1. The Hilltop Institute was formerly the Center for Health Program Development and Management. Non-Emergency Medical Transportation Study July 24, 2008 Cheryl Powell Maryland Medicaid Advisory Committee Meeting

2. -2- HB 235 Passed in the 2008 Maryland legislature Department of Health and Mental Hygiene to study the creation of a uniform statewide non-emergency medical transportation program Requires consultation with stakeholders Report due to legislature on October 1, 2008

3. -3- Required Elements of the NEMT Study The feasibility of creating a uniform non- emergency statewide transportation program Any cost savings that might arise from the creation of a statewide program Any potential for quality improvement that would result from the creation of a statewide program The impact that creation of a statewide program would have on local health departments

4. -4- Consultation In conducting the study, the Department shall consult with the appropriate stakeholders, including providers, consumers, and local health departments

5. -5- Maryland NEMT Study Methodology

6. -6- Components of NEMT Study Review of current NEMT program Potential for cost savings – Analysis of financial impact of the 1993 transition to the current county-level broker system Estimate of effect of transition to statewide or regional broker model Potential for quality improvement Evaluation of NEMT programs in other states Analysis of impact on local health departments

7. -7- Planned Data Collection Other States Cost Effectiveness of various models Measures of quality and quality improvement Impact on stakeholders Local Health Departments Current and historical utilization, cost, and quality data Interaction with other programs Projected impact of change in current system

8. -8- Maryland’s Current NEMT Program

9. -9- History: NEMT System in Maryland Prior to 1993, the Department operated transportation as an optional medical service with Medicaid reimbursing providers directly on a fee-for-service basis In response to increasing costs, Maryland created a local broker program in which local health departments receive grants to arrange screening and transportation

10. -10- Scope of Services All Medical Assistance recipients who do not have restricted eligibility (e.g. PAC, Family Planning) Provides transportation to individuals in Medicaid to covered services for which no other transportation is available Carved out of managed care agreements under HealthChoice with some exceptions Grants made to each of the 24 local jurisdictions Local jurisdictions may arrange for screening and transportation either directly or through subcontractors Curb-to-curb or door-to-door service

11. -11- Transportation Provided Trips to and from scheduled Medicaid-covered medical services Return trips from hospital emergency room, return trips from hospital stays, medically necessary inter-hospital transfers Modes of transportation covered: wheelchair van, sedan/van, ambulance, public transportation, taxi, as appropriate Air transport (arranged statewide through Baltimore City Health Department)

12. -12- Medicaid NEMT: A National Overview

13. -13- Medicaid NEMT: What States Provide Is provided for individuals to whom no other transportation is available Ensures necessary transportation for recipients to and from providers Provides transportation that is the least expensive and is appropriate for the client Transports to the nearest appropriate provider

14. -14- Trends - Growing Use of Brokers in NEMT In response to growing expenditures, states have increasingly begun using transportation brokers to manage NEMT The Deficit Reduction Act of 2005 provided additional options for states to provide NEMT using brokers in Medicaid States contract with brokers to conduct a variety of functions Brokers generally perform administrative and coordinating services, but in some instances also provide transportation

15. -15- Typical Contracted NEMT Functions Educating recipients about transportation services available and how to access them Verifying Medicaid eligibility status Establishing that trip is eligible for NEMT benefit Authorizing transportation and selecting least costly, most appropriate mode of transportation Establishing a network of transportation providers and coordinated transportation resources Providing transit passes/tickets, reimbursement for miles, etc. Assuring uniform, quality services and access to needed health care Tracking and reporting quality, costs, and utilization

16. -16- Variation in NEMT Programs State programs vary considerably Carved out of managed care vs. included in managed care capitation Reimbursement Fee-for-service plus administrative fee Capitation Models State Medicaid agency Transportation broker Single NEMT broker Multiple regional or county brokers

17. -17- NEMT Models and Experiences in Other States

18. -18- Evaluation of NEMT Programs in Other States Survey of states representing a variety of models in providing NEMT Focus on states which have recently transitioned to a brokerage program Evaluate experiences in those states related to cost savings, quality improvement, impact on stakeholders Comparative analysis of the information gathered from those states and NEMT in Maryland

19. -19- Models Single broker for Medicaid FFS; MCOs provide transportation for enrollees in Medicaid managed care Carved out of Medicaid managed care Statewide single brokerage program Statewide single brokerage program – broker provides transportation as well as administrative and coordinating services Regional brokerage program (multiple county regions) Regional brokerage program mixed model (county- level & region-level) County-level brokerage program

20. -20- Single Broker for Medicaid FFS Enrollees Only DC Transitioned to broker in October 2007 for Medicaid FFS enrollees Transportation included in capitation rate to MCO for individuals in managed care Broker generally provides administrative and coordinating services Virginia Single broker for Medicaid FFS enrollees Transportation included in capitation rate to MCO for individuals in managed care Broker generally provides administrative and coordinating services

21. -21- Statewide Single Brokerage Program for FFS and Managed Care Enrollees Delaware Provided through a separate transportation brokerage contract on a statewide basis Carved out of managed care Broker generally provides administrative and coordinating services Mississippi Transitioned to a statewide brokerage program in November 2006 No comprehensive managed care - voluntary disease management program Broker generally provides administrative and coordinating services

22. -22- Statewide Single Brokerage Program – Broker Provides Transportation Utah One statewide broker provides both administrative services and transportation Bus passes and individual mileage reimbursement administered by state and separate from broker program Carved out of managed care

23. -23- Regional Brokerage Program Kentucky Regional brokerage program – 13 brokers in 15 regions Brokers may provide some transportation Carved out of managed care Washington Broker program with 9 broker agencies serving 13 separate regions Brokers may provide some transportation Carved out of managed care

24. -24- Regional Brokerage Program Mixed Model Colorado County-based broker program One transportation broker is contracted for an 8-county region in the Denver metropolitan area Carved out of managed care County level brokers may provide direct, administrative and/or coordinating services

25. -25- County-Level Brokerage Program Pennsylvania County-based broker program that uses local transportation resources and direct management at the local level In Philadelphia, the state contracts with a private broker Counties may provide transportation services directly and/or administrative and coordination services through subcontracts Carved out of managed care

26. -26- Consultation with Stakeholders Comments on study design Comments on states that will be surveyed Potential for quality improvement with a statewide program Impact on local health departments

27. -27- About The Hilltop Institute The Hilltop Institute at the University of Maryland, Baltimore County (UMBC) is a nationally recognized research center dedicated to improving the health and social outcomes of vulnerable populations. Hilltop conducts research, analysis, and evaluation on behalf of government agencies, foundations, and other non-profit organizations at the national, state, and local levels. -27-

28. -28- Contact Information -28- Cheryl Powell Senior Research Analyst The Hilltop Institute University of Maryland, Baltimore County (UMBC) 410.455.6845 cpowell@hilltop.umbc.edu www.hilltopinstitute.org