June 18, 2018
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Maine Medicaid ride program baffles transportation experts

By James McCarthy, Mainebiz

Sandra Buchanan, general manager of Western Maine Transportation Services, knows her agency from top to bottom. She began her 24-year career there as a dispatcher, steadily working her way through the ranks to supervisor of customer services, director of operations, deputy manager, to her appointment to general manager in May.

All of that experience and expertise will be challenged — in fact, she says, already is challenged — by a new transportation system being developed by the Maine Department of Health and Human Services and the federal Center for Medicare and Medicaid Services (CMS). Her worst fear, shared by her counterparts across the state, is that it could upend a network of regional providers that serve not only low-income and elderly Mainers covered by MaineCare, but many others who depend on public transportation for shopping, getting to work or utilizing other social services.

“Everyone in transportation is very concerned,” Buchanan says.

The general framework of the new system differentiates riders covered under the state’s MaineCare program from other riders served by the regional transportation providers, raising the risk that now-integrated services will become broken into separate silos, according to funding sources. Additionally, the new system requires competitive bidding to manage the MaineCare transportation services, a function performed for decades by nonprofits such as Western Maine Transportation. Finally, it will set monthly budgets for each regional transportation broker, putting them at risk of losing money if expenses exceed that cap.

The new system has been evolving since November 2010, when CMS told the state a redesign was necessary to achieve compliance with federal regulations to maintain the current federal matching funds. CMS’s chief objection is that the state’s 10 regional transportation providers also serve as MaineCare transportation brokers – in its view, a conflict of interest.

Since then, the state’s Office of MaineCare Services, which oversees those transportation providers, has held several stakeholder meetings and published updates regularly on its website. During that time, Buchanan has been working with her staff to identify various scenarios and their potential impacts so that Western Maine Transportation Services can respond quickly and effectively to any new requirements.

But, as the saying goes, the devil is in the details, and those won’t be known until the state issues a request for proposals seeking brokers to manage eight regional transit districts under a new risk-based structure that will introduce a competitive bidding process for managing each region and also set monthly budgets for paying transportation providers. Buchanan says until she and her counterparts actually see the RFP, they really don’t know how it will affect them or the elderly, disabled or qualifying low-income clients who need transportation to MaineCare-covered services.

“It could be great, it could be completely different,” she says of the new system that’s expected to be in place by early next year. “It all depends on the wording of the RFP.”

Michelle Probert, director of strategic initiatives at the state’s MaineCare Office, understands that concern. She expects the RFP seeking proposals from brokers to oversee the existing eight transportation regions will be released in July. It will be followed by an open bidding process in which the submitted proposals will be scored according to various criteria, including cost.

“It’s a big change and the system we now have has been in place without competition for some time,” she says. “With the new model, the broker receives a set monthly amount for MaineCare [eligible clients] and will have a strong incentive to manage those dollars wisely.”

Other states using similar models, she says, have been able to decrease costs per trip, increase ridership and access to non-emergency transportation services, and improve customer service.

Koriene Low, director of transportation and corporate technology at Community Concepts Inc. in Lewiston, which serves MaineCare clients in Androscoggin, Franklin and Oxford counties, says regional providers won’t know until the RFP comes out if it makes sense for them to submit a bid to become a broker as well – which, because of the new elements of risk and capped budgets, will be allowed under a one-year waiver granted by the federal CMS.

Last August, she sent a letter to Probert raising questions about a slew of issues, including what happens if ridership exceeds what was calculated by the state when it set the budget cap for a given region. To date, she says, there’s been no response. She also worries national for-profit brokers could submit bids based on lower training standards than those already established by Community Concepts for its 250-plus volunteer drivers, who in recent years have earned client-satisfaction ratings in the 95 percent to 98 percent range.

Low says Community Concepts and other regional providers have made considerable software investments to interface with the current MaineCare billing system: If the RFP requires new billing software, she says, that alone could be a deal-breaker for regional providers who might otherwise be interested in becoming a broker.

“We still want to be a provider,” she says. “We think there is a place for us. We just don’t know what it is.”

Tom Meyers, South Portland’s director of transportation and the waterfront, who also serves as president of the Maine Transit Association, says the state’s regional providers, by cobbling together funding from a variety of sources, already provide a full array of transportation services “at the least cost.” Slicing MaineCare revenues from that mix, he says, in some regions could jeopardize a provider’s ability to offer those other services at a reasonable cost, if at all.

“We fully understand what DHHS has to do, we understand we have to follow the [federal CMS] rules” he says. “That’s why we’ve been working diligently with them on how this will be achieved.”

Meyers says the association’s overriding concern is that an at-risk / fixed-budget brokerage model introduces a “profit incentive” to Maine’s regional transportation system. “Where is that ‘profit’ going to come from?” he asks. “Go to any of our regional providers. There is no ‘fat.’”

“What Maine has had in place is a way to serve all of the residents in Maine who have need of transportation, whether they are MaineCare clients or not,” agrees Connie Garber, transportation director for York County Community Action. “What the regional providers have been able to do is consolidate funding from a variety of revenue sources and they’ve been able to provide more service to more people than would otherwise be possible.”

Garber, who was honored by the Legislature last fall for being named 2011 Community Transportation Director of the Year by the Community Transportation Association of America, says the pending change in the MaineCare transportation system is tied to the much-larger question of how that might impact the state’s existing full-service regional transportation providers.

“Our biggest concern is the people we serve – seniors, low-income people, people who rely on us and don’t have any other recourse,” she says.

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