Medicaid Policy
Medicaid Policy
Under certain circumstances, recipients eligible for Traditional Medicaid may receive mileage reimbursement, up to the amount specified in 651-6, when they use personal transportation to go to and from medical appointments outside of their local area. Traditional Medicaid recipients may also be reimbursed for overnight costs including lodging and food costs, when overnight stays are necessary to obtain medical treatment. See 651-6 for rates and limits.
Mileage Reimbursement
When services are not available locally, a Traditional Medicaid recipient may be reimbursed for the miles traveled in a personal vehicle to go to and from their medical appointments outside their local area. The travel must be necessary to receive a Medicaid-covered service from a Medicaid provider. If no local providers accept Medicaid, medical treatment is not available locally.
If medical care is available in-state, recipients may go to an out-of-state provider for the medical care when the out-of-state provider is closer than in-state providers. Reimburse Traditional Medicaid recipients for mileage when the mileage cost is less than or the same as it would be for the recipient to travel to an in-state provider. (Typically this occurs when a Traditional Medicaid recipient lives close to a state border.)
If medical treatment is not available in-state, a recipient may have to travel to an out-of-state provider to receive medical treatment. If out-of-state travel is required because the necessary medical treatment is not available in-state, transportation may be paid as well. However, prior authorization is required for the treatment, the transportation costs and overnight costs (lodging & food), even if a recipient has a referral from a physician for the medical treatment. The member's medical provider should call the Department of Health and Human Services at 538-6155 or 1-800-662-9651 to obtain prior authorization. Do not reimburse the recipient for travel expenses unless instructed to by the HCF Prior Authorization staff. These costs should be covered in a different manner.
In some cases, workers may need to request verification that medical treatment outside of the local area is necessary. A copy of the referral from the recipient’s primary care provider may be sufficient. If the reason for receiving medical treatment out of the local area seems questionable, workers may need to contact the provider. No verification is required under the following circumstances.
No local providers accept Medicaid, or
It is the general practice for recipients in a local area to obtain medical treatment outside of the local area. This is particularly true for people in rural communities and small border towns because there may not be any local Medicaid providers.
When treatment is not available in a Traditional Medicaid recipient’s local area, the recipient may be reimbursed for the mileage to the nearest Medicaid provider who is able to provide the necessary medical services. If the recipient chooses to receive services from a Medicaid provider that is not the nearest provider, he or she may be reimbursed only for the mileage that it would have been to travel to the nearest qualified Medicaid provider. (In some situations, more than one provider may be about the same distance away from where the member lives. In such cases, the member can choose which provider to go to. For example, someone from Roosevelt may be a similar distance from providers in Provo and Salt Lake. The member may choose which city to go to for medical services.)
Overnight Costs (Lodging & Food) Reimbursement
At times, Traditional Medicaid recipients may need to stay overnight to receive medical treatment outside the local area. When a recipient must stay overnight, the Medicaid Eligibility worker may reimburse the member for one night of overnight costs up to the rate specified in section 651-6 if one of the following situations exist:
The Traditional Medicaid recipient must travel over 100 miles one-way to obtain medical treatment, and would not arrive home before 8:00 p.m. due to the drive time, or
The Traditional Medicaid recipient must travel over 100 miles one-way to obtain medical treatment, and would have to leave home before 6:30 a.m. to arrive at the appointment on time, or
The medical treatment requires the Traditional Medicaid recipient to stay overnight.
Recipients must verify the actual overnight costs for lodging and food.
Medicaid eligibility staff may approve a second night's stay and reimburse the recipient for overnight stay costs when extreme circumstances of scheduling or multiple appointments exist. A second night may also be needed when an unexpected situation comes up such as a provider decides at the first appointment that the recipient needs more tests and schedules them for the very next day.
If a Traditional Medicaid member expresses a need to stay more than two nights to receive medical treatment, the treating provider or the member must receive prior authorization for the additional nights. The Medicaid Eligibility worker can only reimburse the member for the additional nights stay after receiving approval from the Prior Authorization staff.
Traditional Medicaid recipients may stay at a motel, hotel, apartment, or other facility that provides overnight shelter, such as the Ronald McDonald House.
If a Traditional Medicaid recipient must stay overnight and has a medical need that requires a companion or attendant, the companion or attendants overnight costs may be reimbursed up to the rate specified in section 651-6. The attendant can only be reimbursed when the Traditional Medicaid recipient stays with the companion or attendant and is not in a medical or treatment facility. Lodging and meal costs for one parent or guardian who accompanies a dependent child may also be reimbursed up to the rate specified in section 651-6 when the child stays with the parent or guardian and is not in a medical facility. If the Medicaid recipient is in-patient in a medical or treatment facility, do not reimburse overnight costs for a parent/guardian or an attendant.