the course of the Service Agreement, where the driver was at fault.

F. Attend training in patient assistance techniques such as the Community Transportation Association's PASS program, defensive driving, customer service, and cultural & disability sensitivity. Training shall be provided to all drivers and Attendants who are not currently certified in any curriculum. Training must be conducted within 30 days of the Transporter beginning service under a Service Agreement and within 30 days of hiring for drivers and Attendants hired during the term of the Service Agreement;

G. Are prohibited from wearing headphones or earpieces, except that a driver may wear a single earpiece if it is part of the Transporter's two way communication system;

H. Are prohibited from using hand-held cellular devices or texting while driving. All cellular use is prohibited while the vehicle is in motion unless the driver is using a headset and communicating with the Broker, Transporter, or calling emergency services;

I. Must wear identification badges that are easily visible and legible. These badges must identify the name of the Transporter as well as the name of the driver or Attendant;

J. Are certified in First Aid and CPR. Such certification must be achieved by the driver or Attendant within 60 days of the first date of operations under the Service Agreement;

K. Are courteous, patient, and helpful to all passengers;

L. Are neat and clean in appearance;

M. Do not engage in any behavior or practices that may subject the Broker to charges of discrimination against protected groups;

N. Are not known abusers of alcohol or known consumers of narcotics or drugs/medications that would endanger the safety of Members. If the Transporter or Broker suspects a driver of driving under the influence of alcohol, narcotics, or drugs/medications that would endanger the safety of Members, the Transporter or Broker shall immediately remove the driver from providing service to Members;

O. Do not smoke in any vehicle used to provide NET services. Drivers and Attendants shall not smoke at any time when they are in the presence of any Member;

P. Ensure that all passengers are secured with the proper restraints (seatbelts, wheelchair restraints and tie downs, child safety seats, etc.) and assist Members as needed prior to putting the vehicle in motion;

Q. Assist Members, including with the movement, securing, and storage of mobility assistance devices. The driver will ensure all such devices are properly secured before putting the vehicle in motion;

R. Meet the following requirements regarding previous criminal convictions:

1. If a person has been convicted of a Class A, B, or C crime under Maine law, or has been convicted of a felony or its equivalent under another state or under federal law, and that conviction was for a violent crime or a crime of a sexual nature, that person shall not be allowed to provide services under a Service Agreement for a minimum of ten (10) years after the completion of that person's sentence. After 10 years, in the event that the individual reapplies to provide services under a Service Agreement, the Transporter shall notify the Broker regarding same and obtain its approval prior to hiring the individual.

2. If a person has been convicted of a Class A, B, or C crime under Maine law, or has been convicted of a felony or its equivalent under another state or under federal law, and that conviction was for a crime related to drugs, that person is prohibited from operating a vehicle being used to transport Members and from having unsupervised contact with a Member for a minimum of seven (7) years after the completion of that individual's sentence. After 7 years, in the event that the individual reapplies to provide services under a Service Agreement, the Transporter shall notify the Broker regarding same and obtain its approval prior to hiring the individual.

3. If a person has been convicted of a Class A, B, or C crime under Maine law, or has been convicted of a felony or its equivalent under another state or federal law within the previous five (5) years, and that conviction was not for a crime related to drugs, a violent crime, or a crime of a sexual nature, that person is not prohibited from operating a vehicle being used to transport Members, nor from having unsupervised contact with Members, so long as the Broker approves.

4. If a person has been convicted of a Class D or E crime under Maine law, or has been convicted of a misdemeanor or its equivalent under another state or federal law, and the conviction was for a violent crime, a crime related to drugs, or crime of a sexual nature, that person shall be allowed to serve in a position with unsupervised contact with Members only with the approval of the Broker.

113.06-18 Monitoring and Enforcement of Driver and Attendant Requirements

EachBroker must have written oversight procedures for ensuring that any Transporters utilized meet all driver and vehicle Attendant requirements as stated in the NET contract between the Broker and the Department. The Broker is not responsible for enforcing these requirements for drivers of Public Transportation or commercial taxis used on an ad hoc basis operating outside of a Service Agreement with the Broker as stated in contract with the Department.

The Broker may establish additional qualifications, which will be approved by the Department prior to implementation.

The Broker must have procedures in place to verify and document that Transporters meet the requirements as stated in the NET contract with the Department.

113.06-19 Wheelchairs

Vehicles used to transport wheelchair passengers must meet ADA requirements, including but not limited to, the following:

A. Maintain a floor-to-ceiling height clearance of at least fifty-six (56) inches in the passenger compartment.

B. Must have wheelchair lift or manual ramp. A hydraulically or electro-mechanically powered wheelchair lift mounted so as not to impair the structural integrity of the vehicle or a secure ramp will satisfy this requirement so long as the Member is capable of utilizing such a lift or ramp.

C. For vehicles equipped with a powered wheelchair lift, the vehicle must have an engine-wheelchair lift interlock system which requires that the vehicle's transmission be placed in park and the emergency brake engaged to prevent vehicle movement when the lift is deployed.

D. Wheelchair Restraint System: For each wheelchair position, the vehicle shall be equipped with a wheelchair securement device (i.e. "tie-down") that complies with applicable ADA standards.

E. The vehicle utilized may accommodate scooter-type wheelchairs. Passengers utilizing these devices may be requested to dismount from the device and be seated in a passenger seat. Alternately, the rider may remain on the device, with the device secured with tie-downs and the rider secured with a separate floor seatbelt.

113.06-20Telephone Call Centers

Each Broker must each establish and maintain a callcenter so that Members may conveniently schedule needed transportation andcontact the Broker regarding potential problems, Complaints, and questions as necessary. Detailed information regarding call center services, hours of operation, telephone numbers, questions and Complaints can be obtained by contacting the Broker assigned to each region.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-113, subsec. 144-101-II-113.06