SECTION 317:35-3-2. SoonerCare transportation and subsistence

(a)   The Oklahoma Health Care Authority (OHCA) is responsible for assuring that necessary transportation is available to all eligible SoonerCare members who are in need of SoonerCare medical services in accordance with 42 CFR 431.53. The agency contracts with a broker to provide statewide curb to curb coverage for non-emergency transportation under the SoonerRide program. The broker provides the most appropriate and least costly mode of transportation necessary to meet the individual needs of SoonerCare members. As the Medicaid Agency, OHCA is the payer of last resort, with few exceptions. When other resources are available, those resources must first be utilized. Exceptions to this policy are those receiving medical treatment through Indian Health Services and those eligible for the Crime Victims Compensation Act. The agency contracts directly with ambulance and air providers for all other transportation needs for eligible members not provided by SoonerRide. SoonerRide excludes those individuals who are categorized as:

(1)   Qualified Medicare Beneficiaries(QMB)when SoonerCare pays only the Medicare premium, deductible, and co-pay;

(2)   Specified Low Income Medicare Beneficiaries (SLMB)only;

(3)   Qualifying Individuals-1;

(4)   individuals who are in an institution for mental disease (IMD);

(5)   inpatient;

(6)   institutionalized;

(7)   Home and Community Based Waiver members with the exception of the In-home Supports Waiver for Children, the ADvantage Waiver, the Living Choice demonstration, and the Medically Fragile Waiver.

(b)   Members seeking medically necessary non-emergency transportation will be required to contact the SoonerRide reservation center. Contact will be made via a toll-free phone number which is answered Monday through Saturday, 8 a.m. to 6 p.m. Whenever possible, the member is required to notify SoonerRide at least 72 hours prior to the appointment. The member is asked to furnish the SoonerRide reservation center their SoonerCare member number, home address, the time and date of the medical appointment, the address and phone number of the medical provider, and any physical/mental limitations which will impact the type of transportation needed. SoonerRide makes arrangements for the most appropriate, least costly transportation. SoonerRide verifies appointments when appropriate. If the member disagrees with the transportation arranged or denied by SoonerRide, an appeal must be filed with OHCA according to OAC 317:2-1-2. The appropriateness of transportation may be appealed only to the extent that the transportation does not meet the medical needs of the member. Dissatisfaction with the use of public transportation, shared rides, type of vehicle, etc., is not appropriate grounds for appeal. The Oklahoma Health Care Authority's decision is final.

(1)   Authorization for transportation by private vehicle or bus. Transportation by private vehicle or bus is administered through the broker when it is necessary for an eligible member to receive medical services.

(2)   Authorization for transportation by taxi. Taxi service may be authorized at the discretion of the broker.

(3)   Transportation by ambulance (ground, air ambulance or helicopter). Transportation by ambulance is compensable for individuals eligible for SoonerCare benefits when other available transportation does not meet the medical needs of the individual. Payment is made for ambulance transportation to and/or from a medical facility for medical care compensable under SoonerCare.

(4)   Transportation by airplane. When an individual's medical condition is such that transportation out-of-state by a commercial airline is required, approval for airfare must be secured by telephoning the OHCA who will make the necessary flight arrangements.

(5)   Subsistence (lodging and meals). Payment for lodging and/or meals assistance for an eligible member and/or an approved medical escort is provided only when medically necessary in connection with transportation to and from SoonerCare compensable services. The member and/or medical escort must make a reasonable effort to secure lodging at a hospital or non-profit organization. The Oklahoma Health Care Authority (OHCA) has discretion and final authority to approve or deny any lodging and/or meal services.

(A)   Lodging and/or meals are reimbursable when prior approved. Payment for lodging and/or meals is limited to a period of up to 24 hours prior to the start of the member's medical services and up to 24 hours after the services end. Lodging is approved for the member and/or one approved medical escort. The following factors may be considered by OHCA when approving reimbursement for a member and/or one medical escort:

(i)   travel is to obtain specialty care; and

(ii)   the trip cannot be completed during SoonerRide operating hours;

(iii)   the trip is 100 miles or more from the member's residence, as listed in the OHCA system, to the medical facility; and/or

(iv)   the member's medical treatment requires an overnight stay, or the condition of the member discourages traveling.

(B)   When a member is not required to have a PCP or when a PCP referral is not required to obtain a SoonerCare covered service, a member may go to any provider they choose but SoonerCare will not reimburse for transportation, lodging, or meals if the distance is beyond what is considered the nearest appropriate facility.

(C)   Meals will be reimbursed if lodging criteria is met, and duration of trip is or exceeds 18 hours.

(D)   Reimbursement for meals is based on a daily per diem and may be used for breakfast, lunch or dinner, or all three meals, whichever is required.

(E)   During inpatient or outpatient medical stays, lodging and/or meals services are reimbursed for a period of up to 14 days without prior approval; stays exceeding the 14 day period must be prior approved. A member may not receive reimbursement for lodging and/or meals services for days the member is an inpatient in a hospital or medical facility.

(F)   For eligible members in the Neonatal Intensive Care Unit (NICU) a minimum visitation of 6 hours per day for the medical escort is required for reimbursement of lodging and/or meals services. Non-emergency transportation services for medically necessary visitation may be provided for eligible medical escorts.

(G)   Lodging must be with a SoonerCare contracted Room and Board provider, when available, before direct reimbursement to a member and/or medical escort can be approved. If the lodging provider provides meals the member and/or medical escort is not eligible for separate reimbursement and may not seek assistance for meals obtained outside of the contracted Room and Board provider facility. If lodging and/or meal assistance with contracted Room and Board providers is not available, the member and/or medical escort may request reimbursement assistance by submitting the appropriate travel reimbursement forms. The travel reimbursement forms may be obtained by contacting SoonerCare Care Management division. Any lodging and/or meal expenses claimed on the travel reimbursement forms must be documented with the required receipts and medical records to document the lodging and/or meals criteria have been met. Reimbursement will not exceed established state per diem amounts. The OHCA has discretion and the final authority to approve or deny lodging and/or meals reimbursement.

(6)   Escort assistance required. Payment for transportation and lodging and/or meals of one medical escort may be approved if the service is required. If the Oklahoma Department of Human Services (OKDHS) removes a child from his/her home, a court must appoint a temporary guardian. During this time the temporary guardian is eligible for escort related lodging and/or meals services. It is the responsibility of the OHCA to determine this necessity. The decision should be based on the following circumstances:

(A)   when the individual's health or disability does not permit traveling alone; and

(B)   when the individual seeking medical services is a minor child.

[Source: Added at 12 Ok Reg 753, eff 1-6-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3133, eff 7-27-95; Amended at 13 Ok Reg 911, eff 8-1-95 (emergency); Amended at 13 Ok Reg 2537, eff 6-27-96; Amended at 14 Ok Reg 779, eff 11-25-96 (emergency); Amended at 14 Ok Reg 538, eff 12-24-96 (emergency); Amended at 14 Ok Reg 787, eff 1-24-97 (emergency); Amended at 14 Ok Reg 1805, eff 5-27-97; Amended at 15 Ok Reg 1117, eff 1-6-98 (emergency); Amended at 15 Ok Reg 1559, eff 5-11-98; Amended at 15 Ok Reg 3679, eff 5-18-98 (emergency); Amended at 16 Ok Reg 60, eff 9-11-98 (emergency); Amended at 16 Ok Reg 162, eff 10-14-98 (emergency); Amended at 16 Ok Reg 1438, eff 5-27-99; Amended at 16 Ok Reg 3363, eff 6-1-99 (emergency); Amended at 16 Ok Reg 3502, eff 7-16-99 (emergency); Amended at 17 Ok Reg 231, eff 9-7-99 (emergency); Amended at 17 Ok Reg 1212, eff 5-11-00; Amended at 17 Ok Reg 3517, eff 8-1-00 (emergency); Amended at 18 Ok Reg 114, eff 11-1-00 (emergency); Amended at 18 Ok Reg 269, eff 10-7-00 (emergency); Amended at 18 Ok Reg 506, eff 1-1-01 (emergency); Amended at 18 Ok Reg 784, eff 1-23-01 (emergency); Amended at 18 Ok Reg 1139, eff 5-11-01; Amended at 20 Ok Reg 2775, eff 7-1-03 (emergency); Amended at 20 Ok Reg 2901, eff 7-1-03 (emergency); Amended at 21 Ok Reg 2234, eff 6-25-04; Amended at 23 Ok Reg 817, eff 3-9-06 (emergency); Amended at 23 Ok Reg 2580, eff 6-25-06; Amended at 24 Ok Reg 93, eff 8-2-06 (emergency); Amended at 24 Ok Reg 943, eff 5-11-07; Amended at 24 Ok Reg 2115, eff 6-25-07; Amended at 29 Ok Reg 1147, eff 6-25-12; Amended at 30 Ok Reg 1244, eff 7-1-13; Amended at 32 Ok Reg 1126, eff 8-27-15]