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2. Transportation

NC Medicaid should offer ridesharing as a form of NonEmergency Medical Transportation (NEMT).

Implementation: • NC Medicaid should apply for CMS approval to require or incentivize PHPs to offer ridesharing as a form of NEMT by partnering with companies like Uber or Lyft.

• NC Medicaid should offer competitive grants for PHPs to innovate in the NEMT market to provide expanded transportation options, specifically for rural enrollees where ridesharing-based NEMT is not a viable option.

NC Medicaid should provide NEMT tailored to the needs of pregnant and postpartum women.

Implementation: • NC Medicaid should require PHPs and NEMT brokers to allow enrollees to bring their children, and possibly an adult attendant if needed, to their appointments in all cases.

North Carolina Context

Effective NEMT is critical for enrollees to access either SCD treatment or pregnancy-related care. In North Carolina, Medicaid covers transportation to appointments using personal vehicles, taxis, vans, mini-buses, mountain area transports, and public transportation. Since the transition to managed care, PHPs have each operated their own NEMT systems by contracting with brokers (including Modivcare and OneCall). PHPs may choose to offer additional transportation services, but they are not required or incentivized to do so. Healthy Blue offers all enrollees a $20 Uber gift card each year.109 Complete Care provides $75 in annual “healthy rewards gift cards,” which can be used for transportation among other uses.110 Currently, all PHPs guarantee that enrollees who use NEMT will not have to arrive at their appointment more than one hour early and will not have to wait more than one hour after their appointment is done to leave.111 However, there are no limits on the amount of time transportation itself will take, as vehicle may pick up and drop off many other enrollees along the way. All PHPs guarantee enrollees that they will be informed about who is allowed to accompany them on NEMT without cost. PHPs allow caretakers and guardians to accompany enrolled children to their appointments. However, PHPs do not include any guarantee or guidance in their contracts, member handbooks, or other enrollee resources explaining their policy on children accompanying their parent to appointments for their parent’s care.112 In interviews, stakeholders reported that many enrollees do not view the current NEMT system as meeting their needs. In particular, enrollees struggle with the long wait times as their NEMT vehicle makes several stops to pick up other enrollees. Further, they often assume or are informed by the NEMT broker or driver that they cannot bring their children on NEMT if the medical appointment is for the parent’s care. This is particularly a problem for women who are breastfeeding, people with unpredictable and inflexible work schedules, and people who do not have stable child care.

A MACPAC focus group of Medicaid enrollees across the U.S. also found that “late pickups and driver no-shows are the primary reasons for complaints from [enrollees], providers, and care managers.”113 All of these issues can result in enrollees missing scheduled appointments. One of our interviewees noted that if the “no-show” rate becomes a major problem, some providers become reluctant to see Medicaid patients. This can further reduce access to necessary care.

Over 20 percent of state residents live in rural areas and coordinating care for this population can be especially challenging, particularly for individuals with complex health needs like pregnant and postpartum enrollees and enrollees living with SCD.114 Enrollees in rural areas have less access to public transportation, taxis, rideshare services, and other means of transportation than their urban and suburban counterparts. In interviews, stakeholders confirmed that challenges in accessing NEMT are exacerbated in rural areas.

Insufficient NEMT may lead to racial disparities, both in maternal health outcomes and outcomes for people with SCD compared to other enrollees. Black non-Hispanic Medicaid enrollees delay care due to transportation issues much more often than white non-Hispanic enrollees.115

Evidence

Rideshare-Based NEMT

Reimbursing ridesharing services as a form of NEMT is a promising approach that 18 states have incorporated into their Medicaid NEMT systems.116 This includes several large states with substantial rural populations, including Florida, Georgia, Tennessee, and Texas. Transportation Network Companies (TNCs) like Lyft and Uber have experience in the NEMT market since 2016 and 2018, respectively.117 Research on the success of rideshare-based NEMT is somewhat mixed, but several studies have found a positive impact on decreasing driver no-shows and late pickups, increasing customer satisfaction, and decreasing health care costs.118 A Lyft-sponsored study found that a Washington, D.C. program allowing Medicaid enrollees to use ridesharing to travel to prenatal appointments, urgent care, and appointment follow-up care led to a 12 percent drop in ambulance use and a 40 percent drop in emergency department use.119 Rideshare-based NEMT does not need to be scheduled as far in advance as traditional NEMT services, which may improve convenience of use for enrollees. Additionally, Medicaid enrollees do not need a smartphone or the Uber/Lyft apps to use rideshare-based NEMT, as they can access service through a simple text message-based system. This may increase access for people who are low-income and may not be able to afford to maintain a phone data plan. Ridesharing-based NEMT may improve access to care for urban and suburban enrollees, but it is likely not a viable option for rural residents. NC DHHS could offer competitive grants for PHPs to innovate in the NEMT market to provide expanded transportation options, specifically for rural enrollees.

Maternal Health-Specific Evidence Several states have experimented with tailoring NEMT to better serve pregnant and postpartum Medicaid enrollees. In 2019, Texas started a pilot program to provide NEMT dedicated only to transporting pregnant and postpartum women and their children to appointments, without sharing the vehicle with other enrollees.120 Georgia allows pregnant and postpartum women to bring their children on NEMT for their mother’s appointments, whereas other enrollees are only allowed to bring an escort that provides medically-necessary assistance to the patient.121

Additional Considerations

Rideshare-Based NEMT

NC Medicaid should require or incentivize PHPs to offer ridesharing as a form of NEMT by partnering with companies like Uber or Lyft. Alternatively, NC Medicaid could require all PHPs to incorporate some form of ridesharing as a value-added service. Additionally, NC Medicaid should offer competitive grants for PHPs to innovate in the NEMT market and offer expanded transportation options for enrollees. This is a relatively short-term solution which can be implemented by updating PHP contracts.

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