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From page 1... ... TRANSIT COOPERATIVE RESEARCH PROGRAM Sponsored by the Federal Transit Administration Program Officer: Gwen Chisholm-Smith October 2014 Research Results Digest 109 Background The Patient Protection and Affordable Care Act of 2010, and the related Health Care and Education Reconciliation Act of 2010 (jointly referred to as the "Affordable Care Act" or ACA) , complete a massive overhaul of the nation's health insurance and health delivery systems. Read the entire page →
From page 2... ... 2providers does not apply. This enables the state to direct NEMT users to specific providers or permits the state to bid the service in an effort to find lower cost methods of service delivery. Read the entire page →
From page 3... ... 3More notable, however, were the legal challenges to the law. A recent Supreme Court upheld the individual mandate but found that the requirement for Medicaid expansion exceeded Congress' constitutional authority. Read the entire page →
From page 4... ... 4the transit community on how public transit and NEMT providers have in the past and can in the future integrate or effectively use their respective resources and services. project scope Overview The project scope was organized based on the original work program developed by the project committee. Read the entire page →
From page 5... ... 5chapter 2 oVerVIeW of the medIcaId program and nemt serVIce delIVery models Brief overview of the medicaid program Origins Medicaid originated in 1965 with passage of Title XIX of the Social Security Act. Undertaken as a funding partnership between the federal government and the states, Medicaid is a program designed to provide medical assistance to needy persons. Read the entire page →
From page 6... ... 6There is also an "Enhanced Federal Medical Assistance Percentages" which applies to the Children's Health Insurance Program (CHIP) under Title XXI of the Social Security Act. Read the entire page →
From page 7... ... 7Nevertheless, there is long-standing regulatory basis for the transportation assurance. The requirement to provide transportation was included in initial rulemaking issued by CMS, then the Department of Health, Education, and Welfare (HEW) Read the entire page →
From page 8... ... 8Medicaid looks to the other funding source to pay for the trip. This concept has presented challenges to those entities seeking to create coordinated transportation service delivery networks involving multiple funding programs. Read the entire page →
From page 9... ... 9assurance and right to transportation was placed in jeopardy based on newly formulated transportation strategies. The absolute right to transportation was recognized by the court, and DPW's specialized transportation plan was found invalid. Read the entire page →
From page 10... ... 10 • Audit and provide oversight to ensure the quality of the transportation services provided and the adequacy of beneficiary access to medical care and services; and • Comply with the prohibitions on referrals and conflict of interest as the Secretary shall establish (21) Read the entire page →
From page 11... ... 11 • The governmental broker must document that its services (or those services contracted to another governmental entity) are the most appropriate and the lowest cost alternative; and • The governmental broker documents that in terms of charges to Medicaid, the entity charges no more than: 4 Fixed-route services -- the standard fare charged to the public; and 4 Paratransit -- the rate charged to other state human service agencies for comparable services. Read the entire page →
From page 12... ... 12 Case Management Transportation This category includes transportation in which agency staff transport individuals and provide other services while the individual or group is being transported. Trips are typically provided in agency-owned vehicles or staff-owned vehicles. Read the entire page →
From page 13... ... 13 A review of the literature suggests that there is no common approach to the classification of NEMT service delivery models. Service delivery models may be statewide, regional, or local in nature; however, there may be various combinations within these levels of responsibilities for trip request intake and actual service provision. Read the entire page →
From page 14... ... table 1 Summary of state service delivery models for NEMT transportation. State Total Population Medicaid Enrollment1 % State-Level Coordination Efforts2 NEMT Involvement with State Coordination Efforts3 NEMT Service Delivery Alabama 4,779,736 1,015,576 21.25% Legislation was proposed in 2010 to create a United We Ride (UWR) Read the entire page →
From page 15... ... table 1 Summary of state service delivery models for NEMT transportation. State Total Population Medicaid Enrollment1 % State-Level Coordination Efforts2 NEMT Involvement with State Coordination Efforts3 NEMT Service Delivery Alabama 4,779,736 1,015,576 21.25% Legislation was proposed in 2010 to create a United We Ride (UWR) Read the entire page →
From page 16... ... table 1 (Continued) State Total Population Medicaid Enrollment1 % State-Level Coordination Efforts2 NEMT Involvement with State Coordination Efforts3 NEMT Service Delivery Delaware 897,934 225,458 25.11% One statewide Medicaid broker selected through a competitive process. Read the entire page →
From page 17... ... table 1 (Continued) State Total Population Medicaid Enrollment1 % State-Level Coordination Efforts2 NEMT Involvement with State Coordination Efforts3 NEMT Service Delivery Delaware 897,934 225,458 25.11% One statewide Medicaid broker selected through a competitive process. Read the entire page →
From page 18... ... table 1 (Continued) State Total Population Medicaid Enrollment1 % State-Level Coordination Efforts2 NEMT Involvement with State Coordination Efforts3 NEMT Service Delivery Kentucky 4,339,367 960,776 22.14% The Coordinated Transportation Advisory Committee (CTAC) Read the entire page →
From page 19... ... table 1 (Continued) State Total Population Medicaid Enrollment1 % State-Level Coordination Efforts2 NEMT Involvement with State Coordination Efforts3 NEMT Service Delivery Kentucky 4,339,367 960,776 22.14% The Coordinated Transportation Advisory Committee (CTAC) Read the entire page →
From page 20... ... table 1 (Continued) State Total Population Medicaid Enrollment1 % State-Level Coordination Efforts2 NEMT Involvement with State Coordination Efforts3 NEMT Service Delivery Nevada 2,700,551 290,758 10.77% The State's coordination of programs has been limited to Sections 5310, 5316, and 5317. Read the entire page →
From page 21... ... table 1 (Continued) State Total Population Medicaid Enrollment1 % State-Level Coordination Efforts2 NEMT Involvement with State Coordination Efforts3 NEMT Service Delivery Nevada 2,700,551 290,758 10.77% The State's coordination of programs has been limited to Sections 5310, 5316, and 5317. Read the entire page →
From page 22... ... table 1 (Continued) State Total Population Medicaid Enrollment1 % State-Level Coordination Efforts2 NEMT Involvement with State Coordination Efforts3 NEMT Service Delivery Pennsylvania 12,702,379 2,303,775 18.14% The state has a long history of service development and support through its lottery funding program. Read the entire page →
From page 23... ... table 1 (Continued) State Total Population Medicaid Enrollment1 % State-Level Coordination Efforts2 NEMT Involvement with State Coordination Efforts3 NEMT Service Delivery Pennsylvania 12,702,379 2,303,775 18.14% The state has a long history of service development and support through its lottery funding program. Read the entire page →
From page 24... ... table 1 (Continued) State Total Population Medicaid Enrollment1 % State-Level Coordination Efforts2 NEMT Involvement with State Coordination Efforts3 NEMT Service Delivery Washington 6,724,540 1,159,333 17.24% The Agency Council on Coordinated Transportation (ACCT) Read the entire page →
From page 25... ... 25 model in the state's most populous urbanized areas (Colorado–Denver, Pennsylvania–Pittsburgh and Philadelphia, New York–New York City, and Texas– Houston and Dallas) where presumably the supply of capable providers is adequate to meet broker requirements. Read the entire page →
From page 26... ... 26 table 2 NEMT state service delivery models. Service Delivery Model Type Geographic Coverage Entity/Broker Responsibility States Brokerage Statewide Private broker Trip intake and trip assignment Connecticut, Delaware, Idaho, Illinois, Iowa, Kansas, Mississippi, Missouri, Montana, Nebraska, Nevada, New Jersey, Oklahoma, South Carolina, Virginia, Wisconsin Region Private broker Trip intake and trip assignment Hawaii Public/nonprofit broker Trip intake and trip assignment Kentucky, Massachusetts, Oregon, Vermont, Washington Mix of private and public/nonprofit brokers Trip intake and trip assignment Arkansas, Georgia, Maine County Mix of private and public/nonprofit brokers Trip intake and trip assignment Florida Fee for Service Models Statewide State Trip intake/provider assignment to regional coordinators Alabama Private entity Trip intake/provider assignment to enrolled providers Alaska Regional Regional trip intake centers Trip intake and trip assignment Louisiana County County unit of state Medicaid agency Eligibility, provider assignment Indiana, Maryland, Minnesota, New Hampshire, North Carolina, Ohio, West Virginia, Wyoming Brokerage/Fee for Service Mix Brokerages in selected area, fee for service model in other areas Private or public/ nonprofit broker Trip intake and trip assignment Colorado, Michigan, Pennsylvania, New York, Tennessee, Texas Public Transit Models Statewide State or local Medicaid agency refers NEMT clients to public transit or other human service agencies Referral South Dakota Regional or Counties State or local Medicaid agency refers NEMT clients to public transit Eligibility, referral, arrangements with other modes when public transit is unavailable or inappropriate California, Utah, Rhode Island Read the entire page →
From page 27... ... 27 Table 2 (Continued) Service Delivery Model Type Geographic Coverage Entity/Broker Responsibility States Managed Care Organization Statewide Comprehensive Health Care/ Insurance Organization Arranges transportation within capitated rate structure Arizona Mixed MCO and Fee for Service Model Comprehensive Health Care/ Insurance Organization Arranges transportation within capitated rate structure New Mexico Source: RLS & Associates, Inc. Read the entire page →
From page 28... ... 28 coverage. Employers may offer "free choice vouchers" to their employees in order to obtain qualified health care coverage. Read the entire page →
From page 29... ... 29 agencies and/or private organizations. Individuals and small businesses with up to 100 employees will be able to purchase qualified health care coverage through the exchanges. Read the entire page →
From page 30... ... 30 documented cases of the agency ever exercising this power (29) Read the entire page →
From page 31... ... 31 legal challenges to aca In a case that reached the U.S. Supreme Court, 26 states and a private business organization sued the federal government, seeking to overturn the Affordable Care Act based on the constitutionality of two key elements: the individual mandate and Medicaid expansion. Read the entire page →
From page 32... ... 32 states for noncompliance, it essentially created a situation wherein Medicaid expansion is optional. The result is that researchers and industry watchers are unsure as to the status of many states in participating in the act's expansion of Medicaid. Read the entire page →
From page 33... ... 33 new enrollees in the Medicaid program is uncertain because enrollment is voluntary; it is up to the individual to take advantage of newly accorded eligibility. Expansion of Medicaid Eligibility Prior to 2014 While most observers cite January 1, 2014 (the ACA's effective date for expansion of Medicaid eligibility) Read the entire page →
From page 34... ... 34 Medicaid expansion model. This meant that approximately 45,000 former SAGA recipients would become eligible for Medicaid benefits. Read the entire page →
From page 35... ... 35 various Section 1115 waivers and expenditure authorities which have allowed the state to expand Medicaid coverage to multiple populations. Prior to the passage of the ACA, Medicaid benefits were already available to many uninsured adults between the ages of 19 and 64 with incomes less than 200% of the FPL through the Medi-Cal Hospital/Uninsured Care Demonstration Waiver. Read the entire page →
From page 36... ... 36 income individuals with access to employer-based coverage. The expanded NJ FamilyCare Childless Adult program includes uninsured childless individuals ages 18 to 65, with household incomes between 25% and 100% of the FPL. Read the entire page →
From page 37... ... 37 in a fee-for-services health care delivery system while all other transition eligibles are required to access services through MCOs. Effective March 1, 2011, two months after receiving the waiver authority, the State of Washington limited eligibility for the BH program to the transition-eligible population and licensed foster parents. Read the entire page →
From page 38... ... 38 specialty, and urgent care to uninsured individuals between the ages of 19 and 64. Participation in the program has grown significantly: In July 2012, 14,900 individuals were enrolled; as of January 2013, enrollment had grown to 19,657. Read the entire page →
From page 39... ... 39 authority of the transportation assurance, CMS could potentially agree to such a provision. Thus, there is no certainty to the transportation assurance. Read the entire page →
From page 40... ... 40 utilize NEMT or the consumption of NEMT services (trips) Read the entire page →
From page 41... ... 41 table 5 Estimated newly enrolled Medicaid participants, by Medicaid expansion status of states. Estimated New Medicaid Enrollees State Total Population Current Medicaid Enrollment1 Participating States Non- Participating States Alternative Plan States Alabama 4,779,736 1,015,576 351,567 Alaska 710,231 136,959 42,794 Arizona 6,412,700 1,783,289 105,428 Arkansas 2,915,918 778,997 200,690 California 37,253,956 11,168,140 2,008,796 Colorado 5,029,196 702,239 245,730 Connecticut 3,574,097 712,350 114,083 Delaware 897,934 225,458 12,081 District of Columbia 601,723 175,678 28,900 Florida 18,801,310 3,421,911 951,622 Georgia 9,687,653 2,048,362 646,557 Hawaii 1,360,301 267,002 84,130 Idaho 1,567,582 251,494 85,883 Illinois 12,830,632 3,017,131 631,024 Indiana 6,483,802 1,243,051 297,737 Iowa 3,046,355 574,625 114,691 Kansas 2,853,118 372,522 143,445 Kentucky 4,339,367 960,776 329,000 Louisiana 4,533,372 1,312,335 366,318 Maine 1,328,361 366,735 43,468 Maryland 5,773,552 960,915 245,996 Massachusetts 6,547,629 1,568,182 29,921 Michigan 9,883,640 2,124,018 589,965 Minnesota 5,303,925 885,311 251,783 Mississippi 2,967,297 772,166 320,748 Missouri 5,988,927 1,146,897 307,872 Montana 989,415 151,422 575,356 Nebraska 1,826,341 286,887 83,898 Nevada 2,700,551 290,758 136,563 New Hampshire 1,316,470 166,363 55,918 New Jersey 8,791,894 1,231,456 390,490 New Mexico 2,059,179 637,856 145,024 New York 19,378,102 5,208,143 305,945 North Carolina 9,535,483 1,974,287 633,485 North Dakota 672,591 80,262 28,864 Ohio 11,536,504 2,427,052 667,376 Oklahoma 3,751,351 851,674 357,150 Oregon 3,831,074 643,941 294,600 Pennsylvania 12,702,379 2,303,775 482,366 Rhode Island 1,052,567 224,282 41,185 South Carolina 4,625,364 971,969 344,109 South Dakota 814,180 142,173 31,317 Tennessee 6,346,105 1,531,074 330,932 Texas 25,145,561 4,488,188 1798,314 Utah 2,763,885 294,904 138,918 Vermont 625,741 199,434 4,484 Virginia 8,001,024 1,039,298 372,470 (continued on next page) Read the entire page →
From page 42... ... 42 Therefore, because of the Supreme Court decision's effectively creating an "opt out" strategy, the demographics of the states that have elected to participate, and the eligibility criteria for the expansion of Medicaid that will target low income individuals, the total number of newly eligible Medicaid enrollees is projected to be much lower than the estimates that were predicated on all states participating in the expansion. More- over, the newly eligible population is less transit dependent than traditional Medic aid enrollees, thus the potential impact on NEMT volumes is further reduced. Read the entire page →
From page 43... ... 43 vide a state with an option to assure statewide coverage in its management of NEMT services. The potential for increased use of brokerages creates additional challenges for public transportation, including: • Dual eligibility issues arising from an individual's being eligible for both public transportation and NEMT; may not be indicative of the fully allocated cost to delivery NEMT services. Read the entire page →
From page 44... ... 44 These dual eligibility cases create cost sharing issues for the transit provider. Typically, a fee-forservice is negotiated with the sponsoring state or local agency. Read the entire page →
From page 45... ... 45 to having clients ride as "unsponsored" passengers (e.g., the general public) Read the entire page →
From page 46... ... 46 another governmental unit, Medicaid embraces the concept of the program's being the payer of last resort. There is little evidence in the literature to suggest this has become a problem for transit operators in dual eligibility situations; however, there remain concerns that billing options for transportation operators that coordinate services may be limited by this provision. Read the entire page →
From page 47... ... 47 Overall, community transit in New Jersey has seen a decrease in NEMT trips since the brokerage was initiated. However, the decrease is due to the fact that two of the three counties that have elected not to participate represent large service areas with a significant amount of NEMT trips. Read the entire page →
From page 48... ... 48 fully allocated costs have limited participation by New Jersey providers, suggesting that information on existing costs of both paratransit and NEMT services should be well documented prior to brokerage establishment. Oregon Overview. Read the entire page →
From page 49... ... 49 using fixed-route services, where available, to a greater extent than the existing Medicaid population. Read the entire page →
From page 50... ... 50 (4) Rosenbaum, Sara, et al., Policy Brief, Medicaid's Medical Transportation Assurance: Origins, Evolution, Current Trends, and Implications for Health Reform, prepared for the U.S. Read the entire page →
From page 51... ... 51 Center, March 26, 2012, retrieved at http://bipartisan policy.org/blog/2012/03/us-supremecourt-oralhearings-health-reform. See also Barnes, Julie and Meredith Hughes, Supreme Court Oral Arguments on Health Reform, Day 2: Analysis, Bipartisan Policy Center, March 29, 2012, retrieved at http:// bipartisanpolicy.org/blog/2012/03/supreme-courtoral-arguments-day-2-analysis and Levy, Allison, Supreme Court Oral Arguments, Day 3: What We're Reading, Bipartisan Policy Center, March 28, 2012, retrieved at http://bipartisanpolicy.org/ blog/2012/03/supreme-court-oral-arguments-day3-what-were-reading. Read the entire page →
From page 52... ... 52 appendix a GAO summary of programs with potential dual eligibility with ADA complementary paratransit programs. Read the entire page →
From page 53... ... 53 appendix a GAO summary of programs with potential dual eligibility with ADA complementary paratransit programs. Read the entire page →
From page 54... ... 54 appendix a (Continued) Read the entire page →
From page 55... ... 55 appendix a (Continued) Read the entire page →
From page 56... ... Transportation Research Board 500 Fifth Street, NW Washington, DC 20001 These digests are issued in order to increase awareness of research results emanating from projects in the Cooperative Research Programs (CRP) Read the entire page →

From page 1...

... TRANSIT COOPERATIVE RESEARCH PROGRAM Sponsored by the Federal Transit Administration Program Officer: Gwen Chisholm-Smith October 2014 Research Results Digest 109 Background The Patient Protection and Affordable Care Act of 2010, and the related Health Care and Education Reconciliation Act of 2010 (jointly referred to as the "Affordable Care Act" or ACA) , complete a massive overhaul of the nation's health insurance and health delivery systems.