MATP EXECUTIVE SUMMARY - Medical Assistance Transportation

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					                     Commonwealth of Pennsylvania
                      Department of Public Welfare
                 Office of Medical Assistance Programs




                 MEDICAL ASSISTANCE
                    TRANSPORTATION
                           PROGRAM



                       INSTRUCTIONS
                            &
                      REQUIREMENTS




MATP Rev 07/10                      i
SCOPE OF SERVICES .................................................................................................... 1
   MATP EXECUTIVE SUMMARY ............................................................................................................... 2
   GENERAL RESPONSIBILITIES ............................................................................................................... 3
   1.        Inform and Educate Consumers ................................................................................................... 4
        A.   Outreach ...................................................................................................................................... 4
        B.   Written Materials ....................................................................................................................... 4
   2.        Operate an MATP Telephone Line ............................................................................................... 4
        A.   Telephone Line............................................................................................................................ 4
   3.        Manage the program to ensure cost effective, appropriate transportation services are provided 4
        A.   Data and Reporting .................................................................................................................... 5
        B.   Waivers ........................................................................................................................................ 5
        C.   Incident Reporting...................................................................................................................... 5
   4.        Maximize cost-effectiveness and quality services through coordination with local programs and
             stakeholders .................................................................................................................................. 6
        A.   Trip Coordination....................................................................................................................... 6
        B.   Service Integration ..................................................................................................................... 7
   5.        Verify Consumer Eligibility and Need .......................................................................................... 7
        A.   Eligibility ..................................................................................................................................... 7
        B.   Application .................................................................................................................................. 7
        C.   Written Notice Requirement ..................................................................................................... 8
        D.   Denial of Services ........................................................................................................................ 8
        E.   Termination or Reduction of Services ...................................................................................... 9
        F.   Sanction Policies and No-Shows ................................................................................................ 9
   6.        Authorize Transportation Services, Schedule and Dispatch Trips ............................................... 9
        A.   Mode of Transportation (determination) ................................................................................. 9
        B.   Urgent Care ............................................................................................................................... 10
        C.   Fixed Route Public Transportation......................................................................................... 10
        D.   Volunteers ................................................................................................................................. 10
        E.   Paratransit................................................................................................................................. 10
        F.   Mileage Reimbursement .......................................................................................................... 11
        G.   Quarter-Mile Rule .................................................................................................................... 11
        H.   Closest Provider Rule ............................................................................................................... 11
        I.   Paratransit Pick Up Rule ......................................................................................................... 12
        J.   Paratransit One-Hour Rule ..................................................................................................... 12
        K.   Escorts ....................................................................................................................................... 12
        L.   Limited English Proficiency (LEP) ......................................................................................... 13
        M.   Curb-to-Curb Service............................................................................................................... 13
        N.   Door-to-Door Service ............................................................................................................... 13
        O.   Exceptional Transportation ..................................................................................................... 13
   7.        Recruit and Maintain Adequate Transportation Network .......................................................... 14
        A.   Provider Networks.................................................................................................................... 14
        B.   Driver Clearances and Training.............................................................................................. 14
        C.   Monitoring................................................................................................................................. 14
        D.   Complaint Process .................................................................................................................... 14
        E.   Maintain Confidentiality of Information ................................................................................ 15

HANDBOOK ................................................................................................................... 16



MATP Rev 07/10                                                                   ii
SAFETY GUIDELINES ........................................................................................................ 17
   1.         Consumer Exiting the Vehicle Prior to Scheduled Stop ............................................................. 18
        A.    PURPOSE: ................................................................................................................................... 18
        B.    POLICY: ...................................................................................................................................... 18
        C.    PROCEDURES ADULT CONSUMERS ........................................................................................... 18
        D.    PROCEDURES FOR CHILDREN .................................................................................................... 19
        E.    ADDITIONAL STEPS .................................................................................................................... 20
   2.         Safety Exception to the Ten-Day Appeal Rule ............................................................................ 20
        A.    WRITTEN NOTICE REQUIREMENT CLARIFICATION RE: SITUATIONS THAT MAY DEEM
              IMMEDIATE TERMINATION OF SERVICES. ................................................................................. 20

   3.         Consumers using Oxygen or Battery Operated Ventilators........................................................ 21

OUTREACH POLICY .......................................................................................................... 23
   1.         Outreach Responsibilities ........................................................................................................... 24
   2.         Suggested Outreach Venues ....................................................................................................... 24
   3.         MATP/CAO Information Interchange ........................................................................................ 24
   Consumer Welcome Brochure : ............................................................................................................... 26
     A. WHAT IS MATP? .................................................................................................................... 26
     B. HOW TO CONTACT US ......................................................................................................... 26
     C. WHAT MEDICAL TRANSPORTATION SERVICES DO WE PROVIDE? ..................... 26
     D. HOW FAR CAN YOU GO WITH MATP? ............................................................................ 27
     E. SCHEDULING A RIDE TO AN APPOINTMENT ............................................................... 28
     F. ESCORT POLICY ................................................................................................................... 29
     G. SANCTION POLICY ............................................................................................................... 29
     H. COMPLAINT PROCESS ........................................................................................................ 29
     I. APPEAL PROCESS ................................................................................................................. 29
     J. OTHER MEDICAL TRANSPORTATION RESOURCES .................................................. 30
   4.         Basic Informational Brochure: ................................................................................................... 31
        A.    WHERE CAN YOU GO WITH MATP? ................................................................................ 31
        B.    HOW IS TRANSPORTATION PROVIDED? ....................................................................... 31
        C.    HOW TO REGISTER FOR MATP SERVICES .................................................................... 32

PROGRAM MANAGEMENT GUIDELINES .......................................................................... 33
   1.         Waiver Guidelines / Samples ...................................................................................................... 34
        A.    Waiver Request Process ........................................................................................................... 34
        B.    Examples/Clarifications ........................................................................................................... 34
        C.    Retention, Notice and Reporting ............................................................................................. 35
   2.         Incident Reports/Forms and Samples ......................................................................................... 35

ELIGIBILITY GUIDELINES ................................................................................................ 36
   1.         Application Process .................................................................................................................... 37
   2.         Self-Referral (HealthChoices, Voluntary Managed Care and ACCESS Plus) ......................... 37
   3.         Medical Assistance enrolled providers include, but are not limited to: .................................... 38
   4.         Medical transportation does not include: ................................................................................... 38
   5.         Specific Requirements For Certain Medical Assistance Providers ............................................ 39
        A.    Community Residential Facilities/Therapeutic Rehabilitative Residential Treatment
              Facilities ..................................................................................................................................... 39
        B.    Drug and Alcohol ...................................................................................................................... 39


MATP Rev 07/10                                                                    iii
        C.   Early Intervention Services for Preschool Children.............................................................. 39
        D.   General Hospitals ..................................................................................................................... 40
        E.   Mental Health Facilities ........................................................................................................... 40
        F.   Nursing Facilities ...................................................................................................................... 40
        G.   Personal Care Homes ............................................................................................................... 40
        H.   Physical Therapists ................................................................................................................... 40
        I.   Psychologist ............................................................................................................................... 41
        J.   Veterans Administration Hospitals ......................................................................................... 41
        K.   Summer Therapeutic Camps ................................................................................................... 41
        L.   Waiver-Funded Services .......................................................................................................... 41
        M.   Behavioral Health Rehabilitation Services (BHRS) For Children and Adolescents........... 41
        N.   Psychiatric Rehabilitation Services ......................................................................................... 41
   6.        Deceased Consumers .................................................................................................................. 42
   7.        General Assistance Consumers .................................................................................................. 42
   8.        Hospitalized Children ................................................................................................................. 42
   9.        Medicare Consumers .................................................................................................................. 42
   10.       Statewide No-Show Policy Guidance ......................................................................................... 42
      A.     Principles of MATP No Show Policies: ................................................................................... 42
      B.     Process of Documenting No Shows: ........................................................................................ 42
      C.     Sanctions for Excessive No Shows:.......................................................................................... 43
      D.     Notice of Proposed Suspension: ............................................................................................... 43
   11.       Office Of Inspector General Contact Information ...................................................................... 43

AUTHORIZE TRANSPORTATION SERVICES-DETERMINATION OF MODE ........................ 45
   1.        Multiple Reimbursements ........................................................................................................... 46
   2.        Quarter Mile Rule....................................................................................................................... 46
   3.        Door-to-Door Service ................................................................................................................. 47
        A.   MATP Agency Responsibilities ............................................................................................... 47
        B.   Consumer Responsibilities ....................................................................................................... 47

RECRUIT AND MAINTAIN ADEQUATE PROVIDER NETWORKS ........................................ 49
   1.        Provider Networks ...................................................................................................................... 50
   2.        Driver Clearance and Training .................................................................................................. 50
        A.   Child Abuse and Criminal History Clearances for drivers .................................................. 50

CONSUMER SPECIFIC GUIDANCE ..................................................................................... 51
   12.       Anti-Retaliation Policy ............................................................................................................... 52
   13.       Non-Discrimination .................................................................................................................... 52
   14.       Confidentiality ............................................................................................................................ 52
   15.       Suggested Strategies for addressing consumer hygiene issues ................................................... 53
   16.       School Age Children Receiving Physical and Mental Health Services ...................................... 54
   17.       Medical Assistance Workers with Disabilities (MAWD) ............................................................ 54
   18.       Limited English Proficiency (LEP) ............................................................................................. 54
   19.       Quality Of Service And Consumer Sensitivity ............................................................................ 55
      A.     Guidelines for Transporting Children and Care Dependent Adults.................................... 55



MATP Rev 07/10                                                                 iv
GLOSSARY OF TERMS ....................................................................................................... 57

FORMS............................................................................................................................... 63
   Service Plan Form ................................................................................................................................... 64
   Assessment of Needs ................................................................................................................................ 69
   Special Needs ........................................................................................................................................... 72
   Application Section .................................................................................................................................. 73
     Waiver Request Form Sample ......................................................................................................... 75
   #        75
        Waiver Request Form Sample ......................................................................................................... 76
   #         76
        Incident Report Form Template ...................................................................................................... 77
        Incident Report Sample Form ......................................................................................................... 79
        SAMPLE INCIDENT REPORT ..................................................................................................... 81

OPS MEMOS ...................................................................................................................... 83

APPENDICES ................................................................................................................. 84

Appendix A ...................................................................................................................... 85
   1.          Budget Submittal ........................................................................................................................ 87
   2.          Quarterly Reporting ................................................................................................................... 87
   3.          MATP Funding Status ................................................................................................................ 88
   4.          Key Dates for the County............................................................................................................ 88
   5.          Least Costly and Most Appropriate Requirement ....................................................................... 89
   6.          Responsibility to Negotiate ......................................................................................................... 89
   7.          Payment of Last Resort ............................................................................................................... 90
   8.          No-Shows .................................................................................................................................... 90
   9.          Multiple Reimbursements ........................................................................................................... 90
   10.         Consumer Fraud ......................................................................................................................... 90
   11.         Interest Bearing Accounts........................................................................................................... 90
   12.         Retroactive Costs ........................................................................................................................ 90
   13.         Payment Procedures ................................................................................................................... 91
   14.         Usual and Customary Charge .................................................................................................... 92
   15.         Notification of Fare Increases – PENNDOT Shared Ride Services ........................................... 93
   16.         Subcontracts ............................................................................................................................... 93
   17.         Premium Services ....................................................................................................................... 93
   18.         Record Keeping .......................................................................................................................... 93
   19.         Record Retention ........................................................................................................................ 94
   20.         Audits .......................................................................................................................................... 94
   21.         Performance Audits .................................................................................................................... 94


MATP Rev 07/10                                                                     v
   22.        Sanctions..................................................................................................................................... 94
   23.        Allocation Termination ............................................................................................................... 95
   24.        Balance of Funds ........................................................................................................................ 95
   25.        Encumbrances ............................................................................................................................ 95
   26.        Administrative Costs ................................................................................................................... 95
   27.        Transportation Costs .................................................................................................................. 95
   28.        Limitations on Purchases ........................................................................................................... 95
   29.        Bidding and Procurement ........................................................................................................... 96
   30.        Vehicle Use Allowance/Depreciation ......................................................................................... 96
   31.        Specialty Equipment ................................................................................................................... 96
   32.        Title to Property ......................................................................................................................... 96
   33.        Disposition of Property .............................................................................................................. 96

FORMS............................................................................................................................... 99
   Budget Projection Report .......................................................................................................................100
   Actual Expenditure .................................................................................................................................104
   Personnel Report ....................................................................................................................................107
   Transportation Report ............................................................................................................................109
   Medical Assistance Transportation ........................................................................................................112
   Trip and Client Data Report ...................................................................................................................115
      MATP Monthly Data File Format ..................................................................................................117
      MATP Monthly File Submission ....................................................................................................117
      Quarterly Reporting Instructions and Clarification.....................................................................118




MATP Rev 07/10                                                                   vi
                                                Scope of Services




                 SCOPE OF SERVICES


   Medical Assistance Transportation
               Program

                 DEPARTMENT OF PUBLIC WELFARE
          Office of Medical Assistance Programs




MATP Rev 07/10                1
                                                                       SCOPE OF SERVICES



                           MATP EXECUTIVE SUMMARY
Federal regulations require that the State Medical Assistance agency assure that
transportation is available for recipients to and from medical providers. The
Department of Public Welfare (DPW) carries out this mandate by providing both
emergency and non-emergency medical transportation services. Emergency
medical transportation services are funded separately through the Medical
Assistance Outpatient appropriation. Non-emergency medical transportation
services are provided through the Medical Assistance Transportation Program
(MATP).

According to the PA State Plan under Title XIX of the Social Security Act, a
funding allocation is made to each county for their use in providing non-
emergency transportation to Medical Assistance consumers who cannot meet
their own transportation needs. Additional funds are available to assure the
provision of non-emergency services to Medical Assistance covered services. In
those counties who choose not to accept a funding allocation, the cost of a
recipient’s non-emergency transportation to covered medical services is paid for
by the County Assistance Office (CAO) located in the county in which the
recipient resides.

Whenever possible, medical transportation funded by the MATP shall be
integrated with transportation services provided by other Department of Public
Welfare programs, programs, funded by the Department of Aging, and Public
Transit Services provided by the Department of Transportation. The degree of
service integration, which is most cost-effective locally, can only be determined
on a county-by-county basis. County governments select the particular
administrative method best suited to provide the transportation in their locale.
This may include the direct provision of service by the county government,
contracting with an independent transportation entity, or through a human
services agency.

Funding for the MATP consists of a State appropriation and Federal Medical
Assistance (Title XIX) funds.

Agreement to accept funding for, and responsibility to administer the MATP by a
County requires full compliance with all sections of the I&R, which include the
Scope of Services, Fiscal Requirements and the Handbook. The MATP
Handbook is a distinct section of the I&R and is intended to provide clarification
and directions for carrying out the requirements.




MATP Rev 07/10                           2
                                                         MATP INSTRUCTIONS AND REQUIREMENTS




                            GENERAL RESPONSIBILITIES

Medical Assistance consumers residing in Pennsylvania are entitled to
transportation services necessary to secure medical care provided under the
Medical Assistance program. Counties that accept the program must comply with
the conditions set forth in this document and its attachments.

The County assures that medical transportation services are provided to eligible
County residents.

Medical Assistance Transportation Services are defined as non emergency
transportation to MA covered services as benefits to which a MA recipient is
entitled under the law. This would include transportation to and/or from a
medical facility, physician’s office, dentist’s office, hospital, clinic, pharmacy or
purveyor of medical equipment for the purpose of receiving medical treatment or
medical evaluation or purchasing prescription drugs or medical equipment. The
term does not include emergency medical transportation that would normally
provided by an ambulance.

The County is not an agent of the Department and is solely responsible for
assuring the safety of consumers whenever consumers receive these services.

The County hereby expressly, and as a condition precedent to the receipt of
state and federal funds, assures that the County and its’ designated entity are in
compliance with 42 CFR §455.104, 105, and 106, as well as 42 CFR 1001.1901
with regard to provider disclosure information, business transactions, criminal
conviction information and the obligation to screen for Medical Assistance
excluded providers. The County must assure that required information
disclosure cited above is obtained from any and all subcontractors for service
delivery under the MATP Grant Agreement. (Please refer to MATP OPS Memos
#02-2010-016, #02-2010-017, #02-2010-018, and #02-2010-019 for further
clarification and direction.)

The County shall undertake the responsibility to:
   1. Inform and educate consumers about the program
   2. Operate a Medical Assistance Transportation Program (MATP) telephone
      line
   3. Manage the program to ensure cost-effective, appropriate transportation
      services are provided
   4. Maximize cost-effectiveness and quality services through coordination
      with local programs and stakeholders
   5. Verify consumer eligibility for Medicaid and assess transportation need
   6. Authorize transportation services, schedule and dispatch trips
   7. Recruit, maintain and monitor an adequate transportation provider network
   8. Ensure quality of services through a complaint tracking system
   9. Maintain consumer confidentiality



MATP Rev 07/10                            3
                                                         MATP INSTRUCTIONS AND REQUIREMENTS



Failure to comply with any term of this Grant Agreement may result in the
Department's imposition of the following sanctions: the County’s submission of a
corrective action plan to correct areas of non-compliance; suspension of
payments; or termination of this Grant Agreement.

1. Inform and Educate Consumers

A. Outreach

The County shall provide consumers, County Assistance Offices, medical service
providers and others upon request, information regarding the availability of non-
emergency medical transportation services, eligibility for these services, the
service authorization process, and how to access and use these services
properly. The County will be required to distribute all mandatory written materials
developed by the Department and shall develop required supplemental written
materials for approval by the Department.

B. Written Materials

Counties who wish to change any of their policies related to complaint process,
no-show policy, sanction policy, urgent care instructions, policy to evaluate the
least costly and most appropriate form of transportation must first obtain prior
approval from the Department. The Department will respond in writing within 60
days of receipt of said request.

The County shall ensure that the consumers are provided with a 30 day notice of
changes in said policies.

2. Operate an MATP Telephone Line

A. Telephone Line

The County shall ensure that a toll-free telephone line is available to request
transportation services, except in counties where all calls are local. The line shall
be staffed during normal office hours. The County shall have sufficient and
appropriate staff to handle all calls. During the hours in which the line is not
staffed, an answering machine or service shall be available. Consumers must be
able to schedule a ride as many as 14 days in advance and as few as same-day-
service (in the case of urgent care). Professional, prompt, and courteous
customer service shall be a high priority. The County shall ensure that the
telephone staff treats all callers with dignity and respect a caller’s right to privacy
and confidentiality. The County shall process all incoming telephone inquiries for
medical transportation services in a timely, responsive, and courteous manner.

3. Manage the program to ensure cost effective, appropriate transportation
   services are provided




MATP Rev 07/10                            4
                                                        MATP INSTRUCTIONS AND REQUIREMENTS



A. Data and Reporting

The County shall be responsible for the management of overall day-to-day
operations necessary for the delivery of cost-efficient, appropriate medical
transportation services and the maintenance of appropriate records and systems
of accountability to report to the Department. The County shall establish and
maintain a database or spreadsheet sufficient to meet the reporting requirements
of the program.

The County shall submit accurate and complete reports to the Department at
required intervals or on request by the Department. Non-fiscal reports required
include:

        Service Plan – Due 45 days following receipt of annual form
        Monthly Data Report – Due 45 days from close of each month.
        Monthly Data Reports shall be based on trip level data including County
        code, the actual date of the trip, the MA ID number of consumer, the mode
        of transportation, whether trip was completed, and whether an escort was
        needed.

Data files shall be retained as per 55 Pa. Code §2070.24(a).

Requirements related to fiscal reporting are covered in the Fiscal Requirements
Section.

B. Waivers

In order to ensure that services are cost-efficient and appropriate to local
circumstances and needs, the County may submit to the Department a written
request for a waiver of any MATP requirement. The request for a waiver must
contain justification for the request, a citation of the requirement to be waived,
and the alternative proposed as a substitute for the waived requirement. The
following factors will be considered in reviewing waiver requests: administrative
efficiency; health and safety of consumers; and the objectives of MATP. Waiver
requests must be submitted in writing to the appropriate MATP Advisor. Any
waivers that are granted will be available to the public. If the County is granted a
waiver, the County shall provide consumers with 30 days notice of the change
and shall convey that the policy change was made possible by a waiver from
DPW.

C. Incident Reporting

Counties shall develop policy/procedures for incident management and ensure
that staff has proper orientation and training to respond to, report, and prevent
incidents.




MATP Rev 07/10                           5
                                                        MATP INSTRUCTIONS AND REQUIREMENTS



The County is required to report significant incidents to the Department.
Incidents requiring reporting include, but are not limited to, the following:
       Assaults (either on a consumer or staff member)
       Threats of assault or injury
       Injury to a consumer or to a staff member by a consumer
       Accidents while consumers are on board that might require medical
       attention
       Involvement of law enforcement officials
       Allegations of abuse
       Medical attention being needed while en route
       Consumer exiting the vehicle prior to scheduled stop (refer to Handbook
       Section 1, Safety Guidelines).

The Incident Report shall include the following (when applicable):
      Name of involved person
      Address
      Date/time of incident
      Location
      Was illness or injury involved
      Description of incident (nature of the incident, witnesses, and narrative of
      what occurred)
      Final disposition (how you intend to handle the incident, any next steps
      required, or likely outcomes)
      Name of person submitting the report
      Date of report
      Date forwarded to DPW/OMAP/MATP

Notification of any MATP incident involving a child shall be reported to the MATP
Program Manager or assigned MATP program advisor by phone or internet
within 24 hours. Written Incident Reports shall be completed and submitted to the
assigned MATP Advisor by FAX within 48 hours of the incident. FAX number
717.705.8112. If final disposition of the incident is not known at the time of
written submission, a follow up report is required within two weeks of the incident.

4. Maximize cost-effectiveness and quality services through coordination
   with local programs and stakeholders

A. Trip Coordination

Whenever possible, the County shall ensure transportation services are
integrated with services provided by other Department of Public Welfare
programs, programs funded by the Department of Aging, and Public Transit
Services provided by the Department of Transportation.




MATP Rev 07/10                           6
                                                       MATP INSTRUCTIONS AND REQUIREMENTS



B. Service Integration

The County shall establish linkages with community programs to coordinate
activities with existing programs serving the MA program population and to
minimize or avoid duplicate efforts and fragmentation of services to the same
consumers. These linkages may include referral protocols or formal written
coordination agreements with such programs.

5. Verify Consumer Eligibility and Need

A. Eligibility

The County shall be responsible for receiving and processing all requests for
medical transportation services for MA program consumers. The County shall
provide transportation to eligible permanent and temporary residents of the
County. Eligibility regulations for MATP are published in Part IV, Chapter 2070,
The Adult Services Manual, 55 Pa. Code 2070. The County assures that
transportation is not otherwise available and is necessary to receive a medical
service. The County must ensure at the time of every trip that the consumer is
eligible for MA.. For consumers who are members of managed care
organizations, the county may check EVS for eligibility once during the month of
service and presume eligibility continues through the end of the month. The
County shall use the Eligibility Verification System (EVS) to verify eligibility.

After consumers Medicaid eligibility is checked in EVS, the next step is to ensure
the consumer’s Category of Medical Assistance and Program Status Codes are
valid for MATP services using the MATP Eligibility Guide. The guide has been
distributed to all program offices and is also available on the MATP Internet
Website. The document can be found at:
http://matp.pa.gov/PDF/MATPEligibleCategories.pdf

B. Application

The County shall require and retain on file a signed application for MATP
services. The application is required only on a one-time basis. The application
must be signed within 30 days of the date transportation began. Eligible
consumers may be transported for up to 30 days without a signed application.
Within the 30-day period, the County shall not deny services because a signed
application has not been received. In instances where a consumer fails to return
a signed application within the 30-day window, transportation services will cease
until a signed application is obtained by the County. The grace period for
receiving the signed application is a one time period.




MATP Rev 07/10                          7
                                                       MATP INSTRUCTIONS AND REQUIREMENTS



C. Written Notice Requirement

The County shall give consumers the Department’s standard Written Notice
Form at the time their request for services is denied, terminated or reduced.
Consumer appeal rights are governed by Appeal and Fair Hearing and
Administrative Disqualification Hearings, 55 Pa. Code 275. The Form shall
include a clear statement of any and all reasons for the action as well as a
citation to the authority for the decision. If the consumer is being terminated or
suspended from the program, the notice must specify the effective date of the
action and must be sent at least fifteen days prior to the effective date of the
action. If the consumer appeals a termination or reduction in service and such
appeal is received within ten calendar days of the effective date, the consumer is
entitled to continuing benefits pending appeal. Whenever a Written Notice Form
is given, a County Assistance Office (CAO) referral form shall always accompany
it.

Consumers may appeal the action identified on the Written Notice Form in writing
or orally. If orally, the MATP shall assist the consumer in reducing the appeal to
writing and shall obtain the consumer’s signature. Within three business days of
the oral appeal, the MATP shall forward a copy of the written appeal—regardless
of whether a signature has been obtained or not—to the Bureau of Hearings and
Appeals. The MATP shall retain a copy of the appeal. If the matter is resolved
or settled anytime prior to a fair hearing, the agency must document the
resolution reached. Copies of all appeals and their resolution must be retained
and made available upon request.
Forward all appeals to:

                    Department of Public Welfare
                    OMAP – Medical Assistance Transportation Program
                    Fair Hearings
                    P.O. Box 2675
                    Harrisburg, PA 17105-2675

D. Denial of Services

A denial of services includes any instance in which a trip has been requested and
no trip has been authorized, or any instance in which an MATP application has
not been accepted, except when the denial is because the consumer is not
eligible for MA. The County need not issue a Written Notice Form in the instance
of denial due to MA ineligibility, however, when an individual maintains that he or
she is MA eligible and EVS indicates otherwise, the County shall confirm with the
CAO that the consumer is not eligible before denying the trip. Additionally, the
County need not issue a Written Notice Form when the client requests a trip to a
nonmedical service.




MATP Rev 07/10                           8
                                                         MATP INSTRUCTIONS AND REQUIREMENTS



Situations which do require a Written Notice Form include but are not limited to:
the transportation requested is not to a medical facility as defined for MATP, the
consumer has not provided requested documentation for purposes of obtaining
mileage reimbursement, the agency is unable to provide the service, and where
a consumer asserts that the mode assigned by the MATP is not appropriate for
his or her needs or has requested a transportation mode that has not been
approved.

E. Termination or Reduction of Services

A termination or reduction of services includes, but is not limited to: the individual
may not use MATP services indefinitely or for a period of time due to misuse of
the services or a pattern of failure to comply with program rules.

F. Sanction Policies and No-Shows

The County shall develop policies to sanction consumers for excessive no-shows
and other unacceptable behavior. The policies shall be forwarded to OMAP for
prior approval and shall be provided in writing to all consumers at the time of
application or at least 30 days before a change is effective. If consumers are
terminated or suspended from the program for any length of time, they must be
sent a Written Notice Form. Consumers who are sanctioned by MATP for
excessive no-shows or unacceptable behavior shall be referred to the CAO for
transportation assistance.

6. Authorize Transportation Services, Schedule and Dispatch Trips

A. Mode of Transportation (determination)

Once eligibility is established, the County shall determine which mode is the least
expensive, most appropriate transportation service available to meet the
consumer’s service need. MATP consumers must use the least costly and most
appropriate form of transportation. The County must, on a case-by-case basis,
carefully review an individual consumer’s situation, and may only authorize the
least costly form of transportation the will meet that individual consumer’s needs.
It is not acceptable for a County to authorize, for example, more costly taxi or
paratransit services without first determining that less costly and equally
appropriate transportation services are not available.

If the consumer asserts that the mode assigned by the MATP is not appropriate
for his or her needs or has requested a transportation mode that has not been
approved, the County shall issue Written Notice Form.




MATP Rev 07/10                            9
                                                        MATP INSTRUCTIONS AND REQUIREMENTS



B. Urgent Care

Urgent care is any illness or severe condition which under reasonable standards
of medical practice would be diagnosed and treated within a 24-hour period and
if left untreated, could rapidly become a crisis or emergency situation; or
discharge from a hospital will be delayed until services are approved; or a
member’s/consumer’s ability to avoid hospitalization depends upon prompt
approval of services.

Urgent care transportation requests include any calls for transportation services
where the consumer indicates his/her medical provider has told him/her to come
to their office or to obtain other medical treatment or services that same day or
within a 24-hour period. The County may require verification of “urgency” from
the medical provider, which may be obtained by the consumer or the MATP
program directly. Verification of urgency from a provider need not be in writing,
and the County program can accept a provider’s verbal authorization.

The County must have a process in place to deal with urgent care transportation
requests made during normal business hours and after normal business hours,
including weekends. The County must inform MATP consumers of their right to
obtain transportation for urgent care matters and of the County’s process for
responding to such requests. This information must be communicated in the
written materials the MATP sends to consumers as well as in the answering
machine/service message a consumer gets when calling the MATP after
business hours, including weekends.

C. Fixed Route Public Transportation

The County shall provide tokens, passes, scrip or reimbursement to eligible
consumers to cover the fare for established public or private transit services,
where available.

D. Volunteers

The County shall coordinate volunteers, where available, to provide
transportation services by driving their personal vehicles or vehicles supplied by
a provider organization.

E. Paratransit

The County shall provide Paratransit services, where available, that include types
of transportation that are more flexible than conventional fixed-route transit but
more structured than the use of private automobiles. This includes demand
response service in which vehicles carrying, at any one time, unrelated
passenger(s) with different origins, destinations and/or different funding sources.
Paratransit also includes multi-modal and taxi services.




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                                                           MATP INSTRUCTIONS AND REQUIREMENTS



F. Mileage Reimbursement

The County may reimburse consumers who have access to private vehicles
(their own or another individual’s) but cannot meet their own transportation
needs. This reimbursement will be at a specified rate per mile for travel
expenses plus any parking or toll fees. The rate of reimbursement shall be
determined by the County, but shall not be less than $.25 per mile. Counties
who wish to change their mileage reimbursement rate must obtain prior approval
from the Department before changing said rate.

Consumers shall be reimbursed within two weeks after submission of the
required form with complete documentation. The form must include written
verification (e.g., a signature) that the medical service was provided. If a
consumer is not able to provide written verification of a medical appointment, the
County must attempt to obtain the verification from the provider prior to denying
the reimbursement request. If a reimbursement request is inaccurate or
incomplete, the MATP must make at least one attempt to contact the consumer
to attempt to resolve the issue before denying the reimbursement request. If an
entire trip is denied, a Written Notice Form shall be issued.

For acceptable examples of meeting the two week reimbursement requirement,
please see the Handbook Section 5.

In situations in which a more costly paratransit trip could be avoided by allowing
reimbursement of four trips of a private vehicle (vs. two paratransit trips), the
County may pay for all four reimbursement trips (i.e., back and forth for the drop-
off and back and forth for the pick-up).

G. Quarter-Mile Rule

MATP will not fund trips where the distance from origin to destination is less than
¼ mile unless the consumer cannot travel the ¼ mile independently. If public
transit is offered, consumers should live no more than ¼ mile from the bus route.
If a consumer lives more than ¼ mile from the public transit route, but public
transit is an appropriate mode, transportation may be provided to and from the
public transit stop.

H. Closest Provider Rule

        Fee-for-Service - For consumers who are part of MA’s fee-for-service
        system, the County may only transport to the medical provider closest to
        the consumer’s residence. Transportation to a pharmacy provider shall
        only be provided to a choice of two pharmacies closest to the consumer’s
        residence or two pharmacies closest to the consumer’s prescribing
        physician’s office (if the prescription was provided at the office visit and is
        being filled in route from the prescribing physicians office). A consumer
        may be transported to a more distant provider if medical verification is
        provided to substantiate the need.


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                                                         MATP INSTRUCTIONS AND REQUIREMENTS




        Managed Care- For consumers who are part of MA’s HealthChoices
        Managed Care system, MATP shall transport to the provider of the
        consumer’s choice, except in the case of pharmacy providers.
        Transportation to a pharmacy provider shall only be provided to a choice
        of two pharmacies closest to the consumer’s residence or two pharmacies
        closest to the consumer’s prescribing physician’s office (if the prescription
        was provided at the office visit and is being filled in route from the
        prescribing physicians office).

        ACCESS Plus – MATP shall transport to the consumer/s selected or
        assigned Primary Care Physician (PCP) and to any specialist to whom the
        PCP refers, except in the case of pharmacy providers. Consumers may be
        transported to the nearest behavioral health provider who can meet their
        needs. A consumer may be transported to a more distant provider if
        medical verification is provided to substantiate the need. Pharmacy
        provider limitations are the same as Fee-for-Service and HealthChoices.

I. Paratransit Pick Up Rule

Consumers shall be picked up within 15 minutes before and after the scheduled
pick-up time. This creates a thirty-minute pick-up window. Counties should make
consumers aware that the expectation is for the consumer to be ready and
waiting at least 15 minutes before the scheduled pick-up time. Vehicles that
arrive before the 30-minute window must wait until the scheduled pick-up time to
accommodate a consumer who is not ready. Vehicles arriving at the scheduled
pick-up time or within 15 minutes after are not required to wait for a consumer
who is not ready. For purposes of the complaint process, pick-ups within the 30-
minute window are on time.

J. Paratransit One-Hour Rule

Consumers shall be dropped off at the medical provider’s office no more than
one hour prior to the medical appointment. After the medical visit, consumers
shall be picked up not more than one hour later.

K. Escorts

If a consumer cannot travel independently, because of age, disability or
language, an escort must be allowed to accompany the consumer on the MATP
trip. The County will be reimbursed for the transportation costs of any escorts
that the County deems necessary to secure medical examinations and treatment
for a consumer. All trips of the escort that are necessary are reimbursable (i.e.,
including return trips of the escort when the MA consumer is not present).




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                                                         MATP INSTRUCTIONS AND REQUIREMENTS



L. Limited English Proficiency (LEP)

MATP agencies and their contractors must comply with Title VI of the Civil Rights
Act of 1964, 42 U.S.C. Section 2000d. This includes taking action as required to
assure that all persons with Limited English Proficiency (LEP) have meaningful
access to programs and benefits. If a consumer does not speak English,
transportation must be arranged with consumer, a volunteer interpreter escort
must be permitted to accompany the consumer, or a translation service such as
the Language Line must be utilized.

M. Curb-to-Curb Service

The standard paratransit service shall be curb-to-curb.

N. Door-to-Door Service

The county shall provide door-to-door service based on the level of service that is
appropriate for the consumer’s physical and metal capacities. The availability of
door-to-door service shall be communicated to all consumers at the time they
apply for services and anytime they request a change to paratransit service.

The County may require verification from a medical provider, which may be
obtained by the consumer or the MATP program directly. Verification of need
from a provided need not be in writing, and the County program can accept a
provider’s verbal authorization and indicate the verbal verification in the
consumer’s file. The physician’s certification/verification should be sufficient for
establishing medical need for door-to-door service.

If the physician’s verification indicates that the consumer’s need for door-to-door
services is time-limited, the verification must indicate the date when the
consumer’s need for door-to-door is not longer necessary. In these situations’
the County should give notice to the consumer before the expiration of the door-
to-door service and assist the consumer with contacting the physician if a door-
to-door service extension is needed.

At anytime door-to-door services are denied and the consumer asserts that the
mode assigned by the MATP is not appropriate for his/her need, the MATP will
send Written Form to the consumer.

O. Exceptional Transportation

Exceptional transportation requests shall be referred to the CAO. The County
and the CAO MATP coordinator should coordinate the meeting requests for
exceptional transportation. Regulations regarding exceptional transportation
requests are published in Part IV, Chapter 2070, The Adult Services Manual, 55
Pa. Code 2070.




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                                                        MATP INSTRUCTIONS AND REQUIREMENTS



7. Recruit and Maintain Adequate Transportation Network

A. Provider Networks

The County shall establish a network of transportation providers to deliver
medical transportation services to MA consumers. The County shall ensure that
it has vehicles that can accommodate persons with disabilities. The County may
negotiate rates through competitive bidding or utilize other strategies to ensure
that the most appropriate and least costly transportation services are provided.
The County shall ensure that access to transportation services shall be at least
comparable to transportation resources available to the general public. The
County shall ensure the provision of service delivery to meet the needs of
consumers for routinely scheduled trips, non-routinely scheduled trips, urgent
care trips, and bariatric trips either within the home county or to medical services
outside of the county.

B. Driver Clearances and Training

The County shall ensure that all drivers have valid licenses and the appropriate
clearances and training. Every driver must have a criminal history check
completed. Drivers transporting children must also have child abuse clearances
prior to transporting children. The County shall develop a policy and apply it to
determine whether employment is appropriate based on the results of the
clearances. The policy shall be available to consumers upon request.

C. Monitoring

The County is responsible for all services provided by subcontracted
transportation providers. The County shall develop and implement a Monitoring
Plan for subcontracted transportation providers. The County shall assure
adequate oversight of subcontracted transportation service providers and assure
that providers comply with the terms of these Instructions and Requirements and
all applicable State and Federal laws and regulations. The County shall monitor
the transportation providers to ensure compliance with the terms of their
subcontracts and assure compliance with all transportation provider-related
requirements. The County shall also ensure that all subcontractors have
procedures for the prevention, detection, and reporting of suspected fraud and
abuse.

D. Complaint Process

The County is responsible for receiving and responding to all complaints
regarding the delivery of medical transportation services. A complaint is a verbal
or written expression of dissatisfaction. The County must develop a complaint
process which shall include: documentation of the complaint in writing, first level
review of the circumstances surrounding the complaint by someone other than
those involved in the action which is the subject of the complaint, the timeframe
by which a written response will be received and how the response will be


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                                                         MATP INSTRUCTIONS AND REQUIREMENTS



documented, the identification of a second level reviewer or reviewers, and the
timeframe by which a written response will be received. If the complainant is still
dissatisfied after at least two levels of review at the County level, the County shall
forward the complaint to the Office of Medical Assistance Programs. The
County’s proposed complaint process shall be submitted to the Office of Medical
Assistance Programs for review and approval. Copies of all complaints,
responses and corrective action plans must be kept by the County and made
available to OMAP staff upon request. Quarterly reports shall be submitted on
the aggregate numbers of complaints received by type and their disposition.

E. Maintain Confidentiality of Information

The County shall maintain the confidentiality of MATP program-related
information including consumer specific information. The County shall take
measures to prudently safeguard and protect unauthorized disclosure of the
MATP information in its possession. The County shall establish internal policies
to ensure compliance with Federal and State laws and regulations regarding
confidentiality.

Counties, prime contractors and providers shall comply with the federal Health
Insurance Portability and Accountability Act (HIPAA) of 1996 with regards to:
   • Use or disclose information only as permitted by law, regulation or
      contract.
   • Appropriately safeguard the protected health information.
   • Report any misuse of protected health information.
   • Secure satisfactory assurances from any subcontractor.
   • Grant individuals access and ability to amend their protected health
      information.
   • Make an accounting of disclosure available to individuals
   • Release applicable records to the secretary of DHHS if requested.
   • Upon termination, return or destroy all protected health information.
   • Report any knowledge of a violation or potential violation of this policy to
      the program office.




MATP Rev 07/10                           15
                       HANDBOOK




   Medical Assistance Transportation
               Program

                 DEPARTMENT OF PUBLIC WELFARE

          Office of Medical Assistance Programs




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MATP Handbook                       Section 1: Safety Guidelines




Handbook           Section 1




                 SAFETY GUIDELINES




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MATP Handbook                                                    Section 1: Safety Guidelines




1. Consumer Exiting the Vehicle Prior to Scheduled Stop

A. PURPOSE:

The purpose of this policy is to provide MATP providers with a process for
handling situations when a MATP consumer exits the vehicle prior to their
scheduled stop.

B. POLICY:

The Commonwealth of Pennsylvania, Department of Public Welfare, Office of
Medical Assistance Programs, Medical Assistance Transportation Program
defines a trip as travel from the consumer’s domicile to the medical assistance
service or the return trip from the service to the domicile, with some exceptions.
Therefore, except in the case of an adult who can travel independently and there
is no known risk or evidence of danger to health and safety, it is expected that
MATP consumers utilizing MATP services remain on the vehicle until arrival at
their scheduled stop. Should an incident occur when a consumer exits the
vehicle prior to their scheduled stop, the actions listed in the procedures that
follow are to be taken.

C. PROCEDURES ADULT CONSUMERS

If the consumer is an adult, the following procedures are expected to be followed:

1. The driver shall inform the individual of the inappropriateness of their
   disembarking prior to their scheduled stop and the ramifications that may
   occur as the result of said action. The consumer should be encouraged to
   remain on the vehicle; however, at no time should the driver have physical
   contact with the individual during this intervention.
2. Should the consumer vacate the vehicle at an unauthorized stop, the driver
   shall immediately contact the dispatcher, relate the incident, and await further
   instruction(s). The driver will not leave the unauthorized stop until directed to
   do so by the dispatcher or until another agent from the MATP arrives on the
   scene. Additionally, the driver should supply any pertinent information to the
   dispatcher as to special circumstances regarding the incident (i.e., the
   consumer appeared disoriented, agitated, distressed, upset, intoxicated, etc.),
   which might assist the dispatcher in determining what next steps would be
   appropriate. At no time, regardless of whether other consumers are
   aboard or not, should the driver leave the vehicle unattended and
   attempt to pursue the consumer.
3. Decisions as to whether to have the involvement of law enforcement
   personnel will be the responsibility of the dispatcher/County MATP office, not
   the driver. Involvement of law enforcement personnel should only occur if it is
   apparent that the consumer is a danger to self or others and that without



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MATP Handbook                                                    Section 1: Safety Guidelines



   immediate intervention could cause injury or significant destruction of
   property.
4. If the untimely disembarkment took place going to a scheduled appointment,
   the dispatcher should notify the service provider of the situation and inform
   the provider that the individual would not be keeping their appointment. In
   cases where the provider is a mental health service, the dispatcher would be
   prudent to seek input from the provider as how to best address the incident.
5. If the incident caused for a significant delay, the dispatcher will contact the
   providers of other consumers riding the vehicle, informing them of the reason
   for untimely arrival for appointments or arrival at home, as appropriate.

D. PROCEDURES FOR CHILDREN

For the purpose of this Policy & Procedure, a child is defined as an individual
less than eighteen (18) years of age unless otherwise emancipated.

If the consumer is a child, the following procedures are expected to be followed:

1. The driver shall attempt to encourage the child to remain on the vehicle until
   the scheduled destination. Should an escort other than the child’s
   parent/guardian be onboard, the escort should attempt to explain the
   responsibilities of the MATP provider and what actions might need to be
   taken if they should exit the vehicle. Under no circumstances should
   either a driver or a non-related escort attempt to restrain or have
   physical control over the child.
2. The driver will immediately notify the dispatcher of the incident and await
   further instruction(s). The driver will not vacate the unauthorized stop until
   directed to do so by the dispatcher or until another agent from the MATP
   arrives on the scene.
3. The driver will not, under any circumstances, vacate the vehicle and
   pursue the child. If a non-related escort is available, the escort may attempt
   to accompany the child and continue with intervention approaches so as to
   convince the child to return to the vehicle.
4. The dispatcher will immediately notify the child’s parent/guardian of the
   situation, providing as much information as available (i.e., location of the
   incident, any precursors to the incident, direction the child was observed to be
   traveling after vacating the vehicle, etc.).
5. The dispatcher will notify the appropriate law enforcement agency as to the
   incident, providing appropriate information.
6. The dispatcher will make every attempt possible to have another agent of the
   MATP program relocate to the site to assist in any way possible.




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MATP Handbook                                                     Section 1: Safety Guidelines



7. If there is going to be a significant delay for other passengers on the vehicle,
   the dispatcher will notify the providers of the other consumers and, if other
   passengers are minor children, contact the parent/guardian to inform them of
   the situation.
8. In all incidents involving a child, the County MATP administrator will notify
   the Department of Public Welfare, Medical Assistance Transportation
   Program Manager of said incident within twenty-four hours of the occurrence,
   or within twenty-four hours of notification from a subcontractor of an incident,
   either via telephone or Internet. Dependent on the situation and the outcome,
   a written report may be requested utilizing the MATP Incident Report Form.

E. ADDITIONAL STEPS

In all incidents of a consumer exiting the vehicle prior to scheduled stops, the
following procedures will occur:

1. Both the driver and the dispatcher will document, in writing, all pertinent
   information. This documentation will include, but not be limited to, the
   following:
       a. Name of consumer
       b. Date and time of incident
       c. Location of unauthorized vacating of the vehicle
       d. Efforts made to encourage the consumer to remain on the vehicle
       e. Any special circumstances related to the incident
       f. Brief summary narrating what occurred
2. The County MATP administrators will review reports and take
   sanction(s)/action(s) as deemed appropriate. As stated previously, an
   exception to sanction actions will be considered in the case of an adult who
   can travel independently and there is no known risk or evidence of danger to
   health and safety,
3. The County MATP administrators will monitor their subcontractors for
   compliance with this policy and institute sanctions for noncompliance.

2. Safety Exception to the Ten-Day Appeal Rule

A. WRITTEN NOTICE REQUIREMENT CLARIFICATION
   RE: SITUATIONS THAT MAY DEEM IMMEDIATE TERMINATION OF SERVICES.

1. 55 Pa Code §2070.42 (b) (3) (i) states “Services to the client may not be
   reduced or terminated pending outcome of the hearing, if the hearing request
   is postmarked no later than the 10th calendar day following the date the notice
   is mailed or hand-delivered to the client.”

2. The Department realizes there are situations and circumstances which
   indicate the need for immediate termination of services based on safety
   issues.



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MATP Handbook                                                      Section 1: Safety Guidelines




3. As per previous and the current I&R and 55 Pa Code § 2070, MATP providers
   are responsible for assuring the safety of consumers whenever a consumer
   receives transportation services.

4. Only if a consumer’s actions clearly pose a threat to the health, safety, and
   welfare passengers on the vehicle, as well as the transportation provider’s
   staff, an immediate termination of services is appropriate (e.g., if an individual
   pulled a knife or other weapon, it would seem an appropriate decision that
   immediate termination would be warranted). It is imperative that the county
   MATP agency review each situation with the consumer’s services should be
   immediately terminated.

55 Pa Code § 2070 also indicates that, in their professional judgment, a provider
may decide that the mode of service currently being provided is no longer
appropriate or that the consumer’s uncooperative behavior or misuse of services
warrants termination. It would be logical to assume that if an individual cannot
ride a paratransit vehicle and maintain appropriate behavior, that paratransit is no
longer an appropriate mode of transportation.

The health, safety, and welfare of all MATP consumers and provider staff is
paramount. Referral to the CAO as an alternative to paratransit services suffices
to meet or equal the intent of this section and also provides for the individual to
have a means to access his/her medical services. The MATP should inform the
Bureau of Hearings and Appeals that the consumer is not receiving services
pending their appeal and request that the appeal be expedited.

The consumer must be sent a Written Notice Form and also told in writing:
      a. that the 10 day rule does not apply to their situation
      b. that the termination will remain in effect unless the decision is
         overturned through the appeal process
      c. what other options or modes of transportation may be available

3. Consumers using Oxygen or Battery Operated Ventilators

The following guidance should be followed when determining the most
appropriate mode of transportation for individuals who use oxygen:

1. Consumers who have begun self-administered home oxygen prior to
   transport may continue administration during transport. However, no new
   regime of oxygen therapy may be started during transport.

2. Oxygen provided and administered by the consumer is appropriate for MATP
   if no other medical equipment or medical care is required en route.




MATP Rev 07/10                           21
MATP Handbook                                                      Section 1: Safety Guidelines



3. If a consumer has a battery-operated ventilator and an individual who has
   been trained to provide ventilator care will travel with the consumer to a
   doctor’s office or other medically necessary health care service, the consumer
   is eligible for MATP if no other medical equipment or care is required en
   route.

        NOTE: Under medical assistance regulations, ambulance
        transportation to a physician’s office or group practice is a non-
        covered service.




MATP Rev 07/10                            22
MATP handbook                      Section 2: Outreach Policy




Handbook          Section 2




                 OUTREACH POLICY




MATP Rev 07/10                23
MATP Handbook                                                       Section 2: Outreach Policy




1. Outreach Responsibilities

MATP providers must assure that MA providers, CAOs and human
services/community agencies are sent information describing MATP services.
The information should be mailed to these entities every year or whenever
policies or procedures change. These entities should be notified of any approved
program waiver. MATP agencies are required to provide a supply of MATP
applications to the CAO in their county, as well as to drop-in centers and senior
centers. All outreach activities should be detailed in the county’s annual Service
Plan.

2. Suggested Outreach Venues

1) Get the local bus system to put signs on their buses that advertise the
   availability of the MATP program; and also have them put large signs in their
   terminal.

2) Have local cable stations run Public Service Announcements for free.

3) Local newspapers, daily and weekly, will run information sent out as a short
   press release. Also, write letters to the editor to talk about the importance of
   the program.

4) Contact churches and ask them to either post information or include it in their
   weekly bulletins.

5) The MH Community/Family Satisfaction Team may provide MATP information
   during their hospital outreach and at the end of their consumer and family
   survey interviews.

6) Local radio stations have talk shows and often are looking for a topic. Most of
   these stations can do the interview so that you can just call in rather than
   having to make your way to the studio.

7) Provide medical offices and psychiatric facilities with notices to post on
   bulletin boards. They may also be posted on super market and other public
   bulletin boards which are free. Including the little tear off numbers result in
   responses.

3. MATP/CAO Information Interchange

The county MATP provider is the single point of contact for determining eligibility
as well as the least costly and most efficient mode of transportation for individual
consumers. If a consumer initially requests service at the County Assistance
Office (CAO), the CAO will refer the consumer to the county MATP provider. If



MATP Rev 07/10                           24
MATP Handbook                                                   Section 2: Outreach Policy



the MATP is unable to provide the transportation service, including mileage
reimbursement, the MATP provider should give the consumer a CAO referral
form and contact the CAO on the consumer’s behalf. The CAO then may issue
the medical transportation allowance. If an eligible consumer has an exceptional
transportation request, there should be coordination between the CAO and
MATP to arrange transportation for the consumer. Air travel is always an
exceptional transportation request and should be referred to the CAO.




MATP Rev 07/10                         25
MATP Handbook                                                    Section 2: Outreach Policy




Consumer Welcome Brochure :
     (To be sent out once a consumer registers with MATP)

WELCOME TO THE MEDICAL ASSISTANCE TRANSPORTATION
PROGRAM! (MATP)

A. WHAT IS MATP?
The Medical Assistance Transportation Program (MATP) is a transportation
service available to Medical Assistance consumers in _____ county. MATP is
funded by the Pennsylvania Department of Public Welfare. In _____ county the
MATP Program is run by _________________________(agency name).

Our program offers transportation or mileage reimbursement to help you get to
medical care or services from a Medical Assistance provider. We are required to
provide you with the least expensive, most appropriate transportation service
available that will meet your needs.

You can use MATP services to go to medical appointments or to get to any
service Medical Assistance pays for. These medical services includes therapies,
tests, dental visits, trips to the pharmacy to get prescriptions, mental health
treatment, drug & alcohol treatment, and trips to medical equipment suppliers.

You cannot use MATP:
   • if you need emergency ambulance transportation
   • for non-medical trips such as for grocery shopping or for social activities
   • to obtain medical care that is not covered by Medical Assistance.

B. HOW TO CONTACT US

Our office is located at ___________ and our phones number(s) are:

Our regular office hours are Monday through Friday from ___ to ___. If you call
us after hours or on a weekend or holiday, you will be able to leave a message
on our answering machine and we will return your call on the next business day.
Our answering machine will also tell you what to do if you need urgent care
transportation (see p. __) or where to call for emergency transportation.

C. WHAT MEDICAL TRANSPORTATION SERVICES DO WE PROVIDE?

Transportation Options
Depending on where you are going, what your needs are, and the costs
involved, we could provide you with transportation in one of the following ways:
(only list the options available)
   • Public fixed route bus (state if the person will get reimbursed for a ticket
        or get a pass in advance)


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MATP Handbook                                                      Section 2: Outreach Policy




    •   Shared van
    •   Lift-equipped vans
    •   Taxi
    •   Other

Mileage Reimbursement
If you have a car available, or if you know someone who has a car and who can
take you to your medical appointment, we will provide you mileage
reimbursement if it is the least costly, most appropriate service available. We will
reimburse you at the rate of ___ cents per mile. We will also reimburse you for
your actual parking expenses and tolls if you provide receipts showing how much
you paid.

If you want to claim mileage reimbursement for a trip, you must tell us in
advance. We will send you a form to fill out to tell us how far you traveled and
whether you had any parking or toll costs. You can turn in your reimbursement
request right after a trip or you can wait until the end of the month. (If there are
any deadlines by which a reimbursement request must be made include them
here) We will reimburse you within 2 weeks.

D. HOW FAR CAN YOU GO WITH MATP?

We are responsible for providing or for arranging your transportation to get you
to the medical care you need.

(Insert all options below that apply in your county)
If you are enrolled in a Medical Assistance MCO (Managed Care
Organization), we can provide or arrange transportation for you to any medical
provider in this MCO region. Your MCO region includes: (list counties) However,
we will only take you to providers in your MCO network, or providers that are
out-of-network but who your MCO has referred you to.

If you are enrolled in the Medical Assistance ACCESS Plus Program, you
can use MATP services to get to your selected or assigned Personal Care
Physician (PCP) and any specialist to whom your PCP refers you. You can use
MATP to go to the nearest behavioral health provider who can meet your needs.
You can use MATP to go to a more distant behavioral health provider if you give
the MATP information that you medically need to go to that provider.

If you are in Medical Assistance fee-for-service, we will provide or arrange
transportation for you to the provider who is closest to your home and who can
meet your medical needs. We will take you to a more distant provider only if you
give us medical information that shows the more distant provider is required to




MATP Rev 07/10                           27
MATP Handbook                                                     Section 2: Outreach Policy




meet your needs. (describe what type of information is needed and how the
consumer can request the exception)
If you have questions regarding the transportation options available to you,
please contact our office.

E. SCHEDULING A RIDE TO AN APPOINTMENT

If you need a ride to a medical appointment or service, you should call us as
soon as possible. For regular appointments, you must call us at least ___days in
advance to arrange a ride.

You can call us up to two weeks before your appointment to arrange a ride.
When you call to schedule we will ask the date and time of your appointment,
where you need to go, and how long the appointment will last (if you know).
Please tell us if you have any special needs like: if you need an escort to go with
you, or if you need accessible transportation due to a temporary or permanent
disability. We will arrange for the least costly way to get you to and from your
appointment that meets your needs. If your appointment is rescheduled or
cancelled, or if things change and you no longer need a ride, you must call us
immediately and let us know.

Pick Up and Drop Off Guidelines
If we will be transporting you using shared ride or a taxi, you will be told in
advance the approximate time you will be picked up by the MATP driver. Please
be ready ahead of time. Our Drivers are required to pick you up no sooner than
15 minutes before your scheduled time and no later than 15 minutes after your
scheduled pick-up time. Our policy is to drop you off at your provider’s office no
more than 1 hour before your scheduled appointment, and to pick you up no
later than 1 hour after your appointment is finished. If we do not meet these
timelines and you are kept waiting, you should call us at ______ to report the
problem and to see if alternative arrangements can be made.

Urgent Care Transportation
At some point you may need transportation on short notice for an urgent care
matter. Urgent care includes any situation where your medical provider has told
you that you need to come to their office, or to obtain some other medical
treatment or service, that same day or within the next 24 hours. We have a
process for responding to any urgent care requests and will make every effort to
help you get to the medical care you need.

If you need transportation for an urgent care matter, you should call MATP
immediately. (Describe here the MATP’s process for handling these requests
during and after normal business hours, weekends, holidays, etc)




MATP Rev 07/10                          28
MATP Handbook                                                      Section 2: Outreach Policy




F. ESCORT POLICY

You may bring someone with you as an escort at no cost to you in the following
situations:
    • If you are under 18, you can be escorted by a parent or other
        relative/guardian
    • If you cannot travel independently, or you need any assistance due to
        age, illness, physical or mental disability (if this must be verified by a
         physician, please indicate that)
     •   If you do not speak English, you can bring someone with you to interpret

G. SANCTION POLICY

(Describe here or attach your sanction policy. Detail the specific actions or
violations that can count toward a sanction. Note that the person will be notified
in writing of a sanctionable offense and how many written warnings will result in
a suspension from the program and for how long. Note that the person will get
prior notice of their suspension and has a right to appeal the action.)


H. COMPLAINT PROCESS

A complaint is any issue or dispute or objection you express to us about our
agency, or about the coverage, operations or policies of our MATP. If you have a
complaint about our services, about how you were treated by our staff or a
driver, or about our policies and procedures, please tell us. We will record your
complaint, investigate it and respond to you within ___ days.

(Provide more information here on the Complaint process or attach)

I.   APPEAL PROCESS

We are required to give you a written notice if we deny your request for MATP
transportation or for mileage reimbursement. We are also required to give you
written notice in advance if we plan to reduce or change your services or
suspend you from the program for any length of time. The notice will tell you the
reasons for our action, when the action will go into effect, and your rights to
appeal from the action.

You can get free legal assistance if you need help with an appeal. If you
need help with an appeal you can call your local legal services office at ______
or the Pennsylvania Health Law Project at 1-800-274-3258.




MATP Rev 07/10                              29
MATP Handbook                                                   Section 2: Outreach Policy




J. OTHER MEDICAL TRANSPORTATION RESOURCES

If we are not able to meet your medical transportation needs, you will be
referred to your caseworker at the local County Assistance Office (CAO).




MATP Rev 07/10                         30
MATP Handbook                                                     Section 2: Outreach Policy




4. Basic Informational Brochure:

(Basic informational brochure to be available at CAOs, social service agencies,
etc)

    THE MEDICAL ASSISTANCE TRANSPORTATION PROGRAM (MATP)

                  in ________ County call _______ (toll free #)



If you or anyone in your family is a Medical Assistance recipient, you may be able
to get help with transportation you need to get to and from medical providers.
The Medical Assistance Transportation Program (MATP) provides rides to
medical care at no cost to you. You can also get mileage reimbursement if you
use your own car or find someone willing to give you a ride.

A. WHERE CAN YOU GO WITH MATP?

You can use MATP services to get to any health care service that is covered by
Medical Assistance. That includes appointments with your doctor, dentist,
psychologist or psychiatrist, drug and alcohol treatment clinics, or any other MA
provider. You can also use MATP to go to the pharmacy for prescriptions, to the
hospital for tests, or to get to medical equipment suppliers.

If you belong to a Medical Assistance MCO (Managed Care Organization), also
called an HMO, you can use MATP services to get to any provider within your
Physical Health plan or your Behavioral Health Plan’s network.

If you are enrolled in the Medical Assistance ACCESS Plus Program, you can
use MATP services to get to your selected or assigned Personal Care Physician
(PCP) and any specialist to whom your PCP refers you. You can use MATP to go
to the nearest behavioral health provider who can meet your needs. You can use
MATP to go to a more distant behavioral health provider if you give the MATP
information that you medically need to go to that provider.

If you do not belong to an MCO or the ACCESS Plus Program, but you receive
your health care through MA fee for service, you can use MATP to go to the
nearest Medical Assistance provider who can meet your needs. You can go to a
more distant provider if you give the MATP information that you medically need
to go to that provider.

B. HOW IS TRANSPORTATION PROVIDED?

The MATP provides rides in the least costly way to meet your needs. You will
usually be riding with other passengers. Depending on where you need to go,



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MATP Handbook                                                      Section 2: Outreach Policy



MATP can arrange a ride for you using vans, taxis, or accessible vehicles for
persons with disabilities. If you can ride a bus, and you do not live far from a bus
route, you may be reimbursed for the cost of riding the bus.

___________ County MATP provides mileage reimbursement at the rate of ___
cents per mile, and also reimburses you for any parking and turnpike toll costs
involved in your trip.

C. HOW TO REGISTER FOR MATP SERVICES

If you are in need of MATP services call your county MATP to “register”. In
________ County you call _______(toll free #). You will be asked for your
ACCESS card number to make sure you are eligible for MATP services, and you
will be asked a few questions about your need for transportation.

        •   Make sure you tell the MATP about any special needs you may have
            like: if you use a wheelchair or walker; if you have any problem that
            keeps you from riding in a bus or van with other people; or if you need
            to have someone go with you to your appointments.
        •   When you get a ride through MATP, you are expected to get to the
            curb to be picked up. If you have any disabilities or limitations that
            keep you from getting to the curb, tell that to the MATP who is required
            to provide you with door-to-door service if you medically need it.
        •   If you are registering a child who is under 18, a parent or guardian can
            accompany the child to their appointments at no cost to you.

Important: You can obtain transportation services while you are completing the
registration process. However, the county MATP must receive a signed
registration form from you within 30 days of when your services begin.
Once you are registered, you will be sent more written information about how to
use MATP services. Your registration is good as long as you continue to receive
Medical Assistance.

For more information about the MATP in _____ County call ________ (county
MATP agency) at __________.




MATP Rev 07/10                            32
MATP Handbook                     Section 3: Program Management Guidelines




Handbook         Section 3




         PROGRAM MANAGEMENT
             GUIDELINES




MATP Rev 07/10               33
MATP Handbook                                            Section 3: Program Management Guidelines




1. Waiver Guidelines / Samples

A. Waiver Request Process

Counties will submit the Medical Assistance Transportation Program Waiver Request
form to their respective MATP Program Advisor. The MATP Program Advisor will
review the waiver request and possibly contact the County for clarification or revisions.

The MATP Program Manager will convene an internal MATP workgroup to meet and
discuss the requests and finalize recommendations. MATP Program Advisor will draft
an approval/denial letter and forward to the Division Director or designee for signature.

An Approval/denial letter will be sent to the County and all approved waivers will be
placed on the DPW website to be made available to all County staff for reference and
to model successful practices.

B. Examples/Clarifications

        Be brief in citing the requirement for which you are requesting a waiver (e.g.,
        “Paratransit One-Hour Rule, Scope of Services”)

        In describing the efficiencies/service enhancements, describe what barrier the
        present requirement causes for your County.

        In describing the proposed alternative, indicate how your program will look if the
        waiver is approved: what is your plan? Also indicate the degree of local input
        that was involved.

        What change will result in level of service? Indicate how the change will impact
        the consumers (e.g., consumer might experience a longer wait time prior to
        scheduled appointment or after their appointment, on-board time will increase
        no more than 25%).

        How were savings calculated (e.g., reducing # of trips to a regional medical
        center by 9 trips/week: 9 trips/week X 52 weeks @ $46/trip average = $21,528)

        The exception process must be completed and indicate clearly how consumers
        will be impacted.




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MATP Handbook                                         Section 3: Program Management Guidelines




C. Retention, Notice and Reporting

The County must keep a record of all waivers granted by the Department with the
appropriate fiscal year documents in order to ensure that exceptions are not cited
during audits.

If a waiver is approved, the MATP agency must provide 30 days written notice to
consumers, the CAOs, providers, and other human services/community agencies of
the waiver before it is implemented.

The County must track changes attributable to approved waivers, particularly financial
savings or efficiencies otherwise observed, related to the implementation of the waiver
and report this information quarterly in the narrative sheet in the electronic MATP
Quarterly Report workbook


2. Incident Reports/Forms and Samples

The Incident Report Form Template is provided. However, so long as all the elements
on the Template are included, the County may use their own form, if one exists




MATP Rev 07/10                          35
MATP Handbook                     Section 4: Eligibility Guidelines


Handbook         Section 4




        ELIGIBILITY GUIDELINES




MATP Rev 07/10               36
MATP Handbook                                                  Section 4: Eligibility Guidelines



1. Application Process


The 55 Pa Code §2070 cite that a signed MATP application form must be on file
for consumers applying for non-emergency medical transportation services.
They also indicate that an applicant has to display a currently valid medical
services eligibility card on which the applicant’s name appears as a recipient.

Counties, prime contractors, and their providers are responsible for developing a
cost efficient screening and intake mechanism for receiving transportation
requests from consumers. MATP agencies are encouraged to develop a user-
friendly application process with possible options of telephone applications and
on-line applications. The intent of 55 Pa Code § 2070.32 and 2070.36 (viii) was
to ensure that persons seeking non-emergency medical transportation services
was, in fact, eligible for services at the time of service rendered. With the
implementation of EVS, this function can be ensured without a “prior to services
rendered” signing of an application or showing of the medical services eligibility
card.

Counties, prime contractors, and their providers are not required to obtain the
signed application or showing of a valid medical services eligibility card prior to
the provision of transportation services. The verification through EVS is sufficient
to validate that a consumer is eligible to receive transportation services through
MATP. MATP agencies are still required to have on file a signed application from
each consumer of services; however this does not need to occur prior to the
provision of services. Eligible consumers may be transported for up to 30 days
without a signed application.

The application process for MATP services should not act as a barrier to the
consumer’s ability to access transportation services to obtain medical services.


2. Self-Referral (HealthChoices, Voluntary Managed Care and
   ACCESS Plus)

Consumers are allowed to self-refer for particular medical services (dental,
vision, OB/GYN, family planning, chiropractic, and behavioral health services).
These services do not require prior approval by a Primary Care Physician (PCP).
For family planning services, a consumer can go to a provider in or out of the
network. For dental, vision, OB/Gyn, chiropractic and behavioral health services,
the consumer must obtain the services from a provider within their MCO (unless
the MCO has authorized the person to go out-of-network). To verify that a
provider participates in an MCO’s network, contact the designated liaison at the
MCO




MATP Rev 07/10                          37
MATP Handbook                                                   Section 4: Eligibility Guidelines

3. Medical Assistance enrolled providers include, but are not
   limited to:

    Physicians
    Dentists
    Podiatrists
    Medical suppliers (including low vision centers and opticians)
    Chiropractors
    Independent medical/surgical clinics
    All outpatient services provided by general hospitals, including psychiatric
    services
    Independent laboratories
    Outpatient - Rehabilitation hospitals and all covered outpatient services
    provided by the hospitals
    Pharmacies
    Private psychiatric hospitals
    Rural health clinics
    Primary health care clinics
    Drug and alcohol clinics (including methadone maintenance services)
    Inpatient Drug and Alcohol Detoxification }           See Section 48
    Inpatient Drug and Alcohol Rehabilitation }           See Section 48
    Nonhospital residential detoxification, rehabilitation, and halfway houses
    Family planning clinics
    Midwives
    Birth Centers
    Psychiatric clinics (including mental health partial hospitalization)
    Optometrists
    Hospice Programs
    Freestanding dialysis clinics
    Short procedure units
    Ambulatory surgical centers
    Certified registered nurse practitioners
    Psychologists
    Comprehensive outpatient rehabilitation facilities
    Physical therapists
    Certified rehabilitation agencies
    EPSDT service providers, including audiologists, behavioral health wrap-
    around service providers, residential treatment facilities, occupational
    therapists, speech therapists, Easter Seal Society and Cerebral Palsy
    Associations.

4. Medical transportation does not include:

    Emergency ambulance transportation
    Nonemergency medically necessary ambulance transportation
    Transportation to sheltered workshops
    Transportation to day care programs (including adult day care)



MATP Rev 07/10                           38
MATP Handbook                                                   Section 4: Eligibility Guidelines

    Transportation to any service not covered through the Department's Medical
    Assistance Program
    Transportation as part of inpatient treatment (responsibility of the inpatient
    facility)
    Exceptional transportation service as defined at 55 Pa. Code 2070.4*
    Air travel, lodging, meals *
    Attendants, stretcher service, door-through-door service
    Transportation for visitation purposes *
    Transports to nonmedical services
    Transportation during severe inclement weather when it is deemed unsafe

*The County Assistance Office (CAO) may provide the service/reimbursement.

5. Specific Requirements For Certain Medical Assistance Providers

Generally, if the MATP is not able to provide transportation to a consumer
because the consumer is accessing a service not covered by MA, the MATP
should refer the consumer to any other transportation options that may exist in
the county.

A. Community Residential Facilities/Therapeutic Rehabilitative Residential
   Treatment Facilities

MATP funded transportation can be provided for a consumer’s admission to a
community residential facility or a therapeutic rehabilitative residential treatment
facility and upon discharge from the facility. No other MATP service will be
provided while the consumer remains in the facility.

B. Drug and Alcohol

    1)    Nonhospital residential drug and alcohol (D&A) detoxification,
          rehabilitation, and halfway house services are covered services only for
          consumers enrolled in the HealthChoices Program.

    2)    Partial hospitalization for D&A is a covered service for HealthChoices
          members when verified by the BHMCO. Outpatient D&A services,
          including Methadone Maintenance Clinics, are covered services for
          HealthChoices and Fee-for-Service consumers.

C. Early Intervention Services for Preschool Children

    ACT 212, the Early Intervention Services System Act, charges the
    Department of Education with responsibility for the delivery of early
    intervention services, including the provision of transportation, for children.
    MATP agencies should check with the Intermediate Unit to determine if a
    needed medical service is in the child’s Individualized Education Plan or
    Individualized Family Service Plan. If the medical service is cited within the
    plan, transportation is the school district’s responsibility. The MATP agency is


MATP Rev 07/10                           39
MATP Handbook                                                    Section 4: Eligibility Guidelines

    required to provide transportation only if the medical service has not been
    specified in the plan.

D. General Hospitals

    MATP funded transportation can only be provided upon a consumer’s
    admission to and upon discharge from the MA covered facility. No other
    MATP service will be provided while the consumer remains in the facility.

E. Mental Health Facilities

    Transportation while a recipient is in an inpatient mental health facility cannot
    be billed to the MATP. All consumer inpatient costs must be claimed through
    the facility’s inpatient billing procedures. MATP service can be provided to
    consumers being admitted to and discharged from these facilities.

    MATP transportation can also be provided for persons 21 and under, and
    those 65 and over, going to and from a psychiatric unit.

F. Nursing Facilities

    MATP funded transportation can be provided for a consumer’s admission to a
    nursing facility and upon discharge from the facility. It is the responsibility of
    the nursing facility, not the MATP agency, to provide nonemergency
    transportation for their nursing home residents as part of their medical
    assistance per diem rate.

G. Personal Care Homes

    Consumers in a licensed personal care home have an agreement with the
    home as to what services are provided by the facility. If routine transportation
    services are provided for the consumer, then the MATP is not responsible for
    the funding of transportation to medical assistance covered services. If
    routine transportation is not provided, then the MATP will fund transportation
    for medical assistance covered services.
    It is the MATP’s responsibility (and not the consumer’s) to contact and
    request a letter from the PCH Administrator whether routine transportation is
    provided to residents.

H. Physical Therapists

    Transportation to physical therapists, speech therapists and occupational
    therapists can be provided to consumers of all ages when provided through
    outpatient hospital clinics. Additionally, Medicare eligible consumers and
    children under 21 years of age may be transported to these specialists
    regardless of location of these services.




MATP Rev 07/10                            40
MATP Handbook                                                    Section 4: Eligibility Guidelines

I. Psychologist

    In a Fee-for-Service setting, transportation to a psychologist is covered only
    for children under 21 and for Medicare eligible consumers.

    Under managed care (HealthChoices and voluntary), transportation services
    to psychologists are covered.

J. Veterans Administration Hospitals

    MATP funded transportation cannot be provided to the VA hospital unless the
    consumer is receiving MA covered services from an enrolled MA provider.

K. Summer Therapeutic Camps

    Trips to and from Summer Therapeutic Camps are the responsibility of the
    MATP; however, activities requiring transportation that are part of the summer
    therapeutic sessions are not the responsibility of the MATP.

L. Waiver-Funded Services

    If funding for medical transportation is included in the waiver, MATP funded
    transportation will not be provided. If funding for medical transportation is not
    included in the waiver, MATP funded transportation may be provided to MA
    covered services.

M. Behavioral Health Rehabilitation Services (BHRS) For Children and
   Adolescents

    Behavioral Health Rehabilitation Services for all children under age 21 with
    psychiatric, substance abuse or mental retardation disorders, are covered
    services for consumers enrolled in the HealthChoices Behavioral Health
    Program and Fee-for-Service. For children in HealthChoices, the MATP
    provider should confirm with the MCO Point of Contact and/or Care Manager,
    that the request for transportation is part of an authorized treatment plan
    before approving a trip to BHRS site-based services, such as Summer
    Therapeutic Activities Program (STAP), Day Treatment Program, After School
    Program, etc. Trips to and from these site-based programs are the
    responsibility of the MATP; however, MATP is not responsible for BHRS
    Mobile services such as Therapeutic Staff Support (TSS), Mobile Therapy
    (MT), or Behavioral Specialist for Children (BSC) being provided at a site
    listed on the treatment plan.

N. Psychiatric Rehabilitation Services

    Psychiatric Rehabilitation Service is a not an MA covered service.




MATP Rev 07/10                            41
MATP Handbook                                                 Section 4: Eligibility Guidelines

6. Deceased Consumers

Payment of a reimbursement check on behalf of a consumer who is deceased
should only be made when an individual can prove that he or she transported the
consumer to medical visits.

7. General Assistance Consumers

General Assistance (GA) recipients with a category of assistance and a program
status code of TD-55 are not eligible for MATP service.

8. Hospitalized Children

Transportation to visit children who are hospitalized is not a covered service and
should not be considered a medical trip.

9. Medicare Consumers

Medical Assistance eligible consumers whose medical service is paid by
Medicare can receive MATP service.

10. Statewide No-Show Policy Guidance

The following guidance was developed by the MATP Stakeholder and Workgroup
and sets a standard floor for county MATP No-Show Policy

A. Principles of MATP No Show Policies:

Each MATP No Show policy shall contain at a minimum:

1) Clear and concise definition of the pick up time

2) Clear and concise concurrence of the designated location

3) Clear and concise definition of the pick up window

4) Clear and concise expectation of an acceptable cancellation notification

5) Waiver of the no-show if the incident involves a medical emergency, other
   documented emergency/crisis or other special circumstance


B. Process of Documenting No Shows:

Prior to any sanction, the MATP must send a minimum of three notices to the
consumer via a written communication advising of the following:

1) Notification of the no-show(s)


MATP Rev 07/10                          42
MATP Handbook                                                   Section 4: Eligibility Guidelines



2) Informing the consumer how they can appeal or dispute the no show finding

3) Reminding the consumer of the county’s sanction policy including what may
   lead to a sanction and defining the sanction

C. Sanctions for Excessive No Shows:

If a consumer has been determined to have excessive no shows in a thirty (30)
day period, the MATP may suspend services to the consumer for up to a thirty
(30) day period with proper notice.

D. Notice of Proposed Suspension:

If a consumer is determined to have accumulated enough no shows to be
subjected to a suspension of services under the MATP’s Sanction Policy, the
MATP must send a Written Notice Form to the consumer at least ten (10) days
before the suspension of services informing the consumer:

1) Of the effective date of the suspension

2) Of the length of time of the suspension

3) How to appeal from the suspension

4) That the consumer can contact their CAO for transportation assistance during
   the suspension

11. Office Of Inspector General Contact Information

Organized into four regions, the Office of Inspector General relies on Welfare
Fraud Investigations and Claims Investigation Agents who together handle fraud
prevention activities and fraud prosecutions and recoveries. Please report
suspected client fraud to your county’s respective regional manager.

        CENTRAL REGION: Clearfield, Cambria, Somerset, Bedford, Fulton,
        Blair, Centre, Huntingdon, Mifflin, Juniata, Perry, Franklin, Cumberland,
        Dauphin, Adams, York, Lancaster, Lebanon, Chester, Delaware,
        Montgomery, Bucks

        Regional Manager:          Jason Shroy
                                   jshroy@state.pa.us
                                   717 705-4072

        NORTHEAST REGION: Potter, Clinton, Tioga, Bradford, Susquehanna,
        Wayne, Pike, Monroe, Carbon, Northampton, Lehigh, Berks, Schuylkill,
        Luzerne, Wyoming, Lackawanna, Sullivan, Lycoming, Columbia, Montour,
        Northumberland, Union, Snyder


MATP Rev 07/10                           43
MATP Handbook                                             Section 4: Eligibility Guidelines



        Regional Manager:        Maureen Mckeowan
                                 mmckeowan@state.pa.us
                                 570 826-2006

        WESTERN REGION: Greene, Fayette, Washington, Westmoreland,
        Allegheny, Beaver Lawrence, Indiana, Armstrong, Butler, Jefferson,
        Clarion, Venango, Mercer, Erie, Crawford, Warren, McKean, Cameron,
        Elk, Forest

        Regional Manager:        Douglas Kunst
                                 dkunst@state.pa.us
                                 412 920-2538

        SOUTHEAST REGION 1: Philadelphia

        Regional Manager:        Donald J. Pritchett
                                 dpritchett@state.pa.us
                                 215 560-2478

        SOUTHEAST REGION 2: Philadelphia

        Regional Manager:        Rickard Johansson
                                 rjohnsson@state.pa.us
                                 215 560-3199




MATP Rev 07/10                        44
MATP Handbook                Section 5: Authorize Transportation Services- Determination of Mode


Handbook         Section 5




                   AUTHORIZE
     TRANSPORTATION
  SERVICES-DETERMINATION
         OF MODE




MATP Rev 07/10               45
MATP Handbook                              Section 5: Authorize Transportation Services- Determination of Mode



1. Multiple Reimbursements

The MATP will not fund multiple reimbursements for consumers traveling
together in one privately owned vehicle. The MATP is a shared-ride program. If
more than one individual is in a vehicle going to covered services, the
reimbursement is the same as if only one individual was receiving service.

2. Acceptable Examples of Meeting the Two Week Reimbursement
   Requirement.

Requiring consumers to submit reimbursement forms on certain specified
deadlines, such as the 15th and the 30th of each month, then issuing
reimbursement checks within two weeks of the two deadlines.

OR

“Mileage reimbursement forms are requested to be submitted by the 5th or each
month. Checks are issued by the 15th. Additional forms received after the 5th are
paid at the end of the month.”

OR

                        2010 SUBMISSION/PAYMENT SCHEDULE

Submission Deadline Date                                        Payment Date
Monday, April 2nd                                               Tuesday, April 10th
Monday, April 16th                                              Tuesday, April 24th
Monday, April 30th                                              Tuesday May 8th
Monday, May 14th                                                Tuesday, May 22nd
Monday, May 28th                                                Tuesday, June 5th
Monday, June 11th                                               Tuesday, June 19th

3. Quarter Mile Rule

     A. MATP will not fund trips where the distance from origin to destination is
        less than ¼ mile.
     B. If public transit is offered, consumers should live no more than ¼ mile from
        the bus route. If a consumer lives more than ¼ mile from the bus pickup
        point, or if the consumer cannot travel the ¼ mile, and public transit is the
        most viable service, then transportation must be provided to the bus stop.
     C. When the distance to and/or from available public transportation does not
        exceed ¼ mile and public transportation is the least costly and appropriate
        level of service, then public transportation will be utilized.
     D. Transportation within ¼ mile to and from a bus stop is warranted on a
        case- by-case basis. Each county MATP agency, prime contractor, or
        subcontractor shall determine on an individual basis, as part of the intake



MATP Rev 07/10                            46
MATP Handbook                             Section 5: Authorize Transportation Services- Determination of Mode

       and screening procedure, exceptions to the ¼ mile policy based on safety
       issues and the mental and/or physical capacity of the eligible recipients.
    E. Consumers that can use public transit and have frequent medical visits
       should be provided with reimbursement for monthly bus passes, if cost-
       effective.

4. Door-to-Door Service

A. MATP Agency Responsibilities

    F. Agency must ensure that consumer provides medical verification from a
       physician that door-to-door service is necessary and for how long.
    G. Agency must isolate costs associated with higher levels of service and
       retain back-up documentation and keep it available for review.
    H. Drivers are to keep vehicle in sightline when consumer is being picked up
       or delivered when feasible.
    I. Drivers must be able to assist riders who need help entering and exiting
       vehicle.
    J. Drivers are to make their arrival known immediately to all passengers.
    K. Drivers are required to deliver passengers to street-level lobbies of
       medical facilities.
    L. Drivers are permitted to assist passengers in entering and exiting origin
       and destination addresses, and to assist in entering and exiting vehicles,
       but are not permitted to enter origin or destination to assist consumers.
    M. Local policies and resources will determine level of service as long as it
       does not preclude the availability of door-to-door service.
    N. If the agency is unable to provide the service and where the consumer
       asserts that the mode assigned by the MATP is not appropriate for his or
       her needs or has requested a mode that has not been approved , the
       agency will send a Written Notice and CAO referral form.

B. Consumer Responsibilities

    O. Consumers must have a physician certify the need and length of time
       door-to-door service is necessary, such as, the inability to safely ambulate
       from door of the domicile to door of the vehicle.
    P. To the extent that they can, consumers with dwellings off the main street
       need to provide traffic lanes free of obstructions and notify the MATP of
       road conditions.
    Q. Consumers are required to anticipate a vehicle’s arrival, and be ready to
       board the vehicle.
    R. Consumers residing in apartment complexes are to await the vehicle in
       the street-floor vestibule or lobby of their complex or specific building.
    S. Consumers residing in duplex apartments or single-family homes are to
       await the vehicle’s arrival on the first floor and/or porch area and be ready
       to exit the building upon arrival of the vehicle.




MATP Rev 07/10                           47
MATP Handbook                             Section 5: Authorize Transportation Services- Determination of Mode

    T. Consumers at a medical facility are to await the vehicle’s arrival in the
       street-level vestibule or lobby of the facility and be ready to exit the
       building upon arrival of the vehicle.




MATP Rev 07/10                           48
MATP Handbook                     Section 6: Recruit and Maintain Adequate Provider Networks


Handbook         Section 6




        RECRUIT AND MAINTAIN
         ADEQUATE PROVIDER
             NETWORKS




MATP Rev 07/10               49
MATP Handbook                                 Section 6: Recruit and Maintain Adequate Provider Networks



1. Provider Networks

In order to assure transportation to medical services outside of the consumer’s
home county, the MATP agencies are encouraged to explore alternative avenues
and to establish cooperative relationships with neighboring counties’ MATP
providers. Several scenarios are suggested for meeting needs that are beyond
the capacity of the home county:

1) In cases where a consumer must be transported to a facility several counties
   away, develop an agreement with the county or counties through which the
   trip will travel and coordinate a feeder service to meet the other counties’
   vehicle at agreed to times for transfer and continuation on to the destination
   and the return run.

2) Where possible, the neighboring county may have capacity themselves or
   through a strategically based subcontractor to go into the consumer’s home
   county to meet the transportation needs to and from a more distant
   destination. Establishing agreed to rates, procedures and reporting methods
   with another county to meet these types of requests may offer a more efficient
   means to meet needs.

3) Having a provider under subcontract with expanded vehicle lease
   arrangements and individual operators may help to fill service gaps. This may
   entail periodic releases of requests for proposals or innovative advertising
   (e.g., placing notices in church bulletins or grocery store bulletin boards, etc.)
   of the need for persons interested in a position on a part time or on-call basis.

2. Driver Clearance and Training

A. Child Abuse and Criminal History Clearances for drivers

MATP agencies must obtain child abuse and criminal history clearances of all
their drivers and obtain proof of clearances from subcontracted drivers at the
time of hire, including volunteers. Child abuse clearance procedures can be
initiated by contacting the Childline Clearance Unit at telephone number (717)
783-6211.

MATP agencies are encouraged to perform child abuse and criminal history
clearance checks more often than just at time of hire, at their discretion. Child
abuse and criminal clearances should be conducted annually or at the customary
frequency used for school bus drivers, or similar programs. Assurance that
drivers have these clearances is important to both the MATP agency and to the
consumers.




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MATP Handbook                     Section 7: Consumer Specific Guidance


Handbook         Section 7




            CONSUMER SPECIFIC
                GUIDANCE




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MATP Handbook                                              Section 7: Consumer Specific Guidance

12. Anti-Retaliation Policy

Counties, prime contractors, and subcontractors may not intimidate, threaten,
coerce, discriminate against, or take other retaliatory action against any
individual who files a complaint or an appeal, including individuals, members of
the workforce, or business associates. Retaliatory actions cannot be taken
against individuals for testifying, assisting, or participating on an investigation,
compliance review, proceeding, or hearing. Any incident of allegation of an
incident of retaliatory actions must be documented on the MATP Incident Report
form and forwarded to the Program Manager of the Commonwealth of
Pennsylvania’s Medical Assistance Transportation Program within twenty-four
hours for investigation.

13. Non-Discrimination

Persons requesting or receiving transportation services may not be discriminated
against because of race, color, religious creed, ancestry, national origin, age,
sex, or handicap.

14. Confidentiality

Under Section 404 of the Public Welfare Code, information that might identify
applicants and consumers is limited to the following:
       Providers shall give access to and allow the use and disclosure of
       information on applicants and consumers to: Federal authorities, the
       Commonwealth, the Department, the County Commissioners or County
       Executive, and prime contractors or their authorized agents, if the
       information is necessary to carry out their required functions with respect
       to the administration of the MATP.
       Providers shall also give access to allow the disclosure of information on
       applicants to official authorities assigned to investigate the amount of
       assistance received. Disclosures beyond this scope require the
       consumer’s written consent. The list of officials to whom information is
       disclosed must be made available to the consumer upon request.
       Providers shall make available to a consumer or to the consumer’s
       authorized representative the contents of the consumer’s record under
       Chapter 105 (relating to safeguarding information).
       Providers shall make efforts to ensure consumer-specific information
       (whether automated or hardcopy), except for the officials listed above, is
       not in view or accessible to any person other than the consumer to which
       the information relates.




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MATP Handbook                                              Section 7: Consumer Specific Guidance



15. Suggested Strategies for addressing consumer hygiene issues

MATP agencies have experienced issues related to core hygiene. The following
are offered as suggested strategies:

        If it’s known that the consumer is being treated through a mental health
        program, contact the MH provider or consumer’s case manager to enlist
        their intervention with the consumer for improved hygiene is
        recommended.
        Consider whether shared ride is the appropriate mode while the hygiene
        issue is being addressed. Advise the consumer that mileage
        reimbursement may be the appropriate mode unless or until the hygiene is
        improved.
        If the consumer is over age 60 or has a physical disability, contact the
        county Area Agency on Aging to request a home visit and or assessment
        and recommend care management intervention.
        If the consumer is a child, contact the parent and notify of appropriateness
        of mode unless or until the hygiene is improved. If positive results are not
        forthcoming, contact either the medical provider or the county children and
        youth agency and request intervention.
        If the consumer is an adult under age 60 without a physical disability,
        contact the case manager at the CAO and request assistance.




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MATP Handbook                                              Section 7: Consumer Specific Guidance

16. School Age Children Receiving Physical and Mental Health Services

MATP agencies should verify with the local Intermediate Unit if transportation for
particular medical services is provided for in the child’s Individual Education Plan
(IEP). If transportation is not provided for and the medical service is MA covered,
the MATP is responsible for transporting the child during school hours. If
transportation is provided for in the IEP, the MATP is not responsible for
transporting the child.

17. Medical Assistance Workers with Disabilities (MAWD)

Individuals who qualify for the MAWD Program are MA eligible and eligible
for the same MATP service as other eligible consumers. MATP agencies
are required to provide cost data relating to MAWD consumers on the
Quarterly Report.

18. Limited English Proficiency (LEP)

MATP agencies and their contractors must comply with Title VI of the Civil Rights
Act of 1964, 42 U.S.C Section 2000d. This includes taking action as required to
assure that all persons with Limited English Proficiency (LEP) have meaningful
access to programs and benefits.

MATP agencies must develop a procedure for how it will serve and work with
consumers with LEP. This includes assisting with applications, handling calls to
and from the consumer, scheduling rides and providing transportation. The
procedure must address not only consumers who speaks a language other than
English, but also the needs of consumers whose disabilities impede speech,
hearing and vision.

If a consumer does not speak English, transportation must be arranged with a
driver who can communicate with the consumer, or a volunteer interpreter escort
must be permitted to accompany the consumer, or a translation service such as
the Language Line must be utilized.

All consumer/community education materials developed by the county MATP
should notify consumers of their right to interpretation/translation services at no
cost and how to request those services.
       The MATP should note in a consumer’s file that they are a person with
       LEP, what their primary language is, as well as their need for translation/
       interpretation services
       If an MATP operates in an area that has “benchmarked LEP populations”
       (that is, language groups which constitute more than 5% of the population
       of any CAO district within the MATP’s zone, or total more than 1,000
       consumers), the MATP should automatically provide materials to those
       persons in their own language




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MATP Handbook                                              Section 7: Consumer Specific Guidance

        “Non-benchmark populations” are entitled to document translation
        language services upon request that includes “sight translation” (the
        reading of an English document to the consumer in their native language).
        These persons should also be provided a notice in their language which
        summarizes their right to oral interpretation.

19. Quality Of Service And Consumer Sensitivity

A. Guidelines for Transporting Children and Care Dependent Adults

County MATP agencies need to provide cost effective services in keeping with
their program service definitions while providers need to have persons with
behavioral health disorders, persons with mental retardation and persons with
debilitating health problems delivered on a consistent and timely basis. Both
objectives are important and can be met when there is a joint commitment to
working cooperatively to ensure quality transportation services. County MATP
agencies can still look to treatment providers to achieve both cost effectiveness
and consistency in providing their own transportation. However, for those areas
where treatment providers are not providing this service, this section is offered to
provide suggestions, which promote cooperation and improve the quality of
service. The following suggestions are offered to address concerns from the
treatment provider community and county MATP agencies. County MATP
agencies working cooperatively with providers are encouraged to:

1) Hold regularly scheduled meetings to discuss ways in which the systems can
   more effectively work together to ensure quality, safe, and timely
   transportation services for these vulnerable populations. Treatment providers
   should contact transportation providers when expanding or instituting new
   programs so that transportation issues may be addressed at the earliest
   possible time.

2) Use the same drivers and vehicles whenever possible. Have drivers cleared
   through the Child Abuse Registry, State Police, and if needed, FBI checks.

3) Have the local mental health agency conduct ongoing training for drivers on
   areas related to behavioral health disorders and mental retardation, which
   includes, at a minimum, understanding of child development stages and
   behaviors, appropriate behavioral management techniques and crisis
   intervention protocols. As with all consumers, drivers must be responsible for
   assuring a respectful, professional atmosphere at all times.

4) Identify a staff member from the mental health agency to ride on group
   service trips and from the provider site at no charge. In this way, the staff
   person becomes a medical services escort and is able to be in an advisory
   position to the transit and/or MATP provider. Regular ridership is
   encouraged; however, if not available mental health staff should at least ride
   on an occasional basis.



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MATP Handbook                                             Section 7: Consumer Specific Guidance

5) Identify the principal and alternate caregiver for persons with behavioral
   health disorders. It is important when transporting persons with behavioral
   health disorders, especially children, that drivers be aware of whether the
   person enters their home. If the principal and/or alternate caregiver is not
   available, the driver should immediately contact the program for guidance. If
   a principal and/or alternate caregiver is consistently not available to accept
   the person, it may be necessary to discontinue transportation service. In no
   case should a child or a care dependent adult be left unattended outside of a
   treatment facility if that facility is not open for business. The MATP provider
   should contact the treatment facility or the principle caregiver.

6) Review scheduling problems with mental health providers. Lateness
   problems in many instances are associated with scheduling changes by either
   the MATP and/or the mental health provider. Solutions are often reachable
   through dialogue and understanding of each other’s situation.

7) Every effort should be made not to leave care dependent adults or children on
   a vehicle unattended.




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MATP Handbook                     Section 8: Glossary of Terms


Handbook         Section 8




            GLOSSARY OF TERMS




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MATP Handbook                                                    Section 8: Glossary of Terms




Abuse – Any practices that are inconsistent with sound fiscal, business, or
medical practice and which result in unnecessary cost to the MA Program, or in
reimbursement for services that are not medically necessary or that fail to meet
professionally recognized standards or contractual obligations (including the
terms of the RFP, contracts, and requirements of state or federal regulations) for
heath care in the managed care setting.

Accessible – Vehicles that can accommodate passengers in wheelchairs as well
as passengers with other special needs.

ACCESS Plus – A healthcare delivery system in which enrollees choose a
primary care doctor (also called a PCP) from whom they will get most of their
medical care. ACCESS Plus only involves physical health services. Behavioral
health services will remain Fee for Service.

Aide – An employee of a transportation provider who in addition to the driver is
required to assist in the transportation of the consumer due to his/her physical,
mental, or developmental status.

Appeal – The consumer’s right to challenge any MATP action or inaction which
affects his/her benefits.

Appropriate mode of transportation – The least expensive mode of
transportation that best meets the physical and medical circumstances of a
consumer requiring transportation to a medical service.

Bariatric transport – Transportation provided to individuals who have a body
mass index of greater than 40 or weigh at least 100 lbs. over ideal weight.

Category – A letter code that identifies coverage for federal and state funding
purposes and the type of medical benefits received. For example, the letter “P”
indicates Nonmoney Payment and the letter “T” indicates Medically Needy Only.

Consumer Reimbursement – Types of transportation that may include private
vehicles or any mode that is paid for by the consumer and reimbursed by MATP,
except mass transit – may include volunteer drivers. Also includes tolls and
parking expenses.

Complaint - A complaint is a verbal or written expression of dissatisfaction.

Coordination – An agreement between agencies to operate one or more
transportation functions jointly in order to better utilize resources. Whenever
possible, transportation funded by the MATP is to be integrated with
transportation services funded by other Department of Public Welfare programs
and programs funded by the Departments of Aging and Transportation.



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MATP Handbook                                                    Section 8: Glossary of Terms




Covered services – Services or supplies for which MA will reimburse.

Curb-to-Curb – A common designation for paratransit services. The transit
vehicle picks up and discharges passengers at the curb or driveway in front of
their home or destination.

Demand response service – Advance reservation transportation service where
riders telephone for pickup at a particular address and are transported to specific
destinations.

Deviated fixed-route service – Where the vehicle travels along a scheduled
fixed route, but also provides service in the general area of the route to demand
response riders upon request.

Dispatch – Radio control of drivers and such vehicle operations as the
assignment of passenger pickups and route changes.

Door-to-door Service – A form of paratransit service which includes passenger
assistance between the vehicle and the door of his or her home or other
destination. It is a higher level of service than curb-to-curb, yet not as
specialized as door-through-door service (where the driver actually provides
assistance within the origin or destination).

Eligible person – A person eligible for PA Medical Assistance in accordance
with the State Plan of Pennsylvania Medical Assistance Program under Title XIX,
who has been certified and enrolled as such by the County Assistance Office.

Escort – An interested individual that must accompany a consumer die to the
consumer’s physical/mental/developmental capacity or limited English
proficiency. Examples of an escort include, but are not limited to, parent,
guardian, or an individual who assumes parental like responsibility, or the adult
child of a geriatric parent. The escort’s presence is required to ensure that the
consumer receives proper medical service/treatment. The escort may not be
employed by or provided by the transportation company delivering the transport.

Exceptional transportation – Nonemergency transportation which is necessary
under extraordinary medical circumstances. This type of transportation may
require great distances for medical treatment not normally provided through
regional medical providers. The term includes air travel.

Fare structure – The established rate charged passengers and third-party
payers by an agency.

Fee-for-Service – A healthcare system that provides medical services to eligible
Medicaid recipients without a referral from a primary care physician. This



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MATP Handbook                                                    Section 8: Glossary of Terms



healthcare system offers the freedom of choice of enrolled Medical Assistance
providers for the Medicaid recipient.

Fixed route – A regularly scheduled transportation service operating on a set
route.

Fraud – An intentional deception or misrepresentation made by an entity or
person with the knowledge that the deception could result in an unauthorized
benefit to the entity, him/herself, or another responsible person.

Group 1 Cases – Categories of assistance and program status codes identified
as receiving federal funding for Medicaid services.

Group 2 Cases – Categories of assistance and program status codes identified
as receiving state funds only for Medicaid services.

HealthChoices – The name of Pennsylvania’s 1915 (b) waiver program to
provide mandatory managed health care to Medicaid recipients.

Managed Care Organization (MCO) – An entity responsible to provide health
care services to Medicaid recipients. Can either be HealthChoices (Mandatory)
or Voluntary.

Mass Transit – A regularly scheduled transportation service operating on a set
route- includes Amtrak and commercial bus.

Medical Assistance Transportation Services - Non emergency transportation
to MA covered services as benefits to which a MA recipient is entitled under the
law. This would include transportation to and/or from a medical facility,
physician’s office, dentist’s office, hospital, clinic, pharmacy or purveyor of
medical equipment for the purpose of receiving medical treatment or medical
evaluation or purchasing prescription drugs or medical equipment. The term
does not include emergency medical transportation that would normally be
provided by an ambulance.

Medical Assistance for Workers with Disabilities (MAWD) – Categories of
assistance and program status codes identified as receiving Federal funding for
Medicaid services. These consumers include employed workers with a disability
and are reported as Group 1 Cases.

Mobile Therapy (MT) – Face-to-face, child-centered, family focused,
individualized, psychotherapy provided in a setting identified in the treatment plan
as the site where the child will most likely benefit from therapy other than a
therapist’s or agency’s office.




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MATP Handbook                                                   Section 8: Glossary of Terms



Non-Ambulatory – Passengers who use wheelchairs or require the use of a
vehicle lift or ramp.

No-shows – Scheduled trips which are not taken and not canceled by
passengers within required timeframe.

Off-peak hours – Those hours when passenger demand and vehicle use is low,
usually in the middle of the day and during evening hours.

Paratransit – Types of transportation that may be shared ride in nature or are
more flexible than conventional fixed-route transit but more structured than the
use of private automobiles – includes demand response service in which vehicles
carrying at any one time, unrelated passengers with different origins, destinations
and/or different funding sources. Also includes multi-modal and taxi services
including exclusive ride services

Program Advisory – The OMAP MATP Program Specialist assigned to specific
counties to provide oversight, monitoring and technical assistance services to the
counties.

Program status code – A code that identifies budgets which meet certain
characteristics. The code, which is determined by the County Assistance Office,
is used for federal reimbursement, reporting and general control purposes.

Shared-Ride Program – The Lottery funded paratransit service for persons 65
years of age and older.

Shared-Ride service – A type of demand response service in which (vehicles)
are allowed to carry at any one time several unrelated passengers with different
origins and destinations.

“Site-Based” BHRS Services not on the MA Fee Schedule - Group programs
that are specifically designed and named by providers by means of a service
description submitted to DPW. These programs need both a service description
approved from DPW, and an authorization for each child prior to the initiation of
services from either the Office of Medical Assistance Programs (OMAP) or the
MCO.

State Plan – A comprehensive written agreement between the state agency
administering the MA Program (DPW) and the Centers for Medicare & Medicaid
Services (CMS) which includes eligibility requirements for recipients and
providers and identifies the scope of medical care for which reimbursement is
available.

Subscription service – Provided to passengers who have a standing order for
trips.



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MATP Handbook                                                    Section 8: Glossary of Terms




Summer Therapeutic Activities Program - Group programs that provide a
range of age appropriate specialized therapies and/or therapeutic activities for
the purpose of furthering individualized therapeutic goals as described in the
individualized treatment plan and are integrated into the overall mental health
treatment of the child.

Therapeutic Staff Support (TSS) – Medically necessary, individualized, one-to-
one treatment of a child’s behavioral health needs directed by a child’s treatment
plan goals, objectives, and planned interventions provided in a setting other than
an agency’s office.

Title XIX – the portion of the Social Security Act which authorizes the Medicaid
(MA) Program.

Trip – MATP funded travel primarily from an eligible consumer’s domicile to a
medical assistance covered service or from a medical assistance covered
service to the consumer’s domicile.

Urgent Care – Any illness or severe condition, which under reasonable
standards of medical practice would be diagnosed and treated within a twenty-
four (24) hour period, and if left untreated, could rapidly become a crisis or
emergency situation. Additionally, it includes situations such as when a
member’s discharge from a hospital will be delayed until services are approved
or a member’s ability to avoid hospitalization depends upon prompt approval of
services.




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MATP Handbook                     Section 9: Forms




Handbook         Section 9




                       FORMS




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MATP Handbook                                                                                Section 9: Forms

Service Plan Form
                                                               DEPARTMENT OF PUBLIC WELFARE
                                                              Medical Assistance Transportation Program
                                                              Grant Allocation Agreement / Service Plan
                                                                July 1,_____ through June 30, ______
                                 County of:                                                                                County
                           Date Submitted/Revised:                                                                          Date:
                                                                    Assurance of Compliance
A. The Transportation services provided by the county shall be provided in conjunction with the instructions for the Medical Assistance Transportation Program
   and Title 55, Pennsylvania Code, Part IV, Chapter 2070: Eligibility for Services funded trough the Medical Assistance Transportation allocation which is
   effective during the term of the grant. The instructions and Requirements, policies & procedures of the Medical Assistance Transportation Program as may
   be amended are incorporated by reference herein and kept on file by the County and Department of Public Welfare.

B. The County assures that it will maintain the necessary eligibility records and other records necessary to support the expenditure reports submitted to the
   Department of Public Welfare.

C. The County hereby expressly, and as a condition precedent to the receipt of state and federal funds, assures:
       That in compliance with the Title VI of the Civil Rights Act of 1964; the Pennsylvania Human Relations Act of 1955, as amended; and Section 504 of the
       Rehabilitation Act of 1973; the Age discrimination Act of 1975; Americans with Disabilities Act of 1990; and 16 PA Code, Chapter 49 (Contract
       Compliance regulation):
       1. The county does not and will not discriminate against any person because of race, color, religious creed, ancestry, national origin, age, sex, or
           handicap:
           a. In providing services or employment, or in its relationship with other providers.
           b. In providing access to services and employment for handicapped individuals.
       2. The county will comply with all regulations promulgated to enforce the statutory provisions against discrimination.

D.    I/We, as the authorized official(s) of the County, hereby authorize the person named below to submit the MATP first, second and third quarterly reports for
     this Fiscal Year on my/our behalf to the Department.

                  ________________________________________                                 ________________________________________________
                                   (Name)                                                                        (Title)

                  _______________________________________________________________________________________________________
                                                                               (Address)

                  ____________________________                  _______________________________                  ____________________________
                          (Telephone)                                          (Fax)                                        (E-mail Address)

                  ______________________________________________________                                         ____________________________
                          (County Commissioner/Executive Officer)                                                           (Date Signed)

                  ______________________________________________________                                         ____________________________
                          (County Commissioner/Executive Officer)                                                           (Date Signed)

                  ______________________________________________________                                         ____________________________
                          (County Commissioner/Executive Officer)                                                           (Date Signed)

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MATP Handbook                                                                         Section 9: Forms



                                                                          Service Plan
                                                             July 1, _____ through June 30, _____
                                                                       County of: County

NAME OF COUNTY DESIGNATED MATP AGENCY


STREET ADDRSS


CITY                                                                STATE                                                    ZIP CODE

                                                                    PENNSYLVANIA
KEY CONTACT PERSON IN DESIGNATED MATP AGENCY                                 E-MAIL ADDRESS


TELEPHONE NUMBER                                                                FAX NUMBER


KEY FISCAL CONTACT PERSON NAME & TITLE                                          E-MAIL ADDRESS


STREET ADDRESS


CITY                                                                STATE                                                    ZIP CODE

                                                                    PENNSYLVANIA
TELEPHONE NUMBER                                                             FAX NUMBER


Is the administering agency a: (Check the appropriate box)
            Transit Authority                                                             Private Non-Profit Transportation Provider
           County Transportation Office                                                   Private Profit-Making Transit Provider
           County Social Service Agency                                                   Other (Describe)

           Private Non-Profit Social Service Organization




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MATP Handbook                                                                          Section 9: Forms



                                                                           Service Plan
                                                              July 1, _____ through June 30, _____
                                                                        County of: County

A. MODE OF SERVICE (Please check the appropriate boxes for the modes of service provided through the MATP.)
         Paratransit – Types of transportation that are more flexible than             Client Reimbursement – Types of transportation that may include
         conventional fixed-route transit, but more structured than the use            private vehicles or any mode that is paid for by the client and
         of private automobiles. Includes demand response service in                   reimbursed by MATP, except mass transit – may include paid or
         which vehicles carrying, at any one time, unrelated passenger(s)              unpaid volunteer drivers. Also includes tools and parking
         with different origins, destinations and/or different funding                 expenses.
         sources. Also includes multi-modal and taxi services.

                Mass transit – A regularly scheduled transportation service                   Volunteers

B. FUNDING FOR PREVIOUS STATE FISCAL YEAR (Please input percentages in provided areas)
   OPERATING BUDGET: Please identify all programs/funding streams and indicate the percent of each within your agency’s
   operating budget for the previous State Fiscal Year, as applicable.
             FTA Section 5307                                                          Community Action Program
             FTA Section 5311                                                          Drug & Alcohol Program
             Lottery Shared Ride Program                                               County Intermediate Unit
             Free Fare for Seniors under fixed Route                                   County Mental Retardation Program
             Persons with Disabilities Program                                         County Child Welfare Program
             Welfare to Work                                                           County Mental Health Program
             Area Agency on Aging                                                      Medical Assistance Transportation Program
             Human Service Development Fund
             Other (Identify)
                         Operating Budget - Entered Information        =     0%                     Your entries should not exceed 100%

      CAPITAL COSTS: Please identify all programs/funding streams and indicate the percent of each within your agency’s
      capital budget for the previous State Fiscal Year, as applicable.
                FTA Section 5310                                                 Lottery Shared Ride Program (Community Transportation Capital Equipment)
                MATP Vehicle Use Allowance/Depreciation (See Section 36 of the I&R)
                Other (Identify)
                                 Capital Budget - Entered information =             0%                       Your entries should not exceed 100%

C. TYPE OF TRANSPORTATION SERVICE PROVIDED (Check the appropriate boxes)
   What type of service does your agency provide to the general public?
            Door to Door                                                                      Curb to Curb
                Other (Describe)




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                                                                            Service Plan
                                                               July 1, _____ through June 30, _____
                                                                         County of: County

D. CURRENT SERVICE DATA
   Please enter the average cost per passenger/per trip for services currently provided, regardless of funding streams.
                 For all modes
                For Paratransit
              For Mass Transit
          For Client Reimbursement

Average length of a paratransit trip for all funding streams                                                                                 miles

E. AGENCY DATA
   Please list the public telephone numbers available for consumers to call
PRIMARY AGENCY TELEPHONE NUMBER                                                       Alternate (If applicable)

TOLL FREE TELEPHONE NUMBER                                                            Alternate (If applicable)

HEARING IMPAIRED TDD NUMBER                                                           URGENT CARE TELEPHONE NUMBER

Enter the current PennDOT approved average paratransit fare rate and attach a              Average
copy of the PennDOT rate structure approval letter, if applicable, to the hard copy         Rate
submission.
                    Are you expecting any fare rate increase this fiscal year?

F. SERVICE AREA
If it has changed since reported in the previous fiscal year, please attach, to both the electronic and the hard copy submission, a detailed description of your
primary, general public service area. You may attach an electronic or scanned image of a map to the version submitted via e-mail, or include a written description
in the space provided below. All are acceptable.




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                                                                         Service Plan
                                                            July 1, _____ through June 30, _____
                                                                      County of: County

G. LOCAL POLICIES AND PROCEDURES
Please attach to both the electronic and the hard copy submission, a copy of your complaint procedure, sanction policies (those provided for internal staff use
and those provided to consumers), no show policy, urgent care policy, and your policy to evaluate the least costly and most appropriate form of transportation.




H. MILEAGE REIMBURSEMENT RATE
PRIOR APPROVAL IS REQUIRED BEFORE CHANGING THE MILEAGE REIMBURSEMENT RATE FROM THAT LISTED BELOW DURING THE STATE FISCAL YEAR.
                                                   CLIENT MILEAGE REIMBURSEMENT RATE PER MILE
List factors and method used to determine mileage reimbursement rate below




I.   COMMENTS




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 MATP Handbook                                                                                                                        Section 9: Forms

 Assessment of Needs
 SECTION I – GENERAL


 Last Name                                                        First Name                                        Middle Initial                       Date of Birth


 Street Address 1                                                                                                   Apartment #

                                                                                                                    PA
 City                                                             Municipality                                      State         Zip Code                                Telephone #

 SECTION II – MEDICAL ASSISTANCE ELIGIBILITY INFORMATION
 Recipient # (10 Digit # on Access Card)           Cared Issue # (2 Digit # following the 10       Group #                                    Social Security #
                                                   digit # on Access Cared



 NURSING HOME/PERSONAL CARE HOME INFORMATION                                                                                                                          Circle One
 Do you live in a nursing home?                                                                                                                    Y              N                I don’t know
 Do you live in a personal care home?                                                                                                              Y              N                I don’t know
 Does the personal care home receive an agreement to provide transportation services for you?                                                      Y              N                I don’t know
                                                                                                                                                            For Children under age : 8 This
                                                                                                                                                            section is required under the PA
 Other Eligible Household Members (List)                                                                                                                    Child Passenger Protection Laws

                  Name                       Birth date             Recipient #           Card #          Group #                       SSN                       Height                   Weight




I hereby certify that to the best of my knowledge, the information contained herein is true, correct and complete. I agree to report any changes in circumstances immediately to the Service
Provider. I understand that documentation of all eligibility factors may be required to determine eligibility correctly or for auditing purposes and that giving knowingly false statements is a
criminal offense. I understand that I have a right to request a Department of Public Welfare fair hearing if benefits are denied. This affirmation statement covers all attachments required for
the determination of eligibility.


______________________________________________________________________________
Signature of Client                                                  Date

                                                             FOR OFFICE USE ONLY – DO NOT COMPLETE BELOW THIS LINE
 Applicant Determined Eligible(circle one)


              Y            N                              Reason for Ineligibility:


 Date Initial Eligibility Determined

 County Code Assignment

 Date Client Notified




                                                          Signature of Interviewer                                                                                      Date




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MATP Handbook                                                                                                                       Section 9: Forms

                                                                            Assessment of Need
                                                                                       (Page 2 of 3)
Complete for each recipient listed on page 1

Recipient Name                                      ________________________________________________________________________________

 Recipient Number # (10 Digit # on Access           Card Issue # (2 digit # following the
                Cared)                                  10 digit # on Access Card)                      Group#                                           Social Security #




Do you have a vehicle that you are able to drive?                                                      Yes                     No

Can you drive yourself to your appointments?                                                           Yes                     No

Do you have family or friends who can transport you to your appointments?                              Yes                     No



Frequency of Transportation Needed (this information is needed to determine the frequency of ongoing transportation needed)

                                                                    Approx.
List known locations for medical services needed                               # of weeks                                                                                            Appt Time if
                                                                 Distance from                          Circle the days of week transportation is needed to this location
                                                                               per month                                                                                               known
                                                                     home

                                                                                                 Mon         Tues        Wed          Thur         Fri          Sat          Sun

                                                                                                 Mon         Tues        Wed          Thur         Fri          Sat          Sun

                                                                                                 Mon         Tues        Wed          Thur         Fri          Sat          Sun

                                                                                                 Mon         Tues        Wed          Thur         Fri          Sat          Sun

                                                                                                 Mon         Tues        Wed          Thur         Fri          Sat          Sun

                                                                                                 Mon         Tues        Wed          Thur         Fri          Sat          Sun


                                                                  Are there medical reasons why         If there are medical reasons why you cannot use the above modes, we need a
Transportation Modes
                                                                  you cannot use this mode              “Verification of Disability and Special Needs” form completed by your medical provider.
Fixed routs (If available)                                                  Y          N
Paratransit Services (If available)                                          Y              N
Taxis (If available)                                                         Y              N


Do you live ¼ mile or less from bus route services?                          Y              N

Instructions to driver on where your home is (if you need paratransit services):




                Name of Emergency Contacts                                                  Phone #                                                       Relationship




MATP Rev 07/10                                                              70
MATP Handbook                                                                                                   Section 9: Forms

                                                                 Assessment of Need
                                                                          (Page 3 of 3)
Complete for each recipient listed on page 1

Recipient Name                                 ________________________________________________________________________________

1.    LANGUAGE
      Can you speak and understand English?                                                     Y                        N


      If not, what language do you speak?                                   ________________________________________________

2.    ESCORT/PERSONAL CARE ATTENDANTS
      Will you be traveling with a Personal Attendant or Escort?                                Y                        N

      If the recipient is not a child, we need a medical statement verifying
      that you need to be escorted and a reason why this can be done through
      a letter from our doctor or by completing a form known as a
      “Verification of Disability or Special Need

3.    DISABILITY ACCOMMODATION SECTION
      Do you have a disability that requires special accommodation?                             Y                        N
      (If yes, attach a completed Verification of Disability or Special
      Needs or a Letter by your medical provider describing the
      Accommodation you need)

                     Nature of Disability                       Check all that apply

      Mobility Disability

      Hearing Disability

      Visual Disability

      Cognitive Disability

      Behavioral Health Disability

      Gross Obesity

      Other


                                                                Check if you use         I only need this mobility aid        Date no longer needed (Complete
4.    Use of Mobility
                                                                this mobility aid                 temporarily                only if this aid is needed temporarily)
      Manual Wheelchair

            Motorized Wheelchair

            Scooter

            Oversized Wheelchair

            Walker

            Crutches

            Braces

            Service Animal

            Other (describe)

            None
5.    Is your wheelchair greater than 30” in width and 48” in length (measured 2 inches above the ground) and
                                                                                                                                    Y                     N
      weigh no more than 600 lbs when occupied?
6.    Can you maneuver your wheelchair/scooter in a small confined area?                                                            Y                     N

7.    Can you transfer to a seat?                                                                                                   Y                     N

8.    Do you need assistance to transfer to a seat?                                                                                 Y                     N




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MATP Handbook                                                                                               Section 9: Forms

Special Needs
Recipient Name

Recipient Number


1.   Do you require the Assistance of a Personal Care attendant while
                                                                                     Yes                    No
     traveling?
     Name of Personal Care Attendant
2.   Will you be using an escort? (This is not a Personal Care
                                                                                     Yes                    No
     Attendant
     Reason for Escort (attach documentation of need)
3.   DISABILITY ACCOMODATION SECTION
Do you have an ADA disability that requires special accommodation?                                            Circle One
(attach documentation of need                                                                           Y                      N
Nature of Disability (Check all that apply)                                 Yes/No                           Accommodation Requested
          Ambulatory
          Motor Dysfunction
          Visual Disability
          Cognitive Disability
          Uncontrolled Fatigue
          Mental Disability
          Obesity
                                               This wheelchair
                                               or scooter meets    Is it difficult to
                                  Check for                                                                 Do you need          Mobility
                                                ADA “common       maneuver your           Can you                                            Date no
                                   use of                                                                   assistance to       Device is
4.   Use of Mobility aids                        wheelchair”*   wheelchair/scooter      transfer to a                                         longer
                                 mobility aids                                                              transfer to a        needed
                                                   definition.  in a small confined         seat?                                            needed
                                    used                                                                        seat?          permanently
                                                                         area?
                                                   Yes or No
       Manual
       Motorized Wheelchair
       Scooter
       Oversized Wheelchair
       Walker
       Crutches
       Braces
       Service Animal
Reason for Escort (Attach documentation of need)




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MATP Handbook                                                                                Section 9: Forms

Application Section
                                                           Medical Assistance Transportation Program Application

                                                                   Verification of Disability or Special Needs
                                                                             APPLICANT SECTION



Last Name                                                              First Name                                                        Middle Initial


Street Address 1                                                                Apartment #                             Telephone #


City                                                           Municipality                                     State                    Zip Code

                                                                      APPLICANT RELEASE SECTION

I understand that the purpose of this evaluation is to help in determine the most cost effective and appropriate mode of transportation for me. I understand that the
information about my disability contained in this application will be kept confidential and shared only with professionals involved in evaluating my eligibility. I hereby
authorize my medical representative to release any and all information required by the Medical Assistance Transportation Program regarding my medical condition, for the
purpose of determining an appropriate method of transporting me to medical services.



                   Applicant Signature                                                                                            Date

If applicant is unable to sign this form he/she may have someone sign and certify on applicant's behalf (e.g., minor, disability)




Signature of Person Signing for Applicant                      Date             Print Name                              Relationship to Applicant


                                                                            CERTIFICATION SECTION

The individual names above has the following disability(ies)

[ ]     Mobility                                     [ ]       Vision                                           [ ]     Hearing
[ ]     Cognitive                                    [ ]       Behavioral                                       [ ]     Other

Continue on back of page




MATP Rev 07/10                                     73
MATP Handbook                                                                                  Section 9: Forms

                                                              Medical Assistance Transportation Program Application

                                                                      Verification of Disability or Special Needs
                                                                                LIMITAITON SECTION

                                                                                             These limitations apply                                      Status
Indicate the tasks related to using public transit that the individual listed    Always     Usually   Occasionally           Rarely        Permanent    Temporary        If so, how
above cannot do.                                                                                                                                                         long?
Boarding vehicle without a wheelchair lift or ramp
Recognizing a bus stop, identifying appropriate bus and route #
Understanding/handling bus fare/money transactions
Recognizing destinations if stops are announced
Waiting for an hour
Walking less than a 1/4 mile
Communicating with people
Understanding emergencies or handling emergencies well
Other (describe)

Does the individual require a personal care attendant or escort for assistance while traveling                                                          Y                  N
                                                                                VERIFICATION SECTION

In signing, I acknowledge that to the best of my knowledge, the information in this evaluation form is true and correct. Furthermore, I certify that I have medical information
on file to document the above statements and will produce such documentation at the request of the Medical Assistance Transportation Program Provider. I understand
that providing false or misleading information could result in prosecution allowed by the laws of the Commonwealth of Pennsylvania.



Print or Type Name of Person Signing                                       Signature                                      Pennsylvania License #                  Date
                                                                                                                          (if applicable)


Office Street Address, city, state & zip                                                                          Office Phone #                         Office Fax #
                                                                                CERTIFICATION SECTION
The individual names above has the following disability(ies)

[ ]   OVR                       [ ]    SSI/SSDI                      [ ]    Bureau of Blindness and Visual Services [ ]                        Ctr for Ind. Lvg
[ ]   MH/MR                     [ ]    United Cerebral               [ ]    Registered Physical/Occupational Therapist                         [ ] Physician
[ ]   Registered Nurse          [ ]    PA Attendant Care             [ ]    Other



MATP Rev 07/10                                        74
    MATP Handbook                                                               Section 9: Forms

                                                       Waiver Request Form Sample
MEDICAL ASSISTANCE TRANSPORTATION PROGRAM: SAMPLE WAIVER REQUEST FORM                              DATE   7/3/04

    Name of Requestor/Contact


      Requesting County(ies)/
           Corporation

   Please cite the requirement for
   which a waiver is being sought
     (from the Instructions and
            Requirements

  Briefly describe the efficiencies
 and/or service enhancements that
    will result from the waiver


    Briefly describe the proposed
        alternative procedure

                                                How will they be affected?
Approximately how many consumers
                                              What change, if any, will result in
        will be affected?
                                                    the level of service?
   Briefly describe the exception
 process for consumers who cannot
   be accommodated by the new
            requirement

  Briefly describe any local input in
this waiver proposal, i.e., consumers,
        medical providers, etc.




    MATP Rev 07/10                       75
    MATP Handbook                                                                              Section 9: Forms



                                                                    Waiver Request Form Sample
MEDICAL ASSISTANCE TRANSPORTATION PROGRAM: SAMPLE WAIVER REQUEST FORM                                                              DATE              7/3/04
                                         Mr. Perry R. Transit                          717-440.2121                                         9/1/04
                                                                                                           Requested Effective Date
    Name of Requestor/Contact


      Requesting County(ies)/
           Corporation
   Please cite the requirement for       I. One-Hour Rule (page 7 0f 9, Scope of Services)
   which a waiver is being sought
   (from the “Scope of Services”)

  Briefly describe the efficiencies      Individual trips to the Regional Medical Center on a daily, and sometimes multiple individual trips, are costly due to
 and/or service enhancements that        compliance with the One-Hour Rule. This proposed waiver request was discussed with our local consumer advisory group.
    will result from the waiver

                                         Our ability to group trips, whenever feasible, would significantly reduce the transportation costs. We would inform consumers
    Briefly describe the proposed        of a policy change for consumers, whenever possible, to schedule appointments at the Regional Medical Center for Monday,
        alternative procedure            Wednesday, or Friday. We will schedule two trips to the Medical Center on each of these days.
                                         Savings would ensure funding to provide transportation services to an increased number of eligible MA consumers. Our
   How will the savings be used?         County has experienced a 2.5% increase in enrollment in MATP in the past two years.

   Briefly describe the exception        If a consumer cannot possibly schedule their appointment on the above days, we would schedule an individual trip for them to
 process for consumers who cannot        access the medical services on the day it was scheduled.
   be accommodated by the new
            requirement
                                         A work group consisting of the County Human Services Director and local consumers have met to discuss the implications of
  Briefly describe any local input in
                                         this change and the consensus is that it would not negatively impact consumers.
this waiver proposal, i.e., consumers,
        medical providers, etc.




    MATP Rev 07/10                                    76
MATP Handbook                                                           Section 9: Forms




                                 Incident Report Form Template
                                      MATP INCIDENT REPORT

NAME OF INVOLVED PERSON ________________________________________

ADDRESS ______________________________________________________

                 _____________________________________________________

            PHONE _______________________ AGE ________              SEX ________

DATE & TIME OF INCIDENT _________________________________________

LOCATION _______________________________________________________

WAS ILLNESS OR INJURY INVOLVED (if yes, describe below)? __________

DESCRIPTION OF INCIDENT (Please include names of individuals involved, nature of the incident, if injury
or illness give name of physician/hospital used, names & addresses of witnesses, and narrative of
what occurred)

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

FINAL MATP DISPOSITION (how you intend to handle the incident, any next steps required, or likely
outcomes)




MATP Rev 07/10                          77
MATP Handbook                                               Section 9: Forms



________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________


PRINT NAME OF PERSON SUBMITTING REPORT _____________________________


SIGNATURE OF PERSON SUBMITTING REPORT ______________________________


DATE OF REPORT __________ DATE FORWARDED TO DPW/OMAP/MATP _________


                       (PLEASE USE ADDITIONAL PAGES IF NEEDED)




MATP Rev 07/10                   78
MATP Handbook                                                           Section 9: Forms



                                  Incident Report Sample Form
                                      MATP INCIDENT REPORT

NAME OF INVOLVED PERSON __William Smith________________________

ADDRESS _123 North 7th Street___________________________________

                 __Anytown, PA 11111___________________________________

            PHONE _717.555.1212___________ AGE ___36___             SEX ___M___

DATE & TIME OF INCIDENT _6/1/03 4:25 P.M.________________________

LOCATION __1200 BLOCK OF S. CHESTNUT STREET_____________________

WAS ILLNESS OR INJURY INVOLVED (if yes, describe below)? _No______


DESCRIPTION OF INCIDENT (Please include names of individuals involved, nature of the incident, if injury
or illness give name of physician/hospital used, names & addresses of witnesses, and narrative of
what occurred)

        Consumer was picked up at the outpatient entrance of the Hospital at 4:15 p.m. for a return trip
to his home. He was visibly intoxicated (i.e., slurred speech, staggering, bloodshot eyes, strong odor
of alcohol). Upon questioning, he denied consuming alcohol. Approximately ten minutes into the trip,
the consumer became physically ill and asked that they van be stopped. The driver complied with his
request. Upon exiting the vehicle, the consumer began laughing and stated that he wasn’t sick, he
just wanted off the van so that he could go to a nearby tavern. The driver attempted to explain to the
consumer the inappropriateness of his behavior and possible ramifications for the same (i.e.,
sanctions). The consumer became upset and threatened physical harm to the driver if he “reported”
him. When the driver attempted to call the dispatcher, the consumer became increasingly angry and
picked up a large rock. Upon observing this, the driver closed the door of the van and began to leave
the scene. The consumer threw the rock, hitting the van on the passenger side, rear portion of the
van. There were no reports of injury to any other individuals on the van.
        The driver called the dispatcher and explained the incident. The dispatcher contacted the local
law enforcement agency and reported the incident.
        Witnesses to the incident include Mary Lange, Sarah Gilbert and Robert West. Contact
information is available upon request.


FINAL MATP DISPOSITION (how you intend to handle the incident, any next steps required, or likely
outcomes)


        MATP Agency mailed the consumer a Written Notice form indicating that his MATP services
would be suspended pending an investigation. He was referred to the CAO and an explanation of his
right of appeal was explained (see attached copy).
MATP Rev 07/10                          79
MATP Handbook                                                       Section 9: Forms

The MATP agency was informed by the police that the individual had been arrested and cited for
public drunkenness and resisting arrest. The police encouraged the MATP to file charges for the
damages sustained by the rock which the consumer threw.
       On June 4, 2003, a second Written Notice was sent to the consumer indicating that his MATP
services were terminated. He was again given his right to appeal.

PRINT NAME OF PERSON SUBMITTING REPORT __Jason L. Jones____________


SIGNATURE OF PERSON SUBMITTING REPORT ______________________________


DATE OF REPORT 6/2/03       DATE FORWARDED TO DPW/OMAP/MATP 6/4/03




                          (PLEASE USE ADDITIONAL PAGES IF NEEDED)




MATP Rev 07/10                        80
MATP Handbook                                                                                                           Section 9 Forms



SAMPLE INCIDENT REPORT
York County Human Services Department
UNUSUAL INCIDENT REPORT
(Page 1 of 2)                    Revised 3/13/03

Date of Report ____/____/____                                                                                                     Time ___:____        AM      PM


 Name of Consumer (Last, First, MI)                                                                               Provider Name



 Address                                                                                                          Address



 City, State, Zip Code                                                                                            City, State, Zip Code



 Telephone Number                                                                                                 Telephone Number


 Date of Birth   ____/____/____                 Sex            Male                                 Female        County where facility is located                  Date of Admission ____/____/____


 Location of Incident                                                                                             Date of Incident ____/____/____                   Time ___:____    AM     PM




 Describe in detail exactly what happened and any circumstances that may have precipitated the incident/unusual incident (attach additional sheets if necessary):




Page 2 of 2
MATP Rev 07/10                                                    81
MATP Handbook                                                                                                                Section 9 Forms

 Result of Incident -- Description of any injury/damage




 Official Statement from Outside Assistance/Intervention (if applicable) - law enforcement entities, fire departments, ambulance services, public health officials, County Coroner or any other outside entities]




 Action Taken by Provider/Others




 Were services denied, reduced or terminated as a result of this unusual incident?                  Yes                  No

 Explain:


 Other Pertinent Information




 Name of Relative or Guardian notified           Relationship                                                        Address                                                  Phone


 Date Notified

 Typed or Printed Name of Person                 Signature of Person Reporting                                       Title                                                    Phone
 Reporting



 Typed or Printed Name of Supervisor             Signature of Supervisor                                             Title                                                    Phone




____/____/____    Date York County Human Services Department Notified by Telephone/by Fax (within 24 hours)
____/____/____                  Date Completed Incident Report Mailed to York County Human Services Department (within 3 working days)




MATP Rev 07/10                                                      82
MATP Handbook                      Section 10 Ops Memos


Handbook         Section 10




                        OPS MEMOS




MATP Rev 07/10                83
MATP Handbook            Section 11 Appendices




                 APPENDICES




MATP Rev 07/10      84
APPENDIX A              FISCAL REQUIREMENTS




                 Appendix A
           Fiscal Requirements




MATP Rev 07/10     85
APPENDIX A                                FISCAL REQUIREMENTS




                    FISCAL
                 REQUIREMENTS

    Medical Assistance Transportation Program

                   DEPARTMENT OF PUBLIC WELFARE

                 Office of Medical Assistance Programs




MATP Rev 07/10               86
APPENDIX A                                                   FISCAL REQUIREMENTS


1.   Budget Submittal

Counties must complete an MATP Budget Projection Report. Copies of the Budget Projection Report
and Instructions are attached. The Budget Report is due within 45 days of receipt of appropriate
forms.

The total cost reported on the Budget Projection Report should represent estimated actual expenses
for the appropriate fiscal year.

Counties should prepare and submit a revised MATP Budget Projection Report only when material
cost changes have been identified. The county should use the Budget Report tab on the quarterly
report submission to provide the revisions.

An electronic version must be e-mailed to the MATP Financial Report Gatekeeper at
FinancialGatekeeper@state.pa.us.

2.   Quarterly Reporting

The hard-copy Quarterly Report with the original signature(s) shall be submitted to the Department
October 30, January 30, April 30, and August 31, or the first regular business day thereafter. The
Department may defer payments to counties when the County fails to submit reports as required.

For the first, second, and third Quarters, the MATP Contact Person or other person designated by the
County Commissioners/County Executive may sign the report if they have obtained the appropriate
level of approval of County officials. For the Fourth Quarter Expenditure Report, the original
signatures of the County Commissioners/County Executive are required. The hard-copy report is to
be mailed to:

                    Department of Public Welfare
                    Attention: Financial Report Gatekeeper
                    Office of Medical Assistance Programs
                    Division of Financial Analysis
                    P.O. Box 2675
                    Harrisburg, PA 17105

                    Or, e-mail the request to:
                    RA-AuditConfirmation@state.pa.us

A copy of the electronic report shall be e-mailed to the Financial Report Gatekeeper at
FinancialGatekeeper@state.pa.us, the MATP Program Manager and the County’s assigned MATP
advisor.

Program allocations are based on four quarters of the state fiscal year beginning July 1 and
continuing through June 30 of the following year. The reporting of expenditures and revenues shall
be on a modified accrual or accrual basis. This requires the reporting of expenses, purchases, and
other bills in the period when incurred (regardless of when paid), and the reporting of interest,
revenues, fees, and contributions in the period when earned (regardless of when received).

MATP Rev 07/10                         87
APPENDIX A                                                      FISCAL REQUIREMENTS
NOTE: When submitting the 2nd, 3rd, and 4th Quarter Reports, make any prior period fiscal year
adjustments in the current quarter being reported. Do not go back and restate prior period quarterly
data previously submitted.

3.   MATP Funding Status

For purposes of the quarterly Actual Expenditures Reports:

Group 1 Cases - Categories of assistance and program status codes identified as receiving Federal
funding for Medicaid services. Former Group 3 cases are now in Group 1.

Medical Assistance for Workers with Disabilities (MAWD) – Categories of assistance and program
status codes are as follows: PW/00, PW/66, PW/80, PI/00, PI/66, and PI/80. These consumers
include employed workers with a disability and are reported as Group 1 Cases.

Group 2 Cases - Categories of assistance and program status codes identified as receiving State
funds only for Medicaid services.

Currently, the following categories of assistance and program status codes are identified as Group 2:
D-00, B-00, PD-00, PD-21, PD-22, PD-29, TD-00, TB-00

If a category of assistance and program status code is not listed above, assume that it is to be
reported as Group1.



4.   Key Dates for the County


             July 1                   County begins operation of the Medical Assistance
                                      Transportation Service for the fiscal year beginning July 1 in
                                      accordance with the budget submittal.

             October 30               County’s hard-copy first quarterly report due to the Financial
                                      Report Gatekeeper.

                                      County’s electronic first quarterly report due to the Financial
                                      Report Gatekeeper, the MATP Program Manager and the
                                      County’s assigned MATP advisor.


             January 30               County’s hard-copy second quarterly report due to the Financial
                                      Report Gatekeeper.

                                      County’s electronic second quarterly report due to the Financial
                                      Report Gatekeeper, the MATP Program Manager and the
                                      County’s assigned MATP advisor.



MATP Rev 07/10                          88
APPENDIX A                                                      FISCAL REQUIREMENTS




             February - March         The Department will calculate reallocation amounts based on
                                      2nd quarter year-to-date actual expenditures.

             April 30                 County’s hard-copy third quarterly report due to the Financial
                                      Report Gatekeeper.

                                      County’s electronic third quarterly report due to the Financial
                                      Report Gatekeeper, the MATP Program Manager and the
                                      County’s assigned MATP advisor.

                                      FY 06-07 Budget Projection Report due to the Financial Report
                                      Gatekeeper.

             August 31                County’s hard-copy final quarterly report due to the Financial
                                      Report Gatekeeper.

                                      County’s electronic final quarterly report due to the Financial
                                      Report Gatekeeper, the MATP Program Manager and the
                                      County’s assigned MATP advisor.


5.   Least Costly and Most Appropriate Requirement

MATP consumers must use the least costly and most appropriate form of transportation. The County
must, on a case-by-case basis, carefully review an individual consumer’s situation, and may only
authorize the least costly form of transportation that will meet that individual consumer’s needs. It is
not acceptable for a County to authorize, for example, more costly taxi or paratransit services without
first determining that less costly and equally appropriate transportation services are not available.
Each County must develop and maintain for independent review, written policies that document the
case-by-case evaluation process they utilize to meet this requirement. Copies of written policies
must be submitted to the Department as part of the MATP Service Plan.

6. Responsibility to Negotiate
Counties have a responsibility to assign skilled negotiators to negotiate contracts with transportation
service providers, and to ensure that contracts are zealously negotiated to obtain quality
transportation services for consumers at the lowest possible cost. Competitive bidding procedures
should be utilized whenever possible. It is the responsibility of the county to negotiate with its
subcontractors a cutoff date to allow appropriate expenditures to be properly recorded in each
submission to the Department Effective December 31, 2006, no prior period adjustments will be
allowed to be made in the current year unless determined material through the appeal or audit
process. It is the responsibility of the county to ensure effective communication of this established
cutoff date and to define required documentation and reimbursement to both consumers and
providers so allowable expenditures will be properly included in each submission to
the Department



MATP Rev 07/10                          89
APPENDIX A                                                       FISCAL REQUIREMENTS
7.   Payment of Last Resort

Medicaid is the payer of last resort. Counties must utilize all existing social service and public transit
resources prior to the expenditure of MATP funds. The MATP may not be excluded from the benefits
derived from grants and/or subsidies for administration, operational expenses, or capital acquisition.
Other available resources that must be used before MATP pays for service to a Medical Assistance
eligible individual include:

        1. Third-Party Payers. This includes third-party payers with whom the consumer may have
              rights, such as insurance companies and accident claims. If a consumer is receiving
              therapy as a result of an automobile accident, for example, the insurance carrier may
              also cover transportation costs as part of their liability.

        2. Children and Youth. Children and Youth agencies may have a line item for transportation
              included in their budgets. Counties should work with their children and youth agencies
              to assess the availability of funding for medical assistance transportation and provide
              transportation when the need is demonstrated due to the lack or limitation of children
              and youth funding.

8.   No-Shows

No-shows cannot be reported as trips but costs incurred may be reported on the Actual Expenditures
Report.

9.   Multiple Reimbursements

The MATP will not fund multiple reimbursements for consumers traveling together in one privately
owned vehicle. The MATP is a shared-ride program. If more than one individual is in a vehicle going
to covered services, the reimbursement is the same as if only one individual was receiving service.

10. Consumer Fraud

Cases involving consumer fraud should be referred to the Office of Inspector General (OIG). OIG
Contact Information, by region, is included in the Handbook section.

11. Interest Bearing Accounts

While it is recommended that counties maintain advance payments and excess funds within interest
bearing accounts, counties must maintain the ability to easily access funds to effect timely delivery of
payment. In addition, counties must ensure that interest earned on MATP funds is accurately
reported and used to support transportation services under the MATP, and used to increase the level
of services provided. Finally, should counties co-mingle MATP funds with other program revenues,
an allocation resulting in an equitable distribution of earned interest must be supported with a written
allocation plan and available for independent review.

12. Retroactive Costs

All MATP services begin with and go forward from the time that the County determines eligibility and
level of MATP service need. The County may, however, determine eligibility for a new enrollee for a
current month’s bus pass, for example, by using the previous month’s appointments. As indicated in
MATP Rev 07/10                           90
APPENDIX A                                                        FISCAL REQUIREMENTS
the Scope of Services, services may begin with an eligibility determination; a signed application is not
required to start services, but must be received within 30 days of the start of services. For example, a
recipient in need of a trip home from the hospital after emergency treatment may be transported as
soon as eligibility is verified (e.g., by phone) even if a signed application has not yet been received.

13. Payment Procedures

The Department will make payment to County programs for MATP services as follows:

Payment #1: The Department will process the first payment at the beginning of the first quarter (July1
- September 30) of the fiscal year. This payment will represent 25 percent of the County's current
fiscal year allocation. It will not include any reconciliation of a prior period or audit adjustments.
Payment will not be made until a signed Allocation Acknowledgement Letter is returned to the
Department.

Payment #2: The Department will process the second payment at the beginning of the second
quarter (October 1 - December 31) of the fiscal year. This payment will represent 50 percent of the
County's current fiscal year allocation less prior payments for the current fiscal year. It will not include
any reconciliation of a prior period or audit adjustments.




Payment #3: The Department will process an allocation settlement for the previous fiscal year by
October 31 of the current fiscal year. This payment will represent the year-end settlement of 100
percent of the county’s allowable expenditures for the prior fiscal year. It will not include any audit
adjustments.

Payment cannot be guaranteed if the hard-copy 4th quarter report is not received timely.

Payment #4: The Department will process the Fourth payment at the beginning of the third quarter
(January 1 - March 31) of the fiscal year contingent upon the Financial Analysis Division’s receipt,
review and approval of the County’s first quarter expenditure report. This payment will represent 75
percent of the County's current fiscal year allocation less prior payments for the current fiscal year as
well as a reconciliation of the first quarter expenditure report. The reconciliation will take into account
the level of expenditures for the first quarter as well as any outstanding audit adjustments. In
addition, a reduction for any funds due to the Department for the prior fiscal year-end settlement may
occur.

Payment #5: The Department will process a reallocation payment for the current fiscal year in the
middle of the third quarter (January 1 - March 31). The Department will calculate reallocation
amounts based on 2nd quarter year-to-date actual expenditures. This payment will represent up to 75
percent of the County’s current fiscal year reallocation. It will not include any audit adjustments.
Payment will not be made until a signed Allocation Acknowledgement Letter is returned to the
Department.

Payment #6: The Department will process the sixth payment at the beginning of the fourth quarter
(April 1 - June 30) of the fiscal year contingent upon the Financial Analysis Division’s receipt, review
and approval of the County’s second quarter expenditure report. This payment will represent 100
percent of the County's current fiscal year allocation or reallocation less prior payments for the current
MATP Rev 07/10                            91
APPENDIX A                                                         FISCAL REQUIREMENTS
fiscal year as well as a reconciliation of the second quarter expenditure report. The reconciliation will
take into account the level of expenditures for the second quarter as well as any outstanding audit
adjustments.

It is expected that counties will operate their programs within their projected budget. In addition, the
counties should manage their programs in an effective and efficient manner and implement reforms
necessary to avoid the need to request additional allocation of funds.

In the event that a County experiences an unexpected fluctuation in utilization that creates a
proportional need for additional funding, an agency should notify the Department and submit a
revised budget projection immediately.



In addition, requests must include all of the following information:

        A detailed narrative explaining the increased utilization and how the increased costs are
        related, proportionally, to the increased utilization.

        A detailed description of the steps taken to reduce, contain, or control costs prior to requesting
        a supplemental appropriation.

        A copy of the audit report detailing the need for additional funds, if available.

        If an audit report is not available, a detailed accounting of the additional expenses and
        supporting documentation, subject to independent review, demonstrating that a supplemental
        payment is necessary to maintain service to MA consumers.

Consideration of allocation increases is contingent upon the availability of state and federal funds.

14. Usual and Customary Charge

Counties shall not pay more than the usual and customary charge to the general public for MATP
services. Contracts between a County and transportation providers must explicitly provide that
transportation providers will not charge the MATP agency more for the same service than their usual
and customary charge to the general public for like service. The only exception to this rule would be
Premium Services (see: Paragraph 17, “Premium Services”). Contracts must also provide that
charges in excess of the usual and customary charge are subject to recovery by both the agency and
the Department.

If a provider uses the Shared-Ride Program's fare structure for billing, the MATP must be charged the
same rates as the Shared-Ride Program. MATP service that is provided within the definition of
general public service should be charged based on the general public fare structure. Trips that are
billed to MATP at the Shared-Ride rate should be reported in the Paratransit section of the
Transportation Report and on the Shared Ride expense line of the Actual Expenditure Report, even if
the trips are provided “in house” and not by a subcontractor. All costs (including those necessary to
provide services to Medical Assistance recipients) associated with Shared-Ride services should be
reflected in any request for a fare increase submitted to Pennsylvania Department of Transportation
(PENNDOT).

MATP Rev 07/10                             92
APPENDIX A                                                        FISCAL REQUIREMENTS




15. Notification of Fare Increases – PENNDOT Shared Ride Services

The Department of Public Welfare must be kept informed of any fare increases in order to anticipate
future costs. Any expected rate increases should be reported on the MATP Service Plan and a copy
of the rate increase letter should be forwarded to the Financial Report Gatekeeper for distribution to
appropriate offices.

16. Subcontracts

The county may rely on subcontractors to perform and/or arrange for the performance of services to
be provided to consumers on whose behalf the Department reimburses the county, notwithstanding
its use of subcontractor(s).

The county and all of its subcontractors must provide a copy of executed transportation related
contracts to the Financial Report Gatekeeper for distribution to the appropriate offices.

17. Premium Services

The Department recognizes that some service is not shared-ride in nature and is beyond the standard
service provided for the general public. Premium service charges are charges above and beyond the
basic service fare structure. The County shall establish its premium service charges based upon its
incremental costs associated with the premium service. Premium services rates shall be reported on
the mode of transportation line that is used to provide the service for reporting on the Transportation
Report and the Transportation portion of the Actual Expenditures Report.

The following are types of premium service:

        Trips requested after the close of the last business day prior to the trip; that is, same day
        service.
        Exclusive ride taxi/paratransit service
        Call or demand service
        Nonpublic transportation service
        Long distance travel not available to the general public

18. Record Keeping

Counties and subcontractors shall maintain books, records, documents, and other evidence
pertaining to costs and expenses of the allocation. These records must properly reflect all costs of
labor, materials, equipment, supplies and services, and other costs and expenses of any nature for
which reimbursement is claimed or payment is made under the MATP. Where feasible, it is
recommended that books and records be maintained based on the account structures used in other
County human service or County transportation programs. Books, records, documents, and other
evidence shall be maintained according to Generally Accepted Accounting Principles. Contracts
between the County and transportation subcontractors must contain provisions that ensure that
subcontractors maintain, and provide access to, the information identified in this section.

MATP Rev 07/10                            93
APPENDIX A                                                         FISCAL REQUIREMENTS
19. Record Retention

Fiscal and consumer records shall be preserved and made available for a period of four years from
the close of the fiscal year for which the allocation was awarded.

20. Audits

The MATP is subject to audit under the Single Audit Act since Federal Title XIX funds are included
within the MATP allocation. All audits must be performed in accordance with the audit guidelines
contained in the DPW Single Audit Supplement issued by the Department.
If a County subcontracts all or a portion of its administrative responsibilities, the County must require
through its agreement with the sub-grantee the inclusion of the Department of Public Welfare's Single
Audit Supplement for the sub-grantee to use in its audit.

If a nonprofit agency assumes the administrative responsibilities of a County, the agency's A-133
audit must be conducted in accordance with the Department of Public Welfare's Single Audit
Supplement. All counties and prime contractors are subject at all reasonable times to review and
audit by the Department, Auditor General, federal auditors, and persons authorized by the
Department to determine compliance with statutes, regulations, and policies.

All counties and prime contractors with more than one funding source for transportation must utilize a
written cost allocation plan that demonstrates equitable cost distribution.

All requests for audit confirmation must be made in writing to the Commonwealth of Pennsylvania,
Comptroller Operations, 9th Floor Forum Place, 555 Walnut Street, Harrisburg, Pennsylvania 17101-
1925. The Federal CFDA number for the MATP is 93.778.

Single audits must be submitted to the:

                 Office of Budget/Bureau of Audits
                 303 Walnut Street
                 Verizon Tower-Strawberry Square
                 6th Floor
                 Harrisburg, Pennsylvania 17101

21. Performance Audits

Department staff will carefully review the quarterly reports submitted by counties during the course of
the year to identify instances where program expenditures appear to exceed those expected of
economically and efficiently operated County programs. Routine on-sites will be performed by the
Department. If necessary, auditors from the Department’s Bureau of Financial Operations may
conduct performance audits of programs to identify program inefficiencies, ensure compliance with
MATP program standards, and recommend corrective action.

22. Sanctions

             The Department of Public Welfare may enforce these Instructions and
             Requirements through the imposition of sanctions. Sanctions may include, but
             are not limited to, total or partial revocation of the allocation or suspension of
             quarterly payments. The Department may also utilize all equitable remedies
MATP Rev 07/10                             94
APPENDIX A                                                      FISCAL REQUIREMENTS
             provided under Pennsylvania law.

23. Allocation Termination

In the event of termination or cancellation of the allocation, the County shall submit a financial
accounting of revenues and expenditures to the Department no later than 60 days after the
termination date. No reimbursement shall be made for any expenditure not submitted in accordance
with this provision. The Department may terminate allocations where it finds a County to be
substantially out of compliance with the requirements, regulations, or assurances that govern the
expenditure of funds.

24. Balance of Funds

The Department retains the authority to review allocations against actual expenditures and revenues
and to make appropriate adjustments against subsequent allocations. If an allocation overpayment
cannot be recovered through such an adjustment, the Department may require a refund from the
County.

25. Encumbrances

Funds may not be encumbered out of a current year's allocation for costs anticipated to be incurred in
a succeeding year.

26. Administrative Costs

Administrative costs are actual County or administering agency expenses for management of the
MATP program and funds. If costs are not transportation-specific, they are administrative in nature.
Allocated Administrative costs must be supported by a written cost allocation plan that is available for
independent review and these costs should be placed on the most appropriate expenditure line of the
Actual Expenditure Report.

The following are examples that are considered by the Department to be Administrative Costs:

        Audit costs.
        Countywide overhead charged to the program via countywide cost allocation plan.
        Costs incurred for invoicing and submission of required reports.
        Costs incurred for negotiating and securing sub-contracts (purchased services).
        Costs incurred for program quality assurance and monitoring of sub-contracts.
        Processing reimbursement checks.
        Determining medical assistance eligibility
        Completing application forms.

27. Transportation Costs

Transportation costs are actual or county administering agency expenses necessary to provide MATP
Transportation.

28. Limitations on Purchases


MATP Rev 07/10                           95
APPENDIX A                                                       FISCAL REQUIREMENTS
The allocation shall not be used to purchase or improve land, or purchase, construct, or permanently
improve any building or other facility. The expenses incurred may be depreciated over the useful life
of the purchase or improvement based upon past experience or the best estimate of the company.
The depreciation and allocation methodology to expense MATP’s portion must be submitted to the
Department for review.

The allocation shall not be used to purchase fixed assets that have a unit purchase price of $10,000
or more. The expenses incurred may be depreciated over the useful life of the purchase based upon
past experience or the best estimate of the company. The depreciation and allocation methodology
to expense MATP’s portion must be submitted to the Department for review. Fixed assets are define
as major items which have a useful life of more than one year or which can be used repeatedly
without materially changing or impairing their physical condition by normal repair, maintenance, or
replacement or components. A class of components normally considered together as a unit may not
be listed at the individual component value in order to avoid the $10,000 unit purchase limit.

No capital acquisitions purchased outright with MATP funds may be subsequently depreciated.

29. Bidding and Procurement

The County shall obtain all supplies and services as required by the applicable County Code, County
Institutional District Law or Home Rule Charter.

30. Vehicle Use Allowance/Depreciation

The County and prime contractors may charge the Department for a use allowance/depreciation of
vehicles and other equipment used in the delivery of MATP funded transportation services as an
operational expense during the current fiscal year.

The allowance/depreciation must be equitably determined, distributed and/or proportioned and
consistently applied to all appropriate funding streams. Contingency accounts may not be funded with
MATP monies.

31. Specialty Equipment

The equipment referred to in this section is limited to radio communications equipment, lift equipment
purchased separately from the vehicle, and computers which are used for dispatching, scheduling,
and tracking expenditures.

32. Title to Property

Title to fixed assets acquired with allocation funds shall remain with the County during the term of the
grant. This includes property purchased by the County for its own use and property purchased by or
for subcontractors or contractors. Counties must maintain a list of MATP purchased fixed assets.

33. Disposition of Property

Upon termination or cancellation of the allocation, disposition of property which has a remaining
useful life, and to which the County holds title, shall be made according to the following provisions at
the discretion of the Department:

MATP Rev 07/10                           96
APPENDIX A                                                     FISCAL REQUIREMENTS
    1. Transferred at no cost by the County holding title to such property to another County or
       providers designated by the Department;
    2. Allowed to be acquired by the County. The County will reimburse the Department for remaining
       life of the property on the basis of an independent third-party appraisal or, where appropriate,
       depreciation tables;
    3. Upon prior written permission of the Department, the County may sell the property and
       reimburse the Department for a determined appropriate share.




MATP Rev 07/10                          97
APPENDIX A                                                    FISCAL REQUIREMENTS
Escort Trips

For both the MATP Quarterly Reports and the Monthly Trip Data Report submission, a trip provided to
a consumer that also includes an escort should be tracked and reported as a single passenger trip
with the associated costs for both the consumer and the escort combined and reported as a single
trip cost. It is imperative that the trip reporting be consistent between the Monthly Trip Data Report
and the MATP Quarterly Reports relative to the count of the number of trips, and in the case of the
quarterly expenditure reports, that the total associated cost be correctly reported.




MATP Rev 07/10                         98
Appendix A               Fiscal Requirements




                 FORMS




MATP Rev 07/10   99
Appendix A                                                        Fiscal Requirements

        Budget Projection Report
                                                    BUDGET PROJECTION REPORT
                                                                                                                  Date of Original:
      PROGRAM COUNTY::                       MEDICAL ASSISTANCE TRANSPORTATION                                    Date of Revision:

                       ITEM                       2005-2006                       2006-2007 Projected Budget
                                                  Estimated
                                                 Expenditures      1st Qtr         2nd Qtr          3rd Qtr            4th Qtr        Total FY
                 BUDGET REPORT
                Administrative Cost
      Salaries & Benefits
        Staff Wages                                                                                                                          $0
        Benefits                                                                                                                              0
        Misc. (details must be attached)                                                                                                      0
      Subtotal Salaries & Benefits                            0              0               0                0                  0            0

      Rent/Lease of Space
        Rent                                                                                                                                     0
        Utilities                                                                                                                                0
        Insurance                                                                                                                                0
        Telephone                                                                                                                                0
        Misc. (details must be attached)                                                                                                         0
      Subtotal Rent/Lease of Space                            0              0               0                0                  0               0

      Materials & Supplies
        Office Supplies                                                                                                                          0
        Printing & Copying                                                                                                                       0
        Postage                                                                                                                                  0
        Misc. (details must be attached)                                                                                                         0
      Subtotal Materials & Supplies                           0              0               0                0                  0               0

      Office Furniture & Equipment                                                                                                               0

      Data Processing
        Computer Equipment                                    0              0               0                0                  0               0
        Subcontract Services                                                                                                                     0

MATP Rev 07/10                             100
Appendix A                                                             Fiscal Requirements

        Software                                                                                         0
        Misc. (details must be attached)                                                                 0
      Subtotal Data Processing                                  0                 0          0   0   0   0

      Travel                                                    0                 0          0   0   0   0

      Fees - Other Related Costs
        Professional Fees                                                                                0
        Bank Charges                                                                                     0
        Insurance (officers, board, liability,
      etc.)                                                                                              0
        Misc. (details must be attached)                                                                 0
      Subtotal Fees - Other                                     0                 0          0   0   0   0

      Total Administrative Cost                                 0                 0          0   0   0   0


      All costs (indirect and direct) are to be placed on the appropriate lines above.


               Transportation Cost
      Salaries & Benefits                                       0                 0          0   0   0   0

      Occupancy Costs
        Rent                                                                                             0
        Utilities                                                                                        0
        Insurance                                                                                        0
        Telephone                                                                                        0
        Misc. (details must be attached)                                                                 0
      Subtotal Occupancy Costs                                  0                 0          0   0   0   0

      Office Furniture & Equipment                              0                 0          0   0   0   0

      Data Processing                                           0                 0          0   0   0   0

      Vehicles
        Depreciation Expense                                                                             0
        Autos-Loan Interest Expense                                                                      0
        Autos-Leased                                                                                     0
MATP Rev 07/10                                   101
Appendix A                                            Fiscal Requirements

        Maintenance Repairs                                                                 0
        Fuel Charges                                                                        0
        Tires
        Insurance                                                                           0
        Misc. (details must be attached)                                                    0
      Subtotal Vehicles                           0            0             0    0    0    0

      Special Equipment                           0            0             0    0    0    0

      Travel                                     0             0            0    0    0     0

      Paratransit
          Shared Ride                                                                       0
          Taxi                                                                              0
          Other
      Subtotal for Paratransit                    0            0             0    0    0    0

      Client Reimbursement
          Mileage Reimbursement                                                             0
          Fixed Route
          Other                                                                             0
      Subtotal for Reimbursements                 0            0             0    0    0    0

      Mass Transit                               0             0             0    0    0    0

      No-Show Cost                               0             0             0    0    0    0

      Subtotal Transportation Cost                0            0             0    0    0    0

      Total Costs                                 0            0             0    0    0    0

      Interest Earned                                                                       0

      Total Funding                              $0          $0             $0   $0   $0   $0




MATP Rev 07/10                             102
Appendix A                                                             Fiscal Requirements


      All costs (indirect and direct) are to be placed on the appropriate lines above.

      Projection of Trips and Clients
      Projected Trips
      (1) Paratransit Trips                                                                                                                   0
      (2) Client Reimbursement Trips                                                                                                          0
      (3) Mass Transit Trips                                                                                                                  0
      (4) Volunteer Trips                                                                                                                     0
        Total Trips                                             0                 0               0              0             0              0

                                                                      1st Qtr YTD        2nd Qtr YTD   3rd Qtr YTD   4th Qtr YTD   Total FY
      Projected Unduplicated Clients                                                                                                          0




MATP Rev 07/10                               103
Appendix A                                                   Fiscal Requirements

        Actual Expenditure
                                                     ACTUAL EXPENDITURE REPORT
      COUNTY:
      PROGRAM:                             MEDICAL ASSISTANCE TRANSPORTATION

      ITEM                                       2006-2007                  2006-2007 Actual Expenditures
                                                  Budget     1st Qtr          2nd Qtr          3rd Qtr      4th Qtr        Total FY
      EXPENDITURE REPORT
      Administrative Cost
      Salaries & Benefits
        Staff Wages
                                                        $0             $0           $0                $0              $0          $0
        Benefits                                         0                                                                         0
        Misc. (details must be attached)                 0                                                                         0
      Subtotal Salaries & Benefits                       0              0            0                 0               0           0

      Rent/Lease of Space
        Rent                                             0                                                                            0
        Utilities                                        0                                                                            0
        Insurance                                        0                                                                            0
        Telephone                                        0                                                                            0
        Misc. (details must be attached)                 0                                                                            0
      Subtotal Rent/Lease of Space                       0              0            0                 0               0              0

      Materials & Supplies
        Office Supplies                                  0                                                                            0
        Printing & Copying                               0                                                                            0
        Postage                                          0                                                                            0
        Misc. (details must be attached)                 0                                                                            0
      Subtotal Materials & Supplies                      0              0            0                 0               0              0

      Office Furniture & Equipment                       0                                                                            0

      Data Processing
        Computer Equipment                               0                                                                            0
        Subcontract Services                             0                                                                            0
        Software                                         0                                                                            0
MATP Rev 07/10                             104
Appendix A                                                             Fiscal Requirements

        Misc. (details must be attached)                    0                                            0
      Subtotal Data Processing                              0                  0             0   0   0   0

      Travel                                                0                                            0

      Fees - Other Related Costs
        Professional Fees                                   0                                            0
        Bank Charges                                        0                                            0
        Insurance                                           0                                            0
        Misc. (details must be attached)                    0                                            0
      Subtotal Fees - Other                                 0                  0             0   0   0   0

      Total Administrative Cost                             0                  0             0   0   0   0
      All costs (indirect and direct) are to be placed on the appropriate lines above.
      Transportation Cost
      Salaries & Benefits                                   0                                            0

      Occupancy Costs
        Rent                                                0                                            0
        Utilities                                           0                                            0
        Insurance                                           0                                            0
        Telephone                                           0                                            0
        Misc. (details must be attached)                    0                                            0
      Subtotal Occupancy Costs                              0                  0             0   0   0   0

      Office Furniture & Equipment                          0                                            0

      Data Processing                                       0                                            0

      Vehicles
        Depreciation Expense                                0                                            0
        Autos-Loan Interest Expense
        Autos-Leased                                        0                                            0
        Maintenance Repairs                                 0                                            0
        Fuel Charges                                        0                                            0
        Tires
        Insurance                                           0                                            0
MATP Rev 07/10                               105
Appendix A                                                             Fiscal Requirements

        Misc. (details must be attached)                    0                                                0
      Subtotal Vehicles                                     0                  0              0    0    0    0

      Specialty Equipment                                   0                                                0

      Travel                                                0                                                0

      Paratransit
          Shared Ride
          Taxi
          Other
      Subtotal for Paratransit                              0                  0              0    0    0    0

      Client Reimbursement
          Mileage Reimbursement                                                                              0
          Fixed Route                                                                                        0
          Other                                                                                              0
      Subtotal for Reimbursements                           0                  0              0    0    0    0

      Mass Transit                                                                                           0

      No-Show Costs                                                                                          0

      Subtotal Transportation Cost                          0                  0              0    0    0    0

      Total Costs by Group
        Group 1                                                                                              0
        Group 2                                                                                              0
      Total Costs                                                              0              0    0    0    0

      Interest Earned                                       0                                                0

      Total Funding                                         $0                 $0            $0   $0   $0   $0
      All costs (indirect and direct) are to be placed on the appropriate lines above.




MATP Rev 07/10                               106
Appendix A                                                          Fiscal Requirements

        Personnel Report
                                                                PERSONNEL REPORT
        COUNTY:
        PROGRAM:                           MEDICAL ASSISTANCE TRANSPORTATION
                                                                 FIRST QUARTER REPORT

                                                                                          % of MATP hours
                                                                 Total Hours Worked                         Hourly Rate   Total MATP Wages
                                                                                               worked

                 Personnel Report
                  Administrative

           Employee #, name, or initials       Employee Title




MATP Rev 07/10                                 107
Appendix A                                                    Fiscal Requirements




                   Subtotal Administrative                                0         $0


                  Transportation

           Employee #, name, or initials     Employee Title




                   Subtotal Transportation                                0          0


          Total Personnel Costs                                           0         $0



MATP Rev 07/10                               108
Appendix A                                                   Fiscal Requirements

        Transportation Report
                                                   TRANSPORTATION REPORT
     COUNTY:
     PROGRAM:                                                                 MEDICAL ASSISTANCE TRANSPORTATION
                                                         FIRST QUARTER REPORT



                                               PARATRANSIT                                           No. of
                        Transportation                 Name of Provider            Type of Payment   Trips    Rate   Amount Paid

       Shared Ride:




       Shared Ride Subtotal:


       Taxi:




       Taxi Subtotal:




MATP Rev 07/10                           109
Appendix A                                                     Fiscal Requirements




       Other:




       Other Subtotal:


       Total ParaTransit:


                                                    TRANSPORTATION REPORT
     COUNTY:
     PROGRAM:                                                                   MEDICAL ASSISTANCE TRANSPORTATION
                                                          FIRST QUARTER REPORT



                                          CLIENT REIMBURSEMENT                                         No. of
                         Transportation                 Name of Provider             Type of Payment   Trips    Rate   Amount Paid

       Mileage:

       Other:

       Total Client Reimbursement:



                                                MASS TRANSIT                                           No. of
                         Transportation                 Name of Provider             Type of Payment   Trips    Rate   Amount Paid

       Mass Transit:




MATP Rev 07/10                            110
Appendix A                                                Fiscal Requirements

       Mass Transit Total:



                                              No-Shows
                       Transportation                Name of Provider           Type of Payment   Numbers   Amount Paid

       No-Shows Total:




MATP Rev 07/10                          111
Appendix A                                                         Fiscal Requirements


        Medical Assistance Transportation

   COUNTY:
   PROGRAM:                         MEDICAL ASSISTANCE TRANSPORTATION


       SUMMARY REPORT                2006-2007                                                                               Budget
                                                     1st Qtr        2nd Qtr       3rd Qtr       4th Qtr   YTD Expenses
                                      Budget                                                                                 Balance
                  ITEM
   Administrative Cost
     Salaries & Benefits
       Staff Wages
       Benefits
     Rent/Lease of Space
     Materials & Supplies
     Office Furniture & Equipment
     Data Processing
     Travel
     Fees - Other Related Costs


   Total Administrative Cost                     0             0              0             0        0                   0             0


   Transportation Cost
     Salaries & Benefits
     Occupancy Costs
     Office Furniture & Equipment
     Data Processing
     Vehicles


MATP Rev 07/10                          112
Appendix A                                     Fiscal Requirements



     Specialty Equipment
     Travel
     Paratransit
     Reimbursements
     Mass Transit
     No-Show Costs




   Total Transportation Cost          0    0           0             0    0    0    0


   Total Costs                       $0   $0          $0         $0      $0   $0   $0


   Interest Earned


   Total Funding




MATP Rev 07/10                 113
Appendix A             Fiscal Requirements




1st Quarter




2nd Quarter




3rd Quarter




4th Quarter




MATP Rev 07/10   114
Appendix A                                                           Fiscal Requirements


Trip and Client Data Report
                                        TRIP AND CLIENT DATA REPORT
     COUNTY:
     PROGRAM:                           MEDICAL ASSISTANCE TRANSPORTATION

                                          Projected                                  Actual
                     ITEM                 2006-2007                              2006-2007 Data
                                                                       2nd                        4th
                                                         1st Qtr                    3rd Qtr
                                           Budget                      Qtr                        Qtr       Total FY
           TRIP AND CLIENT DATA
                   REPORT
               Trip/Client Data
     (1)   Paratransit Trips                                                                                       0
     (2)   Client Reimbursement Trips
     (3)   Mass Transit Trips                                                                                      0
     (4)   Volunteer Trips                                                                                         0
                                                                                                                   0
       TOTAL TRIPS                                  0          0             0             0            0          0

       Urgent Care Trips                                                                                           0
       No Shows                                                                                                    0

                                                                       2nd                        4th
                                                         1st Qtr                    3rd Qtr
                                                                       Qtr                        Qtr       Total FY
                                                                       YTD           YTD          YTD         YTD
     Unduplicated Clients (Group 1)                                                                                 0
     Unduplicated Clients (Group 2)                                                                                 0

       TOTAL CLIENTS                                                                                               0

       MAWD Clients                                                                                                0

       Number of Complaints                                                                                        0

     Summary of Type of Complaints:
                                            Type of Complaint and Disposition
     First Quarter




MATP Rev 07/10                             115
Appendix A                  Fiscal Requirements




     Second Quarter




     Third Quarter




     Fourth Quarter




MATP Rev 07/10        116
            Appendix A                                                        Fiscal Requirements




            MATP Monthly Data File Format

            MATP Monthly File Submission
                                        MATP Monthly File Submission
NAME:                            MATP County Transmits:

                                 File Name: CCMATP


                                 CC is the submitter’s County code
                                 Where MATP is a constant


DESCRIPTION:                     MATP trip level detail in comma delimited text file format

FORMAT:                          .csv

                                              Alpha/
                Field Name                                           Special Instructions
                                              Numeric

County Code                                      N                    County Codes 1-67

Recipient Medical Assistance Identification      N                ID Number on Access card
Number

Trip Date                                       A/N                      mm/dd/yyyy

Mode                                            A/N                    M= Mass Transit
                                                                        P= Paratransit
                                                                     R = Reimbursement
                                                                        V= Volunteer

Trip Completed                                  A/N                    Y = Yes, N = No

Escort Needed                                   A/N                    Y = Yes, N = No




            MATP Rev 07/10                            117
Appendix A                                                        Fiscal Requirements

Quarterly Reporting Instructions and Clarification
Budget Projection Report:

       Revise budget figures when there is a material difference between the budget and actual
experience during the fiscal year.

        Submit revised budget figures on the Budget Projection Report tab with your quarterly report.

        Include additional information on the Narrative Tab to explain the revisions that were made.

        We have added the following new expense line:

                 Transportation Cost
                       Vehicles
                              Autos-Loan Interest Expense

      This expense line should be used to report interest from loans when purchasing a vehicle to be
used to provide Medical Assistance transportation trips.

Actual Expenditure Report:

        Administrative Costs should include all costs that are not the actual trip.

      Transportation Costs for the following should only be present when the contractors have their
own vehicles and are providing actual expenses for the trip:

                 Salaries & Benefits
                 Occupany Costs
                 Office Furniture & Equipment
                 Data Processing
                 Vehicles
                 Specialty Equipment
                 Travel

       Transportation Costs for all contractors that submit expenses based on a cost per trip should
only include the following:

                 Para Transit
                 Reimbursement
                 Mass Transit
                 No-Show Costs


        We have added the following new expense line:

                 Transportation Cost
                       Vehicles
MATP Rev 07/10                           118
Appendix A                                                        Fiscal Requirements

                             Autos-Loan Interest Expense

      This expense line should be used to report interest from loans when purchasing a vehicle to be
used to provide Medical Assistance transportation trips.

       Calculate Total Costs by Group for Total Costs. These are the costs before you subtract the
Interest Earned.

Personnel Report:

      All contractors that only provide expenses based on cost per trip should include all personnel
under Administrative.

      Contractors that have their own vehicles and provide actual expenses should include Drivers
or Vehicle Maintenance personnel under Transportation.

Shared Ride Report:

        If each zone within the county has different rates, provide separate lines of data for each zone.

        If there are trips that cross zones, provide one line of data for these trips with an average rate
per trip.

      If a county is providing their own transportation and reporting actual expenses, please
complete the following:

        Name of Provider
        Type of Payment
        Number of Trips

       “Number of Trips” multiplied by “Rate” should equal “Amount Paid” with the exception of the
counties that provide their own transportation.

        Examples of Name of Provider:

                 ABC Bus Company




        Examples of Type of Payment would be:

                 Zone Rate per Trip
                 Multi-Zone Average Rate per Trip
                 Hourly Rate per Trip
                 Daily Rate per Trip
                 Mile Rate per Trip
                 Actual Transportation Expenses


MATP Rev 07/10                           119
Appendix A                                                       Fiscal Requirements

Transportation Report:

       Reimbursement – Fixed Route should be completed when the recipient is paying for the fixed
route trip and the contractor is reimbursing the recipient after the trip is completed.

      Mass Transit should be completed when the contractor is paying for the transportation in
advanced and providing the recipient with a bus pass or token. This would also include paying the
transportation provider in advance of the recipient taking the trip.

      The number of no-shows reported should only be the number that the contractor is providing
expenses for. If there are no-shows that the contractor is not receiving reimbursement for, then those
no-shows should not be included on this report.

TRIP AND CONSUMER DATA REPORT:

      Para Transit, Reimbursement and Mass Transit Trips are linked to the Shared Ride and
Transportation Reports.

        Provide total no-shows on this report.

        Unduplicated Consumers by Group are reported on a Year-To-Date basis.


NARRATIVE:

       Provide information on a quarterly basis that will assist DPW in understanding the data that is
being reported.

        Examples:

                 Change in shared ride rates.
                 Increased unduplicated clients.
                 New initiatives for cost savings.
                 Movement of clients to different modes of transportation.
                 Increased administrative costs.
                 Fuel surcharges.
                 Increased types of trips (i.e. methadone/out-of-county/dialysis)
                 Waiver information (financial savings and observed efficiencies)

MONTHLY DATA FILE:

        The files should be submitted monthly between the 15th and 22nd.

        The file name should include the following:

                 County Code (2 digits)
                 MATP (Capital Letters)
                 .csv


MATP Rev 07/10                            120
Appendix A                                              Fiscal Requirements

                 Example: 19MATP.csv

        The date format should include the following:

                 Month (2 digits)
                 Day (2 digits)
                 Year (4 digits)

                 Example: 05/31/2005




MATP Rev 07/10                          121

				
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