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{ timecode: 0, handler: 'blob', id: 1, data: {text: 'DAVE WHITE: So without further ado, I’m going to introduce our next panel, led by David Raphael. And David is the former and first executive director of the Community Transportation Association '}},
{ timecode: 15, handler: 'blob', id: 2, data: {text: 'of America. I don’t think he really needs introduction, but I wanted to mention that. David is currently one of our ambassadors. And when he left CTAA, David kind of took on the task, which I '}},
{ timecode: 30, handler: 'blob', id: 3, data: {text: 'was very impressed with, of developing, of continuing the development or developing some research on non-emergency medical transportation, which actually was very helpful to me and to many in our '}},
{ timecode: 44, handler: 'blob', id: 4, data: {text: 'industry. We didn’t have that base of knowledge that he started putting together at the time, and I certainly was appreciative of that, and so David has continued that work over the years and so '}},
{ timecode: 62, handler: 'blob', id: 5, data: {text: 'he’s a real expert in this area. And he’s going to talk to us about where we are today with Medicaid non-emergency medical transportation, he and his panel. So without further ado, as '}},
{ timecode: 75, handler: 'blob', id: 6, data: {text: 'they’re getting hooked up over here, I will introduce David Raphael and his panel. Thanks very much. DAVID RAPHAEL: Sorry. I had to get wired up here. Good afternoon. How is everybody? Oh, '}},
{ timecode: 113, handler: 'blob', id: 7, data: {text: 'there’s so much to say. I won’t get into all the things that have gone through my mind the last couple of days, but before we get into our immediate discussion, and with the patience of '}},
{ timecode: 125, handler: 'blob', id: 8, data: {text: 'the panel, I just want to go back a moment to Dale’s opening yesterday, which was really an incredible job. I hope most of you who are here today were here yesterday morning. I mean, that was a '}},
{ timecode: 139, handler: 'blob', id: 9, data: {text: 'graduate course in health policy, with humor and with simplification, and really highlighting the really important issues. I was just overwhelmed with all that he’s got on his plate to do this, '}},
{ timecode: 157, handler: 'blob', id: 10, data: {text: 'not on medical transportation, but on health policy. And I think we are really very fortunate. I know I sound like I’m sucking up to him, but even if I didn’t work for him, I would be '}},
{ timecode: 170, handler: 'blob', id: 11, data: {text: 'saying this. I think it was marvelous, and he helped put the crisis that we\'re in, and the situation that we\'re in now in focus and in perspective, and he helped put our topic of '}},
{ timecode: 182, handler: 'blob', id: 12, data: {text: 'Medicaid, I think in terms of the origins and the perspective, on it, and so I’m really very grateful. during his talk and afterward, I kept going through my mind about what do we do with that '}},
{ timecode: 201, handler: 'blob', id: 13, data: {text: 'kind of information, and what are all you doing with that, I don’t know, pitiful history that sad, sometimes glorious history, what do you do with it? And I think there’s a couple of '}},
{ timecode: 214, handler: 'blob', id: 14, data: {text: 'things. You could be cynical about the struggle, the fact that we start human service policy, social policy in this country at least a half a decade later than the western Europeans, and we kind of '}},
{ timecode: 229, handler: 'blob', id: 15, data: {text: 'make a muckle of it when we try. Either that or do you take out of there something hopeful. What I was reminded of, when I first came to Washington as a 25-year-old war on poverty warrior, we went up '}},
{ timecode: 249, handler: 'blob', id: 16, data: {text: 'to our kind of mother ship – I worked for a nonprofit that was supported by American Friends Service Committee, and we went up to Philadelphia – sort of the Mecca of the Quakers – '}},
{ timecode: 259, handler: 'blob', id: 17, data: {text: 'and had a dinner and a speech by a wonderful woman, Eleanor Eaton, a Quaker staff up there, and the title of her talk was "Where There\'s Hypocrisy, There\'s Hope". And I was jolted. And she '}},
{ timecode: 277, handler: 'blob', id: 18, data: {text: 'went on to say that - much along the lines Dale did yesterday - that we’re a society that in 1939 passed a housing legislation that declared every American had a right to a decent home and a '}},
{ timecode: 293, handler: 'blob', id: 19, data: {text: 'suitable living environment. And then in 1947 with Harry Truman we declared that everybody has a right to a job. And in 1964, sort of my era, we declared war on poverty, and announced that we had to '}},
{ timecode: 311, handler: 'blob', id: 20, data: {text: 'eliminate it. More recently we declared war on welfare, as we know it, and tried to eliminate it. What you could take from that - well, first of all, that was hard as a 27-year-old to sort of '}},
{ timecode: 323, handler: 'blob', id: 21, data: {text: 'accept, and I don’t know if it’s wisdom or weariness, but what you take from that is that this is a society that likes to think about itself and likes to think about the issues in those '}},
{ timecode: 336, handler: 'blob', id: 22, data: {text: 'sorts of ways. We do care. It is a people who do care about housing and poverty and human misery. We don’t always live up to those ideals. We do put them in law, we do put them in policy, which '}},
{ timecode: 349, handler: 'blob', id: 23, data: {text: 'is the important thing, I think for organizations like ours, because you work on the hypocrisy. It’s not really hypocrisy, but you work on the disconnect. You work on the gap between what this '}},
{ timecode: 364, handler: 'blob', id: 24, data: {text: 'ideal is that the society has put up there and what the realities are. And in a way that levels the playing field a bit, I think, with the big money interests who lobby in D.C., who can bring campaign '}},
{ timecode: 376, handler: 'blob', id: 25, data: {text: 'contributions to Congress. Our role is we can kind of hold up that vision, that positive sense of ourselves that is encapsulated in many of these legislations and policies. And we can talk about the '}},
{ timecode: 391, handler: 'blob', id: 26, data: {text: 'neglect, the inequities, how far we’ve missed the mark, and we can push, we can push the agenda forward. So I take from that a, take a positive message from it. I don’t know if I would go '}},
{ timecode: 408, handler: 'blob', id: 27, data: {text: 'around giving speeches about hypocrisy and hope, but I think there is a very important message in a way of looking at this country that was reflected in Dale’s remarks. Now we’ll try to '}},
{ timecode: 423, handler: 'blob', id: 28, data: {text: 'get onto our topic, and sort of why Medicaid. And there’s been a lot of talk today about Medicaid. And one of the, probably one of the most important reasons is that for our industry, for the '}},
{ timecode: 435, handler: 'blob', id: 29, data: {text: 'community transportation industry, it’s huge. It’s sort of the Willie Sutton approach to fund raising. You go to Medicaid because that’s where the money is, and, or in a more recent '}},
{ timecode: 449, handler: 'blob', id: 30, data: {text: 'kind of analogy, it’s a program like AIG that’s too big to be ignored. So it’s big. Second, and very important I think, and especially important to the recipients of it, it’s '}},
{ timecode: 466, handler: 'blob', id: 31, data: {text: 'the only program that guarantees access to a service. Where the recipients, the clients have a legal entitlement to get to the services that they need. ADA is probably the closest connection to that. '}},
{ timecode: 479, handler: 'blob', id: 32, data: {text: 'But in the federal human service programs no other program guarantees a ride. And so in that case it is particularly important that Jennifer talked about maintaining some of the Medicaid benefits and '}},
{ timecode: 494, handler: 'blob', id: 33, data: {text: 'provisions in any kind of health care reform. And I think it’s even more than that. There never was a transportation benefit written into the program. It was because the program is an '}},
{ timecode: 506, handler: 'blob', id: 34, data: {text: 'entitlement. And it took the courts to determine that if you have an entitlement and a health card, an entitlement to get decent health care, that you have a right to get to that health care, and the '}},
{ timecode: 517, handler: 'blob', id: 35, data: {text: 'states can’t deny that, and that’s basically the whole basis around which the Medicaid program today exists. There’s not a shred of legislation, and there’s no policies that '}},
{ timecode: 530, handler: 'blob', id: 36, data: {text: 'lay out a transportation benefit. It is really built out of case law with the federal courts. A quick bit of history – bear with me guys, I’m covering. But just to help put it in '}},
{ timecode: 545, handler: 'blob', id: 37, data: {text: 'perspective. It adopted in 1964 as an entitlement to be state administered and jointly funded. It was a wonderful story of Dale\'s, of how Lyndon put that over on the states. They\'ll never forgive'}},
{ timecode: 561, handler: 'blob', id: 38, data: {text: 'him. There was no mention of transportation, as I said, and it was through the courts. Today Medicaid covers 55 million people, almost a quarter, more than a quarter of the population. It spends on '}},
{ timecode: 577, handler: 'blob', id: 39, data: {text: 'non-emergency medical transportation, combined federal and state, 3 billion dollars annually. Now to put that in perspective, that’s roughly 20 percent of the entire federal transit budget. '}},
{ timecode: 591, handler: 'blob', id: 40, data: {text: 'It’s only 1 percent of the Medicaid budget. Medicaid spends 300 million a year, and only 1 percent of that goes for transit. But in our field, that’s a lot of money. By contrast, Medicaid '}},
{ timecode: 605, handler: 'blob', id: 41, data: {text: 'funding is as large as all the FTA funding for large urban areas. About another twenty percent of the budget. If you add Medicare, which is sort of the sleeping giant - and we’re not going to '}},
{ timecode: 618, handler: 'blob', id: 42, data: {text: 'get a chance to talk about it here today because it\'s irrelevant, unfortunately, to us. Medicare spends about 3.5, three and a half billion a year on transportation for Medicare recipients, but they'}},
{ timecode: 632, handler: 'blob', id: 43, data: {text: 'can’t ride in any of our vehicles. It was written in early on by the ambulance industry that Medicare transportation is limited to ambulance only transportation. And we squander an enormous '}},
{ timecode: 646, handler: 'blob', id: 44, data: {text: 'amount of money every year as a result of that. And we leave millions of seniors and Medicare covered people without access to care. So in that health care reform agenda that we’re talking '}},
{ timecode: 661, handler: 'blob', id: 45, data: {text: 'about, the Medicare has got to be brought into it as well. Twenty percent of the federal budget. I think we covered that. There’s three transportation programs under Medicaid. We kind of lump '}},
{ timecode: 676, handler: 'blob', id: 46, data: {text: 'them together and we just sort of talk about Medicaid transportation, but there’s non-emergency medical transportation, which is the major one that we talk about. These are trips to medical '}},
{ timecode: 688, handler: 'blob', id: 47, data: {text: 'appointments and treatment. There’s the waivered non-medical transportation program in which for waivered clients, to help keep people in their homes and communities and out of institutions, '}},
{ timecode: 704, handler: 'blob', id: 48, data: {text: 'Medicaid will pay for non-medical transportation to maintain people\'s independence. And then there\'s the CHIP or whole range of children\'s health services, including the ESPD, but '}},
{ timecode: 721, handler: 'blob', id: 49, data: {text: 'anyway, the Children’s Screening Program, which are all mandated to assure access to health care. So that’s the background quickly, and sort of why we’re focusing on that today. And '}},
{ timecode: 739, handler: 'blob', id: 50, data: {text: 'what we’re going to try to do in this panel is to deal with the crisis, the looming crisis that Dale talked about. The crisis, sort of a perfect storm in many ways that have come together at '}},
{ timecode: 752, handler: 'blob', id: 51, data: {text: 'this point. We\'ve got the economic collapse that is just wreaking havoc throughout the country, and particularly with states. We\'ve got the expanding coverage and services, that Dale talked'}},
{ timecode: 762, handler: 'blob', id: 52, data: {text: 'about yesterday, and the declining funding. The failure of the Congress to live up to the funding needs. So the squeezes come together. And so we’ve thought at this time, this would be a time to '}},
{ timecode: 775, handler: 'blob', id: 53, data: {text: 'talk with our state partners and people working at the state level about the impact that many of these cuts have and what people are doing creatively and not so creatively to deal with it. '}},
{ timecode: 792, handler: 'blob', id: 54, data: {text: 'We’ve asked 3 people to join us here. Let me introduce them quickly, but also ask for your help and your participation in this, so you can ask questions, and I hope you will, but you can also '}},
{ timecode: 807, handler: 'blob', id: 55, data: {text: 'share with us your experience of what’s going on in your community and your state as we all try to grapple with this. This is sort of the pre-pending health care crisis. I think, as Jennifer was '}},
{ timecode: 822, handler: 'blob', id: 56, data: {text: 'talking about, we’re headed for a major one on the whole level of health care. But in Medicaid we’re in a crisis right at the moment. With us today is Nick Farber, Transportation Policy '}},
{ timecode: 834, handler: 'blob', id: 57, data: {text: 'Associate with the National Conference of State Legislators in Denver. He works in transit, transportation finance and emergency preparedness policy. He currently is working with the California '}},
{ timecode: 846, handler: 'blob', id: 58, data: {text: 'Department of Transportation, Cal-Trans, on an interagency coordination project. And he has also authored briefs on school buses, using school buses for paratransit trips, volunteer driver liability, '}},
{ timecode: 860, handler: 'blob', id: 59, data: {text: 'and paratransit insurance. With him we have 2 state administrators, people who are administering state Medicaid programs. First, Bob Knox, in the middle over there. Bob is celebrating an anniversary '}},
{ timecode: 877, handler: 'blob', id: 60, data: {text: 'of sorts. Yesterday was his 23rd anniversary as a Senior Policy Analyst and Program Manager for the Commonwealth of Virginia. All his work has been in the human service area, with a focus on '}},
{ timecode: 890, handler: 'blob', id: 61, data: {text: 'transportation for people who are elderly or disabled. He has spent 14 years with the Department of Aging, and for the last, what does that add up, 7 or more than 7 years, he has managed the Medicaid '}},
{ timecode: 907, handler: 'blob', id: 62, data: {text: 'Transportation Program in Virginia, which amounts to managing a brokered transportation program, which he’ll talk with us about. And last, but not least, we have Jeanne Lang from Washington '}},
{ timecode: 925, handler: 'blob', id: 63, data: {text: 'State. And Jeanne has been a program manager with the Medicaid Transportation Services of Washington State, which is part of the Department of Social and Health Services, for the past 7 years. And '}},
{ timecode: 941, handler: 'blob', id: 64, data: {text: 'previously she was Transportation Broker, so she’s been in the trenches for 10 years with the Regional Council of Governments, which is sort of a unique type of brokerage allowed in Washington '}},
{ timecode: 951, handler: 'blob', id: 65, data: {text: 'State, which she’ll talk about. And Washington State, as you will see, or hopefully already know, has been a leader among the states in the development of brokerages. To start it off, I’m '}},
{ timecode: 969, handler: 'blob', id: 66, data: {text: 'not quite sure where I’m going to sit. I can’t figure out this format, how well it works. I’m not Oprah, and she would make it more lively, so I’ve got to still figure that '}},
{ timecode: 980, handler: 'blob', id: 67, data: {text: 'out, but I\'ve got to ask Nick to start us off and to talk about the current fiscal crisis and the fiscal situation that the states find themselves in, and kind of give us a report first from '}},
{ timecode: 992, handler: 'blob', id: 68, data: {text: 'that level. Could you do that Nick? NICK FARBER: Yeah, sure thing. As Dave was saying, there’s a coming storm, and the storm is just that the state fiscal situation is dire. As revenue '}},
{ timecode: 1008, handler: 'blob', id: 69, data: {text: 'shortfalls continue to mount, budget gaps are swelling. To date, states have reported a total estimated budget gap of 281 billion dollars. That’s combined, that’s 50 states. The bright '}},
{ timecode: 1023, handler: 'blob', id: 70, data: {text: 'spot is stimulus funding. Without it the states’ fiscal situation would have been even worse. The problem states are experiencing is primarily due to the recession. Even now, revenues are '}},
{ timecode: 1040, handler: 'blob', id: 71, data: {text: 'continuing to decline, and we’re hearing from our states that the fiscal situation is unprecedented. When enacting their budgets, state lawmakers have collectively resolved a 40.3 billion dollar '}},
{ timecode: 1059, handler: 'blob', id: 72, data: {text: 'shortfall. Even though they filled that hole, those actions haven\'t been enough because revenues are continuing to trickle in and another 62.4 billion dollar gap has opened up, and we'}},
{ timecode: 1077, handler: 'blob', id: 73, data: {text: 'expect that gap to get worse. As bad as the last year’s been, it’s going to get bigger. We’re projecting 121.2 billion dollar shortfall for fiscal year 2010. Therefore, in the coming '}},
{ timecode: 1096, handler: 'blob', id: 74, data: {text: 'years we’re definitely likely to see more cuts and more cuts in programs like non-emergency medical transportation, Medicaid. More bad news. Sorry guys, but the nightmare doesn’t end '}},
{ timecode: 1113, handler: 'blob', id: 75, data: {text: 'there. Thirty-one states and Puerto Rico have already forecasted budget gaps in the fiscal year 2011, in around 44.5 billion dollars. So where the NCSL sees the state budget situation not coming, not '}},
{ timecode: 1135, handler: 'blob', id: 76, data: {text: 'making some money or not getting out of this hole until about 2012. States kind of lag behind the federal government in pulling in more money. So as we hear the economy is getting better, as the '}},
{ timecode: 1151, handler: 'blob', id: 77, data: {text: 'economy gets better, job creation kind of lags, so, and job creation is what states kind of rely on to, with taxes, property taxes, income taxes, to make money. So as the economy gets better, I think '}},
{ timecode: 1171, handler: 'blob', id: 78, data: {text: 'we’ll start seeing things get better in states, but I think – DAVID RAPHAEL: Nick, almost before that, can you talk with us a little bit about the economic stimulus program. My sense is '}},
{ timecode: 1181, handler: 'blob', id: 79, data: {text: 'that the Congress has been – was aware, at least to some extent, of these state crises, and through the stimulus, and the Medicaid stimulus particularly, pumped quite a bit of money. We were, '}},
{ timecode: 1196, handler: 'blob', id: 80, data: {text: 'none of us had our exact notes here, but compared to the 8 billion in transit in the stimulus program, the state Medicaid program received more than 100 billion, a huge amount. Talk about what the '}},
{ timecode: 1210, handler: 'blob', id: 81, data: {text: 'stimulus money, to what extent you can see now what it’s doing, how it’s affected the states. NICK FARBER: Yeah. The stimulus package provides roughly about 140 million dollars in fiscal '}},
{ timecode: 1222, handler: 'blob', id: 82, data: {text: 'relief for states. The stimulus funding, however, only covers about 40 percent of Medicaid shortfalls for the next 2 years. So states are going to have to come up with the other 60 percent in the next '}},
{ timecode: 1240, handler: 'blob', id: 83, data: {text: '2 years, and then that funding is gone in the next 2 years, and so I think we’re going to – yeah, it’s going to fill a hole for the next 2 years, but I don’t think – '}},
{ timecode: 1248, handler: 'blob', id: 84, data: {text: 'states have to come up with ways to fill that gap. DAVID RAPHAEL: The stimulus did something else with Medicaid as well, and that is it altered the federal-state matching rate. And we’re going '}},
{ timecode: 1262, handler: 'blob', id: 85, data: {text: 'to talk about that pretty soon. It added right off the top 6.2, 6-plus percent of every state’s Medicaid budget. The feds are picking up 6 percent more of that than they did a year ago, and it '}},
{ timecode: 1277, handler: 'blob', id: 86, data: {text: 'could go as high as 12 or 13 percent more, depending upon the levels of distress in the state. That must be unemployment figures and maybe other distress indicators. So one of the sweeteners was not '}},
{ timecode: 1287, handler: 'blob', id: 87, data: {text: 'only a big bump in money, but money on more favorable terms to the states. Let’s shift a bit with Jeanne and Bob and first ask you, Jeanne, talk with us about Washington State’s broker '}},
{ timecode: 1304, handler: 'blob', id: 88, data: {text: 'Medicaid program and how you operate it, and then we’ll talk about what some of the current activities are. JEANNE LANG: Okay. To give you a little bit of history, Washington State first set up '}},
{ timecode: 1315, handler: 'blob', id: 89, data: {text: 'Medicaid transportation brokers back in the late 1980s. So about 1987 set up 2 or 3 pilot programs around the state, and then by 1988, ‘89, the brokerage program went statewide. We have the '}},
{ timecode: 1340, handler: 'blob', id: 90, data: {text: 'state – we have 39 counties, we have the brokers brokered into 13 different regions. Some of the bigger counties, like where Seattle is or Tacoma, Spokane, those are single county broker '}},
{ timecode: 1352, handler: 'blob', id: 91, data: {text: 'regions. Other counties, or other regions, are multi-county. So we have contracts with 8 different brokers. Some brokers have more than one region. They’re all private nonprofits with the '}},
{ timecode: 1367, handler: 'blob', id: 92, data: {text: 'exception of one governmental, which is a Council of Governments. The last procurement was about 5, 6 years ago. Washington State decided at that time to make a requirement that the broker – it '}},
{ timecode: 1386, handler: 'blob', id: 93, data: {text: 'was preferable that the broker not be a provider, and that’s largely the case in Western Washington, which is more highly concentrated population. In Eastern Washington where it’s much '}},
{ timecode: 1401, handler: 'blob', id: 94, data: {text: 'more rural, I think all but one of the brokers are broker providers, but there are still limitations on it. DAVID RAPHAEL: This has been an issue that the state has wrestled with for many years, and '}},
{ timecode: 1415, handler: 'blob', id: 95, data: {text: 'it comes up again now in the CMS regs. But let’s go to Bob real quickly for a description, Bob, of how you operate the Medicaid program in Virginia, and a description of the brokerage operation '}},
{ timecode: 1431, handler: 'blob', id: 96, data: {text: 'that you have. BOB KNOX: In Virginia, the reason they went to brokerage was fraud. When I was still at Aging, the Medicaid director called and said, we want to do a couple of pilots with 2 of your '}},
{ timecode: 1448, handler: 'blob', id: 97, data: {text: 'aging agencies, and see if not really pre-authorizing the trip, but just having to be notified that a trip was occurring, would deter fraud. And that was literally about all that these 2 pilot '}},
{ timecode: 1465, handler: 'blob', id: 98, data: {text: 'agencies did. They did a little bit of training, but primarily they just answered the phone and wrote down that ABC taxi was carrying Ms. Jones to the hospital. And in the first year that they did '}},
{ timecode: 1483, handler: 'blob', id: 99, data: {text: 'that, they had – oh, the other thing they did was pay the bills. They would total up what the trip mileage was and pay the provider’s claim, and so the first year, one thing they saw was '}},
{ timecode: 1501, handler: 'blob', id: 100, data: {text: 'that non-emergency ambulance trips diminished 57 percent to 60 percent in both pilots. Just because somebody knew that an ambulance trip was being taken. There was the famous case of one guy who was '}},
{ timecode: 1520, handler: 'blob', id: 101, data: {text: 'sent home from the hospital in an ambulance because he’d never been, gotten a chance to ride in one before, so he rode up in the front seat and rang the bell and the siren and had a great time. '}},
{ timecode: 1534, handler: 'blob', id: 102, data: {text: 'It made him feel better about himself, there’s no question. DAVID RAPHAEL: Therapeutic. BOB KNOX: Yeah. But the other problem they had was what was called a Registered Driver Program, which was '}},
{ timecode: 1544, handler: 'blob', id: 103, data: {text: 'kind of home and community-based fraud. People would volunteer to take their neighbors, and if they didn’t have any neighbors, they’d just file a claim of the neighbor they wished they '}},
{ timecode: 1555, handler: 'blob', id: 104, data: {text: 'had. And it was really pretty bad. But they, after they finished that, they decided they definitely needed some kind of a broker or somebody to pre-authorize trips, check eligibility, check where '}},
{ timecode: 1572, handler: 'blob', id: 105, data: {text: 'people were going. And they put out a bid and got 2 brokers, DynCorp, which was a defense contractor in D.C., and LogistiCare, which at that time was pretty new in the brokerage business. I think '}},
{ timecode: 1594, handler: 'blob', id: 106, data: {text: 'Virginia was the fifth contract they got. And so we’ve had brokerage since July of 2001. The first year and a half were somewhat difficult with DynCorp and the company that they merged with, but '}},
{ timecode: 1616, handler: 'blob', id: 107, data: {text: 'so that one of the issues, if you’re looking at brokerage in your state or whether or not to do it, you got to decide pretty early, do you want to put all your chips on one broker, or do you '}},
{ timecode: 1628, handler: 'blob', id: 108, data: {text: 'want to have a second one just in case you need it. And we’ve always been grateful of LogistiCare for being there when we had to cancel the contract with the other one. But that’s a big '}},
{ timecode: 1640, handler: 'blob', id: 109, data: {text: 'consideration if you’re a state. We’ve got about 250,000 people who are eligible for transportation in the fee for service side of things. We do three-quarters of the transportation for '}},
{ timecode: 1657, handler: 'blob', id: 110, data: {text: 'Medicaid and fee for service contract with LogistiCare. LogistiCare\'s also the broker for our managed care agencies, and that\'s about another million trips. We do three and a half million in fee for '}},
{ timecode: 1672, handler: 'blob', id: 111, data: {text: 'service and a million in managed care. We spend - our fee for service contract last year was about 67 million. And when we went to brokerage - when they went to brokerage - I didn\'t '}},
{ timecode: 1691, handler: 'blob', id: 112, data: {text: 'come until the next year, but when they started brokerage, the last year before brokerage, we spent 61 million dollars on transportation. So it took 7 or 8 years to get beyond the level we’d '}},
{ timecode: 1709, handler: 'blob', id: 113, data: {text: 'been at in 2000, year 2000. We’re a 50 percent match state, so that makes some difference to us, whether we’re admin or medical. Or it makes no difference to us, excuse me, whether '}},
{ timecode: 1724, handler: 'blob', id: 114, data: {text: 'we’re running as an administrative service – DAVID RAPHAEL: Let me get to that because that’s I think where we want to go. And just to clarify, in Virginia the fee for service '}},
{ timecode: 1737, handler: 'blob', id: 115, data: {text: 'Medicaid population covered by the brokerage arrangement that Bob operates, the Medicaid individuals who are in managed care organizations get their transportation, it’s called carved in, in '}},
{ timecode: 1752, handler: 'blob', id: 116, data: {text: 'that state, they get their transportation from their health plan. It so happens that the same contractor is used by the health plan agencies and the state; am I right? BOB KNOX: Yeah. That '}},
{ timecode: 1763, handler: 'blob', id: 117, data: {text: 'didn’t happen – DAVID RAPHAEL: And the state. BOB KNOX: There was no connection between the 2. They gradually got the managed care contracts over several years. DAVID RAPHAEL: But not all '}},
{ timecode: 1773, handler: 'blob', id: 118, data: {text: 'the states do it that way. That’s what I was going to ask Jeanne. In Washington State you’ve got a lot of people in managed care. Who handles their transportation? JEANNE LANG: In our '}},
{ timecode: 1782, handler: 'blob', id: 119, data: {text: 'state it’s carved out of the managed care contracts, so the brokers arrange for trips, whether it’s fee for service client or a managed care client. DAVID RAPHAEL: And essentially exactly '}},
{ timecode: 1795, handler: 'blob', id: 120, data: {text: 'the same, scheduled the same regardless? JEANNE LANG: Right. DAVID RAPHAEL: Let’s just talk a little bit about the financing of non-emergency medical transportation, because it’s going to '}},
{ timecode: 1806, handler: 'blob', id: 121, data: {text: 'affect sort of the next subject that we get into. Everybody’s aware, you could, a state can choose and support - and I think you know what your state does - but your state can choose to operate '}},
{ timecode: 1818, handler: 'blob', id: 122, data: {text: 'its transportation, non-emergency transportation program either as an administrative service or as a medical service. The difference is if it’s an administrative service, they have a great deal '}},
{ timecode: 1831, handler: 'blob', id: 123, data: {text: 'of flexibility as to how to administer it, how to organize it. Then they can guide it into brokerages or they can restrict and limit the providers who are available to provide service. But the '}},
{ timecode: 1848, handler: 'blob', id: 124, data: {text: 'consequence is they receive only 50 percent match reimbursement. So a less generous funding, more flexibility. The option is to declare Medicaid transportation as a medical service, in which case you '}},
{ timecode: 1866, handler: 'blob', id: 125, data: {text: 'get the full Medicaid federal matching funds that your state is entitled to. Bob was saying Virginia was, up until now, has been a 50-50 state. It really didn’t much matter, so you sort of '}},
{ timecode: 1880, handler: 'blob', id: 126, data: {text: 'choose the administrative side, which gives you more flexibility. But in states, and most many states are the federal match is more than 50 percent, and the states are in a quandary about losing money '}},
{ timecode: 1895, handler: 'blob', id: 127, data: {text: 'and maintaining flexibility. There have been, there has been one way to get around it, and now there are 2. In the past, the state could request a waiver from CMS, a freedom of choice waiver '}},
{ timecode: 1912, handler: 'blob', id: 128, data: {text: 'it’s called, or sometimes it’s called a transportation waiver, which allows the state to restrict how many providers and which providers provide transportation services. Medicaid requires '}},
{ timecode: 1924, handler: 'blob', id: 129, data: {text: 'a freedom of choice of providers for all recipients. The waiver allows the transportation to get away from that and still claim the higher match. Recently CMS has published regulations that provide '}},
{ timecode: 1941, handler: 'blob', id: 130, data: {text: 'another way for states to operate a brokered medical transportation program and still receive the medical match, and that’s the provisions that came out of the Deficit Reduction Act that Dale '}},
{ timecode: 1957, handler: 'blob', id: 131, data: {text: 'talked about yesterday. And what that involves is the state applying for and amending its State Medicaid Plan to write into that a brokered transportation, medical transportation operation, and meet '}},
{ timecode: 1973, handler: 'blob', id: 132, data: {text: 'the other requirements that CMS has established for that. So with that background, you can ask questions. But I wanted to go to Jeanne right now, because they’re in the midst of that plan '}},
{ timecode: 1984, handler: 'blob', id: 133, data: {text: 'amendment, and I kind of wanted to ask you what encouraged the state to move in that direction, and where are you in that process? JEANNE LANG: Okay. Up until a couple years ago we were like Virginia '}},
{ timecode: 1996, handler: 'blob', id: 134, data: {text: 'in that we were a 50-50 match. The match rate for your state is based on your per capita income, poverty income. So if you have a population where the income is higher, your match rate is lidded at 50 '}},
{ timecode: 2015, handler: 'blob', id: 135, data: {text: 'percent federal match. If your poverty rate, and if you have a higher poverty rate and more low income people, then your match rate could be 60, 70-some percent that the feds chip in. When '}},
{ timecode: 2030, handler: 'blob', id: 136, data: {text: 'you\'re 50-50 it doesn\'t really matter if we were administrative rate or medical match rate. When we got to our state being 51 and a quarter, it meant a difference to us of 900,000 dollars a year in '}},
{ timecode: 2046, handler: 'blob', id: 137, data: {text: 'additional federal contributing. So we made the decision that we were going to move towards the medical match rate, and – DAVID RAPHAEL: And now it’s even better with the enhanced rate '}},
{ timecode: 2059, handler: 'blob', id: 138, data: {text: 'under the DRA. JEANNE LANG: Well, yeah, but we didn’t know that yet when we were starting filling out the application and turning it in and everything. You have – we submitted our '}},
{ timecode: 2066, handler: 'blob', id: 139, data: {text: 'application by about December 28th. For those of you who are familiar with state plan amendments, if you get it in by the end of the quarter and it’s approved, then it’s retroactive to the '}},
{ timecode: 2076, handler: 'blob', id: 140, data: {text: '1st of October, so we got ours in about the 28th of October. It’s going to be retroactive approved to October 1st, if it’s approved. But in the meantime, the stimulus package went through, '}},
{ timecode: 2087, handler: 'blob', id: 141, data: {text: 'and so instead of looking at a match rate that was at 51.25, ours got kicked up, so we’re going to be at 62 or 63 percent federal match rate. So instead of looking at getting an additional '}},
{ timecode: 2102, handler: 'blob', id: 142, data: {text: '900,000 dollars in federal funds, we’re looking at 9 million dollars in federal funds. And given the state of the state budget and having a 9 million dollar or 9 billion dollar gap, we really '}},
{ timecode: 2116, handler: 'blob', id: 143, data: {text: 'have no choice but to go down that path. DAVID RAPHAEL: What’s been the process? What’s gone on with that, and how is it likely to affect your program? JEANNE LANG: Well, the timing was a '}},
{ timecode: 2125, handler: 'blob', id: 144, data: {text: 'little bit tricky because at about the time that we were talking about yes, we’re going to do this, we’re going to submit the application to get our state plan amendment changed, they '}},
{ timecode: 2133, handler: 'blob', id: 145, data: {text: 'actually came out and published the new regs under the DRA, and that was published in mid-December. So here we wanted to put in application, but we had to be sure that we read the regs and are we in '}},
{ timecode: 2143, handler: 'blob', id: 146, data: {text: 'compliance with the new regulations. They were published, we read through this – you know, we’re doing this, we’re doing this, we’re doing the other. And so we got our '}},
{ timecode: 2152, handler: 'blob', id: 147, data: {text: 'application in to switch the medical match rate by the end of December. We had some discussions with CMS staff. Both the CMS staff in the region 10 office, which is in Seattle, as well as CMS staff in '}},
{ timecode: 2168, handler: 'blob', id: 148, data: {text: 'headquarters. Region 10, I don’t think region 10 office had dealt with one of these before because most of the guidance was coming out of Baltimore office. They actually have been very helpful '}},
{ timecode: 2178, handler: 'blob', id: 149, data: {text: 'to us. Yes, they challenged us and we had to submit documentation about our previous procurement, competitive procurement, the types of brokers that we have lined up, submitted copies of our '}},
{ timecode: 2191, handler: 'blob', id: 150, data: {text: 'contracts, and they went through that with a fine tooth comb. And it looks like that we’ll be able to claim medical match on about 75 to 80 percent of our trips statewide. The balance of the '}},
{ timecode: 2205, handler: 'blob', id: 151, data: {text: 'trips are provided in rural areas where the broker may be a provider, and where the brokers are providers, yes, there are exceptions that you can deal with, but for us we’re only talking about '}},
{ timecode: 2219, handler: 'blob', id: 152, data: {text: 'small percentages of trips, so we’ll be able to convert 80 percent of our trips to medical match. And the remainder, because they don’t quite meet the federal requirements, will stay at '}},
{ timecode: 2232, handler: 'blob', id: 153, data: {text: 'administrative match in those counties or those regions. So I think what some states may not realize is that you can have a mixed state, as far as match rate. DAVID RAPHAEL: Let me come back to that '}},
{ timecode: 2246, handler: 'blob', id: 154, data: {text: 'in a second and talk with Bob. I don’t know if that’s clear to people. A number of states are now moving to take advantage of it. It can be mixed. I know in Pennsylvania they recently '}},
{ timecode: 2256, handler: 'blob', id: 155, data: {text: 'applied simply for the County of Philadelphia, where they have a broker contract, which meets the CMS guidelines on that. The rest of the state is going to be continued to be operated in an '}},
{ timecode: 2268, handler: 'blob', id: 156, data: {text: 'administrative match, at a 50-50 match, and Philadelphia will be grandfathered in under this plan amendment. Bob, your state’s done both, right? You went for a waiver and now are in on the plan '}},
{ timecode: 2286, handler: 'blob', id: 157, data: {text: 'amendment; is that right? BOB KNOX: Right. We started out as admin. How many of you work closely with Medicaid? I mean, who are not Medicaid transportation providers? Very many of you? Okay. We '}},
{ timecode: 2304, handler: 'blob', id: 158, data: {text: 'don’t want to get too far, too deep into the state Medicaid operations unless it’s useful to you, but we started out with transportation in administration. We took it out because in '}},
{ timecode: 2317, handler: 'blob', id: 159, data: {text: 'Virginia when there’s going to be a budget cut, the first thing they cut is agency admin costs, so that meant either the broker would get cut or we’d have to spread the broker’s '}},
{ timecode: 2329, handler: 'blob', id: 160, data: {text: 'share of the cut in admin to the rest of the program, so we moved it over to, moved it over to medical with 19.15(b) waiver. When that expired we just, we already had it in the state plan before the '}},
{ timecode: 2347, handler: 'blob', id: 161, data: {text: 'DRA so we really didn’t have to do – DAVID RAPHAEL: Just the operation? BOB KNOX: Yeah. DAVID RAPHAEL: Good. Nick, let me come back to you. Not on waivers, but on – I mean, these are '}},
{ timecode: 2357, handler: 'blob', id: 162, data: {text: 'movements that these states and others are doing under the financial pinch. And I really wanted to ask you what other states are doing and what you’re aware of in the way of attempts to cut '}},
{ timecode: 2370, handler: 'blob', id: 163, data: {text: 'Medicaid expenses or reduce them? Let me ask Nick. NICK FARBER: At least 19 states have implemented cuts so far that affect eligibility of people to get health insurance or access, their access to '}},
{ timecode: 2389, handler: 'blob', id: 164, data: {text: 'health care. For example, Arizona is reducing its Medicaid rolls or requiring some adult beneficiaries to reapply for benefits more frequently. And some studies have shown that requiring people to '}},
{ timecode: 2404, handler: 'blob', id: 165, data: {text: 'reapply more frequently reduces the amount of people who can qualify for Medicare because they’re, one, either not aware of that they have to reapply, or they don’t get the paperwork in '}},
{ timecode: 2419, handler: 'blob', id: 166, data: {text: 'time. So that reduces the amount of people on Medicare, or Medicaid, excuse me. Rhode Island has reduced the maximum income level at which a parent can receive public health insurance from 185 percent '}},
{ timecode: 2430, handler: 'blob', id: 167, data: {text: 'of the poverty, federal poverty line, to 175 percent, eliminating coverage for around 1,000 parents. 7800 other low income families are paying higher monthly premiums for public health insurance. In '}},
{ timecode: 2448, handler: 'blob', id: 168, data: {text: 'Tennessee, 30 to 40,000 people are going to lose their hospitalization benefits and other needed medical services. Also several other states, like California, Michigan, Nevada, and Utah, have cut '}},
{ timecode: 2463, handler: 'blob', id: 169, data: {text: 'their dental and vision services for Medicaid. So that’s what states are doing right now. I mean, they’re pretty broad cuts right now, but I think we’ll start seeing – DAVID '}},
{ timecode: 2477, handler: 'blob', id: 170, data: {text: 'RAPHAEL: We’re trying to monitor, as an organization, also the various changes that are going on. And they’re kind of all in 2 categories. One are efforts to try to manage the program '}},
{ timecode: 2486, handler: 'blob', id: 171, data: {text: 'better, I think you could call that. And that’s kind of practical and maybe desirable things. Moving to public transit. Shifting the cost to try to shift costly trips formerly on paratransit, '}},
{ timecode: 2500, handler: 'blob', id: 172, data: {text: 'onto fixed route bus service, or moving into mileage reimbursement programs. Moving to capitation, shifting Medicaid into managed care is another cost saving effort that the states are doing. Florida '}},
{ timecode: 2517, handler: 'blob', id: 173, data: {text: 'has been moving in that direction. Moving to brokerages. I’ve talked to people here in this audience from New Jersey. And New Jersey is just going into a brokerage operation, which I assume is '}},
{ timecode: 2530, handler: 'blob', id: 174, data: {text: 'aimed at trying to reduce costs of the program. There are the more radical or extreme actions. I mean this is the challenge here, is how to balance budgets and not take it out on the backs of Medicaid '}},
{ timecode: 2544, handler: 'blob', id: 175, data: {text: 'recipients. Some of the extreme things that are coming forward, client dumping, which is sort of an old history, but sort of making public transit do it. Say these are public transit riders, and we '}},
{ timecode: 2558, handler: 'blob', id: 176, data: {text: 'ought not be paying for them, we Medicaid. Or legislatively, simply capping the funds. They did that in Maryland several years ago. They simply said, next year our Medicaid transportation budget is X. '}},
{ timecode: 2571, handler: 'blob', id: 177, data: {text: 'It’s legally challengeable, but, you know, you’ve got to have a court, and you got to have a lawyer to make that go through. More recently, we’ve been alarmed at reports in Idaho, '}},
{ timecode: 2582, handler: 'blob', id: 178, data: {text: 'for example, the state legislature suspended non-emergency Medicaid transportation as a service, administrative or medical, in their program. Fortunately, it appears the administration has blocked '}},
{ timecode: 2597, handler: 'blob', id: 179, data: {text: 'that, but in another end around in Michigan – and some of you may have more experience, and I wish you’d talk with us – in Michigan, we understand, the Governor has, through '}},
{ timecode: 2607, handler: 'blob', id: 180, data: {text: 'executive order, has eliminated non-emergency medical transportation, and raises a real challenge as to – Nick, do you have something to add on that? NICK FARBER: Yeah, I looked at it yesterday, '}},
{ timecode: 2618, handler: 'blob', id: 181, data: {text: 'I looked at the executive order. I just took some notes on it. I think it zeros out the transportation budget, which is 1.3 million dollars. It reduces the community services budget by 661,900 '}},
{ timecode: 2636, handler: 'blob', id: 182, data: {text: 'dollars, nutrition services by 479,400 dollars, and a senior companion volunteer program by 85,900 dollars. The executive order reduces total expenditures by 127 million dollars. I think we’re '}},
{ timecode: 2653, handler: 'blob', id: 183, data: {text: 'going to start seeing this in more states. One in Minnesota. They have a Democratic legislature and a Republican governor. If they can’t agree on a budget, Governor Pawlenty has said he’s '}},
{ timecode: 2666, handler: 'blob', id: 184, data: {text: 'going to figure out the budget himself, and I could see him, governors cutting, like in Nevada, California, so I think we’re going to start seeing this right now. DAVID RAPHAEL: And is the '}},
{ timecode: 2678, handler: 'blob', id: 185, data: {text: 'challenge for us an educational one? I’m shocked that a state like Michigan would cut a program that equals one percent of its budget, with pretty proven statistics that the costs for the state '}},
{ timecode: 2691, handler: 'blob', id: 186, data: {text: 'will rise ultimately through all the things we were talking about earlier. Increased use of emergency room care. And it seems like a very penny wise, pound foolish move. Do you have any sense whether '}},
{ timecode: 2704, handler: 'blob', id: 187, data: {text: 'or not Medicaid transportation funding is understood and its relatively small part of the Medicaid program, Nick? NICK FARBER: I don’t think it’s well understood. You know, with the '}},
{ timecode: 2717, handler: 'blob', id: 188, data: {text: 'statistics we were looking at this morning, with only 10 percent of the Medicaid population actually using non-emergency medical transportation. I, you know, I just don’t see legislators or '}},
{ timecode: 2730, handler: 'blob', id: 189, data: {text: 'governors understanding the complete breadth of NEMT. DAVID RAPHAEL: For a largely voiceless constituency. Are there other examples that didn’t fall in the range of things that you’re '}},
{ timecode: 2745, handler: 'blob', id: 190, data: {text: 'seeing in your own states, in terms of cutbacks or restrictions or barriers that are being thrown up? We hit most of them? Yeah, in the back? AUDIENCE MEMBER: I was wondering for Nick, at Legislative '}},
{ timecode: 2776, handler: 'blob', id: 191, data: {text: 'Council. A lot of what I’ve been reading in the social services area, quite a few states are also cutting back or instituting wait lists or caps on the Medicaid home care waivers. And, of '}},
{ timecode: 2791, handler: 'blob', id: 192, data: {text: 'course, that’s where a lot of non-emergency, you called it separate kind of transportation, but that’s where a lot of transportation Medicaid money right now comes into various systems. '}},
{ timecode: 2801, handler: 'blob', id: 193, data: {text: 'And there’s been a lot of protests, but there are several big states that are talking about capping the waivers, cutting back on in-home services and other things, so I think that, they '}},
{ timecode: 2811, handler: 'blob', id: 194, data: {text: 'aren’t calling it directly transportation, but I think it will have an effect on transportation. DAVID RAPHAEL: The tragedy, of course, is those waivers were put into place and the governors '}},
{ timecode: 2820, handler: 'blob', id: 195, data: {text: 'jumped on them because it was a way of saving money in the long run. I understand, but in the long run, that will raise other types of services. Before we go back to our discussion on brokers, anybody '}},
{ timecode: 2834, handler: 'blob', id: 196, data: {text: 'else on a – yeah, Steve? STEVE IN AUDIENCE: Sorry. This isn’t necessarily a question on brokers, but in thinking about state budgets, and I’ve sort of had this argument with '}},
{ timecode: 2852, handler: 'blob', id: 197, data: {text: 'colleagues in that I believe that the budget crisis gets worse in 2011 for states just because the stimulus money’s gone, right, and that’s sort of the way I understood it. I mean, what do '}},
{ timecode: 2867, handler: 'blob', id: 198, data: {text: 'you think the, what do you suppose the worst year for budgets will be over the next 3 or 4 years? When – because I’m afraid when the stimulus money’s gone, right, like a state like '}},
{ timecode: 2878, handler: 'blob', id: 199, data: {text: 'Michigan loses that, you know, that 10 percent Medicaid match that we got, we’re still cutting things like medical transportation that don’t make much sense in a logical sort of way, but '}},
{ timecode: 2892, handler: 'blob', id: 200, data: {text: 'there’s not much left to cut, I think is the problem, and so I was just wondering what your thoughts were on that. NICK FARBER: Well, talking with my colleagues, we had kind of an organization '}},
{ timecode: 2906, handler: 'blob', id: 201, data: {text: 'wide conversation about this. I think our executive director, people on our staff, our fiscal staff, definitively see 2010, 2011, it’s not going to get better from here. Basically. I think '}},
{ timecode: 2924, handler: 'blob', id: 202, data: {text: 'we’re seeing 2012 is we’re going to start seeing states come out of it. I haven’t heard anything about the stimulus money affecting states. I think what the goal of the stimulus '}},
{ timecode: 2939, handler: 'blob', id: 203, data: {text: 'package was is to maybe make that 2 years, 2 to 3 years not as bad as it would have been. So I think that’s our take on it. DAVID RAPHAEL: Nick, while you’ve got the mike, would you give '}},
{ timecode: 2954, handler: 'blob', id: 204, data: {text: 'us a couple paragraphs on the National Conference on State Legislatures. Just give us a little bit of background. NICK FARBER: Sure thing. We\'re a bipartisan organization. All 50 state '}},
{ timecode: 2965, handler: 'blob', id: 205, data: {text: 'legislatures and state territories belong, so every legislator is a member. We cover all policy areas. I cover transportation. There is fiscal, health, education, criminal justice. And we provide '}},
{ timecode: 2984, handler: 'blob', id: 206, data: {text: 'states non-partisan research on laws, and we also lobby Congress for states’ rights. We have bipartisan commissions on 11 different areas, and we, they have to have a two-thirds majority in '}},
{ timecode: 3002, handler: 'blob', id: 207, data: {text: 'order for us to have a position in order to lobby Congress. So it’s definitely very bipartisan, and we’re here to help the states and that’s basically about it. We’ve been '}},
{ timecode: 3015, handler: 'blob', id: 208, data: {text: 'around for like 30 years. DAVID RAPHAEL: Let me get back, Jeanne, on your program. One of the dreams, I think for years, in the early days, certainly in Washington, was that this broker platform would '}},
{ timecode: 3029, handler: 'blob', id: 209, data: {text: 'become just that. A platform for a coordination of transportation of all types in those regional areas. And I guess the question to you is how much progress have the states been able to make on that, '}},
{ timecode: 3042, handler: 'blob', id: 210, data: {text: 'or to what extent are the brokers operating and coordinating more than simply Medicaid transportation today? JEANNE LANG: Well primarily, brokers in our state also broker interpretative services, '}},
{ timecode: 3059, handler: 'blob', id: 211, data: {text: 'spoken language interpretative services. We consider it an access service, like transportation is an access service. The clients need to have interpretative services at the medical appointment is also '}},
{ timecode: 3070, handler: 'blob', id: 212, data: {text: 'access. And so our brokers interpret both. I mean broker, both transportation as well as interpretative services. CMS doesn’t seem to have a problem with that, having sort of 2 books of '}},
{ timecode: 3083, handler: 'blob', id: 213, data: {text: 'business. They were really clear. They wanted to have the funding be really clear and clean and separate, separate contracts, although we can have it with one broker. Some of the brokers also get '}},
{ timecode: 3097, handler: 'blob', id: 214, data: {text: 'separate funding for transportation of homeless children to schools through the McKinney-Vento Act. Others have separate contracts with other parts of the Department of Social and Health Services to '}},
{ timecode: 3109, handler: 'blob', id: 215, data: {text: 'buy bus passes for people going to JARC funded work-related trips. The primary thing is that you need to keep your funding sources straight. You need to be sure that the trips are charged to the '}},
{ timecode: 3124, handler: 'blob', id: 216, data: {text: 'appropriate funding source, and that that funding source’s portion of the administrative of your brokerage is there is funding to pick that up too. You can’t layer on these additional '}},
{ timecode: 3138, handler: 'blob', id: 217, data: {text: 'things and then expect Medicaid operating the brokerage to pick up the admin for trips funded by other funding sources. So in our state, the administrative cost at the broker level is prorated across '}},
{ timecode: 3154, handler: 'blob', id: 218, data: {text: 'on a trip basis. If 75 percent of the trips are for the SSI funding category, 75 percent, you know, if 25 percent, whatever. So you’ve got to really keep your funding straight. DAVID RAPHAEL: '}},
{ timecode: 3167, handler: 'blob', id: 219, data: {text: 'We’ve got a question here. And while you get him a mike, let me just – I don’t know if Gail Bauhs is here from TriMet, my city, in Portland, but Oregon has a series of regional '}},
{ timecode: 3181, handler: 'blob', id: 220, data: {text: 'brokers also, but unfortunately they don’t qualify under the CMS guidelines. But one of the challenges there, and at least one area’s trying to do it, and that is have the same broker '}},
{ timecode: 3192, handler: 'blob', id: 221, data: {text: 'operate ADA paratransit and Medicaid transportation with one call center, one network of providers. That’s the sort of dream that I think many of us thought this brokerage arrangement might lead '}},
{ timecode: 3206, handler: 'blob', id: 222, data: {text: 'to, and it’s been slow and difficult coming. And we can get back to that in a second. I’m sorry, I talked right over your question. AUDIENCE MEMBER: Does the regional broker do scheduling '}},
{ timecode: 3235, handler: 'blob', id: 223, data: {text: 'and eligibility? BOB KNOX: In Virginia they do, it’s pretty much a full service brokerage model. They determine eligibility of the person. They determine eligibility of the trip. If it needs a '}},
{ timecode: 3254, handler: 'blob', id: 224, data: {text: 'pre-authorization. If the procedure, like an MRI for Virginia, needs a pre-authorization, they’ll make sure you’ve got that. They recruit the network, assign the trips, look at complaints, '}},
{ timecode: 3271, handler: 'blob', id: 225, data: {text: 'do all the reporting, and pay all the claims. That’s not the only way to do a broker, but that’s what we’ve done. As we do this, getting ready for a new procurement in the next '}},
{ timecode: 3291, handler: 'blob', id: 226, data: {text: 'couple of years, we’ll go back and look at each one of these functions and see if it’s, if there’s any that we want to do differently. DAVID RAPHAEL: Jeanne, how about the '}},
{ timecode: 3304, handler: 'blob', id: 227, data: {text: 'broker’s role in Washington? Just a follow-up on that. JEANNE LANG: In Washington it’s very similar. The broker does the eligibility check and assignment to one of their subcontracted '}},
{ timecode: 3316, handler: 'blob', id: 228, data: {text: 'providers. In those, like King County, which is where Seattle is, where it’s very population dense, they do actually set up routed trips for – they pay for a vehicle on a per hour basis '}},
{ timecode: 3332, handler: 'blob', id: 229, data: {text: 'instead of on a per trip basis. And assign what people are going to be picked up along the route. In other brokers that are not as population dense, some of that grouping is done by the broker. '}},
{ timecode: 3347, handler: 'blob', id: 230, data: {text: 'Sometimes the grouping is done by the actual provider. It depends. There are certain populations that you don’t mix, methadone and children. There are other populations that can be, '}},
{ timecode: 3362, handler: 'blob', id: 231, data: {text: 'they’re groupable. It depends on if there’s anybody else going to, from that origin area to destination at a similar time. AUDIENCE MEMBER: First just a comment. One thing hasn’t '}},
{ timecode: 3374, handler: 'blob', id: 232, data: {text: 'been mentioned yet, is, at least in Alaska, and I’m assuming other parts of the country – DAVID RAPHAEL: I can’t hear you. AUDIENCE MEMBER: Okay. Is that better? DAVID RAPHAEL: A '}},
{ timecode: 3384, handler: 'blob', id: 233, data: {text: 'little bit. AUDIENCE MEMBER: I’m assuming that Alaska’s not unique this way. But it’s true in Alaska that if the Medicaid biller is a federally recognized tribal organization, and '}},
{ timecode: 3400, handler: 'blob', id: 234, data: {text: 'usually referred to as a compacted 638, section 638. They in fact receive 100 percent reimbursement for their medical trips. And so I know the State of Alaska is very intent in trying to train the '}},
{ timecode: 3415, handler: 'blob', id: 235, data: {text: 'native health organizations in how to do third party billing so that they will take on that function and save the state a lot of money. So I don’t know if that’s relevant to other states, '}},
{ timecode: 3424, handler: 'blob', id: 236, data: {text: 'but I thought it might be something to mention here. The other point I wanted to make was we had some good questions today for Jeanne, because I am familiar with one of her brokerages, the one '}},
{ timecode: 3439, handler: 'blob', id: 237, data: {text: 'government one, she said the Northwest Regional – what’s it called? JEANNE LANG: Council of Northwest – AUDIENCE MEMBER: Council of Governments, right. I think they’re '}},
{ timecode: 3447, handler: 'blob', id: 238, data: {text: 'dynamite. It’s amazing what they do in very rural counties, we’re talking about. But they link in with all the other counties, that I can tell, and they even link in with Oregon health '}},
{ timecode: 3459, handler: 'blob', id: 239, data: {text: 'facilities. It’s pretty amazing. So someone in a very rural spot on an island up north can get into Seattle or to Portland for their medical appointments. One of the points I wanted to ask you, '}},
{ timecode: 3471, handler: 'blob', id: 240, data: {text: 'Jeanne, though was that one of the gals today from Access said, well, what do they do when they get down there and have to wait around in Seattle so far from home, and that’s idle time. And I '}},
{ timecode: 3482, handler: 'blob', id: 241, data: {text: 'couldn’t remember the answer to that question, but this is the level in which they’ve worked these things out, so I’m really impressed for Washington. JEANNE LANG: It’s a '}},
{ timecode: 3495, handler: 'blob', id: 242, data: {text: 'complicated question. When - different brokers do it different ways. Some brokers set up these group trips where they leave, you know, at zero dark thirty in the morning and they go over to Seattle, '}},
{ timecode: 3508, handler: 'blob', id: 243, data: {text: 'and when the last appointment’s done, they all go back. Others try to group; maybe ask if the appointment could be changed so it’s not at 3 o\'clock. If it’s at 1 o\'clock then '}},
{ timecode: 3518, handler: 'blob', id: 244, data: {text: 'it’s more groupable, and that sort of thing. It depends on the locale. It depends on how far you are to go back to the origin. So you try to eliminate dead head when you can, because that is a '}},
{ timecode: 3532, handler: 'blob', id: 245, data: {text: 'cost. It may not be a cost that the provider can charge for, but they bill it into their cost overall, whether it’s a trip cost or an hourly rate cost, and so to the ability that you can group '}},
{ timecode: 3544, handler: 'blob', id: 246, data: {text: 'things and have less dead head, ultimately you have less cost. DAVID RAPHAEL: I’m aware of some really very fascinating coordination models in Washington State also where the brokers work '}},
{ timecode: 3556, handler: 'blob', id: 247, data: {text: 'together. So someone out of state will send somebody on Greyhound. Will pick them up, bring them to Greyhound or Amtrak. The person rides to Seattle where the Seattle broker, King County broker, will '}},
{ timecode: 3569, handler: 'blob', id: 248, data: {text: 'pick them up and handle that trip locally. It’s in everybody’s interest to do that. JEANNE LANG: We have required in our contract that the brokers work together, neighboring brokers. If '}},
{ timecode: 3581, handler: 'blob', id: 249, data: {text: 'you’re sending a client into Seattle or whatever, you may send a fax ahead of time to the Seattle broker saying this person’s going to be in your area, they may or may not call you, so '}},
{ timecode: 3590, handler: 'blob', id: 250, data: {text: 'you’ve already screened them, you know what their eligibility is, what they’re going for, estimated time they’re going to be there. So we consider it very client focused. If we can '}},
{ timecode: 3601, handler: 'blob', id: 251, data: {text: 'take care of the needs for the client, then you can also reduce trip cost. DAVID RAPHAEL: Nick, do you have something to add? NICK FARBER: Yeah. Washington recently passed a bill that makes their '}},
{ timecode: 3613, handler: 'blob', id: 252, data: {text: 'coordination system I think a little bit more streamlined and a little bit better. House Bill 2072 requires the Agency Council On Coordinated Transportation to appoint a work group to ID federal '}},
{ timecode: 3625, handler: 'blob', id: 253, data: {text: 'requirements related to special needs transportation and streamline the process in providing services to persons with transportation needs, establishes a statewide oversight agency to kind of oversee '}},
{ timecode: 3639, handler: 'blob', id: 254, data: {text: 'local service providers, including public agencies, private organizations, organizations in community-based groups, increase local coordinating coalition at each non-emergency medical transportation '}},
{ timecode: 3650, handler: 'blob', id: 255, data: {text: 'brokerage region, to help local efforts to coordinate and maximize special needs transportation. It requires local coordinating coalitions to develop or implement a pilot project in the region to '}},
{ timecode: 3663, handler: 'blob', id: 256, data: {text: 'demonstrate cost sharing and cost saving opportunities. It requires, at the beginning of next year, any organization applying for state paratransit or special needs grants must explain how the '}},
{ timecode: 3674, handler: 'blob', id: 257, data: {text: 'requested funding will advance efficiencies in accessibility to, or coordination of, transportation services provided to persons with special transportation needs. DAVID RAPHAEL: Washington State is a '}},
{ timecode: 3684, handler: 'blob', id: 258, data: {text: 'wonderful model for coordination. I mean, they’ve collapsed all of those stovepipe programs that we talk about. 53.10, JARC, New Freedom. The state just has those soft money programs. You apply '}},
{ timecode: 3697, handler: 'blob', id: 259, data: {text: 'for your need there and they decide whether that’s fundable under 53.10 or something else. Unfortunately, this legislation, because of the budget crisis, got passed, but without the money that '}},
{ timecode: 3708, handler: 'blob', id: 260, data: {text: 'people were hoping would be there to fund some of the demonstrations. I think we’ve got a question there in the back? AUDIENCE MEMBER: Yes. I’m from New York state and I had a question '}},
{ timecode: 3717, handler: 'blob', id: 261, data: {text: 'about, we have Medicaid, a program called Spend Down, where somebody doesn’t qualify, but they have to sort of keep their receipts and then they submit it to DSS, and it just is an absolute '}},
{ timecode: 3729, handler: 'blob', id: 262, data: {text: 'inefficient system when it comes to transportation, because people provide the transportation only to find out that at the end of the month they didn’t meet their spend downs so they’re '}},
{ timecode: 3738, handler: 'blob', id: 263, data: {text: 'ineligible for the transportation, and the transportation provider gets burned. And I’m curious whether you have seen this modified elsewhere? Certainly I hear from New York, counties want it '}},
{ timecode: 3750, handler: 'blob', id: 264, data: {text: 'modified. But what method have they done to replace that crazy idea? BOB KNOX: We call that Medicaid pending. It’s not only for spend down, but other people that apply for Medicaid, it takes a '}},
{ timecode: 3767, handler: 'blob', id: 265, data: {text: 'month or so to get all your paperwork reviewed and get enrolled. Sometimes it takes much longer. But we have, by contract, our broker is supposed to provide transportation if those people request it '}},
{ timecode: 3784, handler: 'blob', id: 266, data: {text: 'and then if they become eligible, then everybody – the eligibility will be retroactive. Occasionally it will be for a year back. Usually it’s more like 4 months, 4 to 6 months most people '}},
{ timecode: 3803, handler: 'blob', id: 267, data: {text: 'are enrolled. But you got to tell the provider because it’s a crap shoot, and if they never get enrolled, the provider may never get paid, although most of them do get enrolled. DAVID RAPHAEL: '}},
{ timecode: 3819, handler: 'blob', id: 268, data: {text: 'Well, and this has been one of the difficulties of Medicaid from the beginning. It\'s not just the Nixon new federalism that Dale talked about. Medicaid has always been a state, a locally'}},
{ timecode: 3828, handler: 'blob', id: 269, data: {text: 'administered program, and you’ve got 50 of them plus the colonies. So that your battles there may be entirely different, and it makes it difficult for organizations like CTAA to mount sustained '}},
{ timecode: 3841, handler: 'blob', id: 270, data: {text: 'campaigns, because it’s so decentralized. And for the most part, regardless of the administration, CMS has basically been hands off. Occasionally they come in and put a few people in jail when '}},
{ timecode: 3854, handler: 'blob', id: 271, data: {text: 'it gets really terrible, but there’s really no guidelines, there’s no medical program, there’s no training, there’s no serious monitoring other than occasionally when they come '}},
{ timecode: 3864, handler: 'blob', id: 272, data: {text: 'after public transit agencies that get involved in it. Is there another question? I think there’s one back there, and then we’ll come forward. JEANNE LANG: David, can I just say something '}},
{ timecode: 3873, handler: 'blob', id: 273, data: {text: 'to the gentleman from New York? DAVID RAPHAEL: Sure. JEANNE LANG: From New York, we also have a Medicaid medically needy program, and it is a headache. I’d be happy to talk with you afterwards '}},
{ timecode: 3883, handler: 'blob', id: 274, data: {text: 'about some of the things we do to deal with that. DAVID RAPHAEL: Thank you on that. Doug? DOUG IN AUDIENCE: I actually heard 2 things that I didn’t quite understand. One was that in Michigan, '}},
{ timecode: 3894, handler: 'blob', id: 275, data: {text: 'because of the budget crisis, they’re talking about cutting out non-emergency medical transportation. I earlier heard, and had believed, that it was because of court cases that that form of '}},
{ timecode: 3909, handler: 'blob', id: 276, data: {text: 'transportation access was actually ensured. So I got 2 questions, but this is the first one. How does that reconcile? How can a governor cut out NEMT if it\'s in fact ensured through court cases '}},
{ timecode: 3924, handler: 'blob', id: 277, data: {text: 'that you must provide that or you’re not providing medical transportation at all? So – not medical transportation, but medical care at all. So that was the first thing. And the second '}},
{ timecode: 3934, handler: 'blob', id: 278, data: {text: 'question I had was something that you raised, David, which was the vision of brokerage. Brokerages work well when you’re brokering more than one program together because then you can share '}},
{ timecode: 3945, handler: 'blob', id: 279, data: {text: 'rides. I mean, that’s the efficiencies that you might get out of brokerage. So if you’re contracting your brokerages separately, that means, in my mind, that you’re, there’s '}},
{ timecode: 3956, handler: 'blob', id: 280, data: {text: 'less chance for efficiency. So the question that I would raise is – and I know that that’s part of the Medicaid rules, that you have to competitively select your brokerage. But is it '}},
{ timecode: 3966, handler: 'blob', id: 281, data: {text: 'possible that a state would bundle several programs and competitively select the brokerage in one competition for several programs? Those are my 2 questions. DAVID RAPHAEL: Well, let me respond and '}},
{ timecode: 3980, handler: 'blob', id: 282, data: {text: 'then see if others want to. On your first one, it’s like you have freedom of the press, but you got to have a press or printing press to exercise it. There is a federal legal obligation to '}},
{ timecode: 3995, handler: 'blob', id: 283, data: {text: 'assure access to services. It could be a calculated thing. California still does not really provide non-emergency medical transportation, in compliance with what we would all consider federal '}},
{ timecode: 4008, handler: 'blob', id: 284, data: {text: 'regulations. They were sued in ’72 and the plaintiffs eventually just wear out. You’ve got to have a lawyer, and you got to have a court. So Michigan may be inviting a court challenge that '}},
{ timecode: 4022, handler: 'blob', id: 285, data: {text: 'may well be effective in the end, but could be 3 years down the road, after the crisis comes and goes or whatever. So it’s a calculated risk. Somebody I would think would be giving the governor '}},
{ timecode: 4035, handler: 'blob', id: 286, data: {text: 'there bad, poor legal advice because it’s challengeable. But we do things in this country that are challengeable all the time. On the brokerage thing, the broker, the Medicaid brokers, '}},
{ timecode: 4050, handler: 'blob', id: 287, data: {text: 'particularly those that began in the early days, like in Washington State, the notion was to coordinate the providers. This was the – you know, Medicaid was a taxi program in this country for '}},
{ timecode: 4061, handler: 'blob', id: 288, data: {text: 'most of its history. It was the presumption that taxis were the carrier of choice for Medicaid recipients, and what was introduced in Oregon and Washington State and these other states was the broker '}},
{ timecode: 4075, handler: 'blob', id: 289, data: {text: 'began to bring in public transit, and began to bring in the non-profits. Maybe introduced a volunteer program or a gas voucher or reimbursement program. So brokering in this case really is brokering '}},
{ timecode: 4090, handler: 'blob', id: 290, data: {text: 'among providers. I would love to see a state – I think Kentucky tried with its Empower Kentucky thing a decade or so ago, to get a couple of its agencies, rehab services, Aging, and Medicaid, '}},
{ timecode: 4105, handler: 'blob', id: 291, data: {text: 'all 3 to pool their operations through a single set of regional brokers, and it didn’t last very long. I’m not sure if anybody’s from Kentucky now. Are they brokering more than one '}},
{ timecode: 4120, handler: 'blob', id: 292, data: {text: 'client transportation group in Kentucky? They are. Aging and Medicaid, or rehab? So this was a very huge effort that the state went on to say we’re going to meld these programs, bundled them up '}},
{ timecode: 4141, handler: 'blob', id: 293, data: {text: 'here, and deliver them in a coordinated way down here. Terrific effort 10 years ago, but it doesn’t go on very often, and this challenge of simply even doing ADA paratransit and Medicaid call '}},
{ timecode: 4156, handler: 'blob', id: 294, data: {text: 'centers is a huge obstacle. Elaine, Eugene, Oregon is one of the few places that I’m aware that they’re even doing it. AUDIENCE MEMBER: Albany, New York bundled – Albany, New York '}},
{ timecode: 4171, handler: 'blob', id: 295, data: {text: 'bundled Medicaid and senior services transportation. DAVID RAPHAEL: Tom, you were saying another one back there? Salem, okay. It’s all of Oregon, what can you say. Thank you for that. NICK '}},
{ timecode: 4189, handler: 'blob', id: 296, data: {text: 'FARBER: I was going to respond to Doug’s – AUDIENCE MEMBER: Rhode Island does it. DAVID RAPHAEL: Others on Doug’s – NICK FARBER: I was going to respond to Doug’s first '}},
{ timecode: 4197, handler: 'blob', id: 297, data: {text: 'question. I think what we’re going to start seeing here in the next couple years with governors coming in and cutting budgets, we’re going to see a fight between legislatures and governors '}},
{ timecode: 4211, handler: 'blob', id: 298, data: {text: 'on who can actually control the budget. Usually legislatures come in, agree on a budget, send it to the governor, governor signs off with line item vetoes, things like that. I think, like in Nevada, '}},
{ timecode: 4227, handler: 'blob', id: 299, data: {text: 'Minnesota, Michigan, I think especially in Minnesota and Nevada, when you have a Democratically controlled legislature and a Republican governor, like in Nevada, they pass the budget, the '}},
{ timecode: 4240, handler: 'blob', id: 300, data: {text: 'governor’s going to veto it, and there’s not going to be enough time for them to overturn that veto, so the governor’s got to go in and line item, or just create his own budget. So I '}},
{ timecode: 4249, handler: 'blob', id: 301, data: {text: 'think, one, we’re going to see that fight, and then, you know, if they’re cutting non-emergency medical transportation, I think we’re going to start, could see lawsuits against '}},
{ timecode: 4258, handler: 'blob', id: 302, data: {text: 'states saying hey, you’re not providing the level of non-emergency medical transportation that you’re supposed to. But it’s one, that’s finding plaintiffs, finding enough '}},
{ timecode: 4267, handler: 'blob', id: 303, data: {text: 'plaintiffs. I think speaking as an attorney, I think you have to, I think you’d want to see a class action lawsuit in that kind of sense because, so it has a little bit more of an impact. So I '}},
{ timecode: 4281, handler: 'blob', id: 304, data: {text: 'think that’s what we’re going to start seeing in the future. I mean, that’s my opinion. DAVID RAPHAEL: I’m going to give our panelists an opportunity for a last word here. I '}},
{ timecode: 4290, handler: 'blob', id: 305, data: {text: 'don’t see any hands. Bob, let me throw you a question, but you can answer any question you want. How about that? BOB KNOX: Oh, that’s great. DAVID RAPHAEL: The question – BOB KNOX: '}},
{ timecode: 4301, handler: 'blob', id: 306, data: {text: 'Well, I think the Aggies are going to do great this year in football. DAVID RAPHAEL: The question really that I had is what are the challenges that a state like yours, where the brokerage is facing in '}},
{ timecode: 4313, handler: 'blob', id: 307, data: {text: 'the current session, and/or related to that, what can states or brokers do to reduce costs that don’t penalize the recipients? BOB KNOX: First thing I would do is move everybody to public '}},
{ timecode: 4326, handler: 'blob', id: 308, data: {text: 'transportation voluntarily that will go, and if that isn’t enough, and you see it’s not, it hasn’t reached the saturation that you think it could, then you could look at making it '}},
{ timecode: 4341, handler: 'blob', id: 309, data: {text: 'mandatory. But I’ll tell you, we got neighborhoods in Richmond where I wouldn’t make my grandmother walk from here to the back wall. So you got to – a half mile walk may not be '}},
{ timecode: 4351, handler: 'blob', id: 310, data: {text: 'practical for a lot of people, but you could work that out the way you want to. The other thing is to make sure you’re using, you got all the cards in your hand that, that you can. One is using '}},
{ timecode: 4363, handler: 'blob', id: 311, data: {text: 'vouchers, whether it’s for gas reimbursement or – and we don’t do this. I’m preaching to myself. But either vouchers – we do this with University of Virginia hospital, '}},
{ timecode: 4376, handler: 'blob', id: 312, data: {text: 'which gives you vouchers for gasoline or for a fare on certain taxis, and the gas voucher’s good at several gas stations there in Charlottesville. The other thing is what we call stretcher vans. '}},
{ timecode: 4392, handler: 'blob', id: 313, data: {text: 'I think that may be, or may not be, similar to an ambulette. It’s a super van. It’s not a small ambulance. It’s a van with stretcher anchorages and what have you. We tried that in '}},
{ timecode: 4413, handler: 'blob', id: 314, data: {text: 'Virginia. It took the broker a long time to figure out that that was a good thing. They went from – they were doing 150 trips a month a year ago, and now they’re doing – or a week, a '}},
{ timecode: 4428, handler: 'blob', id: 315, data: {text: 'year ago. Now they’re doing over 1,000 a week in the last few months. And so that’s really beginning to show, to be as productive in reducing costs without changing the quality of service. '}},
{ timecode: 4445, handler: 'blob', id: 316, data: {text: 'That’s just for people that don’t need Medicaid – don’t need medical attention in route. Mostly stretcher-bound people going to dialysis. The last thing is, I started off '}},
{ timecode: 4458, handler: 'blob', id: 317, data: {text: 'talking about fraud, which is always providers. But I think in Virginia, and I think this is true most places. The people that were committing fraud are not doing Medicaid transportation anymore. A '}},
{ timecode: 4473, handler: 'blob', id: 318, data: {text: 'lot of them in jail, going to Club Fed every day. And that’s a good thing. But the thing that a state with a brokerage has to always keep in mind is that your broker could go bust tonight. You '}},
{ timecode: 4491, handler: 'blob', id: 319, data: {text: 'never know how long the brokers, if they’re going to survive the recession like anybody else. And, or they may, for whatever reason, you may not have that broker or you may not have a broker '}},
{ timecode: 4505, handler: 'blob', id: 320, data: {text: 'that you want to do business with after you do any procurement. You’re always going to need that transportation provider network because whether you got a broker or not, you still got to get all '}},
{ timecode: 4519, handler: 'blob', id: 321, data: {text: 'those trips delivered. So you want to make sure that your broker is, has some sense of having a partnership with your transportation providers and is giving them, helping them make more money or save '}},
{ timecode: 4535, handler: 'blob', id: 322, data: {text: 'more money. Either one of those will work. DAVID RAPHAEL: Thank you very much. I’m going to ask, Jeanne, any closing words? I’ll lead you with a question about do you envision all your '}},
{ timecode: 4547, handler: 'blob', id: 323, data: {text: 'regions ultimately being converted to a medical match or not? JEANNE LANG: That’s our goal. Even those brokers that are providers, they’ve been lidded the number of trips that they could '}},
{ timecode: 4560, handler: 'blob', id: 324, data: {text: 'provide themselves. The percentage of non-transit trips could be no more than say start at 25 percent, then 20 percent. We’re now down to probably less than 10 percent, where the broker actually '}},
{ timecode: 4573, handler: 'blob', id: 325, data: {text: 'provides the trips themselves. Because we wanted them to go out and develop other resources, develop gas voucher programs, and that sort of thing. DAVID RAPHAEL: Well, you’ve been a good '}},
{ timecode: 4585, handler: 'blob', id: 326, data: {text: 'audience, and it\'s been a great panel. I want to thank all of them for joining us today. Please join me in thanking them. Thank you.'}},
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