waiver transportation rate study methodology and ... · 1212 / ©2018 navigant consulting, inc. all...

/ ©2017 NAVIGANT CONSULTING, INC. ALL RIGHTS RESERVED1

OCTOBER 23, 2018

WAIVER TRANSPORTATION RATE STUDY

METHODOLOGY AND

RECOMMENDATIONS

/ ©2017 NAVIGANT CONSULTING, INC. ALL RIGHTS RESERVED2 / ©2018 NAVIGANT CONSULTING, INC. ALL RIGHTS RESERVED2

OBJECTIVES

• Summarize the stakeholder feedback received during the Waiver

Transportation Study

• Present the recommendations developed by the Navigant

Consulting team

• Invite your comments and questions during and after this meeting


ASKING QUESTIONS AND PROVIDING COMMENTS

How to ask questions during the public webinar:

During this presentation you may submit written questions using the “raise your hand”

webinar option and we will respond to them at the end of the presentation

How to ask questions after the public webinar:

• If you have questions or comments you wish to submit after the webinar, please use

the online feedback form at the link below

• The comment period will end on November 6, 2018

• The project website will provide a summary of comments and questions received

Availability of this presentation:

A taped recording of this webinar will be posted on the study website

For more information, visit the project website:

https://public.navigant.com/sites/MNTranspStudy/SitePages/Rate%20Study.asp

To provide comments on the methodology and recommendations, please use

the online form on the project website:

https://navigantmarketing.co1.qualtrics.com/jfe/form/SV_2tbtusYdK25YMAd

https://public.navigant.com/sites/MNTranspStudy/SitePages/Rate Study.asp



AGENDA

1. Waiver transportation study overview

2. Waiver transportation study methodology

3. Minnesota’s waiver transportation providers

4. Key themes that informed recommendations

5. Rate Study recommendations


SECTION I: WAIVER

TRANSPORTATION STUDY

OVERVIEW


MEDICAID HOME AND COMMUNITY-BASED SERVICES

PROGRAMS

What are home and community-based services (HCBS)?

• Services that provide opportunities for aging people and people with disabilities to

receive services in their own homes or communities rather than other potentially isolating

settings

• Examples of services are adult day services, customized living, personal care assistance,

and waiver transportation

How do states use Medicaid to pay for HCBS?

• States must ask special permission from the federal government to use Medicaid funding

to implement HCBS

• This permission is granted in the form of a waiver of federal requirements. As such, these

programs are called “HCBS waiver programs”

• All states offer HCBS waiver programs. These programs vary in terms of the included

services and eligibility


MEDICAID HOME AND COMMUNITY-BASED SERVICES

PROGRAMS

What agencies or organizations are in charge of HCBS in Minnesota?

• The Minnesota Department of Human Services (DHS) administers HCBS programs

• There are four waiver programs for Minnesotans with disabilities and two programs for

aging Minnesotans where services are available if individuals meet certain eligibility

standards

• Lead agencies deliver the services including county social service agencies, managed

care organizations (MCOs), and tribal agencies

• Managed care organizations are the lead agencies for the Elderly Waiver Program

• Counties and Tribes are the lead agencies for disability waiver programs and the

Alternative Care Program


HCBS WAIVER PROGRAMS FOR AGING PEOPLE

Waiver Description

Waiver Transportation Recipients and

Expenditures

(State Fiscal Year 2016)

Alternative Care

(AC)

(fee-for-service)

Serves individuals over

age 65 years who are at

risk of nursing home

placement

• 572 recipients

• $298,915 in Medicaid expenditures

• $523 per recipient

Elderly Waiver

(EW)

(fee-for-service

and managed

care)

Serves individuals older

than age 65 who require

the level of care provided

in a nursing facility and

choose to reside in the

community

• 5,095 recipients

• $12,075,901 in Medicaid expenditures

• $2,370 per recipient


HCBS WAIVER PROGRAMS FOR INDIVIDUALS WITH DISABILITIES

DELIVERED BY COUNTIES AND/OR TRIBES

Waiver Description

Waiver Transportation

Recipients and

Expenditures


Brain Injury

(BI) Waiver

Serves individuals with a traumatic,

acquired, or degenerative brain injury (BI)

who require the level of care provided in a

nursing facility that provides specialized

services for persons with BI, or who

require the level of care provided in a

neurobehavioral hospital

• 641 recipients

• $1,052,033 Medicaid

expenditures


Community

Alternative

Care (CAC)

Waiver

Serves individuals who are chronically ill

and medically fragile who require the level

of care provided in a hospital

• 9 recipients

• $3,658 Medicaid

expenditures

• $406 per recipient


HCBS WAIVER PROGRAMS FOR INDIVIDUALS WITH DISABILITIES

DELIVERED BY COUNTIES AND/OR TRIBES, CONTINUED

Waiver Description

Waiver Transportation

Recipients and

Expenditures


Community Access

for Disability

Inclusion (CADI)

Waiver

Serves individuals with disabilities who

require the level of care provided in a

nursing facility


• $9,006,953 in Medicaid

expenditures


Developmental

Disabilities (DD)

Waiver

Serves individuals with developmental

disabilities or a related condition who

require the level of care provided in an

Intermediate Care Facility for Persons

with Developmental Disabilities

(ICF/DD)


• $2,250,692 in Medicaid

expenditures



CONTEXT FOR LEGISLATIVE MANDATE FOR


• In 2013, the Centers for Medicare and Medicaid Services (CMS) required states,

including Minnesota, to develop standardized service definitions and rates for all

HCBS waiver programs

• In 2014, DHS implemented new statewide HCBS rates

• Waiver transportation was excluded, because DHS did not have a process for

certifying waiver transportation providers as a group

• In 2017, the DHS Long Term Services and Supports Gap Analysis and Olmstead

Subcabinet consumer reports indicated gaps in service related to transportation for

people receiving HCBS waiver program services

• As a result, the Minnesota legislature directed DHS to conduct a study to identify

and recommend the following:

1. Waiver transportation service rate(s)

2. Waiver transportation technical and administrative improvements


DEFINITION OF WAIVER TRANSPORTATION SERVICES

What are waiver transportation services and why are they important?

• Waiver transportation allows seniors and individuals with disabilities to access

their communities and lead a productive and fulfilled life

• Examples of transportation destinations include:

- Shopping for groceries and household supplies

- Going to work

- Participating and recreational activities

• In State Fiscal year 2016, 16,254 HCBS waiver recipients received waiver

transportation services totaling $24,688,151 in Medicaid expenditures

What are the types of waiver transportation providers?

Types of waiver transportation providers include taxis, van services, public buses

and trains, and volunteer drivers


DEFINITION OF WAIVER TRANSPORTATION SERVICES

Which transportation services are not included in this study?

• Transportation services that are provided as an essential component of another

Medicaid HCBS service, for example:

- Adult day health care

- Day treatment and habilitation

- Group homes

• Transportation services related to medical care, for example:

- Emergency medical transportation (EMT)

- Non-emergency medical transportation (NEMT) services for recipients to access

doctor’s appointments


WAIVER TRANSPORTATION PROVIDER ENROLLMENT AND

BILLING

• How are waiver providers enrolled and how do they bill?

• The Centers for Medicare and Medicaid Services requires that all Medicaid HCBS

providers be Medicaid-enrolled. To meet these requirements, DHS created policies

that allow lead agencies to deem a provider as Medicaid-enrolled for the purposes

of waiver transportation services

• The majority of waiver providers enroll with lead agencies and submit invoices (not

in a Medicaid claim format) for payment. Lead agencies then convert this

documentation into Medicaid claims to receive DHS reimbursement


OVERVIEW OF TRANSPORTATION STUDY

There are two components of the Minnesota waiver transportation study:

1. Rate Study: Identify and recommend service rates for transportation

available under Minnesota’s four disability waiver programs and the Elderly

Waiver and Alternative Care programs

2. Access Study: Identify and recommend technical and administrative

improvements to transportation available to individuals under Minnesota’s

four disability waiver programs and the Elderly Waiver and Alternative Care

programs

Today’s public webinar discusses recommendations

developed as part of the Rate Study

(October 23, 2018 from 1:00 – 3:00 pm)


DHS ESTABLISHED ADVISORY GROUPS FOR EACH STUDY

• The Department of Human Services convened a Rate Study Advisory Group and an

Access Study Advisory Group to provide input and feedback throughout the study

via monthly meetings

• Members of these two stakeholder advisory groups included representatives for

waiver program consumers, state agencies/organizations, and statewide

associations and providers that influence transportation services

• Rate Advisory Group topics

- Provider cost and wage survey input

- Rate components / assumptions

- Feedback regarding rate recommendations

• Access Advisory Group meeting topics

- Access survey input

- Feedback regarding transportation access barriers and solutions


SECTION II: WAIVER


METHODOLOGY


STUDY METHODOLOGY

• Navigant developed key

observations and

recommendations from

extensive and comprehensive

research on waiver

transportation issues

• Research included qualitative,

quantitative, and mixed

methods

Recommendations

Quantitative

Mixed Method

Qualitative


QUALITATIVE RESEARCH

1. Qualitative Research

• Input and guidance from Access and Rate Advisory Groups

• Approximately 90 stakeholder interviews with individuals, groups, and online

email discussions including:

- Consumer organizations: National Alliance on Mental Illness Minnesota,

Governor’s Council on People with Developmental Disabilities and Minnesota

Disability Council

- Lead agencies: Representatives from four counties, seven MCOs covering

services to the elderly waiver participants, and email feedback from tribal agencies

- Minnesota State agency representatives: DHS, MnDOT, Metro Council, University

of Minnesota Humphrey School of Public Affairs

- Providers of transportation services


QUALITATIVE RESEARCH: CONTINUED

1. Qualitative Research

• Interviews with representatives from nine other state NEMT and HCBS

programs

• Literature and document review:

- Relevant Minnesota transportation-related programs, activities, and published

documents/reports

- Minnesota State statutes, policies and regulations

- National and local emerging transportation initiatives and new technologies

- Studies conducted on Medicaid transportation programs across the country


MIXED METHOD AND QUANTITATIVE RESEARCH

2. Mixed Method Research

• Navigant contracted with the University of Minnesota Humphrey School of

Public Affairs to develop and conduct an Access Survey directed at

providers of waiver transportation services and focused on understanding

fleet capacity and barriers to providing waiver transportation

3. Quantitative Research

• Navigant conducted a Rate Survey of providers of waiver transportation

services requesting specific information on the costs of providing services

• Navigant reviewed and analyzed two years of fee-for-service Medicaid

claims data (State Fiscal Years 2016 and 2017)


RATE SURVEY PROCESS

• Navigant developed a cost and wage survey to capture provider

information related to delivering waiver transportation services

• The survey was released through the relevant provider associations on July

17, 2018 and through MN-ITS on July 24, 2018, with an original due of

August 14, 2018

- There were two MN-ITS communications, one to day training and

habilitation (DT&H) and waiver transportation providers, and the other

going to all providers

- An extension was granted through August 17, 2018 to increase survey

responses

• Each survey was reviewed for consistency and completeness

• The results of the cost survey were used to inform the development of the

updated waiver transportation rates


RATE SURVEY REVIEW PROCESS

Cost Survey is submitted

Navigant reviews

Cost Survey

Questions are sent to Provider (if necessary)

Responses by Provider

are reviewed (if necessary)

Further questions are asked

(if necessary)


RATE SURVEY RESPONDENT PROFILE

• Surveys were received from:

- 61 providers (this represents approximately 12% of the 491 active and

enrolled waiver transportation and DT&H providers)

- Providers deliver services in 72 out of the 87 Minnesota counties

• Respondents generally provide:

• Respondents provide the following level of services:

• Day training and habilitation services • Occupational training

• Adult day care services • Other disability services

• Public transit • Other private transportation services

• Fixed route services – 26% • Door-through-door – 20%

• Curb-to-curb – 31% • Other assistance – 1%

• Door-to-door – 21%


SECTION III: EMERGING STATE

AND NATIONAL TRENDS


EMERGING TRANSPORTATION TRENDS – STATE AND

NATIONAL

Mix-model (fee-for-service, broker and/or managed care organization):

- Fee-based payment in some areas of the state,

- Contracts with transportation coordination companies who coordinate all

transportation services in other areas, and

- Managed Care Organizations

On demand request or ride-hailing services:

- Some states contract with “ride-hailing” companies to provide NEMT services

(e.g. Uber and Lyft)

- Dakota County has a similar pilot project with Lyft for waiver transportation



NATIONAL

1) MCOTA. Vehicle Sharing Among Human Service Providers in Minnesota: Steps to Address Barriers; Sept. 2013

Vehicle Sharing:1

• To increase access to transportation services, organizations are leveraging

vehicle-sharing services to increase coordination of transportation among many

consumers and lower overhead costs

• Definition: there are two types of vehicle-sharing:

- Time Sharing: One or more organizations operating the same vehicle at

different times

- Ride Sharing: Using the vehicle of one organization to provide

transportation for the clients of another organization

• Minnesota has several examples of vehicle sharing between county and city

transportation providers and private human service organizations


Regional Transportation Coordination Councils or RTCCs:2

• MnDOT, DHS, and other State agencies are working with the Metropolitan

Council and other local governments to create RTCCs throughout 8-10 regions in

the State

• MnDOT approved RTCCs will be funded in 2019 and operational in 2020 or later

• RTCCs will be responsible for coordinating transportation services through a

network of existing public, private, and non-profit transportation providers

• Each RTCC will be composed of residents within each service area with oversight

from the State and local agencies and organizations


NATIONAL

2) Coordinate MN Transit, Regional Transportation Coordinating Councils (RTCC’s). Available online: http://www.coordinatemntransit.org/regional/rtccs/


SECTION IV: KEY THEMES THAT

INFORMED

RECOMMENDATIONS


CONSISTENT THEMES FROM STAKEHOLDERS

Stakeholder feedback yielded the following themes regarding barriers to access for

waiver transportation. These findings provided context and a solid foundation for

Navigant’s final recommendations.

1. Lead agency authorization and coordination of services takes a lot of time and

could be made more efficient

2. There is a wide variability provider approval requirements and payment policies

across lead agencies

3. Lead agencies and providers could benefit from improved infrastructure support

and centralization of administrative functions


CONSISTENT THEMES FROM STAKEHOLDERS, CONT’D

4. Vehicle-sharing among transportation providers is limited, if not prohibited due to

liability and other issues. Vehicle sharing could increase the availability and hours

of operation of waiver transportation providers

5. Evaluating the quality and costs of waiver transportation services is challenging

without defined statewide service standards, more detailed utilization and

expenditure reporting capabilities, and a process for uniform tracking of consumer

access and service issues

6. Provider participation is hampered by the widespread perception of an inadequate

and uneven rate structure

The following slide summarizes stakeholder feedback related to theme number six

and is not specific to the stakeholder type providing the feedback.


STAKEHOLDER FEEDBACK: PERCEIVED INADEQUATE AND

UNEVEN RATE STRUCTURE

• Providers reported that rates do not cover the costs of transportation delivery,

including but not limited to:

- Licensing and compliance with policies and regulations

- Unloaded miles

- Vehicle maintenance

- Cancelled rides

- Driver recruitment and training

- Insurance costs

• There is a large variation between waiver transportation rates and methodologies

across lead agencies

• Current rates established by lead agencies through the market rate do not

consistently account for these specialized services:

o Curb-to-curb = drivers will assist passenger in and out of vehicles only

o Door-to-door = drivers will assist passengers to the entrance of their origin or destination

o Door-through-door = drivers will assist passenger to the inside of their origin or destination

• There is a lack of reimbursement for unloaded miles which discourages volunteer

driver participation


SECTION V: RATE STUDY

RECOMMENDATIONS


OBJECTIVES TO GUIDE RECOMMENDATIONS

The following objectives were created to guide the development of the

recommendations and reflect feedback from the Rate and Access Advisory Groups:

1. Advance access and availability of waiver transportation services to all waiver

participants, regardless of program type, participant’s abilities, or geographic

location

2. Support an increase in appropriate and cost-effective person-centered delivery

of transportation, including an on demand (“demand request”) response option

3. Maximize use of cost-effective pre-existing community capacity for

transportation

4. Adjust the current reimbursement structure to support the delivery of quality

services to meet identified individual needs


RATE APPROACHES TO ADDRESS DIFFERENT TYPES OF

TRANSPORTATION PROVIDERS

• Per Trip

- Build-up approach that incorporates wages, miles, vehicle costs, administrative

overhead, and other factors to determine a standardized per trip rate

• Public Transit (contracted through lead agencies)

- Advertised per trip rate

- Ability to purchase monthly/annual pass at discount

• On-demand (contracted through lead agencies)

- Negotiated or market rates with on-demand transportation service

• Per Mile (Volunteers)


PER TRIP: RATE METHODOLOGY

• Analysis is built from the ground up

• Recognizes the costs of specific services

• Assumptions can be derived from provider, state, or industry standard data

• Employs assumptions of:

- Wages – hourly wages

- Employee related expenses – costs related to employee taxes and benefits

- Client absences – time related to missed appointments

- Program plan support – non-service delivery time (meetings, documentation, and

other activities to support the service)

- Vehicle programming and supports – support costs related to providing the

service

- Administrative overhead – costs related to an organization’s overhead and

operations


PER TRIP: RATE METHODOLOGY BENEFITS

• Transparency

- Models contain the factors and values that drive the final rate

• Ability to include policy objectives

- Examples could include improving direct care staff salaries or benefits or

incentivizing increased access to services

• Efficiency in maintaining rates

- Models can be easily scaled and adjusted for inflation or specific cost factors

• Alignment with similar services

- Assumptions from similar services can be aligned to create consistent policy


PER TRIP: WAIVER TRANSPORTATION (WAGES)

• Wages – accounts for hourly wages for program employees providing the

service directly to the individual

• Cost survey results

- Median wage: $13.30

• Preliminary recommendation for wage: blend of two occupational

classifications based off of 2017 Bureau of Labor Statistics Wage Data3

- 60% - Personal and Home Care Aides: $11.78

- 40% - Bus Drivers, School or Special Client: $16.42

- Total recommended wage: $13.64

• Using BLS wages will allow for more frequent rate adjustments as data is

published annually

3 Minnesota statewide median value


PER TRIP: WAIVER TRANSPORTATION (EMPLOYEE RELATED

EXPENSES)

• Employee Related Expenses (ERE) – accounts for employee taxes,

benefits, and insurance as a percent of employee salaries and wages


- Median ERE: 21.9%

• Preliminary recommendation for ERE

- Use the ERE that is incorporated into the Disability Waiver Rate System (DWRS)

of 23.6% as this is similar to the cost survey results

• Using the DWRS value will create consistent methods across waivers and

allow for easier updates in the future


PER TRIP: WAIVER TRANSPORTATION (CLIENT ABSENCES)

• Client Absences – accounts for consumer “no-shows” for scheduled pick-up

(scheduled service where the individual does not use the transportation

service)


- Median Absence Factor : 3.69%

• Preliminary recommendation for Absence Factor

- Use the Absence Factor that is incorporated into the Disability Waiver Rate

System (DWRS) of 3.9% as this is similar to the cost survey results




PER TRIP: WAIVER TRANSPORTATION (PROGRAM PLAN

SUPPORT)

• Program plan support – accounts for time that program staff must spend on

non-reimbursable activities as a percent of employee salaries and wages


- Median Program Plan Support Factor : 16.7%

• Preliminary recommendation for Program Plan Support Factor

- Use the program plan support factor that is incorporated into the Disability Waiver

Rate System (DWRS) of 15.5% as this is similar to the cost survey results




PER TRIP: WAIVER TRANSPORTATION (VEHICLE

PROGRAMMING AND SUPPORTS)

• Vehicle programming and supports – accounts for expenses tied to

supporting the delivery of the transportation services (for example, fuel,

vehicle, tires, licensing fees, insurance, maintenance, and other expenses) as

a percent of employee salaries and wages


- Median Vehicle Programming and Supports Factor : 23.10%

• Preliminary recommendation for Vehicle Programming and Supports Factor

- Use the median Vehicle Programming and Supports Factor of 23.10%

- Calculated as the ratio of total vehicle-related program/support costs to direct

worker costs. We expect that this ratio will be higher than we would see in other

services because there are likely higher program costs for the numerator and

fewer direct care workers to establish the denominator.


PER TRIP: WAIVER TRANSPORTATION (ADMINISTRATION

FACTOR)

• Administration (admin) factor – accounts for administration expenses to

program employee salaries, wages and benefits (for example, administrative

salaries, IT costs, and office supplies) as a percent of employee salaries and

wages


- Median Administration Factor : 20.8%

• Preliminary recommendation for Administration Factor

- Use the admin factor that is incorporated into the Disability Waiver Rate System

(DWRS) of 23.0% as this is similar to the cost survey results




PER TRIP CALCULATION

• Cost survey results and DWRS factors are represented as a percent of

wages plus employee related expenses

Total Staff Compensation = Wages * ERE Factor

Total cost per day =

Total Staff Compensation * Absence Factor

Total Staff Compensation * Program Plan Support Factor

Total Staff Compensation * Vehicle Programming and Supports Factor

Total Staff Compensation * Admin Factor


PER TRIP CALCULATION (CONTINUED)

• To convert total cost per day to a per trip value: need to determine

a reasonable estimate of the number of trips that can be provided

during an 8 hour shift.

• Established Mileage Bands to account for the range of distances

traveled when delivering waiver transportation services

• Proposed mileage bands

- 0-9 miles

- 10-19 miles

- 20-39 miles

- 40-59 miles

- Greater than 60 miles


PER TRIP CALCULATION (CONTINUED)

• Single occupant rate per trip

- Divide total cost per day by the maximum number of trips per day within

each mileage band, to arrive at a single occupant rate per trip

➢ 270 miles per day (6.76 billable hours per day * 40 miles per hour)

➢ Divided by the highest mile value within the mileage band

➢ Divided by two to determine number of one-way trips

➢ Multiplied by 1.5 to assume half of return trips are empty vehicles

• Proposed trips per day for each mileage band

• Apply add-on component for assisting passengers to enter and exit

the vehicle for multi-passenger trips

– 0-9 miles = 23 trips




– Greater than 60 miles = 3 trips


RATE CHANGES FOR FUTURE CONSIDERATION

• New rates will be implemented in 2021

- DHS must assess the impact the rate changes have on access to services and

providers

• Advisory group members identified the following rate recommendations,

which will be revisited after the initial rate changes have been implemented

and monitored:

- Adjust payment rates to account for high demand and low availability

times (for example, weekends and evening hours)

- Adjust payment rates based upon the type of vehicle and modifications


ASKING QUESTIONS AND PROVIDING COMMENTS

How to ask questions during the public webinar:

During this presentation you may submit written questions using the “raise your hand”

webinar option and we will respond to them at the end of the presentation

How to ask questions after the public webinar:

• If you have questions or comments you wish to submit after the webinar, please use

the online feedback form at the link below

• The comment period will end on November 6, 2018

• The project website will provide a summary of comments and questions received

Availability of this presentation:

A taped recording of this webinar will be posted on the study website

For more information, visit the project website:

https://public.navigant.com/sites/MNTranspStudy/SitePages/Rate%20Study.asp

To provide comments on the methodology and recommendations, please use

the online form on the project website:


https://public.navigant.com/sites/MNTranspStudy/SitePages/Rate Study.asp



CONTACT INFORMATION:

ANDREA PEDERSON, DIRECTOR AT NAVIGANT

[email protected]

BETSY WALTON, DIRECTOR AT NAVIGANT

[email protected]

DENNIS FINNEGAN, ASSOCIATE DIRECTOR AT NAVIGANT

[email protected]

FRANK DOUMA, STATE AND LOCAL POLICY PROGRAM DIRECTOR

HUBERT H. HUMPHREY SCHOOL OF PUBLIC AFFAIRS

UNIVERSITY OF MINNESOTA

[email protected]

GWYN VOLK, DIRECTOR AT NAVIGANT

[email protected]

waiver transportation rate study methodology and ... · 1212 / ©2018 navigant consulting, inc. all...

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