441—78.13 (249A) Nonemergency medical transportation. Nonemergency transportation to receive medical care, including any reimbursement of transportation expenses incurred by a Medicaid member, shall be provided through the broker designated by the department pursuant to a contract between the department and the broker, as specified in this rule.
	 78.13(1) Member request. When a member needs nonemergency transportation, one way or round trip, to receive medical care provided by the Medicaid program, including any reimbursement of transportation expenses incurred by the member, the member must contact the broker in advance. The broker shall establish and publicize the procedures for members to request transportation services. The broker is required to provide transportation within 72 hours of a request only if receipt of medical care within 72 hours is medically necessary.
	 78.13(2) Necessary services. Transportation shall be provided only when the member needs transportation to receive necessary services covered by the Iowa Medicaid program from an enrolled provider, including transportation needed to obtain prescribed drugs.
	 78.13(3) Access to free transportation. Transportation shall be provided only if the member does not have access to transportation that is available at no cost to the member, such as transportation provided by volunteers, relatives, friends, social service agencies, nursing facilities, residential care centers, or any other source. Exception:	If a prescribed drug is needed immediately, transportation will be provided to obtain the drug even if free delivery is available.
	 78.13(4) Closest medical provider. Transportation beyond 20 miles (one way) shall be provided only to the closest qualified provider unless:
	  a.   	 The difference between the closest qualified provider and the provider requested by the member is less than 10 miles (one way); or
	  b.   	 The additional cost of transportation to the provider requested by the member is medically justified based on:
	 (1) 	 A previous relationship between the member and the requested provider,
	 (2) 	 Prior experience of the member with closer providers, or
	 (3) 	 Special expertise or experience of the requested provider.
	 78.13(5) Coverage. Based on the information provided by the member and the provisions of this rule, the broker shall arrange and reimburse for the most economical form of transportation appropriate to the needs of the member.
	  a.   	 The broker may require that public transportation be used when reasonably available and the member’s condition does not preclude its use.
	  b.   	 The broker may arrange and reimburse for transportation by arranging to reimburse the member for transportation expenses. In that case, the member shall submit transportation expenses to the broker on Form 470-0386, Medical Transportation Claim, or an equivalent electronic form.
	  c.   	 When a member is unable to travel alone due to age or due to physical or mental incapacity, the broker shall provide for the expenses of an attendant.
	  d.   	 The broker shall provide for meals, lodging, and other incidental transportation expenses required for the member and for any attendant required due to the age or incapacity of the member in connection with transportation provided under this rule.
	 78.13(6) Exceptions for nursing facility residents.
	  a.   	 Nonemergency medical transportation for residents of nursing facilities within 30 miles of the nursing facility (one way) shall not be provided through the broker but shall be the responsibility of the nursing facility.
	  b.   	 Nonemergency medical transportation for residents of nursing facilities beyond 30 miles from the nursing facility (one way) shall be provided through the broker, but the nursing facility shall contact the broker on behalf of the resident.
	 78.13(7) Grievances. Pursuant to its contract with the department, the broker shall establish an internal grievance procedure for members and transportation providers. Members who have exhausted the grievance process may appeal to the department pursuant to 441—Chapter 7 as an “aggrieved person.” For transportation providers, the grievance process shall end with binding arbitration, with a designee of the Iowa Medicaid enterprise as arbitrator.
This rule is intended to implement Iowa Code section 249A.4.
[ARC 8344B, IAB 12/2/09, effective 12/1/09; ARC 8643B, IAB 4/7/10, effective 3/11/10; ARC 8994B, IAB 8/11/10, effective 10/1/10]