By Alex King

MACPAC Releases Medicaid Non-Emergency Medical Transportation Report

November 2, 2020

On Oct. 29, 2020, the Medicaid and CHIP Payment and Access Commission (known as MACPAC) provided preliminary results on its congressionally-mandated study of Medicaid non-emergency medical transportation (NEMT). CTAA’s Public Health and Transportation Policy Consultant Alex King listened in, and here are her notes.

MACPAC online overview of the NEMT report: “Federal Medicaid regulations require that states ensure transportation to and from providers, a benefit known as non-emergency medical transportation (NEMT). In recent years, policymakers at the state and federal levels have begun to re-examine this benefit. The Senate Appropriations Committee report language for fiscal year (FY) 2020 directs MACPAC to examine the benefits of NEMT for beneficiaries, and the benefits of improving coordination of NEMT with public transportation and other federally assisted transportation services. To respond to the committee’s request, MACPAC is conducting a multi-pronged study.

This presentation provides background information on the NEMT benefit and details MACPAC’s approach for this study, including the policy and analytic questions of interest and plans for analysis. It describes what we have learned to date, including 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.”

Timeline

  • Staff anticipated that the final results will likely be published in MACPAC’s June report to Congress
    • Intermediary findings in early winter meeting

Notes

  • The $2.2 Million annual spending number – does not include managed care or brokerage spending on NEMT (so likely a low balled estimate of overall cost)
  • Looking specifically at the necessity of NEMT for Low income adults, not eligible for Medicaid on the basis of disability
  • The expected CMS RFI on the required provision of NEMT was supposed to be released in Fall 2019 – still has yet to be released as of Fall 2020
  • Congressional bi-partisan efforts to protect the benefit
  • MACPAC Study has three primary components
    • Hired Health Management Associates to assist with study completion
    • Did 50 state scan and doing deep dive on six stated (AZ, CT, GA, IN, MA, and TX)
    • Doing virtual focus groups of beneficiaries
    • Analyzing utilization and spending (looking at TMSIS data)
      • The goal of this is to have a more complete understanding of the data
      • Note: This is MACPACs first attempt to use TMSIS data to look at service level utilization: expecting data challenges
  • Findings from interviews and 50-state scan
    • Interviewees did not all point to the same groups as high utilizers
    • Most common form of utilization control: prior authorization
    • Mode of transportation varies based on availability within geographic area
      • Urban areas: rely on public transit
      • Limited or no public transit: result on taxis and mileage reimbursement
      • Still ill-suited vehicles are a common reason for beneficiary compliant
    • Quality depends on other factors than delivery model (strength of oversight, and beneficiary engagement policies)
    • Coordination
      • Many study states highlighted coordination as a policy priority
      • Different beneficiary needs make it a challenge to share rides
      • Difficult and administratively burdensome to calcite the Medicaid payment component of a shared ride
      • Some asked to do single passenger for Medicaid to alleviate these challenges
    • Quality and Performance
      • Mixed views to the extent to which programs meet the needs of beneficiaries
      • Acknowledge problems that lead to beneficiary complaints
      • Quality varies widely by states
    • Performance improvement efforts
      • Scheduling processing improvements
      • Driver training programs
      • Some include performance incentives for brokers, providers, and/or drivers
      • Strong contracts and oversight mechanisms
      • Data and reporting – but also there is a visible lack of enforcement mechanisms, and state staff lack time, ability, or expertise to make changes
    • Transportation Provider Networks
      • Biggest challenge in terms of administering the benefit: maintaining adequate provider network
      • States and Brokers use strategies such as mileage reimbursement for rural areas, and incentives to get providers in rural areas, and leverage public transit
    • TNC
      • At least a dozen states have specifically authorized their use
      • Helpful for reducing strain on provider networks (particularly last minute or late night trips)
      • Opportunity to enhance customer satisfaction (e.g. provider location)
      • Few data on cost savings
      • Concerns as drivers and vehicles are not trained to meet the needs of beneficiaries
      • Also requires a smart phone which many beneficiaries may not have
      • Safety and fairness concerns in states where TNCs are not required to meet same requirements
      • TNCS feel they only are meant to be helpful for small portion of Medicaid beneficiaries
    • Technology
      • Tools for program integrity, performance, and customer satisfaction
      • GPS: date, time, location for NEMT pick up and drop off to ensure it took place as authorized
      • Increased GPS capacity among drivers is a key priority for drivers
      • Challenges: Smartphone/tablet literacy among drivers, internet and data bandwidth particularly in rural areas, expensive to implement
      • Broker: It is Easier to get these new technologies in drivers when required by the states
    • Program Integrity
      • At the state level Medicaid officials and other interviewees do not state it as a major concern
      • Contributed stronger program integrity to the shift from Medicaid agency’s to Brokers and MCOs
    • Role of NEMT
      • Important and essential tool (particularly for people with chronic conditions)
      • Medicaid agencies generally thought they would keep the benefit, but some Governors or Legislature may try otherwise
    • Opposition from Fed Government
      • CMS officials: guidance on TNCS is under discussion and development
    • Next Steps
      • Staff is continuing other components
      • Focus groups, and admin analysis data
      • Expert more results to be presented later in winter meetings

The full presentation from MACPAC can be found here.

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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.