RoutingBox Friday Recap: Varying Medicaid Models
Medicaid and NEMT models vary a great deal from state to state. Some transporters focus mainly on Medicaid transportation, while others focus on different industries as their main type of transportation. In this recap of RoutingBox Friday live, we’re going to focus on Medicaid and the three different models that are used in different states. Let’s get started!
- State Medicaid
- Transportation brokers
- MCOs (managed care organizations – a group that works with state Medicaid and is contracted by state Medicaid to manage the care of members within the program).
- g. Health plan
- MLTCs (managed long-term care providers)
- g. Nursing homes
- Medical providers
Where do MCOs and MLTCs come in?
- In some states, they’re partially involved. They tend to lean towards just a couple of MCOs.
- While in other states, they may rely on dozens of them.
- In other states, they are completely removed from transportation (i.e., not involved in the process at all).
- NYS Medicaid Program
In New York State, we have MCOs such as Fidelis, AgeWell, ElderServe and Kalos. Trips go directly from state Medicaid to a transportation broker, unless that patient is in an MLTC program. If they’re in an MLTC program, then the MCO handles their transportation. The transportation broker in New York is MAS (medical answering services). MAS contracts directly with the transportation providers. The transportation providers are assigned trips and execute transportation. They are then responsible for communicating information back to MAS or the broker. When all is said and done, they’re responsible for billing directly back to the New York State Department of Health, eMedNY, for their transportation. Using Fidelis as an example, this MCO will contract directly with the transportation provider. This represents a direct relationship with the MCO and the transportation provider. Generally, the transportation provider bills trips directly to that MCO. Sometimes the MCO will contract with a transportation broker instead of managing it on their own. In New York State, Logisticare is one of the brokers that has a few contracts with MCOs, where instead of managing it themselves, they rely on the transportation broker.
- Full Liability Broker (using New Jersey for this example)
In New Jersey, you have 1 broker, Logisticare. They manage all the transportation. Logisticare then contracts with transportation providers, who turn around and bill Logisticare.
This model is much simpler than others because there’s less back-and-forth. A lot of times there’s not only one broker. Many times, state Medicaid puts transportation on the MCO, who then contracts with the broker. In smaller states, there’s three MCOs that are split evenly in terms of the members throughout the state. Each of those MCOs work with different brokers. So, each broker has one third of the overall trips. There’s no one broker that really dominates that state.
- Medical Providers and Passengers are Involved in the Process
This model is where the medical providers and passengers are going to get involved in the process. When a medical provider determines that transportation is necessary for a passenger, either the medical provider or the passenger reaches out directly to the transportation provider. The transportation provider then has an interface with the state Medicaid system which is where they’re going to check eligibility, and request pre-authorization for the trip. Sometimes the pre-authorization is done by the transportation provider themselves, and sometimes it’s done by the medical provider. They provide transportation and then they bill trips directly to the state Medicaid system.
There are many different ways of managing transportation and billing for NEMT across the country. Each individual model has its own advantages and disadvantages. It’s important to understand the procedures your state follows to assure accuracy and compliance.