Running Head: Non Emergency Medical Transportation in Wisconsin

Running Head: Non Emergency Medical Transportation in Wisconsin Sally Richie and Maureen Garvey Social Work 999 May 18, 2012 Instructor: Eric Lock

2 Non Emergency Medical Transportation in Wisconsin Non Emergency Medical Transportation provides rides for qualified Medicaid beneficiaries to and from qualified Medicaid services. Federal regulations require each state to provide plans detailing how the transportation will be administered. The federal government and the Center for Medicaid Services (CMS) then reimburses states for qualified Non Emergency Medical Transportation (NEMT) rides. Wisconsin hired LogistiCare to manage NEMT throughout the state in Fall 2010 and began providing service on July 1, 2011 (see Appendix #). This paper seeks to address the policy narrative surrounding the hiring of LogistiCare. This paper addresses the following questions: What was the political climate surrounding the hiring and implementation of LogistiCare? How was NEMT managed in Wisconsin before the hiring and implementation of LogistiCare? Who are the stakeholders involved in this policy change? What does the contract entail? How does the state oversee LogistiCare s NEMT services? What are the advantages of hiring a central ride management service? What are the disadvantages of hiring a central ride management service? It is important to note that LogistiCare has been operating in Wisconsin for less than one year. This examination should be considered ongoing. Stakeholders and Impact (See Stakeholder Map in Appendix A) MA Members According to an update released from ForwardHealth in April 2011(See Appendix B), Non Emergency Medical Transportation is a service provided to people enrolled in the following programs: Wisconsin MedicaidFamily Planning Only Services The BadgerCare Plus Standard Plan The BadgerCare Plus Benchmark Plan Tuberculosis-Related Services-Only Benefit BadgerCare Plus Express Enrollment for Pregnant Women At this time, there are a number of people who are not affected by implementation of LogistiCare because Logisticare has not been awarded the contract in these regions and populations. These include: Wisconsin Medicaid or BadgerCare Plus members who are enrolled in an HMO in Milwaukee, Waukesha, Washington, Ozaukee, Kenosha, and Racine counties. Members who are enrolled in an HMO in these counties will continue to receive NEMT services from their respective HMO. All other Medicaid and BadgerCare Plus members in these six counties who are not enrolled in an HMO will participate in the NEMT management system. Members residing in a nursing home. Members residing in a nursing home will continue to receive their SMV services on a fee-for-service basis and ForwardHealth will be responsible for reimbursing claims. If members residing in

3 a nursing home require common carrier transportation, that is the responsibility of the nursing home and the nursing home should continue to submit claims for reimbursement for common carrier transportation according to the February 2010 ForwardHealth Update (2010-05), titled Reimbursement and Claims Submission Changes for Nursing Home Provided Non-emergency Transportation for Nursing Home Residents. Members who are enrolled in Family Care. Members enrolled in Family Care will continue to receive NEMT services from the Family Care care management organization. *The information listed above is not up-to-date based on interviews with Greg DiMiceli from the Department of Health Services. In an interview with him on May 8, 2012, he stated that LogistiCare had been awarded the contract for the southeastern region. LogistiCare still does not provide services for those in nursing homes or on Family Care. The people who qualify for these programs represent a diverse population, both in their individual needs and in the communities in which they live. There is a significant difference in transportation in rural versus urban communities, and every county previously had their own system for Non Emergency Transportation. The eligibility criteria for Medicaid varies depending on the specific program, but in general, the program is intended for people who are elderly, blind, or disabled, and/or fall below a specific percentage of the federal poverty line. The law defines disability for Medicaid as: The inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months. As noted above, not all people who are eligible for Medicaid are also eligible for NEMT, but there is a substantial population in need of these services. Personal mobility is a critical need for all individuals, but especially for those who are do not have access to transportation due to disabilities that prevent them from operating a vehicle, or those with income constraints. It should be noted that nearly one in five people in Wisconsin was covered under one or more Medicaid programs (See Appendix C) in recent years due to the enhanced eligibility criteria made possible by increased funding through the American Recovery and Reinvestment Act of 2009. Now that the enhanced federal medical assistance percentage (FMAP) is being decreased, the state has requested a change in the eligibility criteria. The Center for Medicare and Medicaid Services (CMS) has approved cuts that remove 17,000 people from the rolls, and affects many others who will now have increased premiums. The individuals who utilize NEMT services have been impacted more than any other stakeholder group becuase it affects their ability to attend necessary services.due to some changes in the implementation of NEMT policies, consumers have lost access entirely. Some individuals have given up on using NEMT and no longer attend appointments, while others have found alternatives or have managed to endure the changes.

4 Social Service and Medical Providers There is a wide range of covered services for NEMT to Medicaid enrolled medical providers. This includes visits to Federally Qualified Health Centers, Ambulatory Surgery Centers, hospitals, medical case management services, dentist, hearing and audiological services, mental health and AODA treatment, physical therapy, podiatry, and many others as outlined in Appendix D. These service providers are affected by the change in transportation management in a number of ways. If transportation is unreliable or inaccessible, no-shows to appointments are more likely, which is costly to the provider. It could also reduce the number of appointments that people schedule because of the barrier to adequate transportation, leading to money lost for service providers. They may also have to provide more costly treatments (i.e. Emergency Room services) if patients are unable to attend necessary prevention and maintenance appointments. Additionally, some providers are spending valuable time calling Logisticare for their patients in an attempt to assist them with a system that can be challenging to navigate for many. However, some service providers have noted that they are actually spending less time arranging transportation. In the past they coordinated all of the rides and had designated people at their facilities who were charged with this responsibility. Now, they only have to deal with transportation when problems arise. Transportation Providers Depending on the needs of the client, there are a variety of types of transportation available to provide rides to and from Medicaid approved services. In some cases, clients will receive a bus pass to attend their appointments, while others may utilize taxis, specialized medical vehicles, or ambulances (for non-emergency purposes). LogistiCare contracts with transportation providers and volunteer drivers who are independent contractors with LogistiCare. LogistiCare then dispatches the rides to providers. Some of the complications that transportation providers have faced are: that these ride requests include inefficient long distance trips that are for members across the state, there are more requests than the provider has capacity for, and have unrealistic pick up times or incorrect mileage for the ride. Even if the error is on LogistiCare s end, it is typically the provider who gets the complaint logged against them. Additionally, many providers have yet to receive a signed, fully executed contract, and payments are often incorrect and incomplete. Providers are having difficulty getting information about training requirements, many of which are more stringent than what DHS requires of certified SMV or human service vehicle providers, making it difficult to retain or replace drivers. These transportation providers had been working with the counties and providing NEMT services for years before the implementation of LogistiCare, and a cooperative of companies put in a bid for the Request for Proposal. They lost the bid to LogistiCare because they were not able to demonstrate the same reputation and scale of clients served. Advocacy Groups Many groups throughout Wisconsin are concerned with the accessibility of these services for the people who need them. There have been a number of horror stories about people missing dialysis appointments, being treated disrespectfully, being denied ride,

5 arriving late to appointments, or being taken to the wrong place. NEMT is a required service under Medicaid, and it is critical that those who need the service are able to access it. Due to these concerns, groups like HealthWatch Wisconsin, outreach coordinators from HMOs, other service providers, and the advisory council have taken it upon themselves to unearth these issues and address them with LogistiCare and the Department of Health Services. The NEMT Advisory Council was a required piece of the state s contract with LogistiCare, and it is composed of various NEMT stakeholders from around the state, selected by DHS. According to the contract, This advisory council acts in a non-binding capacity to provide feedback and suggestions to the State and to the Contractor. They meet on a quarterly basis, and the meetings are held in various geographical regions of the state to ensure diverse input. LogistiCare is required to staff each meeting to ensure all Council feedback is actively addressed. Political Climate Surrounding the Hiring and Implementation of LogistiCare President Bush s Deficit Reduction Act of 2005 grants states the authority to contract with an NEMT brokerage program (Appendix E). Prior to this, states could only hire a broker if the sought a waiver from Center for Medicare and Medicaid Services (CMS). Now, electing to hire a brokerage service also changed the reimbursement schedule for NEMT services: a transportation broker that uses a vendor payment system consistent with applicable regulations is eligible for reimbursement as a medical assistance service (CMS, 2006). States without a broker that follows payment regulations are reimbursed for NEMT as an administrative cost. Administrative costs are reimbursed at a lower rate than medical assistance costs. Because these changes were included in part of the Deficit Reduction Act it is fair to assume that contracting with a central broker represents a cost saving in comparison to states coordinating NEMT rides. At the time these changes were implemented, Dennis Smith was the director of CMS. Governor Scott Walker appointed Dennis Smith as Secretary of Health Services in Wisconsin in 2011. Dennis Smith was the Secretary of Health Services when LogistiCare was implemented as NEMT broker in Wisconsin. Consultants from the Madison firm of Broydrick & Associates registered with the Wisconsin Government Accountability Board as lobbyists on behalf of LogistiCare in 2005, just as these federal changes were signed into law and then implemented (Wisconsin Ethics Board, 2006). The Department of Health Services began seriously considering the benefits of a central transportation broker at this time (Greg DiMiceli, Personal Communication, March 28, 2012). Jim Doyle (Democrat) was governor when these talks began and when the initial Request for Proposal (RFP) went out for a statewide broker. Wisconsin Budget The Wisconsin Department of Health Services received $14, 518, 534 in federal stimulus funding between February 2009 and December 2010 (United States Government, 2012). These one-time funds stabilized existing programs, but the expiration of the funds in 2011 created a massive challenge for balancing the next biannual budget (Peacock, 2009). Budget concerns were one of the primary reasons the Department of Health Services released an RFP in September 2010. At that point, many

6 other states had implemented the single broker system. Wisconsin was eager to do the same and begin receiving the higher medical services reimbursement rate for NEMT from CMS. The State s debt increased by $866.4 million during the 2011 fiscal year, amidst the worst recession in decades (State Controller s Office, 2011). According to Wisconsin Department of Health Services Policy Analyst Greg DiMiceli, the department s budget shortfalls made it reasonable to make the move to a centralized broker: it was a move the department and state had been considering for several years (Personal Communication, March 28, 2012). The deficit was used as one of the reasons for contracting out this service as a cost-saving measure. Political Climate during Implementation The decision to hire LogistiCare to broker NEMT rides in Wisconsin came in November 2010, when Jim Doyle was governor. LogistiCare began operating and coordinating rides in July 2011, after Scott Walker was elected governor. Governor Walker s Budget Repair Bill, proposed in February 2011 and passed in June 2011, created a firestorm in Wisconsin resulting in weeks of protests and a recall election that will take place on June 5, 2012. Every policy decision made in the state since Governor Walker took office has therefore been scrutinized and commented on by both critics and supporters of the governor. The switch to LogistiCare was no exception: early difficulties with cab companies in Madison brought bad press (Doherty, 2011). In the first month of implementation missed rides and late rides upset consumers (Schlicht, 2011). The Department of Health Services feels strongly that much of the initial criticism from consumers and news sources believed the hiring of LogistiCare was part of Governor Walker s changes to the state, and voiced anger about the program simply because they were upset about Governor Walker s politics (Greg DiMiceli, Personal Communication, March 28, 2012). Although it is notable that the RFP was written while Governor Doyle was in office, it is also of note that Dennis Smith was the Secretary of Health Services during implementation; Dennis Smith was Director of CMS when the Deficit Reduction Act simplified the process for hiring a central broken. How was NEMT managed before LogistiCare? Prior to contracting with LogistiCare, NEMT was administered by Wisconsin s 72 counties (Appendix F). Ride reservation procedures varied by county. Volunteer drivers completed a large number of the rides; LogistiCare is currently not using as many volunteers as the counties did previously. Anecdotally, we have heard it was previously easier for riders to request specific drivers or have the same driver for standing appointments. There was no standard record keeping, which prevented Wisconsin from claiming the cost of NEMT rides as a medical service and instead forced the state to claim only administrative reimbursement. This lack of record keeping also makes it difficult to know much at all about NEMT: it is not known how many rides were given annually, nor how ride coverage varied across the state. The Department of Health Services believes that many rides were completed that did not fit the federal standard for NEMT. This includes allowing a parent with a child requiring medical service to bring additional children along for the ride. The State has indicated that they never intended for such rides to be covered, but when the counties controlled NEMT the State had little

7 oversight or ability to prevent uncovered rides from being covered with State and Federal Medicaid funding (Greg DiMiceli, Personal Communication, March 28, 2012). The Office of the Inspector General (OIG) conducted an audit of NEMT in Milwaukee County in 2005. In studying a random sample of 100 rides completed between January 1, 2005 and December 31, 2005 the OIG found 18 rides completed on dates when beneficiaries did not receive Medicaid-covered services and two rides with insufficient records to determine whether the ride was appropriate (see appendix F). Based off this information the OIG estimated that the Department of Health Services claimed a total of $694,066 ($347,033 Federal reimbursement) in inappropriate rides. This audit concluded with a recommendation that the State repay the Federal government all the money that was estimated to be fraudulently claimed ($347,033). Hiring a central broker should prevent inappropriate rides from being completed and definitely prevent incomplete records. The Contract On August 31, 2010, The Department of Health Services released a Request for Proposal to provide interested parties with information to enable them to prepare and submit a proposal to manage the non-emergency medical transportation needs of Medicaid and BadgerCare Plus members in the State of Wisconsin. They used the results of the RFP to award a contract to LogistiCare, which was implemented July 1, 2011. The RFP is what the state uses as their contract, since it details the requirements and information about services and oversight. LogistiCare is contracted with the state for three years, with the option to renew the contract for two additional one-year periods. After the initial five years, the contract will go up for bid again, and other organizations have the opportunity to apply. The contract outlines requirements for drivers, vehicles, volunteers, provider training, provider records, member management (determination of eligibility), denial of service, pick up and delivery, communications and outreach, provider service agreements, service complaints and appeals, policy and procedures manual, call center performance standards, business requirements, implementation, turnover plans, costs, and general information about contracting with the state. There are some elements of the contract that address the protection of clients, but in comparison to the remainder of the content, this section is slim. Some of the ways they seek to protect clients are: the establishment of an advisory council (5.3.3.1), the employment of a Member Advocate (5.4.5.3), employment of Spanish speakers at the call centers (5.5.1.2), set performance standards (5.5.2.2), service complaints and appeals (5.4.5), and the development and maintenance of a quality assurance plan (5.10.1). Unfortunately, when asked about patient protections, Greg DiMiceli was unable to provide much more information than what is included in the original RFP. He stated that DHS reviewed the training manuals and all written documentation of LogistiCare s policies, but that it is not routinely reviewed. The populations served by NEMT in Wisconsin represent some of our most vulnerable citizens: they are individuals unable to transport themselves to necessary medical treatments. This group is in particular need of protection because they often cannot protect or advocate for themselves. Children, individuals with physical and developmental disabilities, and people with mental illness rely on this service for their daily health and wellness. By offering NEMT rides the State

8 has made a commitment to the health and wellness of this population, but has not built in patient protections to ensure the program meets its goals. Oversight The Wisconsin Department of Health Services is involved in providing oversight of Non-Emergency Medical Transportation Management, as detailed in the RFP. The way that they are typically involved is in dealing with service complaints and appeals. The contract states that, Resolution of complaints by the contractor (LogistiCare) is subject to the discretionary review of the Department and may be overridden. The contractor may be required to implement and submit proof of any corrective policies or procedures as a result of the Department review. An example of a change that has been made is that they have adjusted the training of call center staff to ensure that their tone is softer when asking questions about why someone is making an appointment and utilizing NEMT services. The customer service representatives receive some training on MA policy and eligibility, but their training is not comprehensive. Greg stated that staffing a call center with knowledgeable, dedicated individuals can be challenging due to the nature (and pay) of the work. LogistiCare has worked to simplify their job as much as possible. DHS does not provide routine oversight to LogistiCare s operations, and rather responds to problems reactively. When presented with ideas for how to measure customer satisfaction and proactively manage consumers needs, Greg DiMiceli responded that those were good ideas, ones he had not yet considered or followed through on (Greg DiMiceli, Personal Communication, May 8, 2012). In Section 5.10.2, the contract details information about quality monitoring. It states that, The Department reserves the right to conduct a review of Contractor s records or to conduct an on-site review at any time to ensure compliance with these requirements. However, based on interviews with DHS, it appears that they do not frequently exercise this right. Greg was not even fully aware of how LogistiCare monitors their own services. He commented that all calls are recorded, but that DHS only listens to them when a complaint has been filed. What are the advantages of a central ride broker? There are many advantages to hiring a central broker, the most obvious of which being the higher Federal reimbursement rate. The Wisconsin Department of Health Services faced an incredibly challenging budget in 2011 partially owing to the infusion of stimulus funding in 2009. Moving to a central broker greatly increases the Federal reimbursement rate for NEMT funding and helps the Department overall. Switching to a central broker also allows the State to really view and understand how NEMT is being used throughout the state. The previous system, which allowed counties to administer their own programs, had no standard record keeping. The state is unaware of how many rides were given annually prior to the implementation of the central broker system. The Department of Health Services is surprised at the number of rides that have been given thus far through LogistiCare: the Department has said they were completely unaware of how many consumers used the service and vastly underestimated the need (Greg DiMiceli, Personal Communication, May 8, 2012). A central broker also provides the additional cost savings that accompany greater oversight: a broker follows standards that attempt to ensure all completed rides are in fact eligible

9 for federal reimbursement. The decentralized system in which the counties made individual decisions, and decisions regarding rides were often made by someone whose primary job duties did not involve detailed knowledge of federal reimbursement requirements, prevented the State from such oversight. A centralized broker can also increase ride access for consumers in rural areas. When counties were solely responsible for coordinating rides it was difficult for them to work within their county borders to find appropriate rides. A centralized broker that works throughout the state can coordinate across county borders to find appropriate transportation. What are the disadvantages of a central ride broker? A centralized broker that coordinates rides for an entire state necessarily lacks the personal touch that counties previously established with consumers. Rides are now reserved through a call center, and there have been many complaints that the dispatchers are rude. The Department of Health Services has recognized this issue and worked with LogistiCare to soften the script used to determine the nature of the ride (Greg DiMiceli, Personal Communication, March 28, 2012). Despite these attempts, a recent meeting in Green Bay addressed concerns that elderly patients are particularly frustrated with the phone service and may be foregoing treatment rather than calling in to reserve a ride (Greg DiMiceli, Personal Communication, May 8, 2012). The loss of a personal touch in ride reservation also affects the personal touch in the rides themselves. Counties made great use of volunteer drivers, but LogistiCare has not developed a strong volunteer base. Additionally, it seems reasonable that when rides were coordinated within a county, riders could request the same driver for standing appointments. While LogistiCare can honor some requests of this nature (particularly in instances of mental illness or other disability that makes consistency a priority), it is impossible to fulfill all requests for specific drivers (Greg DiMiceli, Personal Communication, March 28, 2012). Additionally, riders are now required to reserve a ride at least 48 hours in advance. This can be nearly impossible to do in instances where urgent (but not emergency) care is needed. This is directly a result of one broker serving a large population. Additional information on the ride reservation process can be found in Appendix G. Hiring a central broker helps to enforce State and Federal policies surrounding NEMT, which is a benefit for the State but has had some negative consequences for consumers. Stricter enforcement of policies can make it challenging for patients to access care. For example, a single mother with three children may have one child who requires regular therapy. This child and his or her mother (or guardian) qualify for NEMT, but the other two children do not and are not permitted to ride. This consequence of a statewide broker is considered a benefit by the Department of Health Services, but presents a real challenge to Wisconsin s most vulnerable populations (Greg DiMiceli, Personal Communication, March 28, 2012). Complaints about this policy were the first indication to the State that the Counties previously granted rides to parents and guardians with multiple children.

10 Conclusion NEMT is an important and indispensable service the State provides to its most vulnerable citizens. Whether rides are coordinated centrally or regionally, it is of the utmost importance that rides continue to be accessible and reliable. LogistiCare has faced many challenges in this first year of implementation, but with vigilant oversight and continuing improvements to consumer relations it may prove to be a successful program. At this point, the program is too new to form a complete judgment. The improved ride access in rural areas of the state are an incredible benefit, as are the cost savings provided by the higher Federal reimbursement rate. Moving forward, it is imperative that the state increase oversight and patient protections through audits, consumer satisfaction surveys, and an improved dialogue with consumers to be certain that LogistiCare is doing its job: increasing access to care for those who need it. The following are areas of concern for social workers that should be continually evaluated moving forward: Is the phone reservation system accessible for all patients? Do patients feel comfortable with the system? o Is the phone reservation system warm or are patients reluctant to call? Are patients arriving to their appointments on time? Are patients asked to wait an unreasonable amount of time for their ride to arrive? Are patients aware of their rights? Are patients able to easily file complaints and receive responses? Has the State implemented any new protections for patients? Has LogistiCare reduced late and missed rides? What is the rate of missed and late rides? Ongoing meetings throughout the state are addressing some of these issues. An annual audit should be conducted to address performance standards and assess ride use. Additionally, because the State vastly underestimated the number of consumers using NEMT throughout Wisconsin in the contract with LogistiCare, LogistiCare is now losing money (Greg DiMiceli, Personal Communication, May 8, 2012). This leaves the future of LogistiCare in Wisconsin a mystery, but could increase the number of probing questions used in the script to determine ride eligibility. LogistiCare s financial situation could hold negative consequences for NEMT riders. Social Workers and advocates should pay particular attention to LogistiCare s operations over the next year. A successful NEMT broker in Wisconsin holds great promise for the health of our state.