Testimony to Medical Services Board (MSB), Regarding Non-Emergent Medical Transportation (NEMT) --12/13/2013
Please accept these comments from the Colorado Cross-Disability Coalition (CCDC).
Many of you know that CCDC is the largest disability rights organization in Colorado. We exist to advocate for social justice for people with all types of disabilities (Cross-Disability). We have membership around the state and the majority of our members are Medicaid clients.
We want to thank Kimberley Smith for her responsiveness and for making improvements to the benefit collaborative process. Because of this, we only have a couple problems with the Non-Emergent Medical Transportation (NEMT) standard, rather than a whole list and are not saying that the entire standard is a problem.
We also want to applaud for putting the broker contract out to bid (again) and appreciate their efforts and the fact HCPF does not find the level of customer service acceptable. We appreciate that.
Our issues with the benefit standard are isolated to a few small areas that may not impact numerous people, but have a profound effect on those who are affected. The problems primarily exist for people who are wheelchair users who live in rural areas and rely on NEMT to go the doctor. There are two problems in this regard:
1) There is a problem with rates. Apparently we are paying more for a taxi than for a wheelchair van. People that can use a regular taxi can quickly get in and out of a vehicle. Taxi cabs are also small and usually economical to run. Wheelchair vans take more time to get in and out of, and they also have to secure the wheelchair using four different restraints. This takes time, usually at least ten minutes per chair on each side of the trip. If the client is not coordinated or mobile it can take longer. There is more maintenance on a wheelchair van, especially the ones that are used commercially and have lifts going all day. They use more gas. So we are paying more for a service that is less costly and less labor intensive and paying less for a service that not only costs more and takes more time, but is likely transporting people with the fewest options. This is why we do not have reliable Medicaid transportation for wheelchair users throughout the state. We lost many providers in 2004 during some temporary rate and utilization cuts that were later overturned by CMS. This change apparently went into effect in July of 2013, as part of overall rate increases. I know a major wheelchair transportation provider in Mesa County is losing money every month and eventually they may not be able to continue despite the fact that the providers (a husband and wife) really love the work and have personal attachments to clients and provide excellent services.
2) People who can drive their own vehicle are reimbursed mileage. People who are unable to drive are provided a service based on their needs, for example if they can use a fixed route bus they get a bus ticket, if they use a wheelchair and cannot use the bus in the metro area they can use access a ride, in other areas it is other services. However, if there is no wheelchair accessible service in their area and they are not able to drive themselves there is nothing. The only way to get to an appointment is to find a vehicle they can use (sometimes that might mean using a manual wheelchair and being lifted in and out and then provided assistance during the appointment) and hire a driver. (Or hire someone who has a vehicle). If the client does not have family or anyone to drive the client as a volunteer and is not able to drive him or herself, there is a problem. HCPF maintains that mileage covers the cost of a driver. CCDC believes that this is discriminatory against wheelchair users who cannot drive. CCDC is in litigation over this matter. The mileage cannot cover gas, wear and tear and wages. Moreover, that forces the client to try to be an employer with no instruction. Does the client have to take taxes out since the client would be directing the work? What if there is not enough for minimum wage? If the driver is an attendant through a Medicaid program (CDASS, IHSS or personal care) it is not legal to require the person to work without pay. HCPF has said that they will pay the worker under the long term care program for the time they are doing personal care for the client. So if a client has to travel 3 hours to see a specialist, HCPF would pay for maybe 45 minutes of that time –the time the attendant is transferring the client in and out of the car, helping the client dress and undress at the doctor, etc. The hours of driving, HCPF says, do not count. This leaves a client in an impossible position. The reality is that this is a fairly rare situation. Most parts of the state have some service. However, using a service for clients who have a vehicle but cannot drive is much more expensive than simply paying a driver. Moreover, in small communities that have a service there may be only one or two wheelchair accessible vehicles. If a client has a specialty appointment in Denver (or New Mexico, Grand Junction or Colorado Springs) and has to travel several hours to get there then the vehicle is out of service to the rest of the community for the whole day. This might mean that seniors or people with developmental disabilities cannot go to a day program or go to their own local doctor appointment. Finally, in a case where the existing system does not work for a client and as a result the client does not have access to services the state is obligated to make a reasonable modification of policy, practice or procedure. Because it is so rare that a client is unable to drive, and there is no accessible service in the area and the client has no family, even allowing for payment of the driver on a case by case basis as a reasonable accommodation is acceptable. We believe that the Department position that mileage covers paying an hourly rate to a non-related driver is discriminatory and unacceptable. It just does not work.
· 200 mile (one way) trip that takes 3.5 hours each way
· 7 hours of driving
· 38 cents a mile for 400 miles =$152
· Gas is about $3.25 in Durango
· 20 MPG is the best one can get with a van –likely less
· Assuming 20 MPG that is 20 gallons of gas for 400 miles
· $65 for gas
· Wear and tear is calculated at .15 to .30 cents a mile so going with 15 cents that will be $60 (According to rideshare.com a van should be calculated at .22 or $88)
If you use the van calculation you have -$1 for wear and tear and gas (remember the MPG is a high estimate). If you use the lowest possible car
calculation the total cost just for the vehicle is $125. This leaves $27 to pay for 7 hours of driving. This is $3.86 per hour.
We also suggest that the Department consider looking at a slightly increased rate for use of a wheelchair van when doing mileage for anyone—urban and rural. It costs more to use a wheelchair van, they use more gas. We want to encourage use of own vehicles. The department said that they cannot verify a wheelchair van was being used but they can verify that or at least use common sense. If the state has purchased a motorized chair for the client then the client will not be able to be transported in a car, it would only be a van. Moreover, the client does have to provide info about the vehicle such as insurance and they could simply take a picture of the vehicle and send it in with the insurance card. This is not a huge issue but is a matter of equity and if the only reason is not being able to prove that the client uses a wheelchair van, then there is an easy solution. Again, both wear and tear and gas mileage are more expensive for a van. People who use wheelchairs do not choose to drive vans, but have no other choices.