California supports one of the largest Medicaid populations in the country with over 14.2 million enrollees. To support the non-medical needs of this population, one of the most critical services offered by Medicaid in California (Medi-Cal) and their managed care health plans is non-emergency medical transportation (NEMT) and non-medical transportation (NMT). However, the same rules of NEMT and NMT that apply in other states may not apply in California.
One of the more unique policies laid out by Medi-Cal is the need for prior authorization for NEMT services. Before taking any NEMT rides, Medi-Cal members are required to get a Physician Certification Statement (PCS) from their care provider that includes details like the function justification (document limitations of the member that make NEMT necessary), appropriate modality for their transport, and the allowed duration of the transportation (up to 12 months). All PCS forms undergo review from the state’s Department of Health Care Services (DHCS) and can’t be changed once prescribed by a care provider.
Given the added complexities around PCS forms, this article will specifically focus on NEMT delivery.
Based on the DHCS All Plan Letter of 2022 about NEMT and NMT, the state’s unique compliance rules and structures mean that there are clear ‘do’s’ and ‘don’ts’ that NEMT brokers can follow to best support their managed care health plan partners.
What NEMT brokers CAN do in supporting managed care health plans
- Align and provide their transportation modalities with the transportation level prescribed by the PCS form.
- Provide transportation with the lowest cost of service that aligns with the member’s needs.
- Provide transportation for all pharmacy prescription needs.
- Provide transportation without a PCS form if the member is being transferred from an emergency room or an acute care hospital to an appropriate inpatient setting, skilled nursing/care facility, or psychiatric healthcare facility.
- Ensure members arrive within 15 minutes of their appointment, and if not, proactively communicate with the Medi-Cal managed care health plan to ensure members don’t miss appointments.
- Allow Medi-Cal managed care health plans oversight to understand how their program is performing in real-time.
- Build a more than sufficient transportation network so that no further supplementation is necessary from the Medi-Cal managed care health plan.
- Have a process shared with the managed care health plan that outlines how they identify specific transportation providers and rides including – driver name, date, time, drop off/pick up locations, and member identification.
- Provide a channel for members to file a grievance about a specific ride including the name of the driver.
- Deliver optimal performance and ride data to ensure program requirements are being met and not requiring corrective action as well as complying with all federal and state regulations.
What NEMT brokers can NOT do in supporting managed care health plans
- Take defined obligations of the Medi-Cal managed care health plan off their plate including monitoring and network providers, grievances, and enrollment of NEMT providers.
- Handle the review and approval of PCS forms from members or care providers.
- Downgrade the modality for transportation outlined in the PCS form.
Considering how much NEMT brokers are able to do for Medi-Cal managed care health plans, it goes to show how helpful they can be as a benefit provider and a partner in helping elevate the level of care for even the most vulnerable of Medicaid beneficiaries.
SafeRide Health’s technology-first approach to NEMT helps Medicaid managed care health plans streamlines many of the day-to-day needs of a NEMT program by providing members with seamless access to care, a customizable platform curated to the plan’s needs, a connected network digitized nationwide, and real-time visibility of ride and program performance. All of these features help give Medi-Cal managed care health plans the peace of mind they need in navigating today’s highly-regulated Medicaid environment.
To learn more about how SafeRide Health elevates NEMT performance in California and helps Medicaid managed care health plans drive member experience, get in touch with us.