EVALUATION REPORT Medical Nonemergency Transportation

SUMMARYxiThe way in which DHS has definedspecial transportation eligibility hasresulted in a few MA recipients falling“between the cracks.” They appeareligible under state law, but are noteligible in practice. Also, state lawdefines eligibility for specialtransportation based on recipients’inability to safely use accesstransportation. But DHS hasconsistently determined that MArecipients are not eligible for specialtransportation when appropriate typesof access transportation are simplyunavailable for them to use.Administrativerules for theprogram areoutdated.The Legislature has made manychanges to the nonemergencytransportation program over the lastdecade, but DHS has not significantlychanged its special transportationrules since 1987. The rules aregenerally silent on many importantmatters open to interpretation, andsome do not reflect current law.The department has limited manyrecipients’ eligibility for specialtransportation to very short timeperiods.The department’s contract with MTMrequires that special transportationeligibility periods generally parallelthose used for Social SecurityInsurance Disability determinations,which are, at a minimum, six months.However, MTM granted eligibility foronly one day to 40 percent of specialtransportation recipients needingambulatory or wheelchair servicesover the last three years.Furthermore, the 2010 Legislaturedirected that, barring changingcircumstances, eligibility assessmentsnot be done more than once a year onany individual (previously twice ayear). While this gives DHSdiscretion to initiate assessments whenneeded, statutes anticipate thatfrequent assessments will be theexception, not the rule.While brokering has reducedcertain transportation costs, totalsavings are unclear.The department has contracted withMTM to “broker” varying parts of itsnonemergency transportation programsince 2004. Brokering includesdetermining eligibility, schedulingtrips, and distributing those tripsamong providers.Because of data limitations, we cannotsay whether using a broker has savedthe state more money than it has cost.However, we identified three areaswhere savings have occurred. First,after the 2003 Legislature made DHS,not physicians, primarily responsiblefor determining special transportationeligibility, the department hired MTMto determine eligibility. Subsequently,there was a large shift in trips providedfrom special transportation to lesscostly access transportation. This shifthas reduced nonemergencytransportation costs by about 400,000a year. Second, when MTM brokeredspecial transportation in the TwinCities area (October 2007 throughJanuary 2008), the number of milesspecial transportation providers werereimbursed for trips dropped, savingabout 400,000 to 600,000 a year.Third, after MTM began brokeringaccess transportation in the TwinCities area in 2004, the proportion oftrips that used taxi-style vehicles toprovide curb-to-curb service increased,while the proportion providing morecostly door-to-door service decreased,which saved about 140,000 to 200,000 in fiscal year 2010.When Twin City area counties begancontracting with MTM to brokeraccess transportation instead of DHS,total administrative costs declined.

xii MEDICWeak oversightby theDepartment ofHuman Serviceshas resulted in thestate paying morethan it shouldhave for someparts of theprogram.Lack of consistentand reliable datahas hamperedoversight efforts.AL NONEMERGENCY TRANSPORTATIONThe counties paid MTM 4.4 millionin fiscal year 2010, or about 5.70 percompleted trip. In comparison, DHSpaid MTM 6.7 million for fiscal year2009, or about 8.30 per trip.Transportation spending pereligible MA recipient has decreasedin the Twin Cities area since 2004,but has increased outstate.Between fiscal years 2000 and 2010,average spending per eligible personin the Twin Cities area declined from 222 to 166. At the same time,outstate spending increased from 88to 131 per eligible person. Outstatecounties’ costs were less because theyused more lower-cost types of travel.In 2010, 69 percent of their spendingwas for reimbursing volunteer driversand recipients (or their families orfriends) for mileage. In contrast, 93percent of Twin Cities area spendingwas for taxi-style vehicles, a highercost option.Statewide, about 4 percent of eligibleMA recipients used specialtransportation in fiscal year 2010.Because DHS does not collectcomparable data on accesstransportation, statewide usage isunknown. In the Twin Cities area,about 18 percent of eligible MArecipients used access transportationin 2010.The department provides littlestatewide oversight of the program.Although its most recent contract withthe broker set forth numerousoversight mechanisms, DHS did notimplement a formal quality assuranceprogram to monitor the broker.Department oversight has largelyconsisted of informal communicationand frequent meetings.Weak monitoring and oversightcontributed, in part, to DHS paying itsbroker about 1 million more than theamount agreed to in its contract forfiscal year 2006. Furthermore, DHS’sdecision to give MTM aninappropriate cost-of-livingadjustment resulted in DHS paying thebroker about 1.5 million too much infiscal year 2009. Also, DHS recentlyexamined special transportationreimbursements for transportingnursing home residents and found ithad paid some providers about 500,000 for trips that did not appearto qualify for special transportationreimbursement.State oversight of outstate counties isalso lax, partly because DHS collectsaggregate spending data, notindividual trip data.The department must improve itsdata collection efforts.The department’s data collectionefforts vary, both across and withinthe two categories of nonemergencytransportation (access and special).Furthermore, DHS does very littlesystematic checking to make sure thatthe data submitted from counties,transportation providers, or its brokerare accurate or reasonable.Given state and county budgetproblems, policy makers need betterinformation about the costeffectiveness of transportationassistance statewide. The departmentshould routinely collect information,such as the number of individualparticipants, number of trips by typeof transportation, and costs per trip ona statewide basis, regardless of howprograms are administered.

IntroductionMinnesotans enrolled in Medical Assistance (MA), Minnesota’s version ofthe federal Medicaid program, are eligible to receive nonemergencytransportation assistance to obtain health-related services. Although a federallymandated benefit, Minnesota has considerable flexibility in how to providetransportation support, and it does so in various ways. Nearly two-thirds ofMinnesota’s MA population are enrolled in, and eligible to receive transportationhelp through, managed care health plans. The remaining one-third is covered bythe state’s fee-for-service system that allows them to receive transportation helpthrough counties or the Department of Human Services (DHS).Over the last several years, the state’s approach for providing transportationassistance to MA recipients served by its fee-for-service system has frequentlychanged, most often regarding DHS’s use of a private vendor to deliver differentaspects of the program. On March 26, 2010, the Legislative Audit Commissiondirected the Office of the Legislative Auditor (OLA) to evaluate medicalnonemergency transportation for MA recipients under the state’s fee-for-servicesystem.1 We focused on the following research questions: How have participation in, and costs for, medical nonemergencytransportation for MA recipients changed over time, and why? Are special transportation eligibility assessments performed in areasonable manner? To what extent have MA recipients appealedresults? Has DHS exercised adequate oversight of transportation servicesstatewide? To what extent do MA recipients receive appropriate and costeffective nonemergency medical transportation? How do other states provide medical nonemergency transportationto Medicaid recipients?We used various research methods to answer these questions. First, we analyzeddata collected by DHS and its contractor, Medical Transportation Management,Inc. (MTM), regarding program participants, trips, transportation providerreimbursements, costs, eligibility assessments, complaints, appeals, and customersatisfaction surveys. Second, we surveyed all county human services directors1The Commission first directed OLA to evaluate medical nonemergency transportation in April2009. Shortly thereafter, however, the Commission postponed the evaluation for one year due toprogram changes adopted by the 2009 Legislature.

2MEDICAL NONEMERGENCY TRANSPORTATIONabout their transportation assistance programs.2 Third, we collected dataregarding MA recipient “no shows” from a small sample of transportationproviders.3 Fourth, we examined contracts, budgets, reports, and otherdocuments related to nonemergency transportation in Minnesota and across thenation. Finally, we interviewed staff from the departments of Human Servicesand Transportation and MTM, as well as representatives from various interestgroups, local governments, and transportation providers.Our evaluation focused on medical nonemergency transportation withinMinnesota’s fee-for-service MA program; we excluded transportation servicesdelivered through managed care health plans. We looked at transportation from astatewide perspective and, with the exception of examining DHS’s use of acontractor to administer transportation services in the Twin Cities area, did notevaluate transportation services in individual counties. Also, we did not analyzethe adequacy of the reimbursement rates paid to transportation providers, nor didwe assess how the Minnesota Department of Transportation performed itscertification responsibilities related to special transportation providers.This report is divided into three chapters. Chapter 1 provides backgroundinformation on Minnesota’s medical nonemergency transportation program anddata on participants, services, and costs over time. Chapter 2 examines issuesspecifically related to special transportation, including eligibility criteria,frequency of assessments, length of certifications, and appeals. Chapter 3examines other management issues of interest to policy makers or interestgroups, including using brokers, state oversight, and customer satisfaction.2We sent questionnaires to 87 county human services directors and tribal health directors. Wereceived responses from 78 directors, for an overall response rate of 90 percent.3“No shows” refer to instances when transportation providers travel to designated pick-up sites totransport MA recipients to or from health-related services, but the recipients do not show up for thescheduled rides.

1BACKGROUNDCreated as a federal/state partnership in 1965, Medicaid is the nation's largestpublicly funded health financing program for low-income people.1 Toqualify for Medicaid, an individual must meet financial criteria and belong to oneof several eligibility categories: children under age 21, parents or caretakers ofdependent children, pregnant women, persons who are blind or have a disability,and persons age 65 or older.2 The federal government defines a minimum set ofhealth-related services that must be offered to Medicaid recipients. Thisevaluation looks at one of those services, medical nonemergency transportation,within the context of Minnesota’s fee-for-service system.The federalgovernmentrequiresMinnesota to helpMedicalAssistance (MA)recipients obtaintransportation toand from medicalappointments.Medical nonemergency transportation is a federally mandated benefit thatenables Medicaid recipients to access approved health-related services. Thefederal government requires state Medicaid programs to provide nonemergencytransportation assistance to the nearest qualified provider for covered services,using the least expensive type of appropriate transportation. The program’spurpose is to help lower overall medical costs by enabling Medicaid recipients toreceive routine, preventive health care. National studies have shown thattransportation-related barriers prevent many Medicaid recipients from obtaininghealth care.3 By providing transportation assistance for routine care, policymakers hope to better control nonemergency and emergency health care costs.ADMINISTRATIONAlthough providing transportation assistance is a federal mandate: States have wide latitude in how to administer medicalnonemergency transportation for Medicaid recipients.Many factors can influence how states design and implement their transportationprograms, including geography (urban vs. rural), population density, and theavailability of transportation providers. According to the Kaiser FamilyFoundation, all 50 states and the District of Columbia provide some form ofmedical nonemergency transportation to Medicaid recipients, although program1Social Security Act of 1965, Title XIX.2For greater detail, see Minnesota House Research Department, Medical Assistance (St. Paul,October 2010); and Minnesota House Research Department, Minnesota Family Assistance (St.Paul, December 2009). States are free to extend services to additional populations as long as thoseservices are paid for with state rather than federal funds. In the past, Minnesota has extendedmedical services to other groups such as unemployed single adults.3For example, see R. Wallace, P. Hughes-Cromwick, and S. Khasnabis, Access to Health Care andNon-emergency Medical Transportation (Washington, DC: Transportation Research Board), 2005;and T. A. Acury, J. Presser, W. Gesler, and J. M. Powers, “Access to Transportation and HealthCare Utilization in a Rural Region,” The Journal of Rural Health, 2, no. (Winter 2005).

4MEDICAL NONEMERGENCY TRANSPORTATIONadministration and services vary considerably.4 For example, some statesadminister their transportation programs through counties or regional entities,while others administer them at the state level. Also, states may use a variety oftransportation options, such as reimbursing for mileage, distributing passes forpublic transit, and paying for taxi-style services.5Minnesota dividesmedicalnonemergencytransportationinto two separatecategories:“access” and“special.”States can also place conditions on or limit recipients’ use of transportationservices. For example, a few states require some Medicaid recipients to makecopayments ranging from .50 to 3.00 per trip.6 Some states restrict the numberor type of trips they will provide. For example, Alabama limits Medicaidrecipients to two trips per month, while Indiana pays for up to 20 one-way tripsof less than 50 miles per year.7 Pennsylvania restricts recipients to trip costs of 50 or less per month.8 California only pays for transportation when recipients’medical or physical condition prevents them from using “ordinary” types oftransportation such as privately-owned cars or public transit.9In Minnesota, the Department of Human Services (DHS) oversees the state’spublic assistance health care program and, more specifically, medicalnonemergency transportation. In general: Minnesota uses a two-pronged approach to provide transportationassistance that depends on recipients’ level of physical or cognitiveimpairment.In the late 1970s, the Legislature created two major categories of nonemergencytransportation for Medical Assistance (MA) recipients: “access transportation”and “special transportation.”10 As shown in Table 1.1, these categories differ interms of recipient eligibility, program administration, and types of transportationthat are available.4Kaiser Family Foundation, “Benefits by Service: Non-Emergency Medical TransportationServices (October 2008),” http://medicaidbenefits.kff.org/service.jsp?gr off&nt on&so 0&tg 0&yr 4&cat 3&sv 21, accessed June 9, 2010.5We use the term “taxi-style” services to refer to rides given in cars and vans operated by privatecompanies, nonprofit groups, or public agencies. These vehicles operate in a similar fashion astaxis in that they provide individualized point-to-point service, but they generally focus onpopulations that have special needs. Taxi-style vehicles must also provide varying degrees ofassistance to passengers not specifically required of taxis in general.6Kaiser Family Foundation, “Benefits by Service.”7Ibid.8Legislative Research Commission, Human Service Transportation Delivery: System FacesQuality, Coordination, and Utilization Challenges (Frankfort, KY, 2004), 60.9California Department of Health Care Services, California’s Title XIX State Plan for Assurance ofTransportation, /StatePlan%20Attachment%203.1-D.pdf, accessed November 26, 2010.10Laws of Minnesota 1978, chapter 560, sec. 10; and Laws of Minnesota Extra Session 1979,chapter 1, sec. 27. Early legislation referred to access transportation as “regular” transportation.For the sake of consistency, we use the term “access transportation” throughout this report.

BACKGROUND5Table 1.1: Minnesota’s Medical NonemergencyTransportation ProgramAccess TransportationSpecial TransportationEligibilityAll Medical Assistance recipientsMedical Assistance recipientsunable to use unty human services agenciesState departments of humanservices and transportationTransportationProvidersRecipients, family, and friends;volunteer drivers; public transit(including buses, light rail, andparatransit); and taxi-style serviceprovidersMnDOT-certified specialtransportation taxi-style serviceprovidersSOURCE: Office of the Legislative Auditor.Access TransportationAccesstransportationincludes taxi-stylevehicles, publictransit, andmileagereimbursementfor using personalvehicles.“Access transportation” is available to all MA recipients covered by the state’sfee-for-service system.11 The Department of Human Services has defined accesstransportation to include: (1) vehicles owned by recipients, family, friends, andvolunteers; (2) public transit, including fixed route buses and light rail,paratransit such as Metro Mobility, and other local options such as dial-a-ride;and (3) private or nonprofit taxi-style vehicles.12

Medical Nonemergency Transportation . Minnesota should complex and confusing administrative structure for the medical nonemergency transportation program. Major Findings: In fiscal year 2010, Minnesota spent about 38 million on medical nonemergency transportation for Medical Assistance (MA) recipients covered by the state’s fee-for