Medicaid Ride Program, Plagued by Fraud, Still Has Its Champions

It’s a money saver for Medicaid, a highly anticipated new benefit for some Medicare patients, and a competitive new battleground for ride-hailing giants Uber and Lyft. But rides to medical appointments could still be scrapped as a mandatory benefit for state Medicaid programs next year.

In December, the Centers for Medicare & Medicaid Services is slated to seek public comment on whether “the Assurance of transportation in the Medicaid program remains administratively necessary.”

The outcome could affect transportation access for millions of Medicaid patients who use the service. The policy initiative also seems to run counter to previous CMS efforts to provide non-medical assistance—like transportation—that helps improve beneficiary health.

In its proposed 2020 HHS budget, the Trump administration committed to change the “benefit from mandatory to optional to provide greater flexibility to states” struggling to contain the cost of the service and to address its “program integrity concerns.” The agency will consider all public feedback in any potential rule-making process but has not made any final decisions.

Iowa and Indiana have previously received federal permission, known as waivers, to stop providing the service for certain beneficiaries.

“My sense is that most people looking to waive it did so out of a reflection that it’s an enormously challenging benefit to manage properly,” said Matt Salo, executive director of the National Association of Medicaid Directors. “It’s not that people were saying it wasn’t important but that cost overruns, abysmal performance records, and yes, fraud and abuse led a lot of people to say, ‘as long as this is a mandatory service, we’re only inviting these problems.’”

In FY 2017, Medicaid spent nearly $2 billion providing rides for beneficiaries who had no other travel options, according to the Medicaid and CHIP Payment and Access Commission. Covered rides can include taxis, public transportation, wheelchair-accessible vans, or reimbursed travel with a friend. Medicaid has provided the free and low-cost rides since the program debuted in 1965.

Beneficiaries who use the service are typically older patients with a chronic illness. The rides are frequently used to attend dialysis treatments, mental health appointments, and substance abuse treatment.

But the service has been plagued by fraud and complaints about late arrivals or no-shows that make people miss or arrive late to appointments. Others say the ride service is less reliable for transportation needs that develop without prior notice and those that require last-minute changes.

Focus on Transportation

While consistent with previous Trump administration efforts to revamp state Medicaid programs, the push to make the transportation benefit optional has raised eyebrows. It comes as the CMS is placing more emphasis on addressing social factors that jeopardize beneficiary health, like the lack of transportation.

Next year, some of the private health plans that provide Medicare benefits will offer services like non-emergency transportation, home-delivered meals, and even home improvements aimed at keeping chronically ill beneficiaries out of the emergency room.

Medicaid’s non-emergency medical transportation (NEMT) benefit serves the same purpose, said Phil Stalboerger, vice president of public affairs at MTM, the nation’s second largest broker for that kind of transportation. MTM contracts with state Medicaid agencies and managed care companies to provide 20 million rides for 12 million Medicaid recipients in 31 states each year. Other major transportation players include LogistiCare and Southeastrans.

“If you take this benefit away, you are severely impacting the health of a population that really needs help,” Stalboerger said. “You would think a ride isn’t that big of a deal, but at the end of the day, that ride is going to get them to and from their lifesaving appointment.”

The CMS will seek comments on the merits of maintaining the service for select beneficiaries like pregnant women, the medically frail, and adolescents eligible for early periodic screening and diagnostic treatment services.

The Medical Transportation Access Coalition, an industry trade group, wants to make sure the “NEMT benefit continues to work and evolve,” said Tricia Beckmann, an adviser to the coalition.

If the request for information “is a way for the administration to get cover for a controversial policy to remove one of the tools that’s helpful to address social determinants [of health] and maintain access to timely care, then we see that as a step in the wrong direction,” said Beckmann, a director at Faegre Baker Daniels Consulting.

Hitting the Brakes

Patient advocates, industry groups, and members of Congress from both political parties are gearing up for a fight to retain the transportation benefit as is. They’re supporting the bipartisan Protecting Patients Transportation to Care Act introduced by Reps. Buddy Carter (R-Ga.) and Tony Cardenas (D-Calif.).

The legislation would add the mandatory transportation benefit to the language of the Medicaid statute. The bill is currently awaiting action in a subcommittee of the House Energy and Commerce Committee.

Companion legislation has been referred to the Senate Committee on Finance.

If neither measure is enacted, Carter has a back-up plan. He is working to get language in a future appropriations bill that would prohibit the CMS from using agency funds to allow states to make the transportation benefit optional, he said.

To better serve patients, some states are exploring on-demand rideshare companies like Uber and Lyft to boost their Medicaid NEMT service.

In August, Uber Health and American Logistics joined forces to expand both companies’ footprint in the non-emergency medical transport field. And in May, Lyft became a certified Medicaid provider in Arizona, the first state Medicaid program to allow ride-hailing companies to do so.

Stalboerger said Uber and Lyft will expand services for able-bodied patients. But neither company will dominate the industry because they can’t accommodate patients in wheel-chairs and others with special transportation needs.