Getting to Care: A Look at Medi-Cal’s Transportation Benefit OCTOBER 2020 AUTHORS Athena Chapman, Elizabeth Evenson, Len Finocchio, and Shawn Blosser Contents About the Authors 3Executive Summary Athena Chapman, MPP, is president and Elizabeth Evenson is policy director at 5Introduction Chapman Consulting, which provides strategic planning, meeting facilita­tion, orga- 5Methods nizational support, market research, and regulatory and statutory analysis to organiza- 9Findings tions in the health care field. 17Considerations for Improvement Len Finocchio leads the Blue Sky Consulting Group’s health care practice. He earned his 18Conclusion doctorate in public health from the University of Michigan. Shawn Blosser leads the Blue Sky 19 Appendix. Interviewees Consulting Group’s data analysis team. He earned his bachelor’s degree from Stanford 21Endnotes University and did graduate work in econom- ics at the University of Chicago. About the Foundation The California Health Care Foundation is dedicated to advancing meaningful, measur- able improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford. CHCF informs policymakers and industry leaders, invests in ideas and innovations, and connects with changemakers to create a more responsive, patient-centered health care system. For more information, visit www.chcf.org. California Health Care Foundation www.chcf.org 2 Executive Summary T o improve access to care for Medi-Cal such as telehealth and e-visits. If these policies are (California’s Medicaid program) enrollees, retained in the long term and enrollees continue state lawmakers significantly expanded trans- to access some care remotely, the impact on NMT portation coverage in 2016. Before the expansion, demand and use should be studied. Medi-Cal’s transportation benefit included non-emer- gency medical transportation (NEMT), which covers transportation to medical appointments for those who Key Findings need specialized transport by ambulance, wheelchair The paper goes into detail on several key findings: van, or litter/gurney van, and require door-to-door NMT is a comprehensive benefit valued by a small assistance. The 2016 law — AB  23941 — created a fraction of Medi-Cal enrollees with recurring needs. second, complementary benefit called non-medical Enrollees who have used the benefit reported that transportation (NMT), which covers transportation to NMT is the main source of transportation to their non-emergency medical services for enrollees who medical appointments and that transportation sup- can reasonably walk or move about and can therefore ports are critical to maintaining their health. use public (e.g., bus or train) or private (e.g., rideshare, taxi, car) modes, and who have no other means of NMT has the potential for ballooning costs due to transportation. Together, the two benefits (NEMT and limited service authorization requirements and heavy NMT) cover transportation to non-emergency medical reliance on rideshare companies. MCPs were required services for most Medi-Cal enrollees.2 to implement the benefit quickly, amid shifting policy guidance, and most decided to delegate the respon- This report was commissioned to provide an over- sibility to transportation brokers. Some provider view of the implementation and experiences of the organizations and consumer groups representing NMT benefit established in 2016. The information Medi-Cal enrollees report significant administrative and analysis in this report draws from interviews with and operational challenges with the NMT benefit key informants including representatives from Medi- that cause frustration and limit access. Most Medi-Cal Cal managed care plans (MCPs), state officials from enrollees do not use the benefit, potentially because the Department of Health Care Services (DHCS), a either they are unaware of its availability or they have small group of Medi-Cal enrollees who have used the less need for the service. Medi-Cal enrollees may still benefit,3 consumer advocates, transportation brokers, have unmet transportation needs, especially in rural providers, policy experts, and other state Medicaid and frontier areas. officials. The report also draws on utilization and cost data provided to the authors by five MCPs and through The paper outlines several potential policy consider- publicly available policy and regulatory documents. ations to improve the NMT benefit and make it easier for more enrollees to use including: The research for this report was conducted before $ Merge NEMT and NMT into a single comprehen- the COVID-19 pandemic, so the data and findings sive benefit. Lawmakers may want to consider if the do not reflect the impact of the pandemic on NMT distinction between the NMT and NEMT benefits is implementation, utilization, or experience. Of note, necessary, or if merging the benefits would reduce the COVID-19 pandemic has reduced use of routine confusion and improve access. health care services, as many enrollees have delayed or avoided in-person care. Additionally, new federal $ Require more outreach and communication to and state policy flexibilities have increased the ability providers and enrollees. DHCS should explore infor- for enrollees to access providers through technology mation gaps and opportunities to communicate Getting to Care: A Look at Medi-Cal’s Transportation Benefit www.chcf.org 3 effectively with providers, enrollees, and MCPs about the NMT benefit and how to use it. $ Address rural and frontier area barriers to service. Transportation services in rural and frontier commu- nities are limited and creative solutions are needed. $ Evaluate the feasibility of including transportation to social services and supports in the NMT benefit. For enrollees with high needs, providing access to social services and supports could help to address social needs and improve enrollee health and well-being. $ Explore NMT driver credentialing or other transpor- tation provider oversight. Proper quality oversight should be put in place while balancing the need to ensure broad access. $ Analyze and publish statewide utilization and cost data reported to DHCS. Analysis of the existing DHCS data would help answer important questions and inform the directionality of Medi-Cal transpor- tation policy and programs. California Health Care Foundation www.chcf.org 4 Introduction Acknowledging that access to transportation can be This report was commissioned to provide an overview a major obstacle for many Medicaid enrollees and of the implementation and experiences of the NMT that missed or delayed health care can result in exac- benefit. Specifically, the report: erbated medical conditions, poorer health outcomes, $ Distinguishes between Medi-Cal’s two and increased costs of care, federal law requires all transportation benefits — NEMT and NMT state Medicaid programs to include a transportation benefit.4 While the exact scope and design varies by $ Explores NMT benefit implementation, state, the Medicaid benefits typically include trans- operations, utilization, and impact portation by wheelchair van, private vehicle (either by $ Offers considerations for improving NMT rideshare, taxi, and/or mileage reimbursement), and policy and programs public transportation. In general, Medicaid enrollees are eligible for the transportation benefit if (1) the transportation is necessary to get to a covered medi- cal appointment or service, (2) the enrollee does not Methods have another means of transportation, and (3) it is the The findings provided in this report are based on lowest-cost option that meets the enrollee’s needs. information obtained in structured interviews, analysis of utilization and cost data from a subset of Medi-Cal California’s Medicaid program, Medi-Cal, through its managed care plans (MCPs), and additional policy and NEMT benefit, has long covered transportation to regulatory research. medical appointments for enrollees who need spe- cialized transport by ambulance, wheelchair van, or litter/gurney van. Historically, Medi-Cal also covered Interviews a more expansive transportation benefit for enrollees The authors of this report completed more than 40 under age 21 to access Early and Periodic Screening, structured interviews in June and July of 2019 (see the Diagnostic, and Treatment services. appendix). Interviewees included staff from 19 of the 24 MCPs, as well as safety-net providers, trade asso- In response to concerns that transportation remained ciation representatives, consumer advocates, health a critical barrier to health care for many Medi-Cal policy researchers, and other state Medicaid offi- enrollees, especially those living in rural and frontier cials. Emphasis was placed on getting input from key areas,5 in 2016 California passed legislation to expand informants in rural and frontier areas, since the imple- its transportation coverage.6 The legislation created mentation of the NMT benefit had an explicit focus a non-medical transportation (NMT) benefit for all on increasing access to transportation in these areas. Medi-Cal enrollees, and expanded on the transporta- tion options available. NMT provides transportation The research firm PerryUndem worked with two MCPs to medical services for Medi-Cal enrollees who can to identify and recruit Medi-Cal enrollees who have reasonably ambulate and can therefore use public accessed the NMT benefit, and then conducted 16 transportation (e.g., bus or train) or private transpor- telephone interviews (2 in Spanish and 14 in English) tation (e.g., rideshare, taxi, car). Despite its name, in January and February 2020. Findings from those California’s NMT benefit does not cover transporta- interviews are incorporated here. tion to appointments or services that are not medically related, such as those that may address social needs. Getting to Care: A Look at Medi-Cal’s Transportation Benefit www.chcf.org 5 Data Analysis $ A small number of Medi-Cal enrollees were inter- DHCS collects monthly utilization data from MCPs on viewed for this research. These enrollees were well the NMT benefit. While the authors requested these connected to NMT through their health plans. This data, DHCS did not provide them. In the absence of research may not have adequately captured the statewide data, the authors received and analyzed experiences of enrollees who have had less success data from the beginning of 2017 through the end of with NMT and have unmet transportation needs. 2019 provided by five MCPs: three County Organized Health Systems (COHS), one local initiative, and one commercial plan.7 Since MCPs collect and analyze NEMT and NMT: their internal transportation data differently, the data What Is the Difference? received were not consistent across plans. In some California’s Medicaid program distinguishes between analyses the authors integrated the monthly MCP NEMT and NMT. Other states offer a comprehen- enrollment data from the California Health and Human sive Medicaid transportation benefit referred to as Services Agency’s Open Data Portal.8 NEMT, which is inclusive of what California covers in its separate NEMT and NMT benefits. Understanding For the reasons above, the data presented throughout that the distinction between NEMT and NMT has this report allow for narrow quantitative illustrations of caused confusion among enrollees, providers, and the NMT benefit implementation and cannot be gen- other stakeholders, this report provides more detail eralized to the statewide experience. Given the small to describe and differentiate the two benefits. See number of plans that submitted data, plan names Table  1 on page 7 and the flowchart on page 8 for have been omitted from the analysis. more information. Limitations This paper presents an early look at implementation of the NMT benefit, informed primarily by qualitative interviews. A few important limitations should be con- sidered when interpreting findings: $ Statewide data were unavailable and therefore, con- clusions about benefit utilization and cost should be interpreted with caution. Quantitative data from individual health plans are shared as illustrative or in combination with qualitative data and may not be representative of statewide trends. $ This paper does not attempt to estimate underlying need for transportation services among Medi-Cal enrollees, and it is unknown the extent to which transportation remains a barrier to care after NMT benefit implementation. California Health Care Foundation www.chcf.org 6 Table 1. NEMT and NMT Eligibility, Benefits, and Transportation Types NEMT NMT Eligibility Available to both limited and full-scope fee-for- Available only to full-scope FFS and MCP enrollees service (FFS), and to MCP enrollees. and limited-scope pregnant women (including 60 days postpartum). Transportation Provided by specialized vehicle: ambulance, Provided by non-specialized vehicles: bus, providers wheelchair van, or litter/gurney van, and specially train, rideshare (Uber/Lyft), taxi, and mileage trained staff. reimbursement in some circumstances. Authorization Enrollees must have a signed Physician Certification Enrollees must be ambulatory and attest that Statement (PCS) form that verifies the enrollee is all other transportation options have been unable to travel by bus, passenger car, taxicab, or reasonably exhausted. another form of public or private transportation Enrollees must attest that any of the following and may require door-to-door assistance.9 applies: the enrollee does not have a valid drivers license, there is no working vehicle available in the household, the enrollee is unable to travel or wait for covered Medi-Cal services alone, or the enrollee has a physical, cognitive, mental, or developmental limitation.10 Accessing services Enrollees in Medi-Cal managed care must provide a Enrollees in Medi-Cal managed care contact their PCS form and use the health plan’s member services plan’s member services department to request department to request NEMT. NMT or contact the plan’s broker directly. FFS Medi-Cal enrollees needing NEMT must obtain a Full-scope FFS enrollees may contact enrolled prescription from their health care provider who will transportation providers directly if they live in then work with a transportation provider to coordi- one of the 26 counties where transportation nate rides to and from their medical appointments, providers are enrolled; otherwise, they must email or they can contact a Medi-Cal FFS field office for DHCS for assistance with arranging transportation. assistance. NMT generally requires 72 hours’ advance notice Approval times vary by MCP, but are generally (except when urgent), and MCPs must make NMT between 3 and 5 days, and DHCS guidance suggests arrangements available 24/7. requesting NEMT at least 5 days in advance. Transportation to MCPs must fulfill an NEMT request from an out-of- MCPs must coordinate transportation to appoint- out-of-network network provider if the enrollee has been referred to ments not covered by the MCP contract, such as providers and or approved to see that out-of-network provider. serious behavioral health and substance use noncovered disorder (SUD) services, and other health care– For a service not covered by the MCP, the MCP services related activities including picking up prescriptions is required make its best effort to refer and or medical supplies and equipment.* coordinate NEMT but is not required to provide it. For FFS, NMT is provided as noted above for all For FFS, NEMT is provided for all covered covered Medi-Cal services. Medi-Cal services. *Pharmacy benefits are currently provided by MCPs, but will be provided through the FFS delivery system effective January 2021. Executive Order N-01-19 (PDF) (January 7, 2019). Getting to Care: A Look at Medi-Cal’s Transportation Benefit www.chcf.org 7 Navigating Med-Cal Transportation Benefits Is Confusing The following flowcharts outline the various processes enrollees (and their health care providers) must follow to obtain transportation services in Medi-Cal. Of note, the process varies by whether the enrollee is trying to access NEMT or NMT, as well as by whether the enrollee is an MCP enrollee or a FFS enrollee. MCP enrollee needs… Requests NEMT Provider MCP coordinates NEMT from provider prescribes NEMT transportation Contacts health plan to MCP connects enrollee to transportation NMT request transportation and vendor or MCP’s member services verbally attests to need to arrange transportation FFS enrollee needs… Enrollee Informs provider Provider NEMT coordinates with of NEMT needs prescribes NEMT NEMT provider Uses the DHCS Contacts the transportation home provider directly* page to look up a or emails DHCS DHCS or enrollee NMT transportation provider to request coordinates if enrollee is in one of 26 assistance for transportation counties with approved coordination of transportation providers transportation *“Transportation Services,” DHCS, last modified September 25, 2020. California Health Care Foundation www.chcf.org 8 Findings The enrollees interviewed were thankful for the NMT benefit and reported that the availability of NMT is key to the management of their health and believe Interviewed Medi-Cal Enrollees Say they would struggle if the service were no longer NMT Improves Access to Care available. Lacking reliable or affordable transporta- Most of the 16 enrollees interviewed by PerryUndem tion options before the implementation of NMT, some reported that NMT is the main source of transportation enrollees said they missed medical appointments and to their medical appointments and that transporta- could not consistently access the pharmacy to obtain tion supports are critical to maintaining their health. prescribed medications. A few said they lived in fear Enrollees reported using NMT services for several that their doctor would drop them if they missed too reasons: many appointments. Enrollees reported that without NMT, missed appointments would become a fact of $ Unable to drive due to health issues or major life life again. events (e.g., accidents, major health conditions that preclude them from driving, or experiencing financial difficulties) $ Not owning a car or having a drivers license “I did have doctors’ appointments, but $ Not having the money to pay for gas or other transportation services (e.g., bus, Lyft, Uber) I was missing them due to not being $ Unavailabilityof family members and friends to able to get a ride. I was not getting give them a ride my medication, and I wasn’t taking my $ Notfeeling comfortable driving to their medical medication right because they won’t appointments give them to you if you can’t get to a One woman used the NMT service because of a high- doctor, and you can’t get to the doctor risk pregnancy that made it difficult for her to take a if you don’t have a ride.” bus to appointments, and she said she could not afford other options like Lyft and Uber. Another enrollee had to travel far distances for appointments — up to 240 miles round trip for one in a frontier area — which would have been cost-prohibitive without NMT. “It’s all very different, because like I said, Many of the enrollees reported that before the avail- 40 days of taking me to and from the ability of the NMT benefit, they often relied on public transportation and in most cases, this was the bus. doctor, imagine how much that would Enrollees reported that taking the bus meant long have cost me. And I didn’t pay a single waits and long walks to and from bus stops, turning cent when they were taking me every what would be a 20-minute car ride into an “all-day” event on the bus. One enrollee seeking care for men- day. And at day 40 I was declared tal health challenges described how difficult it was to cancer free!” get motivated to leave her home and walk to the bus stop knowing she was facing a long commute to her appointment. Getting to Care: A Look at Medi-Cal’s Transportation Benefit www.chcf.org 9 Delivery of NMT Benefit Relies NMT drivers and enrollees were more prevalent when Heavily on Transportation Brokers a transportation broker was handling the NMT benefit. These communication issues were reported to cause and Rideshare Companies, Which Has delays in notification to an enrollee about the status Quickly Expanded Access but Created of their ride and delays in access. It was explained that Concerns Around Cost and Quality this break in communications occurs because of the established process: The enrollee generally contacts The Majority of MCPs Delegate NMT to the MCP or broker to request the benefit, the MCP or Transportation Brokers broker communicates with the driver, and the enrollee Due to the requirement that NMT must be available 24 is cut out of any communication with their assigned hours a day, 7 days a week, most MCPs found that it driver. When drivers do not have a way to directly was necessary to delegate the benefit to transportation communicate with the enrollee, confusion and delays brokers. Transportation brokers have long provided in scheduling rides or resolving issues are often the NEMT services in California,11 and MCPs were able result. Broker arrangements that allow for direct com- to build upon existing relationships or quickly engage munication with the enrollee can help mitigate these these companies to manage NMT. Transportation bro- access issues. kers manage the entire transportation benefit including prior authorization; utilization management; customer The enrollee interviews also revealed some com- service; provider credentialing, licensing, and over- plaints regarding customer service, including long sight; and network development.12 As of July 2019, hold times while trying to schedule a ride, or lacking a 18 MCPs reported using a transportation broker, 4 are helpful customer service representative. One enrollee managing the transportation benefit internally, and 2 described a time when a driver only dropped her at are contracting with providers for use of their fleet but her appointment but never returned to pick her up as are otherwise managing the benefit internally. scheduled. When she tried to contact customer ser- vice, they were closed since it was Saturday and she Other states have also found it necessary to rely on had to find another way to get back home. This dem- transportation brokers to manage their transportation onstrates that the scope and delivery of the Medi-Cal benefit. For example, in Colorado, the state legisla- transportation benefit requires improved communica- ture approved a move to a statewide broker, and the tion between plans, brokers, and enrollees. Medicaid agency began a contract with IntelliRide on September 1, 2019, to arrange for all Colorado Several MCPs reported that creating a no-wrong- Medicaid transportation services. State officials in door approach, where enrollee phone calls would Idaho also moved to a contract with a transportation be automatically routed to the transportation broker broker because of the added oversight of vehicle regardless of where they called, was very helpful in safety and driver credentialing required of their con- streamlining the NMT process and reducing enrollee tracted providers. confusion when using a transportation broker. MCPs also educated member services staff on how to best Despite the increased oversight and administrative assist enrollees seeking transportation. simplification that transportation brokers can provide to MCPs, some challenges with this model were noted during the key informant interviews. Consumer advo- cates reported that communication difficulties between California Health Care Foundation www.chcf.org 10 Most NMT Trips Are Provided by Rideshare also has advantages for MCPs. It allowed Rideshare Drivers them to quickly expand their transportation networks MCPs reported that the number of trips provided by and respond to enrollee transportation needs, and rideshare drivers such as Lyft and Uber are exceeding rideshare companies make it easy to track in real time the number provided by bus or other means of public where enrollees are going to ensure the ride is com- or private transportation. Quantitative data provided pleted to and from the correct location. by three MCPs support that conclusion, with rideshare trips accounting for just over 89% of the NMT trips, While rideshare may be the most accessible and although the share has varied by plan and over time, enrollee-preferred mode of transportation, MCP as shown in Figure 1. staff reported concerns with the high cost compared to alternative options. As a result, many MCPs have Key informant interviews attributed the high volume implemented utilization controls intended to ensure of rideshare use in part to enrollee preference and lack the most cost-effective transportation option is used, of public transit options. Enrollees often request this as required by regulation. These and other utilization mode of NMT because it provides curb-to-curb ser- management controls are described later in the paper. vices. In addition, several plans cover rural and frontier geographies where public transportation may be In addition to the concerns about cost, rideshare may inadequate. Even in mostly urban geography, MCPs not offer enough support for some Medi-Cal enrollees noted that using public transit between cities requires or sufficient oversight of drivers. Consumer advocates using different metropolitan bus systems that do not expressed concerns that MCPs are using NMT ride- necessarily offer easy connections or reciprocal trans- share when more supportive transportation services fer passes. Consequently, rideshare is a more effective (e.g., door-to-door instead of curb-to-curb service) transportation option in these circumstances. would be appropriate. Additionally, rideshare drivers Figure 1. Share of Non-Medical Transportation Trips Provided by Rideshare Services, California, 2017-Q3 to 2019-Q3 ShareofNon-MedicalTransportationTripsProvidedbyRideshareServices,California,2017-2019 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2017-Q3 2017-Q4 2018-Q1 2018-Q2 2018-Q3 2018-Q4 2019-Q1 2019-Q2 2019-Q3 COHSA 88% 83% 78% 76% 81% 78% COHSC 76% 86% 89% 90% 91% 93% 94% LocalInitiative 77% 77% 84% 89% 89% 95% 95% 95% 96% Source:DatawereprovidedbythreeMedi-Calmanagedcareplans. The data used for these analyses were provided by five Medi-Cal managed care plans, including three County Organized Health Systems (COHS), one local initiative plan, and one commercial plan. Given the small number of plans that submitted data, plan names have been omitted from the analysis; instead, the three COHS plans are referred to as COHS A, COHS B, and COHS C, and the other two plans are simply described as “Local Initiative” and “Commercial Plan,” respectively. Source: Data were provided by three Medi-Cal managed care plans. Getting to Care: A Look at Medi-Cal’s Transportation Benefit www.chcf.org 11 are not required to have any specialized training or recognize the needs for medical transportation must certification to assist Medi-Cal enrollees who may have be made available if it wants to expand this line of specialized needs. Uber and Lyft are only required to business. review an individual’s driving record and criminal his- tory. By contrast, NEMT companies (which generally serve different population with different needs) are Medi-Cal Enrollees May Still Have required to be enrolled as Medi-Cal providers, and Unmet Transportation Needs drivers must be credentialed. The credentialing pro- cess includes verification of first aid / CPR certification; Use, While Increasing, Is Highly Concentrated defensive driving certification; HIPAA compliance Among a Small Subset of Members attestation; fraud, waste, and abuse training; passen- Quantitative data provided by the five MCPs for this ger-assistance training certification; drug screening; study indicate that NMT use, as measured by trips, has and background checks.13 increased since 2017 (see Figure 2). However, only a small fraction of MCP members appear to use NMT To address this need, there has been a movement in services. Of the five MCPs that shared data for this the rideshare industry to adjust and create specialized report, only one (COHS B) provided data on the num- transportation options for Medicaid. For example, ber of unique NMT users (see Figure 3 on page 12). both Uber and Lyft have launched health care arms For this health plan, NMT use has been limited to less and are working with the industry to create unique than 0.5% of enrollees in any given month. platforms that are HIPAA compliant. By making these changes, the rideshare industry is working towards Consistent with the data that were provided by demonstrating that it can meet regulatory require- COHS  B, other plans reported during interviews ments of Medicaid programs and that solutions that that approximately 1% of enrollees use NMT. MCPs, Figure 2. Completed Non-Medical Transportation Trips, Calfiornia, 2017 to 2019 CompletedNon-MedicalTransportationTrips,Calfiornia,2017-2019 120,000 100,000 80,000 60,000 40,000 20,000 0 2017-Q1 Q2 Q3 Q4 2018-Q1 Q2 Q3 Q4 2019-Q1 Q2 Q3 Q4 COHSA 2,743 6,348 15,898 27,410 39,142 54,646 44,836 40,363 COHSB 14,733 15,995 18,062 21,217 24,984 23,177 26,653 28,973 27,709 COHSC 18,326 27,844 35,422 39,808 46,772 51,481 57,840 62,267 CommercialPlan 15,135 15,965 29,157 44,489 46,487 46,638 52,571 43,893 LocalInitiative 4,603 16,833 33,459 45,832 60,684 73,055 86,786 94,526 113,649 Source:DatawereprovidedbyfiveMedi-Calmanagedcareplans. Source: Data were provided by three Medi-Cal managed care plans. California Health Care Foundation www.chcf.org 12 Figure 3. M onthly Unique Non-Medical Transportation Users as a Percentage of Total Members, California, July 2017 to April 2019 MonthlyUniqueNon-MedicalTransportationUsersasaPercentageofTotalMembers,California,2017-2019 0.50% 0.45% 0.40% 0.35% 0.30% 0.25% 0.20% 0.15% 0.10% 0.05% 0.00% Aug-18 Jan-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Oct-18 Mar-19 Apr-19 Feb-18 Sep-18 Nov-18 Dec-18 Jan-19 Feb-19 Jul-17 Nov-17 Oct-17 Aug-17 Dec-17 Sep-17 COHSB Source:UniqueriderdatawereprovidedbytheMedi-CalCountyOrganizedHealthSystem.MemberhipdataweredownloadedfromtheCaliforniaHealthandHumanServicesAgency’s Source: Unique rider data were provided by the Medi-Cal County Organized Health System. Memberhip data were downloaded from the California Health OpenDataPortal. and Human Services Agency’s Open Data Portal. providers, and advocates all reported that the high- Additionally, the challenges of using rideshare for NMT est volume of NMT trips are for dialysis appointments, in rural and frontier counties was noted by several key followed by other specialty care needs that require informants. In an eastern frontier county, the county frequent appointments like substance use disorder representative interviewed noted that Uber and Lyft treatment, chemotherapy, or physical therapy. Of note, only provide service in a single population area and Medicaid officials from Rhode Island also reported that not in the rather sprawling outlying areas. In addition, only a small fraction of its Medicaid enrollees (about a Lyft policy restricted one-way distances to under 117 3%) utilize the benefit, and many are repeat users. For miles, and most enrollees needing specialty services Rhode Island, the more frequent rides are to dialysis, or outpatient surgery must travel as many as 200 miles SUD treatments, and adult day care. each way. Another major challenge identified with rideshare use Access to Transportation in Rural and Frontier in these counties was the high rate of “no-shows,” Areas Remains a Challenge meaning either the driver or the enrollee did not show In rural and frontier areas of the state, providers as expected. Both MCPs and consumer advocates interviewed remarked at the limited provision of the reported that drivers would cancel rides or not show benefit by the responsible MCP. They attributed this up in rural or frontier areas. Transportation brokers mainly to the lack of transportation providers — ride- confirmed that because drivers are not compen- share or vans — in remote areas but also to limited sated for their time if the enrollee does not complete investment and staff resources from the MCP. Clinics the ride (aside from a flat rate for the ride out), and located in rural and frontier areas noted that arranging because it is unlikely the driver will be able to pick up a ride through the MCP transportation broker took too another rider in a rural area, it is a real challenge to long, and frequently no ride was ultimately available. secure rideshare drivers. One MCP reported utilizing taxis instead of ridesharing services, but this results in MCPs paying for the transportation whether or not the ride is completed. Getting to Care: A Look at Medi-Cal’s Transportation Benefit www.chcf.org 13 To address these access issues, providers in rural areas Access to Social Services and Supports have taken additional steps to alleviate the barriers for Remains a Gap enrollees, often working around the NMT program. In key informant interviews with consumer advocates, One clinic noted that they use their own van and finance providers, and MCPs, it was noted that while the NMT the cost directly. Another clinic found it easier to sim- benefit is expansive, there remains a gap in available ply provide the cellphone number of their van driver transportation for non-medical needs, such as access to the small number of patients who use the service. to social services and supports. As California explores Other providers implemented additional strategies options to support Medi-Cal enrollee access to social such as scheduling rides with the MCP transportation supports, it must also examine how transportation broker well in advance of an appointment or contract- access to these vital services can be improved. ing with the MCP transportation broker directly to use their van for rides. While these approaches and other For example, Arizona expanded its Medicaid trans- limited solutions have been used to increase access, portation benefit to include transportation to some challenges remain for NMT to be sustainable in the noncovered services (e.g., grocery stores, Alcoholics rural and frontier areas of the state. Anonymous meetings, and community activities for social services) when providers determine they are Colorado, a largely FFS state, also reported challenges necessary.14 Colorado operates 10 waiver programs with provider capacity in the rural and frontier areas, that cover approximately 50,000 enrollees who may especially for enrollees with higher needs for assis- qualify for rides to and from non-medical activi- tance. To address this challenge, Colorado identified ties such as grocery shopping, visiting family, or art that its current rate structure — mileage bands that therapy. In both states, the expansion of the transpor- result in lower reimbursement for longer rural trips — tation benefit to support social needs has included may create a disincentive for providers to cover those strict eligibility and utilization criteria, which are likely areas, thus exacerbating the problem. Colorado also intended to limit utilization and control costs. explored the use of ridesharing (Uber/Lyft) to allevi- ate some of the provider capacity issues but noted that fluctuating prices (peak vs. off-peak) made financ- Concerned About Cost, MCPs Have ing transportation in a FFS environment challenging. Slowly Tightened Utilization Controls The state currently uses taxis to provide transporta- Many MCPs reported concerns that the state had not tion for ambulatory enrollees and has standardized estimated the true cost of NMT and said that their reimbursement rates, so there is no fluctuation in NMT costs exceeded premium revenues received the reimbursement for the transportation service. from the state to provide the benefit. Available data California should examine how a similar evaluation of from MCPs suggest that cost of the overall NMT ben- reimbursement and identification of alternative mod- efit is rising over time, and as access to NMT expands els may help increase access in rural and frontier areas. this trend is expected to continue. In response to rising utilization and costs, MCPs have tightened utilization controls. This reaction may have been somewhat delayed because MCPs reported that, due to the confusion around the implementation of the NMT benefit, and its expansive scope, the general default (and expectation of DHCS) at the initial imple- mentation was to approve most if not all requests to avoid delays or disruption in care. California Health Care Foundation www.chcf.org 14 Utilization management strategies reported by the Better Communication, Coordination MCPs include, but are not limited to: Across Systems and Transitions of $ Requiring prior authorization processes for NMT Care, and Streamlined Operations, services and reauthorization every 12 months for Would Improve NMT Benefit Delivery ongoing approvals The rollout of NMT was rushed and fragmented. $ Requiringenrollees to make travel arrangements as DHCS staggered the implementation timeline for the soon as an appointment is scheduled, but at least NMT benefit due to last-minute policy clarifications three days in advance unless there is an urgent that required MCPs to provide NMT for services that need enrollees access outside of the MCP contract through $ Requiring that NMT rides be scheduled to arrive fee-for-service (FFS) Medi-Cal. These are commonly within one hour of the scheduled appointment time referred to as “carved-out” services and include treat- ment for specialty behavioral health, substance use $ Requiring prior approval for trips over 75 miles disorders (SUD), and dental care. The rushed timeline $ Verifyingappointments with carved-out providers and fragmented policy clarifications hampered benefit before approving NMT, especially if it is for multiple implementation (see Table 2). scheduled rides $ Followingup with providers to ensure that enroll- Table 2. Timeline of NMT Rollout ees completed their appointments 2016 $ Reviewing requests for private modes of transpor- September 25 AB 2394 signed into law by the governor tation and only approving a different mode if the 2017 enrollee must travel more than a quarter mile by foot, or if the trip would take longer than two hours June 28 DHCS publishes All Plan Letter (APL) 17-010 to provide guidance to the MCPs on public transportation July 1 DHCS guidance clarifies that NMT is to be $ Verifyingthat a prescription is ready for pickup provided by MCPs to all services covered before approving an NMT ride to the pharmacy under the contract and that MCPs are required to refer and coordinate NMT for $ Utilizingthe provider directory to verify the location all carved-out services of the provider, and that the provider is in-network October 1 MCPs required to transition from referring (unless the trip is to a provider of a carved-out and coordinating NMT for carved-out services to providing and covering NMT service) for all Medi-Cal-covered services $ Requesting a frequent-rider report from the vendor 2018 for enrollees taking more than five trips per week February 2 DHCS provides additional guidance and clarification to the APL in the form of FAQs15 $ For enrollees suspected of fraud or abuse, putting a restriction on the enrollee until member services July 1 DHCS begins directly arranging for access to is contacted to resolve issues NMT to its FFS enrollees $ Implementing “no-show” policies that limit or restrict the use of NMT for a period of time when enrollees repeatedly miss scheduled rides already paid for by the MCP Getting to Care: A Look at Medi-Cal’s Transportation Benefit www.chcf.org 15 Limited Communication About the Benefit that referred the enrollees back to the MCP reported Could Limit Access that there is no communication from the MCP to verify Many stakeholders reported minimal communica- whether the enrollee ultimately received NMT or if tion from MCPs and DHCS about the availability of there is still an unmet need. the NMT benefit. Key informant interviews with both MCPs and DHCS confirmed that in most instances, outreach to providers was minimal and embedded MCP Responsibility for Transportation to into regular communications such as provider bulle- Services Not Covered Under the Medi-Cal tins or monthly updates. Contract Creates Unique Operational and Oversight Challenges Consumer advocates stated that in their experience, For NMT to services such as SUD and serious mental most Medi-Cal enrollees are unaware of the NMT illness treatment not under the purview of the MCPs, benefit, and those that are aware continue to report traditional utilization controls and authorization pro- confusion about how to access the benefit and the cesses are complex and difficult to apply. This was types of services for which NMT would be provided. especially challenging at the start of implementation The enrollee interviews confirmed that many became when MCPs had to quickly develop operational work- aware of the NMT benefit via health care providers, arounds and relationships with such providers to verify social workers, or transportation providers, rather than appointments and appropriate transportation needs. through outreach from either their MCP or DHCS. For These noncontracted providers are not typically part example, an enrollee living in a small town reported of the MCPs’ networks, and therefore MCPs lack the that she heard about the NMT program through word ability to share information due to privacy concerns, of mouth initially and then from staff at her health especially when related to sensitive services. MCPs clinic. Another interviewed enrollee learned about the also noted that oversight of NMT for these services NMT program from the shuttle driver that was pro- continues to be especially difficult because there is vided by the local clinic she visits. a very limited ability to verify that an appointment occurred or that the most appropriate and cost-effec- Providers interviewed for this report also expressed tive mode of transportation is being utilized. that MCPs and DHCS conducted minimal outreach related to the implementation of the NMT benefit and how to help enrollees with access. Some provid- Continuity Through Transitions of Care Is Also ers were only aware of the benefit anecdotally and a Challenge, Especially for Dialysis Patients could not recall or find any direct communication from MCPs, providers, and consumer advocates all either the MCPs in their service area or from DHCS. expressed that transporting dialysis patients with com- Those providers that had heard about the NMT ben- plex needs presents unique challenges. To bypass the efit and proactively conducted outreach to either the intake process for each appointment, MCPs have set MCPs or DHCS reported frustration at the lack of up processes to arrange for and authorize transporta- consistent information regarding what types of rides tion for three- to six-month periods. However, even were covered, the approved distances the enrollee with these extended approvals there can be issues could travel, and other logistical information. This was with access. For example, if an enrollee is hospitalized specifically noted for rural and frontier populations the NMT benefit can take time to be updated. Then, if and those receiving mental health or SUD treatment. the transportation coordinator is not notified when the Therefore, these providers found little to no benefit to enrollee is discharged, NMT may be delayed and the their patients and either referred them to the MCP or enrollee may miss routine appointments because the worked to provide the transportation directly. Those service was suspended while they were hospitalized. California Health Care Foundation www.chcf.org 16 Enrollees Report Some Concerns with and services as NEMT and to reserve the distinction Ride Logistics of NMT to mean transportation to social services and While most of the 16 enrollees interviewed for this supports. report said they were generally satisfied with the NMT benefit, many were able to point to challenges with the benefit’s implementation. These included Require More Outreach and customer service representatives not being helpful, Communications to Providers appointments being missed because the driver did and Enrollees not show up or was late, language barriers between DHCS should explore information gaps and oppor- rider and driver, drivers arriving in a vehicle that could tunities to communicate effectively with providers, not transport the enrollee and their stroller or wheel- enrollees, and MCPs about the NMT benefit and how chair, drivers arriving with other service users, and to use it. Based on the key informant interviews and “hassle” when trying to schedule an appointment the use of the benefit by a small fraction of enrollees, it that does not fit into the required authorization time appears that there is significant opportunity for DHCS frame. One enrollee said that on several occasions, and MCPs to create a comprehensive outreach and drivers picked her up in a vehicle that was inappro- communications strategy with resources for all stake- priate for her limited mobility. Other enrollees had holders so that there is a consistent understanding of last-minute cancellations and had to reschedule their the benefit and how to help enrollees access transpor- appointments if customer service was unable to send tation services. them another ride on time. As mentioned earlier in this report, these logistical challenges can be multi- plied due to the many potential points of contact and Address Barriers in Rural and interaction (i.e., enrollee, provider, managed care Frontier Areas organization, transportation broker, driver). It appears that despite the original intention of the NMT legislation, challenges with implementation and access in rural communities persist, and creative solutions are needed. To start, DHCS could further Considerations for diagnose the problem by analyzing the available Improvement data on rural implementation. Some initial ideas for addressing rural transportation barriers include these: To address challenges and improve the benefit for enrollees, policymakers could consider the program- $ Utilize brokers to develop more-robust regional matic and policy changes detailed below. transportation networks that could be made avail- able to all Medi-Cal enrollees regardless of their MCP enrollment. This could increase access by Merge NEMT and NMT into a Single giving the broker increased purchasing power by Comprehensive Benefit leveraging all the Medi-Cal lives in a rural service Lawmakers and DHCS may want to consider if the area under one contract, increasing the likeli- distinction between the NMT and NEMT benefit is hood that more-robust networks could be made necessary and if consolidating them would reduce available. confusion and improve access. Other states have effectively implemented similar, and even more $ The state and/or MCPs could explore options to expansive, transportation benefits without creating increase access to local transportation networks siloed programs. One approach that has worked in through partnerships with existing regional public other states and is recommended as a best practice and private transportation entities. Working directly would be to classify all rides to medical appointments with local transportation providers who know the Getting to Care: A Look at Medi-Cal’s Transportation Benefit www.chcf.org 17 unique needs of the community could result in Analyze and Publish Utilization and innovative partnerships and approaches to address Cost Data Reported to DHCS rural transportation barriers. DHCS collects data from managed care organiza- tions on NMT benefit implementation, which were not $ California could consider a rate supplement for made available to the authors of this report. Analysis of hard-to-reach rural areas so that transportation the existing DHCS data would help answer important providers serving these areas would be better questions and inform the directionality of Medi-Cal incentivized. transportation policy and programs. Analysis of DHCS data should prioritize understanding utilization trends statewide and by health plan and identifying remaining Evaluate Feasibility of Covering NMT gaps in transportation access for Medi-Cal enrollees. for Social Services and Supports The NMT benefit has been most widely used for regularly occurring appointments such as those for dialysis and SUD services. Some consumer advocates Conclusion have promoted the expansion of the NMT benefit NMT has resulted in greater access to medical care to include coverage for non-medical-related trips to for a small group of high-need Medi-Cal enrollees. address social isolation and other social determinants Enrollees interviewed for this report were thankful for that can negatively impact health status. Given the the benefit and said it works well for the most part. challenges with the implementation and oversight of the current NMT benefit, the potential cost of provid- Nevertheless, significant challenges remain to making ing a more expansive benefit to millions of enrollees, this benefit accessible and useful to the broader Medi- and the capacity issues referenced throughout our Cal population. The state and MCPs should take the interviews, such an expansion would potentially be information known to date and consider the recom- expensive and complex. As was noted, states that mendations in this report to improve the delivery of have developed an NMT benefit to address non- the NMT benefit. medical needs have limited eligibility to very specific populations rather than a program-wide NMT benefit. Going forward, it will be key for DHCS to provide data on utilization rates and the true cost of the transporta- tion benefit across the state. This will provide a better Explore NMT Driver Credentialing picture of implementation and unmet need and what or Other Transportation Provider additional steps should be considered by the state to Oversight ensure a financially sustainable transportation benefit It was suggested during key informant interviews with and access to covered Medi-Cal services. transportation brokers that the state should consider requiring a standardized credentialing process for all transportation providers and drivers that would include background checks, drug testing, and sensi- tivity training for drivers. While this could potentially address some of the concerns around the handling of Medi-Cal NMT rides, it could also exacerbate network issues (especially in rural areas) and increase costs significantly. Coordination with the rideshare industry would be required. California Health Care Foundation www.chcf.org 18 Appendix. Interviewees ORGANIZATION INTERVIEWEES Health Plans Aetna Better Health Jeff Dziedzic Alameda Alliance for Health Scott Coffin Anthem David Mosher and team Blue Shield Tracie Howell and team CalOptima Albert Cardenas and T. C. Roady Central California Alliance for Health Marina Owen Contra Costa Health Plan Frank Lee and team Gold Coast Health Plan Marlen Torres Health Plan of San Joaquin Cheron Vail and team Health Plan of San Mateo Pat Curran IEHP Keenan Freeman Kaiser Martha Shenkenberg Kern Jeremy McGuire and team L.A. Care AJ Lopez and Victoria Truong Molina Michael Nguyen and Bob O’Reilly Partnership HealthPlan Amy Turnipseed and Wendi Peterson San Francisco Health Plan Sumi Sousa Santa Clara Family Health Plan Christine Turner United HealthCare Kerri Balbone State Officials DHCS — Managed Care Aaron Toyama and Nathan Nau DHCS — FFS Benefits Rene Mollow and team Health Services Advisory Group (DHCS’s External Quality Review Organization) Paul Niemann Consumer Advocates NHelp Abbi Coursolle and Alicia Kauk Justice in Aging Denny Chan Western Center on Law and Poverty Linda Nguy Neighborhood Legal Services Los Angeles Toni Vargas Getting to Care: A Look at Medi-Cal’s Transportation Benefit www.chcf.org 19 ORGANIZATION INTERVIEWEES Transportation Providers/Brokers Veyo Stanton Sipes Non-Emergency Medical Transportation Accreditation Commission (NEMTAC) Michael Shabkie Providers Inyo County Health and Human Services Agency Meaghan McCamman Janus of Santa Cruz County (SUDS) Rudy Escalante Livingston Community Health (FQHC) Leslie Abasta-Cummings MedPoint Management Russel Soria and team Mountain Valley Health Centers (FQHC) Brandon Watkins River City Medical Group Cordia Losh Santa Cruz County Health Services Agency Joey Crottogini WellSpace Health (FQHC) Jonathan Porteus Other States Arizona Christina Quast Colorado Cassandra Keller Idaho Sara Sith Rhode Island Mario Olivieri and Jason Lyon California Health Care Foundation www.chcf.org 20 Endnotes AB 2394, 2015–16, Reg. Sess. (Cal. 2016). 1. 2.The descriptor of medical or non-medical transportation in the Medi-Cal program refers to the type of vehicle needed to transport the enrollee, versus the service to which the enrollee is being transported. Non-emergency medical transportation is transportation in a medically equipped vehicle (e.g., wheelchair van) by a specially trained driver. Non-medical transportation is transportation by traditional car, bus, etc. Medi-Cal only covers transportation to medical services, versus non-medical services like social services and supports. 3.Medi-Cal enrollee interviews conducted by PerryUndem. 4.42 C.F.R. § 431.53. 5.Assembly Committee on Health’s April 8, 2016, analysis of AB 2394. 6.AB 2394. 7.These five MCPs collectively represent 1.7 million of the 13 million total enrollees statewide for the period analyzed. For detailed descriptions of the different plans see Medi-Cal Managed Care Program Fact Sheet - Managed Care Models (PDF), California Dept. of Health Care Services (DHCS), January 2, 2020. 8.Monthly Medi-Cal enrollment data by plan were downloaded from the California Health and Human Services Open Data Portal. 9.Frequently Asked Questions for Medi-Cal Transportation Services (PDF), DHCS, last updated February 6, 2019. 10.Nathan Nau (chief, Managed Care Quality and Monitoring Div., DHCS) to all Medi-Cal Managed Care Plans, all-plan letter 17-010 (PDF), July 17, 2017. 11.Several large transportation brokers operate in California. The most used are (1) Logisticare, (2) Call the Car, (3) American Logistics Company, and (4) Medical Transportation Management. 12.In the industry, transportation brokers are often referred to as transportation specialty benefit management companies, since they provide more than just access to transportation, but for simplicity the term transportation brokers will be used in this report. 13.“Medical Transportation Provider and Non-Emergency Transportation Provider (NEMT) Application Information,” DHCS, last modified June 19, 2020. 14.AHCCCS Medical Policy Manual: Section 310 – Covered Services (PDF), Arizona Health Care Cost Containment System, effective May 1, 2019. 15.DHCS Transportation Workgroup Frequently Asked Questions (FAQs) (PDF), DHCS, September 8, 2020. Getting to Care: A Look at Medi-Cal’s Transportation Benefit www.chcf.org 21