Brief Issue Description
This best practice document outlines how states should approach reporting transportation Prepaid Ambulatory Health Plans (PAHPs) in the T‐MSIS Managed Care file, Claims files, and Eligible file. This reporting touches data elements across several different file types, and states should ensure that this type of managed care arrangement is being correctly identified across their T‐MSIS submissions.
Background Discussion
Context
State non‐emergency medical transportation (NEMT) PAHPs are full‐risk, capitated managed care arrangements that contract with transportation providers to form a network of providers for their enrollees. States that have Medicaid or CHIP eligibles enrolled in transportation PAHPs need to ensure that these arrangements are properly captured in T‐MSIS reporting.
Challenge
States are required to cover non‐emergency medical transportation for Medicaid enrollees. These services are often provided by NEMT PAHPs which are entities that provide only NEMT services to enrollees under contract with the State1. It is important for states to properly understand how to code NEMT PAHPs, as this type of managed care plan can be confusing given that it covers nonmedical services.
CMS Guidance
States should report all managed care plans in which a beneficiary is enrolled in the T‐MSIS Eligible file's MANAGED‐CARE‐PARTICIPATION‐ELG00014 record segment, which includes NEMT PAHPs. For the Eligible file record segment MANAGED‐CARE‐PLAN‐PARTICIPATION‐ELG00014, states should report individuals enrolled in a NEMT PAHP with data element MANAGED‐CARE‐PLAN‐TYPE = '15' (individual is enrolled in a transportation PAHP). As part of the Managed Care file record segment MANAGED‐CARE‐MAIN‐MCR00002, states should report MANAGED‐CARE‐PLAN‐TYPE = '15' (transportation PAHP) for that plan. In addition, it is important to note that the plan IDs on the encounter records should be consistent with what is reported on the record segment MANAGED‐CARE‐PLAN‐PARTICIPATION‐ELG00014 in the Eligible file as well so that an individual's enrollment in the plan can be linked to his or her encounters. Encounters for transportation PAHPs should be reported in the T‐MSIS Claims file with TYPE‐OF‐CLAIM = '3' (Medicaid or Medicaid‐expansion Managed Care Encounter [a.k.a. dummy] record). NEMT PAHP capitation payments should be reported under the Claims OT file with TYPE‐OF-SERVICE = '122' (capitated payments to prepaid health plans [PHPs])
Transportation arrangements where the rides are paid on a fee‐for‐service basis do not get reported as managed care in T‐MSIS. Non‐risk‐bearing transportation brokerage arrangements that operate on a FFS basis using State Plan authority and the state's reimbursement rates should not be reported as managed care in TMSIS. States should also pay close attention if they have different arrangements in different geographic regions of the state to ensure that only those actually enrolled with the transportation PAHP are included under their managed care reporting.
Please also refer to CMS Guidance: Best Practice for Reporting Managed‐Care‐Plan‐ID in the Eligible File.