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18 <br /> NC Medicaid Medicaid and Health Choice <br /> Ambulance Services Clinical Coverage Policy No: 15 <br /> Effective Date:January 15,2020 <br /> h. Separate additional charges for nursing personnel who are <br /> employees of a facility or ambulance service are not covered. <br /> i. Waiting fees are not covered. <br /> j. Costs for oxygen and other items and supplies provided are <br /> included in the base rate and not separately reimbursable. <br /> k. Services other than those listed in Subsection 3.2 are not covered. <br /> 4.2.2 Medicaid Additional Criteria Not Covered <br /> 4.2.2.1 Maternity Transport <br /> Ambulance transport of beneficiaries with routine pregnancies is not <br /> covered. Beneficiaries without complications that would endanger the <br /> life of the mother,the child, or both do not meet medical necessity <br /> criteria. <br /> Beneficiaries with Medicaid coverage through Family Planning are not <br /> covered to receive ambulance services. <br /> 4.2.2.2 Nursing Facility Non-Ambulance Transportation <br /> Non-ambulance transportation of Medicaid-eligible beneficiaries to <br /> receive medical care that cannot be provided in the nursing facility is <br /> covered in the per diem that is reimbursed to the facility. The facility <br /> may contract with a service(including county-coordinated <br /> transportation systems)to provide transportation or may provide <br /> transportation services using its own vehicles. <br /> Note: The nursing facility cannot charge the beneficiary or the beneficiary's <br /> family for the cost of this transportation. <br /> 4.2.3 NCHC Additional Criteria Not Covered <br /> a. In addition to the specific criteria not covered in Subsection 4.2.1 of this <br /> policy,NCHC shall not cover prenatal or childbirth services. <br /> b. NCGS § 108A-70.21(b)"Except as otherwise provided for eligibility, fees, <br /> deductibles, copayments, and other cost sharing charges,health benefits <br /> coverage provided to children eligible under the Program shall be equivalent <br /> to coverage provided for dependents under North Carolina Medicaid <br /> Program except for the following: <br /> 1. No services for long-term care. <br /> 2. No nonemergency medical transportation. <br /> 3. No EPSDT. <br /> 4. Dental services shall be provided on a restricted basis in accordance with <br /> criteria adopted by the Department to implement this subsection. <br /> 5.0 Requirements for and Limitations on Coverage <br /> Note:Refer to Subsection 2.2.1 regarding EPSDT Exception to Policy Limitations for a <br /> Medicaid Beneficiary under 21 Years of Age. <br /> 20A13 12 <br />