Free rides to doctor limited in state's private-option proposal

Posted: August 2, 2014 at 4:09 a.m.

Enrollees in Arkansas' private-option health insurance program would be limited to eight Medicaid-funded rides to or from medical appointments per year under a proposal unveiled by state officials Friday.

The limit on nonemergency medical transportation is contained in proposed amendments to the "special terms and conditions" of the federal waiver that authorizes the private option, which allowed the state to expand its Medicaid population largely through coverage purchased for recipients on the state's health insurance exchange.

The proposed amended version of the terms and conditions were released for public comment Friday, the deadline imposed by special language the Legislature attached to the appropriation bill for the Medicaid program during this year's fiscal session.

The amendments also spell out the state's plans to require many private-option enrollees to have "independence accounts" encouraging them to make monthly payments, ranging from $5 to $25, to help pay for the cost of their medical care.

The special legislative language requires the amendments to be submitted to the U.S. Department of Health and Human Services by Sept. 15, and for the changes to be in place by Feb. 1.

Nonemergency medical transportation is required by federal Medicaid rules but not covered by the private plans, so the state pays for the service for private-option enrollees directly through the traditional Medicaid program as a "wraparound" benefit.

From Jan. 1, when coverage under the private option started, through June, the state had spent $2.5 million in federal dollars on the service for private-option enrollees.

Suzanne Bierman, assistant director of the state's Medicaid program, said private-option enrollees are more likely than those in the traditional Medicaid program to be working and have access to their own transportation.

"There's also a cost factor associated with this," State Department of Human Services spokesman Amy Webb said. "This is one of the more expensive benefits for the wraparound services, and the Legislature wanted us to limit it."

The expansion of the Medicaid program, approved by the Legislature last year, extended coverage to adults with incomes up to 138 percent of the federal poverty level: $16,105 for an individual, for instance, or $32,913 for a family of four.

As of June 30, 157,183 Arkansans were enrolled in the private option, while an additional 19,508 newly eligible adults were assigned to the traditional Medicaid program because their health needs were considered exceptional.

The state now provides nonemergency medical transportation to those on the private option, as well as those in the traditional Medicaid program, through contracts with seven private companies and nonprofit organizations.

Medicaid recipients, including private-option enrollees, who lack access to other transportation are eligible for the service.

The vendors, known as transportation brokers, have been paid a certain amount every month for every eligible Medicaid recipient in their service areas, regardless of how many recipients use the service.

In January, the state amended the contracts to include a "utilization factor," that adjusts the monthly fees every quarter based on the number of rides provided per recipient during an earlier three-month period, said Dan Adams, a manager with the state Medicaid program.

Since April 1, he said, the adjustment has been saving the Medicaid program about $250,000 a month.

The utilization factor prevented the "expenditure spike that we would have seen otherwise without it, and it didn't allow for these brokers to get a windfall, or as much of one, for these people who are presumptively lower utilizers," he said.

The proposed waiver amendment would limit private-option enrollees to eight "trip legs," or one-way rides, per year. But recipients "may request additional units" through an "extension of benefits process," according to the proposed amendment.

Bierman said the additional rides will be granted to enrollees with "extenuating medical circumstances." Officials are still working out the details of how the requests would be handled, she said.

The limit would not apply to newly eligible adults who are assigned to the traditional Medicaid program because of their health needs.

After the state rebids the contracts with transportation brokers, the brokers will be paid one fee based on the number of traditional Medicaid recipients in their service areas and another rate based on the number of private-option enrollees, Adams said. The new contracts will take effect July 1 of next year, he said.

Tony Barr, transportation officer for the Pine Bluff-based Area Agency on Aging of Southeast Arkansas, said his agency provided 15,846 rides for private-option enrollees and other Medicaid recipients in June, up from 14,574 in June of last year.

The agency provides the rides in Arkansas, Ashley, Bradley, Chicot, Cleveland, Desha, Drew, Grant, Lincoln and Jefferson counties.

"It started out kind of slow, but here in the last couple months it's really started to pick up," Barr said. "I think there will be some upset clients once they've been able to ride, and then now they're going to get limited, and I'm sure we'll be the ones that are going to have to tell them."

Benjie Alexander, chief administrative officer of Atlanta-based Southeastrans, which has a contract to arrange rides for Medicaid recipients in central and northeastern Arkansas, said his company arranged 999 trips for private-option enrollees in the central region, which includes Pulaski, Faulkner and Lonoke counties, in June, up from 293 in January.

In the northeastern region, which includes Clay, Craighead, Crittenden, Cross, Greene, Lawrence, Mississippi, Poinsett, Randolph and St. Francis counties, the company arranged 763 trips for private-option enrollees in June, up from 162 in January, he said.

By contrast, the company arranges 30,000-35,000 trips per month for all Medicaid recipients in the central Arkansas region and 35,000-50,000 per month in the northeastern region, he said.

"I can understand the state is conscious of the expense of the program," he said. "I'm sure their perspective is that they don't want to pay for an excessive amount of services that aren't necessarily needed."

Wraparound benefits provided to private-option enrollees also include dental and vision benefits for 19- and 20-year-olds. The expense for those benefits so far has been smaller -- just under $65,000 through June.

Under the independence account program, which would be required for private-option enrollees with incomes of at least 50 percent of the poverty level, the state will provide a $15 match, using federal funds, for each monthly contribution by an enrollee.

Enrollees would be allowed to accumulate up to $200 of the state contributions in their accounts, which could be used to pay a premium for a non-Medicaid insurance plan when the enrollee leaves the private option.

Enrollees who make a contribution for a given month would not have to pay out of pocket for their medical care for that month. Enrollees with incomes above the poverty level who fail to make contributions would have to make copayments in order to receive medical services, as they do now. For instance, enrollees now pay $8 for a doctor's office visit or $10 for a visit to a specialist's office.

Enrollees with incomes below the poverty level who fail to contribute to their accounts would have the copayments charged to their accounts. If the account is empty, the enrollee would owe a debt to the state.

The Human Services Department will accept comments on the proposed amendments until midnight Sept. 1. The comments can be submitted in writing or during two public hearings. The hearings, both starting at 5:30 p.m., will be Thursday at the University of Arkansas Cooperative Extension Service auditorium at 2301 S. University Ave. and Aug. 8 at Jefferson Regional Medical Center, 1600 W. 40th Ave. in Pine Bluff.

A Section on 08/02/2014