Potential Impacts of Federal Health Care Reform on Public Transit (2013) / Chapter Skim
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NAtioNAl CooperAtive HigHwAy reseArCH progrAm Responsible Senior Program Officer: Gwen Chisholm-Smith June 2013 C O N T E N T S Executive Summary, 1 1 Introduction, 5 2 Provisions of Federal Health Care Reform That Are Most Relevant to Public Transit, 6 3 Review of Relevant Legal Requirements for Public Transportation, 10 4 Case Studies, 15 5 Monitoring Process for Health Care Reform Effects on Transit, 36 6 Conclusions, 38 References, 40 Acronyms, 41 Appendix, 41 POTENTIAL IMPACTS OF FEDERAL HEALTH CARE REFORM ON PUBLIC TRANSIT This digest presents the results of NCHRP Project 20-65, Task 39, "Impacts of the New Health Care Bill on Mass Transit," by ICF International and Nelson\Nygaard Consulting Associates. The research was conducted by Antonio Santalucia of ICF International and Bethany Whitaker and Ellen Oettinger of Nelson\Nygaard, with support from Richard Weiner of Nelson\Nygaard.
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2Increasing the Availability of Health Care Services in Underserved Areas. The ACA contains numerous provisions intended to improve access to health care services in underserved areas such as rural communities.
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3Laws and Regulations Governing Transit Participation in Medicaid NEMT. Under federal Medicaid regulations, each state's Medicaid plan must specify that the administering state agency will ensure necessary transportation for recipients to and from Medicaid-covered health services.
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4transportation operating in different geographical settings and under different NEMT delivery frameworks. Specific findings or lessons learned from each case study can be found in Section 4 of the digest.
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5of traveling to Medicaid-funded medical services. Public transit agencies have historically participated in the provision of this transportation assistance, known as NEMT.
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6rural and small urban areas, the research team consulted existing summaries and analyses of the ACA by health policy organizations such as the Kaiser Family Foundation. The team also searched the websites of public transportation organizations such as the Community Transportation Association of America and organizations interested in rural health care to determine which provisions of the ACA were of special interest.
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7cise of Congress's spending clause power because it improperly coerced the states into participating in the expansion. The Supreme Court accepted the case of Florida v.
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8patients. Community health centers will play a role in implementing many provisions of the ACA and in providing access to care for millions of Americans who will gain health insurance coverage under the law.
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9Table 2 (Continued) Provision Summary Implementation Timeline Nature of Provision (Required vs.
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10 3 REVIEW OF RELEVANT LEGAL REQUIREMENTS FOR PUBLIC TRANSPORTATION This section provides an overview of the preexisting legal requirements for public transportation providers and services that are most relevant to federal health care reform. First described are the federal rules for Medicaid NEMT and how they affect the participation of public transit operators in providing or coordinating (i.e., brokering)
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11 •• Administrative Expense. If a state opts to claim NEMT as an administrative expense, the federal share in the expense is 50 percent, usually less than a state's FMAP rate.
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12 the same time, the DRA added several conditions that make using public brokers more challenging: •• The broker must be a wholly separate governmental "unit"; •• The broker must be able to prove that it is the "most appropriate, effective, and lowest cost" mode choice for every trip that it awards to itself; and •• The broker must be able to document that, for each individual transportation service, the rate charged is no more than that charged to the general public. Additional requirements in the DRA for competitive bidding processes and avoidance of conflictof-interest have further restricted the ability of states to use public brokers such as public transit agencies.
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13 CMS also appears to be actively encouraging statewide, private brokerages as a way to combat fraud. As a result of these trends, a handful of private entities have emerged that specialize in operating Medicaid NEMT brokerages, and a majority of statewide broker contracts are with these two or three large companies.
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14 is required to work with the statewide public transportation operator to assign as many trips to transit as possible. Recently, however, several states have come under CMS scrutiny based on federal regulations prohibiting self-referrals.
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15 have standards for delivering service in a timely and fair fashion. Significantly late pick-ups, trip denials, missed trips, and excessively long trips must be tracked and kept to a strict minimum.
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16 The first three criteria were used because of the ACA's significant expansion of Medicaid and the presumed accompanying impacts on Medicaid NEMT service. The next two criteria were used to help ensure that the project's results are relevant to a larger number of transit providers.
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Case Study NEMT Management Model Service Area Other Programs Included in Brokerage Method for Paying NEMT Broker Statewide NEMT Program Costs (millions) NEMT Trips Provided Statewide Statewide Average Cost per Trip Statewide Trips on Transit Integration with Transit Montachusett Regional Transit Authority Boston/ Fitchburg, MA Regional brokerage – public-sector broker Varied – includes four regions (rural, suburban, and urban)
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18 Feature Massachusetts health care reform law (2006) Federal Patient Protection & Affordable Care Act (2010)
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19 many of the same provisions as the ACA, including expanded access to publicly funded or subsidized health care. Because Massachusetts has already implemented many of the health care reforms required by the ACA, the federal law is not expected to have a large impact on the number of Massachusetts residents enrolled in Medicaid.
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20 can respond to the requests for proposals, but RTAs can hold contracts for HST regions that are not part of their RTA service area. The RTA brokers subcontract with qualified, local transportation service providers to provide the NEMT trips.
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21 provide expanded reports and data according to new requirements. As a case study for how the ACA could affect demand for NEMT services, Massachusetts's experience with its health care reform is inconclusive.
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22 the provider that can provide the trip for the least cost; this automated process is intended to eliminate any human bias and dispel concerns about self-referrals. Even with these assurances, the HST Office monitors trips referred to MART closely.
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23 •• MART uses a combination of qualitative and quantitative techniques to manage the program. The staff uses data and customer feedback and site visits to monitor service providers and service quality.
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24 areas such as the counties northwest of Jackson. Public agencies entering into contracts with the broker receive a reimbursement per trip that is higher than the fare but lower than the actual cost per trip.
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25 ever, that if trip rates per person do increase due to implementation of the ACA, the state would likely renegotiate the capitated rate rather than consider a different service delivery model. Conclusions and Lessons Several key lessons can be learned from Jackson's current NEMT service delivery system: •• The State of Mississippi's NEMT service delivery model is less coordinated with public and human service networks than that of several other case study states, and there is significantly less interaction between public transportation authorities and either the State Medicaid office or the NEMT broker.
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26 nearly 20 percent by 2019, according to a projection by Georgia DCH. Estimates mark the cumulative increase in state spending at $2.5 billion through 2019 (6)
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27 5311 funds for either general public transportation in the rural areas, or to purchase vehicles to provide human service transportation. The private operators have fairly large vehicle fleets and provided the majority of Medicaid transportation in the region.
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28 Perspective of NEMT Broker In the past few years, the number of Medicaid NEMT trips has risen rapidly in Georgia's southwest region. SWGRC attributes this increase to an increase in the price of gas and to the difficult economy (i.e., more people qualifying for human and medical services)
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29 ation is bundling NEMT services into managed-care contracts. Bundling NEMT would be a significant change in Georgia's model, and Georgia DCH believes that the current brokerage model has served the state well in terms of service and fraud control.
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30 a time when other states have been freezing or cutting Medicaid provider reimbursement rates, North Dakota increased provider rates by 6 percent across the board in fiscal year 2011. Providers other than physicians received an additional rate increase of 3 percent in fiscal year 2012 (6)
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31 that transit operators have cited several issues as discouraging them from providing NEMT trips for Medicaid. For example, some transit providers are discouraged by the lag time in receiving payment from the Medicaid program for trips provided, although this may be an issue only for those transit agencies that submit paper invoices instead of submitting bills online.
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32 designing the benefits plan for the population made eligible for Medicaid by the ACA, and that North Dakota will be making decisions about the benefits plan during the 2013 biennial legislative session. Perspective of Transit System In 2011, Bis-Man Paratransit provided approximately 8,300 NEMT trips, an average rate of about 700 NEMT trips per month.
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33 ington's Medicaid NEMT services are managed by eight transportation brokers, which are a mix of public agencies and private nonprofit entities. The Northwest Regional Council (NWRC)
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34 broker organizations are a mix of public agencies and private nonprofit entities. The NWRC, an association of county governments, serves as the NEMT broker for Whatcom County and three adjoining counties (Island, San Juan, and Skagit)
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35 Medicaid participants. NEMT services comprise approximately 1 percent of the state's Medicaid budget.
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36 •• Washington State Medicaid officials do not expect a sizable increase in the demand for NEMT services resulting from the implementation of health care reform, primarily because the new enrollees will have higher incomes and fewer debilitating disabilities than current Medicaid participants. •• A long, close working relationship between the Medicaid NEMT broker (NWRC)
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37 Depending on how transportation costs are reimbursed, NEMT brokers and providers collect additional information, including trip cost, mileage, mode, any shared rides, day of the week, and time of day. Such extensive data collection efforts mean that the number of trips by individual and the costs of those trips are well-documented.
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38 point out that all information is about how the card is used; the card cannot easily and reliably (i.e., without requiring drivers to check photo identification) be traced to a particular individual.
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39 significant to public transit because many Medicaid participants are entitled to transportation assistance if they have no other means of traveling to Medicaid-funded medical services. Public transit agencies have historically participated in the provision of this transportation assistance, known as nonemergency medical transportation (NEMT)
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40 transit agencies are less willing to provide demand-response services to NEMT riders for the published fare, because the cost per trip is so much higher. Some transit agencies are reimbursed by Medicaid for the fully allocated cost of providing paratransit service; some are reimbursed based on the public fare; and some are reimbursed for another amount in between the fare and the fully allocated cost.
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41 9. Georgia Department of Community Health.
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Baseline Medicaid Enrollment Standard Participation Scenario Enhanced Outreach Scenario Total New Medicaid Enrollees* Previously Uninsured Newly Enrolled % Decrease in Uninsured Adults <133%FPL % Change in Enrollment Total New Medicaid Enrollees*
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Baseline Medicaid Enrollment Standard Participation Scenario Enhanced Outreach Scenario Total New Medicaid Enrollees* Previously Uninsured Newly Enrolled % Decrease in Uninsured Adults <133%FPL % Change in Enrollment Total New Medicaid Enrollees*
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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)
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