Friends or family of Louisiana Healthcare Connections members who use their own vehicle to drive a member to a Medicaid-covered appointment may be eligible for gas reimbursement.
Complete the form below to register as a driver. You must submit a driver registration form before asking for reimbursement. To register as a driver, you will need:
- Full name of driver
- Physical address of driver (Must match the driver’s license and cannot be a PO Box)
- The driver’s contact information, including email and phone
- The social security number of the driver
- A list of the Louisiana Healthcare Connections members they are looking to drive (no more than 5)
- A valid driver’s license
- Vehicle information, including the VIN and license plate number
- A copy of the vehicle’s insurance card
- A copy of the vehicle registration
- The driver’s bank information for payment
The gas reimbursement rate for all trips is $0.67 cents per mile. MTM will use Google Maps to determine the length of the trip. The amount of gas reimbursement is based on the length of the trip. You will be paid per mile. The rate of payment per mile is based on the current mileage rate for state employees and is set by the Louisiana Legislature.
Terms and Conditions of Participation
- Before you drive a Medicaid member to their appointment, the member must first get approval for the ride from MTM. The member can schedule their trip by calling 1-855-369-3723, (TTY: 711), Monday-Friday, from 7 a.m. to 7 p.m.
- At the appointment, the doctor will stamp or sign the Gas Reimbursement Form.
- You will get one gas reimbursement payment for each round trip even if you are driving more than one member.
- MTM will use a computer program to determine the shortest distance in miles that your trip should take. The amount of your gas reimbursement payment is based on this mileage calculation. You will be paid per mile. The rate of payment per mile is based on the current mileage rate for state employees. This rate is set by the Louisiana Legislature.
- All payments to drivers will be reported by MTM to the Internal Revenue Service (IRS).
- You must maintain a current and valid driver’s license, auto insurance, vehicle inspection and vehicle registration to remain enrolled in the program.
- The completed Gas Reimbursement Form must be submitted within 365 days from the date you gave the member the ride. Forms received after this deadline will not be paid. For example, if the ride was given on January 1, the form must be received by MTM no later than December 31.
To view our full Gas Reimbursement Guidelines, please download the guide from our Print Forms page.
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