21-130 Offer 24-Hour Non-Emergency Medical Transportation to Medi-Cal Members Who Need a Ride to Pharmacies and Urgent Care (Dual Risk)

Date: 11/16/21

This information applies to Participating Physician Groups (PPGs) and Hospitals.

For Medi-Cal, this information applies to Fresno, Kings, and Madera counties.

Dual-risk entities are financially responsible

Participating physician groups and hospitals that have risk for non-emergency medical transportation (NEMT) in the Division of Financial Responsibility (DOFR) must authorize and coordinate with their transportation provider to ensure Medi-Cal members have 24-hour access to NEMT to a pharmacy or urgent care facility.

Why the change?

On January 1, 2022, Medi-Cal pharmacy services will transition from managed care plans to Medi-Cal fee-for-service. Magellan Medicaid Administration, Inc. (Magellan) will manage this new pharmacy services program called Medi-Cal Rx.

As part of the change to Medi-Cal Rx, the Department of Health Care Services requires NEMT to be available 24 hours a day to members who need transportation to pharmacies and urgent care facilities that are open 24 hours a day.

Additional information

Relevant sections of the provider operations manuals will be revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library, located on the provider website. Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569.