By Alex King

MACPAC Presents Further Findings from NEMT Report

February 10, 2021

On Jan. 29, 2021, the Medicaid and CHIP Payment and Access Commission (known as MACPAC) provided additional results from its congressionally mandated study of Medicaid non-emergency medical transportation (NEMT). The Final results will be included in MACPAC’s June 2021 report to Congress. CTAA’s Public Health and Transportation Policy Consultant Alex King listened in, and here are her notes.

MACPAC Summary of the Presentation:

“To respond to the committee’s request, MACPAC is conducting a multi-pronged study. At the October 2020 meeting, MACPAC described preliminary findings from an environmental scan of state NEMT policies and interviews with stakeholders in six states (Arizona, Connecticut, Georgia, Indiana, Massachusetts, and Texas) and at the federal level.

This presentation described the findings from two additional components of the larger study: analysis of transformed Medicaid statistical information system (T-MSIS) data to describe NEMT utilization and spending and focus groups with beneficiaries who have used NEMT. Specifically, the presentation included background information on the NEMT benefit and federal requirements, reviewed MACPAC’s analytic plan for this study, and what we have learned to date from our analysis.”

View slides from Jan. 29 Presentation here (PDF)

Notes from Jan. 29 Presentation:

  • The Consolidated Appropriations Act, 2021 (P.L. 116-260) codified NEMT into statute.
    • Prior to this action, NEMT was required by regulation, not statute.
    • Based on this action it is no longer possible to make NEMT an optional benefit via administrative action (as previously proposed by the Trump Administration).
    • This does mean the context for MACPAC’s student has changed. However, they plan to continue to complete it as requested.
  • This presentation shares the results from the second two components of the study (1. administrative data research and 2. findings from beneficiary focus groups)

1. Analysis of administrative data on NEMT utilization and spending

  • Used Fiscal year (FY) 2018 Transformed Medicaid Statistical Information System (T-MSIS)
    • TMSIS is a standardized coding system used to collect utilization and claims data for Medicaid and CHIP (Children’s Health Insurance Program) services
  • Goal of this data review was to be able to provide data on NEMT utilization and spending by various factors (e.g., destination, transportation type, basis of eligibility, dually eligible status, urban versus rural, and diagnosis)
  • The findings are presented as single ride-days
    • Note: they acknowledged the number of door-to-door rides are much higher. They see the findings of “single ride days” as the floor of NEMT use – with the actual number being much higher
  • Key Finding: NEMT use is concentrated, used extensively, and by a small number of beneficiaries. Among NEMT users, transportation is a HIGHLY used benefit
  • Key Finding: Spending totaled 2.6 Billion dollars (but this excluded payments from Managed Care Plans to NEMT providers)
  • Key Finding: There was minimal variation in NEMT use in urban versus rural residents
  • Key Finding: Aged and disabled persons are the most frequent users when compared to other eligibility groups
  • Key Finding: Beneficiaries diagnosed with end-stage renal disease (ESRD) use NEMT most frequently
    • Those with intellectual or developmental disabilities and serious mental illnesses also use NEMT more frequently than those with none of these conditions
    • They acknowledged that Noted: they are underestimating the total ride days in Opioid Use Disorder as Methadone is not explicitly listed
  • Key Finding: NEMT users primarily ride in a van or taxi-which includes Uber and Lyft
    • Also found that beneficiaries use multiple modes of transportation per day
  • Key Finding: The most common NEMT destinations are to the home or a physician’s office
    • Beneficiaries can have multiple locations in a single ride
    • A few states follow a standardized way of measuring destinations – used six states that used similar descriptions

2. Beneficiary Focus Group Findings

  • MACPAC commissioned eight online video focus groups with Medicaid enrollees (or a caregiver representative) who are enrolled in the Non-Emergency Medical Transportation (NEMT) benefit and have experience using these services
    • Worked to make it as accessible as possible – supported any way they were willing to participate
  • Focus Group Participants
    • 41 total participants from six states (Ariz., Conn., Ga., Ind., Mass., and Texas)
  • Mix of direct beneficiaries, caregivers of beneficiaries, and parents of children who used the benefit
    • Have chronic conditions that require monthly to daily mental or physical health care visits.
    • While some have been using NEMT services for a short time, most have been using NEMT services for a year or more
  • Key Finding: Prior to enrolling in NEMT participants reported a variety of different transportation barriers to accessing needed car
  • Key Finding: Participants viewed NEMT as a resource that helped them manage their physical and chronic conditions, as well as it assisted in improving the emotional health (particularly for those with disabilities for physical limitations)
    • Helped with isolation and at a very base level made beneficiaries feel more connected
  • Key Finding: NEMT provided more independence to participants and lessened reliance on family members.
    • NEMT services also had a big impact on family income – often helping beneficiaries get to appointments took someone out of a job- NEMT provided an economic benefit by allowing a family member to go back into workforce
    • NEMT simplified commutes back and forth to health care
  • Key Finding: While there was overall positive feedback, beneficiaries still mentioned a few challenges within the program
    • Note: Participants wanted to ensure that researchers noted the benefit was not taken for granted, it is highly valued, but at the same time they thought at times it could be better
    • List of challenges and ideas for improvement as mentioned by focus group participants are listed in the slide deck
  • Key Finding: benefieciaires all showcased an emotional response and fear when asked what would happen if NEMT services would go away
    • They rely on these services for care, services, progress, life and death
    • All thought the would face mental health consequences
    • Well-being is tied to the health care system – if that were limited or taken away it would have individual and family impacts
    • Also, financial impact of assuming the cost of transportation – for some/most it is not even feasible
  • Commissioner Discussion Summary
    • Martha Carter (W.Va.) – In W.Va., contract with a transportation vendor, one of the options was gas mileage reimbursement. How often is that used, did you look at that in this report?
  • It is definitely used. They heard from focus group participants that some had used it. And from the stakeholder interviews they heard that the brokers, and managed care, whoever is administering the benefit manage the use of mileage reimbursement. Overall heard that it is a tool that is being used (particularly in rural areas), but at times there are burdensome application and administrative policies.
    • Sheldon Retchin (Ohio) – Since the pandemic hit we have seen a new water level of telehealth. What are the thoughts on when NEMT is necessary expedient vs. when telehealth would be an important contribution? This comment is also made with the acknowledgement that a good percentage of Americans don’t have access to broadband.
  • Based on the participant interviews, patients were generally negative about experiences with telehealth. It was not a replacement for them. They could not wait to go back in person.
  • They also heard from a number of beneficiaries had serious bandwidth issues. Very hit or miss
  • The general feeling with telehealth was frustration – would take a while for this population to embrace it if they can
    • Tricia Brooks – Provided a comment that she was happy to see attention regarding the fact that states are required to provide transportation to children and their families under EPSDT. This is a sticking point in many states when there is a single parent and services are not allowing siblings. How could we gather some information for that? Could we also list how the regulations read different for caretakers of adults vs. parents of children eligible for EPSDT?
    • Kisha Davis (Md.) – A big theme of the discussions yesterday was where the dollars are spent, and that the best investments in health are not necessarily always in health care. Providing services that are validating, keeping people independent, and allowing people to manage their own care. Investing in NEMT allows people to keep their independence. To the idea of keeping care to people, there are some of these services that can bring some services to patients.

The Final results of this report will be included in MACPAC’s June 2021 report to Congress.

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The Community Transportation Association of America (CTAA) and its members believe that mobility is a basic human right. From work and education to life-sustaining health care and human services programs to shopping and visiting with family and friends, mobility directly impacts quality of life.