Medicaid Transportation Petition & Questionnaire
For about 2 years now Integrity has been attempting to negotiate with Medicaid transportation brokers (MTM & Modivcare) that ensure transportation for Medicaid MCO’s (BCBS, Aetna, etc.). After multiple attempts we have been told multiple times by those brokers that there is not a need Northeast Missouri or West Central Illinois. This is simply not the case..... In our area we have lacked a reliable NEMT service that can provide this service, therefore, people have either tried to find other means of transportation or have neglected their own healthcare needs because there isn't Medicaid transportation available. We are now fighting back to help provide for those that are being neglected. We appreciate your help in fighting for this cause!
Petitioner Info:
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Phone Number
Format: (000) 000-0000.
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Yes
No
Please Refer Anyone That Can Help!
Rows
Full Name
Address
Contact Number
Email
1
2
3
4
5
If you arrange Medicaid transports or are a Medicaid recipient are you willing to fill out a questionnaire about your experience with Medicaid transportation? This will provide us with some useful data that will help us in the fight for access to healthcare
*
Yes
Just Here To Sign!
Signature
*
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Medicaid Questionnaire
Are you a Medicaid recipient OR a Medicare/Medicaid Alignment Initiative (MMAI) recipient?
Yes
I used to be
No
Which Type of Insurance Do you Have?
*
Medicaid
Medicare Medicaid Alignment Initiative
Medicaid Plan:
*
Blue Cross of Illinois
Aetna Better Health
Meridian Health
Molina
Youthcare
Other
Medicare-Medicaid Alignment Initiative (MMAI)
*
Aetna Better Health Premier Plan
Humana
Molina
BlueCross Blue Shield
Meridian Medicare/Medicaid
Other
If not, are you a:
Organization/Facility That Schedules Medicaid Transport
Organization/Facility That Cares For Medicaid Recipients
A Supporter For Medicaid Recipients Access to Healthcare.
How often do you set up rides for Medicaid transports?
Daily
Weekly
Monthly
Quarterly
Semi-Annually
Annually
Other
How would you rate the difficulty in scheduling Medicaid transportation?
Difficult
1
2
3
4
5
6
7
8
Easy
9
1 is Difficult, 9 is Easy
How long have you been experiencing problems with Medicaid transportation?
Months/Years
What percentage of Medicaid rides were:
Rows
0-5%
6-15%
16-25%
26-35%
36-50%
50% or more
On Time
Late
Cancelled
No-Show
No Transport Available
Other:
What percentage of Medicaid rides result in appointments being:
Rows
0-5%
6-15%
16-25%
26-35%
36-50%
50% or more
On Time
Late
Cancelled
No-Show
Rescheduled
Other:
Have you or someone you know experienced health problems or co-morbidities because you weren't able to make it to your Medicaid appointment due to transportation issues?
Please Describe
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Continue
Continue
Next
Tell Us About Your Experience With Medicaid Transportation:
Submit
Submit
Should be Empty: