May 26, 2018
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Medicaid patients need rides to the doctor. How can Maine ensure they’re reliable?

Abigail Curtis | BDN
Abigail Curtis | BDN
Mary Putansu (left) of Belfast, heads to work in August at Little River Apparel after getting a ride there by Waldo County Transportation driver Winnie Fowler.
By Matthew Stone, BDN Staff

It’ll pay for a ride to a doctor’s appointment or physical therapy session but not a ride to the pharmacy to pick up a prescription — unless that pharmacy stop is in conjunction with a medical visit.

It generally won’t cover rides to medical appointments from nursing homes. But when it does, a patient escort is allowed to ride along. Escorts can also ride along when patients are younger than 12, blind or deaf, or have intellectual disabilities.

It’ll pay for overnight stays and meals when a patient has to travel far for a medical service. And it will cover a ride to the hospital for a parent whose child has been admitted.

It’s the MaineCare rides system that has been at the center of frequent controversy since the summer. That’s when Maine’s Medicaid program reconfigured its nonemergency transportation system, putting three contracted transportation brokers in charge of arranging rides to and from medical appointments, daytime services for the elderly and disabled, methadone treatments for recovering addicts and more.

Previously, the same agencies that arranged rides also provided much of the transportation.

The controversy erupted last summer as thousands of MaineCare-covered patients struggled to get through on newly set-up phone lines to arrange rides. In other cases, the rides they managed to schedule didn’t show up, causing them to miss medical appointments.

Coordinated Transportation Solutions, which was selected as the broker for six of Maine’s eight transportation regions, has come under the most intense criticism for abandoned calls from clients, missed rides and deficient performance under the terms of its state contract. The Maine Department of Health and Human Services said last month it wouldn’t renew Connecticut-based CTS’ contracts come July 1 and would solicit new bids.

The federal default

While Maine debuted the broker system in the summer of 2013, the shift to the new setup has its roots in February 2006.

That’s when President George W. Bush signed the Deficit Reduction Act, making a Medicaid transportation broker system a standard part of Medicaid law.

Maine had long dealt directly with the organizations that provided the rides themselves — generally, local community action agencies — often using their own wheelchair-accessible buses and vans, along with volunteer drivers. The programs also arranged rides they didn’t provide themselves, sometimes setting up taxi rides or coordinating the mileage reimbursement for friends and family members with vehicles.

“That integrated model has worked very well,” said Rick McCarthy, who represents the community action programs and Maine public transit agencies before the Legislature. But, “We understand some of the pressures the state was facing.”

The federal government denied Maine DHHS’ request in 2010 for approval to continue its transportation system as it existed. Maine’s system was wrought with potential problems, mostly administrative but with major funding implications, that the federal Centers for Medicare and Medicaid Services outlined in a November 2010 letter, more than a month before Gov. Paul LePage took office.

Without a broker system, the letter explained, the state had to directly pay each entity providing transportation. It couldn’t rely on the regional community action program to pass the payment along to the taxi or volunteer driver. And with the regional community action program both arranging transportation and providing it, federal officials asked the state “to provide a description of its oversight to prevent potential fraud and abuse.”

Plus, the state would have to stop claiming a full federal match rate — Maine’s is currently 61.55 percent — for the administrative portion of the transportation program. Instead, the state could claim only 50 percent federal reimbursement for administrative expenses. In 2011, Maine DHHS estimated it would cost the state $6.1 million from lost federal funds to continue the rides system as it existed.

Federal officials were also concerned that Medicaid was funding rides for nonmedical purposes — for example, rides to the grocery store for non-Medicaid clients riding in the same vehicle as a Medicaid recipient on the way to the doctor’s office. There was also concern about reimbursing volunteer drivers for miles driven without a Medicaid patient on board, said Stefanie Nadeau, director of the Office of MaineCare Services.

“We didn’t have a way to identify rides that were being delivered for Medicaid-approved services,” she said.

The state also had no way of tracking the performance of its transportation providers, she said.

“We didn’t know how many calls were made and how many calls weren’t answered,” Nadeau said. “We didn’t collect that data. A lot of the previous providers, frankly, didn’t have the capability of reporting that data.”

Rides brokers and risk

Transportation to doctors’ appointments and other medical services is a guaranteed benefit for Medicaid recipients in Maine unless they have other means of transportation, like their own vehicle. Maine spends $33 million-$40 million annually from state and federal funds to provide transportation.

Some 75,000 MaineCare recipients — out of more than 300,000 total — used the service at some point last year, said Nadeau. “Some of them used it once. Some of them used it five days every week.”

Now, the three contracted brokers arrange all MaineCare transportation, and they’re held to a variety of performance expectations outlined in their contracts, or else their payments are reduced. For example, no more than 5 percent of calls to the call center can be “abandoned” before an agent picks up, no member can be left stranded at a doctor’s office with no way to get home, and the company can receive no more than one complaint each month for every 100 of its assigned MaineCare recipients.

The brokers are also paid differently than the providers were under the previous setup: They’re paid a lump sum each month for every MaineCare recipient in their region. If it ultimately costs more to provide the service, the contractor — rather than the state — is responsible. Previously, MaineCare paid transportation providers based on the rides they provided.

The Green Mountain way

As the Legislature debates the future for MaineCare rides, Sen. Colleen Lachowicz is suggesting Maine adopt the transportation model used by its northern New England neighbor Vermont, which doesn’t rely on brokers.

“Out of the choices in the new federal guidelines that every state was given,” said Lachowicz, D-Waterville, “in a rural state with lots of miles of road, pretty spread out with an older, rural population, that seemed to me a better fit for what we actually are.”

Vermont has a special waiver from the federal government that allows it to use a network of seven regional transportation providers much like Maine’s regional community action programs. The Department of Vermont Health Access handles the administration, said Peter McNichol, the agency’s transportation quality control chief.

“When you’re dealing with a small state like Vermont, it works having a smaller regional carrier work in an area that they know,” he said. “They know the geography. They know the people. They know how the system works. It’s easy for them to forge relationships with volunteer drivers and cab companies.”

Through its special waiver with the federal government, Vermont can claim its full 56 percent federal match rate for all transportation-related services — and not a 50 percent rate for administration.

But service is largely unavailable except for patient discharges after business hours and on weekends, said McNichol. Maine’s brokers are required to guarantee transportation at all times.

If Maine adopted Vermont’s model, it would either have to secure a special federal waiver, which could take time, or it could implement it without the waiver and risk losing about $1.2 million annually in federal funds, Nadeau said. Plus, Nadeau said she’s concerned Maine’s community action agencies might not have the manpower and technological infrastructure to measure abandoned call rates, missed and late rides, and other information.

“We believe we need to have that data,” Nadeau said.

Moving forward

In the coming weeks, Maine DHHS plans to issue requests for bids for the six regions where CTS is the contracted broker — all but Penobscot, Piscataquis and York counties.

“We are committed to the brokerage model,” Nadeau told lawmakers on the Health and Human Services Committee on Tuesday.

But the department is considering some changes to this request for bids that McCarthy said could make it more feasible for regional community action agencies to apply and be chosen as the broker.

DHHS is deciding whether it can allow brokers to provide more than 25 percent of rides on their own. And the department will allow brokers to find some way to reimburse volunteer drivers for so-called nonload miles — miles driven by a volunteer on the way to the patient’s home with no Medicaid patient in the car.

Nadeau said DHHS will also ensure the selected bidders secure performance bonds before the finalized contract takes effect. Performance bonds act as insurance the state can tap into if the broker can’t pay drivers or can’t fulfill the terms of its contract. CTS never purchased the required performance bond.

“We’re going to be a lot more diligent about that one,” Nadeau said. “I can tell you that.”

Matthew Stone is BDN opinion page editor.


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