By: Robin Cohen, Principal Analyst
You asked (1) how nursing home residents are transported to and from medical appointments and hospitals, (2) how the rates for these services are set, and (3) who pays for them.
Please see OLR Report 99-R-1304 for a description of the Department of Public Health ' s (DPH) rate setting system for certain emergency and non-emergency transportation, as well as the extent of coverage state law requires of health insurance carriers.
Nursing home residents can be transported to medical appointments and hospitals in a number of ways, from an ambulance with advanced life supports, to a taxi. The head of the state ' s for-profit nursing home trade association maintains that most residents in the homes her group represents travel by chair car or ambulance without advanced life support for non-emergency medical trips. DPH sets the maximum rate that ambulance companies may charge for their services, as well as the amount that can be charged for invalid coaches (or chair cars, which we believe are the same thing). The Department of Transportation (DOT) sets a medical livery rate and the market determines the rates charged for other modes of transport such as taxis.
While two state agencies set the rates, two other governmental entities often determine what providers receive since most nursing home residents ' care is publicly funded. Medicare and Medicaid generally pay for transportation for medically necessary services that the respective programs cover, but Medicare coverage is much more limited. Private insurance generally does not cover transportation to medical appointments but emergency ambulance service is a mandated benefit.
State law authorizes DPH to establish rates for transporting patients by licensed ambulance services and invalid coach. The Office of Health Care Access (OHCA), through a memorandum of agreement with DPH, sets these rates. The rates are the same regardless of the nature (emergency or non-emergency) of the transportation need. Rather, they reflect the level of service required. In addition to the regular rate, DPH sets rates for other charges, such as waiting time. (For more detailed information on how these rates are set, please refer to the Legislative Program Review and Investigation ' s (LPRI) 1999 report Regulation of Emergency Medical Services. which is available in the Legislative Library or from LPRI.) According to the LPRI report, the 1999 average rate for basic life support (BLS) ambulance services was $260, with a range of $212 to $386.
OHCA also sets the rates for the 11 companies providing invalid coach transports. These coaches are defined as vehicles used exclusively for transporting nonambulatory patients who are not confined to stretchers (1) to or from either a medical facility or home in a nonemergency situation or (2) in an emergency situation when insufficient emergency vehicles exist. These rates range from $50 to $60, according to Jose Aguilar of OHCA ' s rate setting division. Aguilar asserts that nursing homes tend to enter into contracts with these providers in order to get reduced rates.
The DOT sets a rate for medical livery—transportation that can be used for people who are not in a wheelchair and who do not require an ambulance because they are not in a stretcher and do not need other medical attention. Most nursing home residents do not use this transport mode. According to the LPRI study, as of 1999, DOT was setting the rate for only five such providers. This rate ranged from a $25 minimum charge to $50, with a waiting charge ranging form $25 to $50 an hour.
While DPH and DOT set these rates, the amount that providers actually receive for their services varies, depending on who is paying for them.
Medicaid Coverage of Medical Transportation (Conn. Agency Regulations, Sec. 17-134d-33)
In general, the Medicaid program must pay for medically necessary services and any transportation needed to get someone to those services. As a condition of Medicaid reimbursement, the transportation provider must be regulated and meet and maintain all applicable state and federal permit and licensure requirements. It must also sign a provider agreement with the department. The regulations provide that the Department of Social Services (DSS) will pay for such transportation if it is not available from volunteer organizations, other agencies, personal resources, or included in a medical provider ' s Medicaid rate. In 1996, the legislature allowed DSS to adjust a nursing home ' s daily Medicaid rate to account for any nonemergency transportation its residents needed but this has apparently not occurred.
Medicaid pays for transportation only if it is the least expensive and most appropriate mode, depending on the availability of the service and the patient ' s physical and medical circumstances.
For each transport mode, DSS pays the lesser of (1) the usual and customary charge to the general public; (2) the Medicare rate, if one exists; (3) the fee published in DSS ' s Medicaid fee schedule; or (4) the amount the service provider charges.
For the last few years, DSS has moved away from the traditional fee-for-service method of paying for nonemergency transportation for Medicaid recipients. Instead, it pays two transportation brokers a monthly “capitated” rate to serve all Medicaid recipients who are not enrolled in managed care plans. These brokers are responsible for
subcontracting for the transportation services required of Medicaid recipients living in the towns in the contractor ' s region. Nonemergency transportation services are defined as private automobile, bus, taxi, livery, invalid coach, ambulance, train, travel agent, and air transportation. Ambulance service claims are not part of the capitated rate. Ambulance service providers bill DSS directly.
The contracts for 1998-99 set the monthly regional rates as follows:
1. North Central Region--$21.41
2. Northwest Region--$14.46
3. Eastern Region--$22.77
4. South Central Region--$21.63
5. Southwest Region--$10.50
We asked DSS to what extent nursing home residents get their transportation from these brokers and are still awaiting a response.
Ambulances. Medicaid payments are available for ambulance rides, only if:
1. the patient ' s condition requires medical attention during transit,
2. the patient ' s diagnosis indicates that his condition will worsen in transit to the point where medical attention would be needed,
3. the patient ' s condition requires hand or feet restraints,
4. the ambulance is responding to an emergency, or
5. DSS determines that no alternative, less expensive means of transport is available.
According to the LPRI report, the Medicaid rate for BLS ambulance services, both emergency and nonemergency, was $99.25 in 1999. Advanced life support (ALS) services were reimbursed at $153.45. Waiting time was reimbursed at $34.87 for the initial hour. LPRI reported that these rates were last set in 1990. According to Neil Ayers of the Office of Fiscal Analysis, all Medicaid fee-for-service providers received a 2% increase in their Medicaid rate for FY 2000-01.
Other Modes of Transport. DSS regulations define “invalid coach” services as a vehicle (1) used exclusively for transporting nonambulatory patients, (2) operating as an invalid coach under DPH regulations, and (3) registered as such by the Department of Motor Vehicles (DMV). Alternatively, it can be a wheelchair accessible livery vehicle.
Medicaid payment for this mode of transport is made if the patient is not ambulatory and must be transported in a wheelchair or there is no alternative, less expensive way to transport him.
DSS regulations define a “livery” as a DOT-licensed sedan or van type vehicle capable of carrying up to 10 passengers that is used for transporting ambulatory patients who may need assistance. A “wheelchair accessible livery” is defined as a vehicle (1) specifically designed for transporting a “wheelchair mobile” patient and (2) operating as a DMV-registered wheelchair accessible livery, under DOT authority and regulations. The regulations state that wheelchair accessible liveries are treated the same as invalid coaches.
As stated above, it appears that these services are covered by the broker contracts.
In general, all transportation services require written prior DSS authorization, except emergency ambulance, nonemergency ambulance with designated medical conditions, in-state invalid coach and wheelchair accessible livery services with designated diagnoses, bus, train, and private transportation within the same town.
The regulations further provide that prior authorization is required for livery and taxi services requested by nursing homes for their Medicaid-eligible residents.
Medicare Coverage for Transportation
Both Medicare Parts A and B pay to transport nursing home residents under limited circumstances, in both emergency and nonemergency situations. In general, Medicare pays for services when (1) they are reasonable and necessary and (2) the provider meets Medicare requirements. The only mode of transportation Medicare covers is ambulances.
Part A coverage is available to a nursing home resident for whom Medicare is paying the home ' s daily rate. This coverage is limited to 100 days. A nursing home must pay for the service up front and then bill Medicare (as part of the overall service bill, rather than separately) to be reimbursed. After that, Part B, which currently has a $100 annual deductible, pays.
“Medical necessity” is established when the patient ' s condition is such that any other means of transportation would be contraindicated. In other words, the patient cannot be transported by any other mode of transportation without endangering herself (e.g. wheelchair van, car, taxi). It makes no difference whether the transportation is available. Medical necessity is determined based on the resident ' s condition at the time of service. Necessity is proven if the resident:
1. was transported in an emergency situtation;
2. needed to be restrained,
3. was unconscious or in shock,
4. required oxygen or other emergency treatment on the way to her destination,
5. had to remain immobile because of a fracture that had not been set or the possibility of a fracture,
6. sustained an acute stroke or heart attack,
7. was experiencing severe bleeding,
8. was bed confined before and after the trip, or
9. could be moved only by stretcher.
The regulations explicitly prohibit coverage for certain trips, including trips from a nursing home to a doctor ' s office.
Medicare pays for both BLS and ALS ambulance services, depending on the nature of the trip.
LPRI reported that Medicare sets ambulance rates for four regions in the state, which ranged from $260 to $318. These rates are the same for emergency and nonemergency trips. Medicare also sets rates for ancillary services, like mileage and night calls, which add to the total bill.