Joel Davis’ State of the Industry Report of the... · 2019. 9. 6. · Why You Need to Build, Grow, Save and Create Wealth 214 . Joel Davis’ State ... industries will benefit could

Joel Davis’ State of the Industry Report

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TABLE of CONTENT

Introduction 4

A Business Philosophy to Ensure Profitability 10

Three Fundamental Rules of NMP 11

The Influence of Medicaid Brokers in a Changing Industry 12

The Medicaid Broker Playbook 69

Keys to Thriving in Broker Infested Waters 79

Subcontracting to Increase Profitability 81

Managed Care Consortium Agreement 90

Obamacare, the BIG Picture 103

The Influence of Obamacare in a Changing Industry 113

Increasing the Size of Medicaid & Impending Effects 114

What Does Obamacare Mean for Your Business? 120

Do You Need to Provide Health Benefits to Your Employees? 128

Ramifications of Obamacare 135

Concierge Care Medicine 145

Why You Need to Diversify Your Business 149

Leveraging New Opportunities, Waiver Programs 151

Leveraging New Opportunities, School Districts & Universities 158



Diversifying Your Business Model, Strategy 1 174





Why You Need to Build, Grow, Save and Create Wealth 214



INTRODUCTION

Congratulations on investing in this material! I sincerely commend and compliment you on your

investment because, in an effort to better your business, your investment illustrates your desire and

eagerness to learn as much as possible about our changing industry. Needless to say, as I will

demonstrate with considerable supporting evidence our industry is definitely experiencing a great deal

of change. The size of our niche market is definitely increasing. But with a troubled economy and

changing policies, as entrepreneurs we have many challenges to contend with – challenges that

definitely influence our bottom line and are not unique just to the NEMT industry!

I am going to provide you with a lot of information in this resource. The further we proceed, the more I

will demonstrate how a wide variety of variables are interrelated and influence our industry. Let me

start by sharing a recent article that underscores the level of opportunity that grows before us:

HOW BOOMERS WILL SHIFT THE ECONOMY

- TOM SIGHTINGS, U.S. NEWS & WORLD REPORT

As people age, they spend differently than when they were younger. Knowing which

industries will benefit could help you grow your nest egg.

In the year 2000, approximately 2.5 million Americans turned 65. This year, more than 3.5

million Americans will pass that milestone. And the number of people joining the ranks of

the elderly will keep increasing, at least for the next 20 years, as more and more baby

boomers hit their 60s, 70s and 80s. By 2030, the over-65 crowd will expand to 72 million

people, up from 40 million in 2010.

The increasing numbers of recent retirees, along with the hordes waiting at the gates, give

politicians headaches as they try to figure out how to finance Social Security and pay the

health care bills covered by Medicare.

But for those of us looking to invest in the American economy, this burgeoning population

means an increasingly lucrative market for products and services focused on the elderly. By



the time they're done, some 78 million baby boomers will have survived millions of hip

replacements and heart transplants, swallowed trillions of Advil and Viagra pills, and

consumed billions of boxes of bran and packages of prunes.

Despite the faltering economy of the past five years, American seniors are richer than ever,

in large part because more older people, especially older women, are working than in

previous decades. According to a 2012 report from the Federal Agency Forum, the number

of senior citizens living in poverty has declined from 15% to 9% since the mid-1970s, while

the proportion of older Americans enjoying a "high income" increased from 18% to 31%. So

even while the burgeoning number of retirees will strain government resources, they will

provide enormous moneymaking opportunities.

These people will travel. They will move to warmer and friendlier climates. Many will

manage their individual retirement accounts and 401k's through financial institutions. They

will buy long-term care insurance, pay rent to senior citizen facilities and drop an average of

$8,000 per funeral.

A great deal of time and research has been invested in the creation of this resource. I strongly

encourage you to read everything! Read everything, not to validate my efforts in the creation of this

resource, but rather, because I wish for you to learn and understand as much as possible about the

future of our industry, our economy, and business in general.

It would be easy for me to simply tell you what I know and continue to witness in working with

Transportation Providers around the country. However, my goal with this resource is to provide you

substantial evidence from a variety of sources so that you can draw your own sound conclusions. For

this reason, I have enclosed a wide variety of supporting data, facts, and predictions from news articles

and professional trade publications authored by physicians, economists, journalists, and associated

professionals.

As a disclaimer, be prepared - there are views that, as an entrepreneur who believes in the “American

Dream” of self-determination and independence, may disturb you. I share all such information with

you, good and bad, because knowledge is critical to your success. You need to understand what is

happening on a macro scale so that you are better equipped and poised to not only make more money

http://www.nih.gov/news/health/aug2012/nia-16.htm



in a troubled economy, but save and protect your growing wealth. Although you will be disturbed to the

point you will question if this is America, do not be disheartened. By reading, learning, and digesting all

of this information you will, by the end, be greatly inspired on how to make more money – in ways that

most business owners are completely unaware.

In reading, ask yourself “How will these changes affect my business? How do these changes provide me

with new opportunity? What action do I need to take to better protect and preserve my business and

enhance my profit-earning potential?”

If there is one thing that I can assure you, the way in which NEMT and Home Care business owners have

planned, prepared, and operated their businesses in the past is now obsolete. If you don’t adjust and

adapt to the changing economy and industry your business will fail. Trust me, I don’t say this to scare

you, but honestly, it’s true. Business as usual is no longer feasible. If you don’t change and adapt you

will eventually be out of business – and, you may be fined along the way too via the IRS (more on that as

we move forward)!

Consider Florida, a very popular and attractive state for elderly and retiring baby-boomers. Florida is a

microcosm of what is being experienced throughout the United States, Canada, and beyond. Consider

the following article that discusses concerns over one of the single most important elements essential to

our healthcare system – the number of competent and qualified doctors!

FLORIDA DOESN'T HAVE ENOUGH DOCTORS FOR MEDICAID EXPANSION, LOBBY GROUP SAYS

- Kathleen Haughney, Tallahassee Bureau, the Sun Sentinel

TALLAHASSEE - Brace yourself for longer lines at the doctor's office. Whether you're

employed and insured, elderly and on Medicare, or poor and covered by Medicaid, the

Florida Medical Association says there's a growing shortage of doctors — especially

specialists — available to provide you with medical care.

And if the Florida Legislature goes along with Gov. Rick Scott's recommendation to offer

Medicaid coverage to an additional 1 million Floridians — part of the Affordable Care Act

that takes effect next January — the FMA says that shortage will only get worse.

http://articles.sun-sentinel.com/2013-02-22/news/fl-doctor-shortage-medicaid-expansion-if-florida-20130222_1_medicaid-expansion-new-medicaid-patients-florida-medical-association



"Florida needs more doctors and it needs more nurses, and it needs them working together

in teams," said Rebecca O'Hara, a lobbyist for the FMA.

About 15 million Floridians have health insurance today, and Obamacare, which requires

most adults to have coverage by January, could add as many as 2.5 million more. One

million would come through a potential expansion of the federal-state Medicaid program

that Scott announced this week he was backing. The others would be the result of new

mandates requiring employers and individuals to have insurance or be fined.

Currently, the state has 44,804 doctors, but about 5,600 of them are expected to retire in

the next five years. And even though Florida has opened three new medical schools in the

past dozen years, the state isn't producing as many doctors as it needs. Scott's budget this

year has $80 million to fund programs to train 700 new residents a year, in hopes they'll

remain in the state.

Of all patients, people covered by Medicaid may have the hardest time finding a doctor;

only 59 percent of the state's physicians are taking new Medicaid patients, according to a

Kaiser Health News study.

Committees in both the House and Senate have been meeting for the past two months to

discuss implementation of the Affordable Care Act. On March 4, they expect to see two

major studies by the Office of Economic and Demographic Research, one that looks at the

overall economic impact of the health-care overhaul and another that simply examines

Medicaid expansion. Scott, however, has already made clear how he feels about that.

On Wednesday, he unexpectedly announced that he had reversed his earlier, adamant

opposition and now wants a three-year expansion that would cover single adults and

families earning up to 138 percent of the poverty line; the costs would be fully covered by

the federal government. If the expansion is re-approved after three years, the federal

government is committed to paying no less than 90 percent of the cost.






House and Senate leaders will begin their budget deliberations in the coming weeks, which

will include the decision over new residency slots, along with the debate over whether to

expand Medicaid. Many lawmakers have expressed opposition.

The federal government this week gave Florida preliminary approval of a plan that would

put most of Florida's current 3.3 million Medicaid recipients — and any added via expansion

— in some form of managed care, either HMOs or doctor-run networks, by 2014. In order

for HMOs or the provider service networks to get state-approved contracts, they must prove

they can provide "adequate" care, which means patients must be able to see a doctor in a

reasonable time. "It's their responsibility to have network adequacy," Negron said of the

private providers. "So, they'll be responsible for making sure people can get care with

network physicians."

Negron also noted that the amount doctors will be paid for seeing Medicaid patients is

rising, which may prompt more physicians to take them. As part of the health care law,

primary-care doctors will be paid as much for a Medicaid patient as they are under

Medicare, a 73 percent increase.

Health care advocates who back the expansion say they aren't worried either. Greg

Mellowe, policy director for health advocacy group Florida Chain, said the state needed to

carefully watch the situation as it develops, but added, "We don't believe that there is a

crisis brewing." Mellowe noted that many uninsured already receive care — often in

emergency rooms, which is more expensive — that hospitals aren't paid for. If many of

these patients have insurance coverage, he said, hospitals may see an opportunity to shift

resources to primary care settings.

Just in this single article, there are many topics and circumstances that affect our economy, the medical

industry in general, and your business specifically! And all of this is coming from various experts;

physicians, politicians, the Kaiser Health News, the Florida Medical Association, and more. So this is

not just Joel Davis telling you about the growing problems in a lack of doctors. Rather, “The Florida

Medical Association says there is a growing shortage of doctors – especially specialists.” Compounding




this problem is that “Only 59 percent of the state’s physicians are taking on new Medicaid patients” –

and at a time when the federal-state government are exponentially expanding the Medicaid system!

The article explains how this dynamic shortage of doctors does not discriminate - it affects everyone

regardless of level of coverage; private health insurance, Medicare or Medicaid. Truly, demand is

increasing while supply is decreasing. To further compound the problem, funding is shifting and

changing. Needless to say, I trust that you’re seeing that these ingredients are a recipe for potential

catastrophic problems! Not even taking the NEMT industry into consideration, think of how the medical

industry itself is spiraling towards an even more precarious situation – one in which even “the experts”

are having a hard time finding consensus in predictions and solutions.

In coming chapters I’m going to show you how a lack of physicians persists in other states and how they

are attempting to resolve the shortfall. Honestly, it’s shocking! If I told you what these states are doing

you wouldn’t believe me – you would think I was crazy, hence, the reason why it’s important for me to

share articles from news and trade publications.

Despite all of the changes and circumstances, I will continue to share with you all possible ramifications

about the economy, our industry, and your business, and one very important lesson, a philosophy, that

you need to learn, internalize and regularly practice.

Now, before I share with you exactly what this very important philosophy is, let me preface everything

by telling you that, although it’s very short and simple, the practice of this philosophy can be more

difficult to implement than one might think. And yes, I am speaking from first-hand experience. Once

you have learned to master the use of this philosophy, I promise, it will liberate and empower you. You

will have greater discernment and a heightened sense of peace in making sound, critical business

decisions. I can’t tell you how many entrepreneurs have expressed appreciation for sharing this simple

philosophy and I am confident that you too will come to appreciate its simplicity.



A BUSINESS PHILOSOPHY TO ENSURE PROFITABILITY

Alright, drum roll please! Here is one of the absolute most important business philosophies that you

absolutely need to learn, internalize, and regularly practice: NMP! Yes, that’s it, NMP! This philosophy

is so simple you can spell it out in texting language!

I know, I know. You’re asking “Joel, OMG, WTF is NMP?!” It stands for NOT MY PROBLEM!

Now before you get hot under the collar and contemplate throwing this resource away thinking I’m

crazy and that I cheated you because NMP is so anticlimactic, trust me, stick with it because starting in

the very next chapter NMP (and all of its powers and abilities) will be revealed and, I promise, you’re

going to be saying NMP is ingenious!

So what is NMP? NMP is the ability, the courage, the discipline, and the foresight to, when presented

with circumstances that are not favorable or advantageous to your business, stand firm and say “NO” –

that is Not My Problem. NMP is the establishment of sound boundaries that are designed to protect

and preserve your business. And yes, saying “No” is easier said than done especially when you’re being

enticed and pressured.

Again, momentarily I will begin sharing with you clear cut examples of where and why NMP is absolutely

critical to the welfare of your business. But in so doing, let me be clear. NMP is NOT the act of being

rude, crude, or selfish. In fact, especially because we are in an industry in which we are charged to help

the elderly and disabled, such characteristics are simply unacceptable. With our clientele, it is all the

more essential that we are inherently kind, giving, and generous. However, that doesn’t mean we allow

ourselves to be taken advantage of!

Let me be clear. I am a firm believer in the Law of Reciprocity – the more you give, the more you receive.

In fact, I am more than a believer. I am an advocate for and a product of this Law. As Luke 6:38 says,

“Give and it will be given to you. A good measure, pressed down, shaken together and running over, will

be poured into your lap. For with the measure you use, it will be measured to you.”

So to be clear, Not My Problem is not about withholding blessings or giving to others. Rather, NMP is

about establishing boundaries and sound practices to protect and preserve the viability of your business.



THREE FUNDAMENTAL RULES OF NMP

Momentarily, we are going to dive in and begin discussing the Medicaid Broker system in detail – an

area where NMP, boundaries and barriers absolutely need to be implemented to protect your business.

In setting the stage for the Three Rules of NMP, let’s reiterate what we already know:

The elderly population is growing exponentially – This is great! It is a statistically proven fact

which leads to an increase in demand for various services and market opportunities

Transportation demand is increasing dramatically – This is obvious! With an increase in

population comes an increase in medical appointments, treatments, and more

Medicaid and Managed Care are dramatically expanding market share and creating changes in

funding and policies – This sounds good, in theory. But the Government, in its infinite wisdom,

is forever interjecting new mandates into the market system; thus, requiring business owners to

be current about policy changes in addition to implementing creative solutions

The cost of care and patient independence is leading to more seniors remaining at home –

Awesome! Obviously, this leads to more market opportunity for inter-related elderly services

Hospitals are incorporating more and more outpatient procedures – Good for us! Due to fear of

penalty from Obamacare and technological advances, ambulatory surgeries and outpatient

procedures are projected to further increase in volume

Taking all of these market variables into consideration predicts new market opportunities are definitely

on the horizon. However, this does not mean that every opportunity is for you! Discernment will reveal

your direction. There are three fundamental rules to internalize and put into practice:

RULE 101: YOU’RE RESPONSIBLE FOR YOUR OWN SUCCESS – “You didn’t build that” slogan doesn’t apply

– you built and you are responsible for every element of your business. There are NO bailouts if you fail!

RULE 102: IF IT ISN’T PROFITABLE, YOU’RE NOT DOING IT! - Stop chasing “Shiny Objects” looking for

quick cash. Pursue sound, methodical strategies that focus on “Select Profitability!”

RULE 103: IT’S BETTER TO NEED IT AND NOT HAVE IT THAN HAVE IT AND NOT NEED IT – do not become

financially over extended (chasing “Shiny Objects”) causing a catastrophic financial liability.



THE INFLUENCE OF MEDICAID BROKERS IN A CHANGING INDUSTRY

As we were discussing in the Introduction, Obamacare is ushering in sweeping expansions of the

Medicaid system. For this reason, it is absolutely impossible to discuss changes in the Medical

Transportation industry without discussing the influence of Medicaid Brokers. As the number of

Medicaid recipients and the cost of healthcare exponentially increase, more and more states will

leverage the Broker model in an effort to reduce cost in managing the transportation needs of Medicaid

recipients. Thus, with opportunity and revenue increasing for Medicaid Brokers, they continue to

become increasingly bold, audacious, and demanding in regards to subcontracting transportation

providers. Hence, the reasons why you need to proceed with great caution in dealing with Medicaid

Brokers and actively practice the Art of NMP.

Consider the following email correspondence from Logisticare, the nation’s largest Broker, to a

transportation provider with whom I was working in negotiating their Medicaid rates:

[From Logisticare to Transportation Provider via email]

1. Proposed rates are within the standard that are currently being paid for NEMT service.

2. Most if not all Medicaid and Medicare transportation service will be handled through

LogistiCare within the near future.

3. You may or may not be comparing your current rates for Workers Comp, Nursing Home or

Private individual transportation to the proposed rates offered by LogistiCare.

What will happen to your business when these same nursing homes, private patients and/or

their sons or daughters realize that they no longer will need to pay for Medical

transportation? As most if not all of these current customers of your company will be

covered under the new Managed Care program that will begin on October 2013. This will be

followed by the Medical Managed Care part of the plan to be in place by January of 2014.

Wow! That is definitely bold, audacious, and even quite arrogant! Essentially, Logisticare is telling my

client, the Transportation Provider, that they need to accept Logisticare’s rates because eventually, all

patients will be covered by Medicaid and, thus, regulated by Logisticare. Why would Logisticare make

such a bold statement? – Brokers love Obamacare because it is exponentially expanding the Medicaid

system, Broker’s core clientele. Obamacare is going to make Brokers a LOT of money!



Ironically, in the example above, we did not accept Logisticare’s rates which were of slim-to-none profit

margin. Rather, we held true to NMP, did not chase “Shiny Objects,” nor wilt under pressure. As a

result, Logisticare eventually conceded and increased their rates of reimbursement! It was a sweet

morale booster and a financial victory.

To introduce you to another very popular broker, Medical Transportation Management, Inc. (MTM), let

me share with you an introduction taken from their own website as follows:

“MTM is a medical and transportation management company whose mission is to improve the

overall health and well-being of individuals by removing barriers to healthcare and promoting

independence.”

“MTM provides transportation management, home and community based services, call center

services, ambulance claims management, and functional assessments and travel training to

state and county governments, Medicaid and Medicare managed care organizations (MCO),

third-party administrators, and health care providers.”

“By providing careful assessments, comprehensive care management, and responsible network

development and oversight, we are able to improve member outcomes while helping our clients

align incentives, reduce costs, and increase customer satisfaction.”

These are all worthy and admirable goals which I applaud. However, as we all know, sometimes what

people say and do can be polar opposites (consider politicians)! To achieve such goals, comprehensive

care management, network development and oversight, reduce cost, and increase customer satisfaction

takes far more than good intentions – especially when you consider that Brokers typically do not have

assets and, thus, rely exclusively on subcontracting to Transportation Providers to accomplish their

mission. Therefore, considering just how much Brokers NEED Independent Providers, it would be safe

to assume that the relationship between Brokers and Transportation Providers would be one of

“Strategic Partnership” and less of a slave master and sharecropper!

In a moment, we are going to systematically go through and analyze the standard “Service Agreement”

that MTM forces transportation providers to sign. This is a very important exercise as I’m going to

reveal the mentality of Medicaid Brokers in greater depth and just how much they value and respect



you, the Transportation Provider. It’s important to note that the enclosed Service Agreement is a literal

copy of the exact Agreement that MTM issues to Transportation Providers. I have transcribed this

document into this resource so that I can systematically interject key thoughts and feedback

throughout.

Why am I using MTM’s Service Agreement as an illustration versus the Service Agreement Logisticare?

Because MTM’s Service Agreement is ONLY 35 pages versus Logisticare’s 78 page Agreement! Now,

think critically. Why on earth would a Medicaid Broker need you to sign a 78 page Service Agreement?

Do you think any of the stipulations in such an excessively large Agreement are designed to protect you

or the Broker? The answer is obvious, everything in the Agreement is designed to protect and favor the

interest of the Broker – not you! So as we consider this Agreement, ask yourself if you are being

respected as a “Strategic Partner” or treated as a sharecropper.

As we go through and analyze the following Service Agreement my comments will be in color

blue font below each stipulation that I am referencing. Get ready, you’re about to witness the

importance of NMP in action!



ATTACHMENT I

TO MEDICAL TRANSPORTATION SERVICES AGREEMENT

Between

MEDICAL TRANSPORTATION MANAGEMENT, INC. and

[Name of Your Company]

MEDICAL TRANSPORTATION MANAGEMENT (MTM)

TRANSPORTATION PROVIDER GUIDELINES

(Quality Management and Risk Management Program)

INTRODUCTION

Medical Transportation Management, Inc. (“MTM”) is a transportation management organization which

contracts with Managed Care Organizations (“MCO”), State and local governments and other medical

businesses, organizations, agencies, and facilities (“MTM Clients”). These contracts provide for MTM

coordination and management of scheduled non-emergency and “urgent” vehicular ground

transportation for the MTM Client’s Members, Customers, and Recipients (referred to in this document

as “Passengers”) through a network for transportation companies and services (“Transportation

Providers”).

Transportation Providers are under contractual agreement to provide transportation for MTM Clients

and their Passengers as defined by the terms of the “Medical Transportation Services Agreement.” It is

the Transportation Provider’s responsibility to be aware of, and to comply with, all terms, conditions, and

requirements of their contractual agreement with MTM and to comply with the “MTM Transportation

Provider Guidelines.” The Transportation Provider understands that Transportation Provider misconduct

will not be tolerated and could result in disciplinary measures including reduction of trips, probations,

suspension, or removal from the Transportation Provider Network.

Joel’s Insight: We are ONLY on the second paragraph and MTM is already making it clear that you, the

Transportation Provider, are responsible “to be aware of, and to comply with, all terms and conditions.”

So, in short, there is no onus or burden of responsibility on the Broker. What I also love, though, is that if

you fail to comply with any of these stipulations you could face “disciplinary measures” as though you’re



in grammar school. But OK, we are interested in doing business with Medicaid Brokers because we know

that Obamacare is further expanding Medicaid; we wish to leverage the growing market to increase

profits. So we’re willing to comply with such stipulations.

Oh, but wait, let’s further put things into perspective. MTM is telling (threatening) us upfront in the

second paragraph that disciplinary measures may include a “reductions of trips, probations, suspensions,

or removal” of their Network. This is a very important message that MTM is sending to you here and

now. They can take transports away from you at any time! How could this affect your business if you

went out and invested in vehicles and assets only to be in jeopardy to have trips/volume taken away

from you? Again, we wish to increase our revenue so, for now, we will comply and work to meet your

requirements in an effort to make money.

Transportation Provider understands that selection of the Transportation Provider’s transportation

services by MTM will be based solely upon the quality and availability of their service and, where

applicable, upon competitive pricing of its services relative to other Transportation Providers doing

business in their services area. Transportation Provider warrants that no monies have been or will be

paid directly or indirectly to any employee of MTM as wages, compensation or gifts in exchange for

favors in granting of transportation services to Transportation Providers.

The “MTM Transportation Provider Guidelines” are the basis for the MTM Transportation Provider

Quality Management and Risk Management Program and are intended to provide consistency and

uniformity in MTM’s operations. These Guidelines comply with MTM Client requirements and provide

procedures, processes, routines, and documents which will clearly establish defined standards for the

Transportation Provider’s participation in the program. These Guidelines are subject to periodic revision,

as needed, to further enhance the MTM Medical Transportation Program and to comply with MTM Client

requirements. The Transportation Provider Guidelines, and any revisions or amendments thereto, are

effective upon receipt by the Transportation Provider. Transportation Providers understand adherence to

the MTM Transportation Provider Guidelines is required. Trip/log sheet documentation referenced in

Appendix E must be provided to MTM contemporaneously with submission of claims. All other

documentation referenced herein must be available at no charge to MTM upon request.

Joel’s Insight: Ah yes, another awesome sentence that I love because MTM is painfully clear on their



intentions and who is in charge. Periodic revisions of this Agreement can be issued at any time for whose

benefit? “To further enhance the MTM Medical Transportation Program” – NOT YOUR Medical

Transportation program! Just reminding you of who the boss is and how you supposedly have no say in

the matter. And when MTM issues a revision, they are “effective upon receipt!”

Note: See definitions section of the Medical Transportation Services Agreement and Appendix F for

guidelines specific to your contract.

MTM TRANSPORTATION PROVIDER REQUIREMENTS

1.0 General Transportation Requirements

1.1 Transportation Provider agrees not to differentiate or discriminate in the treatment of any

passenger on the basis of sex, marital status, age, race, color, national origin, ancestry, religion,

disability, medical condition, veteran status, political affiliation, economic status, or sexual

orientation.

1.2 Transportation Provider must immediately report to MTM any change in Transportation

Provider’s ownership, corporate officers or controlling interest.

1.3 Transportation Provider must immediately report to the MTM Network Management

Department any change in Transportation Provider’s address, phone number and/or fax number,

or federal tax ID number.

1.4 Transportation Provider and its employees and agents must maintain the confidentiality of any

and all information related to MTM services, Clients, and passengers, and comply with the Health

Insurance Portability and Accountability Act of 1996 (HIPAA).

1.5 Breach of confidentiality may result in suspension and/or termination from the Transportation

Provider Network.

1.6 Transportation Provider understands if there is suspicion of fraudulent Transportation Provider

activity, an investigation will be conducted by MTM, with appropriate action taken, including

notification to the MTM Client, recovery of overpayments from Transportation Provider, or



offset future Transportation Provider payments, and potential termination of the contract

between the Transportation Provider and MTM.

1.7 Transportation Provider agrees to cooperate with MTM and the MTM Client in the investigative

process of suspected fraudulent activity.

1.8 Transportation Provider and driver shall ensure that services available to MTM passengers are at

least comparable in quality to services available to the general public.

1.9 Transportation Provider agrees that MTM trip requests will have equal priority with

Transportation Provider’s day-to-day services.

Joel’s Insight: Let the games begin! So, MTM suggests that their “trip requests will have equal priority”

with other trips of our day-to-day service. I totally agree with that – as long as they’re paying the same

rates as other clients! Or is MTM suggesting that they pay less per transport of equal value yet they

somehow warrant “equal priority?” I’m all for taking great care of ALL clients equally, as long as they’re

ALL paying relatively the same price! If not, you’re (MTM) not expecting me to jump over a quarter to

get to a nickel, are you? If yes, sorry, but that’s YOUR problem - NMP!

1.10 Transportation Provider must not inquire as to the nature of a passenger’s illness or medical

services received, except in the following instances:

a) Transportation Provider needs to know such information due to medical necessity

relating to appropriate transportation.

b) The passenger becomes ill during the course of the trip and acquiring such information is

considered pertinent to assuring the passenger’s safety and well-being.

1.11 Transportation Provider shall provide drivers with visible employee picture identification card,

picture ID badge and uniform with name for security and identification purposes.

Joel’s Insight: Identification cards with picture ID, uniforms, etc. are all great suggestions and definitely

improve the appearance of your company. But they do cost money. How much are you (MTM) paying

me? Are the rates of reimbursement enough for me to cover all my costs and overhead expenses or were



you expecting me to look professional, provide great service, and operate in the red?

1.12 Transportation Provider, for itself and its drivers, must obtain and maintain in current status any

and all licenses, permits, certificates, and registrations that are required by Federal, State or local

laws, rules and regulations.

1.13 It is the Transportation Provider’s responsibility to understand and comply with all applicable

State and Federal laws including, but not limited to, the Americans With Disabilities Act (ADA) of

1990; Federal Transit Administration (FTA) regulations (including FTA’s drug and alcohol

regulations); the Federal Highway Administration’s drug and alcohol regulations’ Rehabilitation

Act of 1973, Section 504; the requirements of 42 Code of Regulations, Part 431, Subpart F; and

Title VII of the Civil Rights Act of 1964.

1.14 Transportation Provider must display any applicable current State and local motor vehicle

inspection sticker.

1.15 Transportation Provider must provide to MTM their Federal Tax ID (“EIN”), or Social Security

number, whichever is applicable, and Form W-9.

1.16 Transportation Provider agrees to respond to complaints within twenty-four (24) hours and to

provide resolution and/or a corrective action plan approved by MTM.

Joel’s Insight: I agree with this, responding in 24 hours. It sounds great, is responsible, and makes sense.

Consider: what if something happens where I can’t respond within 24 hours? What if I’m on vacation,

out of town, or whatever, and I need more time? Maybe I need 48 or 72 hours. Does that constitute

“misconduct” and, thus, I’m going to face “disciplinary conduct?”

1.17 Transportation Provider agrees to allow, cooperate, and participate in MTM on-site visits of the

Transportation Provider’s place of business and inspection of business records and vehicles.

Joel’s Insight: Ok, coming to my place of business to inspect my vehicles is reasonable. By what

measures or standards will you (MTM) be “inspecting my business records and vehicles?” The last thing

we want to do is be vague. Vague creates a lot of room for confusion and miscommunication. Again,

what happens if some of my business records or vehicles don’t meet your standards, will I face



“disciplinary conduct?”

1.18 Transportation Provider agrees to respond to MTM recommendations of the on-site visit and

understands that failure to respond by the requested date may result in a Corrective Action Plan

(CAP) and/or future trips not being scheduled with the Transportation Provider until such time

that satisfactory responses are in place.

Joel’s Insight: Ah, now I get it! So you, the Broker, want me to agree to allow you to come to my place of

business, according to your schedule, to inspect my business and vehicles according to your vague

standards, and if I refuse or “fail” your inspection it “may result in a Corrective Action Plan?” Even more

so, I, the business owner working to build a thriving and prosperous business, am at risk of having trips

taken away?

Hmm, I’m not sure I understand. Am I a strategic partner for which we respect each other, we share a

common vision of helping and profiting with each other to the benefit of our shared clients or, am I just a

sharecropper that is to be told what to do? I have no say so? If I don’t like it or fail to comply according

to your ambiguous standards I will be punished? Let me ask you (MTM) again, what are your rates of

reimbursement? How much are you paying me again?

1.19 Transportation Provider must comply, at a minimum, with their chosen service level. MTM

service levels are:

a) Curb to Curb

Driver must pull the vehicle up to the pick-up and destination entrances.

b) Door to Door

Driver must go to passenger’s residence door or facility entrance and announce

arrival as referred to in Guideline 10.5.

Upon arrival at the destination, it is the driver’s responsibility to bring the

passenger to the appropriate entrance or specified office as requested.

Return trip must follow the above instructions.



Door to Door service will also encompass points noted in Curb to Curb

c) Door through Door

Driver must enter the residence or facility and help passenger to assure safe

assistance to and from the vehicle.

Driver must deliver the passenger at destination inside the facility or residence

to an appropriate facility representative.

Return trip must follow the above instructions.

Door through Door service will also encompass Door to Door and Curb to Curb

service.

2.0 Driver Qualifications

2.1 All drivers for MTM trips must possess a current, valid driver’s license appropriate for the

services rendered and for the size vehicle driver is operating and as required by the State and

local governmental entity in which driver provides transportation. A legible copy of each driver’s

license must be provided to MTM as part of the credentialing process.

2.2 Drivers must be at least 21 years of age and must be a U.S. citizen or legal resident

Joel’s Insight: So, you’re (MTM) telling me whom I can and cannot hire? What if I have a very

responsible and dependable 20 year old with a two year college degree? I can’t hire this person, why? Is

this my NEMT company or yours? Are we strategic business partners or, again, am I just a sharecropper

that has to follow orders to avoid “disciplinary conduct?”

2.3 Drivers must be able to read, write and communicate effectively in English. It is in the

Transportation Provider’s best interest to employ drivers and/or office personnel who are also

fluent in any other languages prevalent in Transportation Provider’s service area.

2.4 Drivers must be physically able to assist passengers entering and exiting vehicles, and capable of

safely providing transportation services. By submission of a driver for credentialing approval by



MTM, both Transportation Provider and driver represent that driver has no physical or mental

impairment that would hinder or prevent driver from performing the services and safely

transport MTM passengers.

3.0 Driver Requirements

3.1 Drivers must obey all Federal, State and local traffic laws in the transport of passengers.

3.2 Drivers understand that in the event a driver or passenger feels there is a need for emergency

medical assistance, the driver must immediately call 911.

3.3 Drivers must drive in a safe and courteous manner, such that all passengers must be transported

safely to their destinations.

3.4 Drivers must conduct themselves in an appropriate, courteous and professional manner.

3.5 Drivers must maintain an acceptable standard of dress, personal grooming and behavior in order

to present a neat, clean and professional appearance. Transportation Provider shall provide

drivers with visible employee picture identification card, picture ID badge and uniform with name

for security and identification purposes.

3.6 Drivers must not smoke in the vehicle, or smoke in the presence of any MTM passenger

3.7 Drivers must not allow passengers to smoke in the vehicle. It is required that Transportation

Provider post a “NO SMOKING” sign in all vehicles.

Joel’s Insight: I have no problem with posting “No Smoking” signs in your vehicles. I am not a fan of

smoking. In fact, I’ve never even tried a cigarette. So posting such signs is a good idea. However, my

ONLY problem with this is having a Broker tell me I have to! What if I have a custom vehicle and, quite

honestly, I just don’t like the way such a sign looks in my vehicle? I know, I know. I am nitpicking. But

again, the reason why we start our own business in the first place is to make our own decisions, not be

told where we have to put a sign by someone (Broker) who is “supposed” to be a strategic partner and

NOT a jail warden!

3.8 Drivers must not eat while driving MTM passengers.



3.9 Drivers must maintain a “trip” or “log sheet” listing all MTM trips for each individual day.

The trip or log sheets must be legible and complete. Required log information is found in

Appendix E.

Joel’s Insight: I am all for Daily Log Sheets or Driver Manifests. In Dispatching Made Easy, they are

readily available for each driver – and they work great, too! But guess what, this is the new millennium

and it’s OK for us to use technology! In Dispatching Made Easy, drivers can receive their trip information

electronically on their cell phones! This significantly reduces the overhead cost for business owners. BUT

because MTM expects us to maintain a paper trail for 10 years, we are supposed to increase our cost,

pain and suffering? We are supposed to incur additional tasks and responsibilities why? OK, my

company will consider such policies, if the price is right! If you’re not paying me a profitable rate of

reimbursement, sorry - NMP! I’m in business to make money and increase efficiency – not lose money

and increase potential burdens!

3.10 Drivers must not use alcohol or drugs at any time, and if taking medication, must still be able to

perform his/her duties in a safe manner. Any driver taking medication which may hinder his/her

performance must report such use to his/her supervisor, and not transport MTM passengers.

3.11 Drivers must not allow personal friends or family to ride in vehicle while transporting MTM

passengers, unless specifically authorized by MTM. Exceptions may be made for larger multi-

passenger vans and buses designed for shared rides, or for approval for a ride-a- long spouse for

a long distance trip.

3.12 Drivers must not allow animals in the vehicle unless necessitated by the passenger for medical

purposes, and requires pre-authorization from MTM.

3.13 Drivers must not make personal stops, other than for restroom and passenger/Transportation

Provider agreed-upon restaurant breaks, while transporting MTM passengers unless specifically

authorized by MTM.

3.14 Drivers must require passengers to use seat belts properly and assist in fastening seat belts

where necessary, and must refuse to continue travel if passengers are non- compliant. Drivers



must carry and be knowledgeable in the use of seat belt extensions for securing passengers of

wide girth.

3.15 Drivers understand infants/children are to be in proper infant/child restraint seats as required by

State or Federal law. In the event a proper seat is not available, or the use of proper child

restraint seat is refused, the driver must deny transportation.

3.16 Drivers must not place children in child restraint seats in the front seat of a vehicle.

3.17 Drivers must exit the vehicle to open and close vehicle doors when passengers enter or exit the

vehicle. Drivers must offer a helping hand or arm to assist passengers exiting the vehicle. Such

limited assistance is included in curb to curb service as well as higher modes of service. Except

where service is curb to curb, they must provide safe assistance to or from the main door or

reception desk of the place of destination, when needed.

3.18 Drivers must assure passengers enter and exit the vehicle in an unobstructed and safe location.

3.19 Drivers are required to store in the trunk of the vehicle, or properly secure for safety, folding

wheelchairs, carry-on packages, and walking aids such as canes, walkers, etc.

3.20 Drivers must not touch any passenger except as appropriate and necessary to assist the

passenger into or out of the vehicle, into a seat and to secure the seatbelt, or as necessary to

render first aid or assistance for which the driver has been trained. Drivers must request

permission from the passenger prior to touching the passenger

3.21 Drivers must not make sexually explicit comments or solicit favors, medications, or money from

passengers.

3.22 Drivers must properly identify and announce his/her presence at the entrance of the building or

with attending facility staff at the specified pick-up location, if a suitable curbside pick-up is not

apparent.

3.23 Drivers must not enter the passenger’s home except under prior authorization from MTM.

3.24 Drivers shall not wear any type of headphones while on duty. Driver shall have the volume of the



radio at a level acceptable to passengers.

3.25 Drivers shall not accept responsibility for any of passenger’s personal items.

3.26 Drivers must confirm that all wheelchairs and motorized scooters are properly secured to the

vehicle and wheelchair and motorized scooter passengers are properly secured in the wheelchair

before allowing the vehicle to proceed.

3.27 Drivers must not allow firearms, alcoholic beverages in open containers, unauthorized controlled

substances, or highly combustible materials to be transported in the vehicle.

3.28 Drivers must check their vehicle to ensure that at the end of each trip or trip route, all passengers

have vacated the vehicle.

4.0 Driver Training

4.1 Transportation Provider must develop and maintain a specific Transportation Provider Driver

Training Policy for providing appropriate training for newly hired vehicle operators (drivers), and

a Driver In-Service Training Policy for annual Training of current drivers. Suggested training

activities may be a combination of reading materials, film or video media presentations, verbal

instruction and on-the-job training. All training and education of drivers is the responsibility of

Transportation Provider.

4.2 Transportation Provider’s Driver Training Policy and Driver In-Service Training Policy are subject

to review by MTM, and a copy provided to MTM upon request.

4.3 MTM requires Transportation Providers to provide all drivers with training in Basic First Aid,

Defensive Driving, Assisting Passengers with Disabilities, Transportation Provider’s established

Emergency Procedures, Universal Precautions for bloodborne pathogens, and use of a fire

extinguisher. Basic First Aid and Defensive Driving Training is to include training listed in

Appendix A. The training must be documented in the employee’s file. Additional suggested

training and training resources are listed in Appendix B.

Joel’s Insight: Man, all of that sounds awesome! And it’s great and worthy training and skills to have!



Again, let me ask you (MTM) this, how much are you paying me? I have a fleet of vehicles and a fleet of

drivers. Are you (MTM) reimbursing me at a rate adequate to ensure that all of my drivers are trained in

all of these skills and techniques? Surely, you’re (MTM) not expecting me to operate at a loss, are you

(MTM), “strategic partner?” If you don’t plan on reimbursing me sufficiently to cover such expenses and

still maintain a healthy profit, sorry – NMP!

4.4 All drivers responsible for transporting passengers in wheelchairs must be trained in proper

loading, unloading and wheelchair tie-down procedures prior to transporting MTM wheelchair

passengers. The training must be documented in the employee’s file.

4.5 All required training must be completed within 90 days of the driver’s hire date, and must be

documented in driver’s file in order to continue to transport MTM passengers.

5.0 Transportation Provider Personnel Policies/Documentation

5.1 Transportation Provider must maintain a file on each driver, including owners, when they have

driving responsibilities, which shall include:

a) Documentation of training

b) Copy of current driver’s license

c) Driver evaluations

d) Results of a criminal background check

e) Results of a child abuse or neglect background check

f) Results of an elderly abuse background check

g) Results of a State specific driver history record check

h) Results of Excluded Provider List check

i) Signed Drug-Free Workplace policy



Note: d-f will be performed, to the extent permitted by law, in Transportation Provider’s state of

operation. Copies of the background record checks (d-h) shall be provided to MTM within ten (10)

days of the date on the records check.

Joel’s Insight: I am all for criminal background checks and all other associated background checks. Note,

it all costs money. Individually, it may not sound like a lot of money. When you have 5, 10, 20, 40 plus

drivers we’re talking several thousands of dollars in additional operating cost. Again, how much do you

plan on reimbursing me?

Note: When you enlist the help of the United Medical Transportation Providers Group (UMTPG) for

insurance, your insurance policies can cover Sexual Abuse and Molestation, child and elderly abuse. Such

stipulations are indeed important as drivers can gain access to nursing homes and hospitals rooms, in

addition to client residences. Especially when you have many drivers, such coverage is highly advisable.

5.2 Transportation Provider must develop a Driver Orientation Policy and Procedure, and provide

MTM a copy upon request.

5.3 Transportation Provider must assure current laws regarding drug and alcohol testing are

enforced for any of their drivers or attendants. Documentation must be available to MTM upon

request.

5.4 Transportation Providers must establish and maintain a Substance Free Workplace Policy to

include, reasonable suspicion and a for-cause testing procedure. This policy must include a pre-

employment drug screening for all drivers and attendants. This policy must be in writing and

signed by all drivers and attendants. Results must be documented in the files of drivers and

attendants.

Joel’s Insight: Pre-employment drug screening is highly advisable – in addition to annual or biannual

drug screening for ALL EMPLOYEES! It is very important that you do not discriminate and focus on drug

testing a select few employees. Doing so can definitely expose you to lawsuits and accusations.

Remember, drug testing costs money. How much are you (MTM) reimbursing me, “strategic partner?”

5.5 If the Transportation Provider has reasonable suspicion of a driver or attendant to be under the

influence of alcohol or drugs, the Transportation Provider must immediately remove the driver or



attendant from MTM service until a proper medical evaluation can be made.

5.6 If MTM has reasonable suspicion, MTM reserves the right to require a driver or attendant to have

an alcohol and/or drug screening at any time at the expense of the Transportation Provider.

Screening tests must be accomplished within the time frame designated by MTM. A driver or

attendant will not be allowed to transport MTM passengers, or provide services to MTM

passengers, until a proper medical evaluation has been received and approved by MTM. Refusal

to submit to testing within the designated time frame is considered a positive test result and will

have the same disciplinary consequences. Drivers or attendants testing positive for drugs and/or

alcohol will no longer be permitted to transport MTM passengers or provide any other service to

MTM passengers.

Joel’s Insight: So you (MTM) can direct my drivers to submit to alcohol and/or drug screening at my

expense? Oh, I’m sorry, I thought I was the owner of my company and that we were just “strategic

partners” working to help each other to serve common clients. But OK, I guess I will submit to your

demands because I would like to service Medicaid clients. Oh, and I have to do it “within the time frame

designated by MTM?” What if I’m out of town, maybe on vacation? What if we’re really busy? What if I

don’t agree with your demand, that a specific driver needs to be drug tested (seeing as how I’m paying

for it!)? Oh, and um, how much are you (MTM) paying me again? I just want to make sure that it is

profitable enough to make being inconvenienced and pushed around worth my while because if it’s not –

NMP!!

5.7 Transportation Provider must subject all drivers, including new drivers, to a State specific driver

history record acquired through the State’s Department of Motor Vehicles and the results must

be documented in the driver’s file.

5.8 Transportation Provider must run State specific driver history records once per year, at a

minimum, on all drivers providing MTM service, and copies shall be available to MTM upon

request.

Joel’s Insight: I totally agree with pulling MVR’s (Motor Vehicle Reports) annually for each driver. A

driver could get a ticket when they are not on duty and you may not know until you realize your

insurance premiums might be going up because of a driver’s poor driving records. Depending on what



state you’re in, ordering MVR’s for each driver can range between $10-25 per driver. Obviously, if you

have several drivers this can become costly. So although it is definitely a good idea, you need to make

sure that you consider all such additional costs when negotiating your rates of reimbursement.

5.9 To the extent permitted by law, all drivers and attendants, including new drivers, must be

subjected to a criminal background check through the State law enforcement agency on an

annual basis. The results must be documented in the driver’s file and copies provided to MTM.

Joel’s Insight: Oh, I’m sorry, previously you (MTM) mentioned that I need to get criminal background

checks, among others, prior to employment. But now, you insist that I have this done annually for all of

my drivers? Oh, OK, I can make that happen. Remind me again, how much are you (MTM) paying me

again?

5.10 To the extent permitted by law, all drivers and attendants, including new drivers, must be

subjected to a child abuse or neglect background check through the appropriate State agency if

such information is not included in the criminal background check. The results must be

documented in the driver’s file. The record of the background check MUST be provided to MTM.

Joel’s Insight: Oh, again, it all sounds so good. Again, please remind me, how much are you (MTM)

reimbursing me? Because honestly, if you’re not paying me enough to make it worth my while, sorry –

NMP!

5.11 To the extent permitted by law, all drivers and attendants must be subjected to an elderly abuse

background check through the appropriate State agency if such information is not included in the

criminal background check. Results must be documented in the driver’s file. The record of the

background check must be provided to MTM.

Joel’s Insight: Well, what a coincidence! I should have known, the jail warden imposes more demands! I

thought we were negotiating because we are “strategic partners?!” Oh, OK. But remind me again, how

much are you (MTM) reimbursing me - NMP?

5.12 No driver may perform transportation services for MTM until the appropriate criminal

background check, child abuse/neglect background check, and elder abuse background check

have been obtained, and the driver has been fully credentialed and approved by MTM.



NOTE: As we continue forward I want you to note how many times MTM says “Transportation Provider

must” or “Transportation Provider agrees.” I have underlined such phrases to illustrate the

frequency. Again, you have to put things into perspective. Are all of these stipulations designed

and inserted into an Agreement such as this to protect you or them, the Broker? The answer is

obvious. And please understand I am NOT presenting you with all of this information to deter

you from subcontracting with a Medicaid Broker. Rather, I am presenting you with such insight

to ensure that you are more aware and knowledgeable so as to better negotiate greater rates of

reimbursement to ensure profitability.

5.13 Transportation Provider must not use any driver or attendant with any of the following

convictions or substantiated incidents:

a) child abuse or neglect

b) spousal abuse

c) a crime against a child

d) a crime against an elderly or infirm individual

e) a crime involving rape, sexual assault, or other sexual offense

f) homicide

5.14 Transportation Provider must not use any driver or attendant who has the following return

notification from the Background Screening/Investigation Unit of the Children’s Division (or

similar agency):

a) “Category” is shown as physical abuse or sexual maltreatment;

b) “Severity” is shown as moderate, serious/severe, permanent damage, or fatal;

c) “Conclusion” is listed as court adjudicated or probable cause.

5.15 Transportation Provider must not use any person as a driver or attendant whose name appears

on the Department of Social Services, the Department of Mental Health, or the Department of



Health and Senior Services Employee Disqualification List (EDL), or on other similar agency list(s).

5.16 Transportation Provider must not use any person as a driver or attendant whose name, when

checked against the Family Care Registry (or similar agency registry), registers a “hit” on any list

maintained and checked by the registry.

5.17 Transportation Provider must not use any person as a driver or attendant in the conduct of MTM

services who has a felony criminal conviction of a felony offense within the immediate past five

(5) years. Further, any conviction (misdemeanor or felony) for any of the following driving

offenses within the previous five (5) years shall disqualify a driver from performing MTM

services:

a) DUI or DWI, or other alcohol related offense

b) Careless and imprudent, or reckless driving

5.18 For purposes of these Transportation Provider Guidelines, the term “conviction” shall also

include any plea of guilty, finding of guilty, plea of “nolo contendere”, or similar disposition,

whether or not such disposition results in a sentence or conviction under applicable state or local

laws. MTM further reserves the right to disapprove of any driver or attendant for safety reasons;

or where disqualification of a driver or attendant is requested by an MTM Client; or for other

reasons of good cause within MTM’s sole discretion. Transportation Provider acknowledges that

the offenses listed herein are not an exclusive listing, but that there are other offenses and

pertinent circumstances which can result in the disapproval of a driver or attendant.

Joel’s insight: I’m sorry I forgot again, I don’t own my own company! For a moment there I actually

thought I did own my company and managed my own employees – silly me! I should have known, you

(MTM) “reserve the right to disapprove” one of my employees. Oh, and um, how much money are you

paying me? I just wanted to make sure it was enough for me to accept that you are in control of my

company and that I have no say in the matter, Mr. Jail Warden.

5.19 Transportation Provider must not allow drivers or attendants to perform MTM services who are

currently on work release, probation, or parole for any felony, or any offense of the type

identified in 5.13-5.17.



5.20 Transportation Provider must not use any driver with the following:

a) Convicted of more than two (2) minor motor vehicle moving violations, such as speeding,

failure to stop, improper operation, etc., within the previous twenty- four (24) months

b) More than one (1) at-fault incident (accident) resulting in personal injury or property

damage within the previous thirty-six (36) months, or three (3) or more cumulative

vehicle accidents within the previous five (5) years

c) A combination of one (1) unrelated minor motor vehicle moving violation and one (1) at-

fault incident (accident) resulting in personal injury or property damage within the

previous twenty-four (24) months

d) Revocation or suspension of the driver’s vehicle operator’s license within the previous

three (3) years for accumulation of points or alcohol related incident

5.21 Transportation Provider must perform periodic performance evaluations of all drivers, at a

minimum, every twelve (12) months and maintain documentation of each evaluation in each

driver’s file, copies of which shall be provided to MTM upon request.

Joel’s Insight: I am a very big fan of employee evaluations. Feedback and directed critiques are essential

for developing and improving your labor force. Yet as I am sure you guessed, as a business owner, I don’t

like being told how and when I need to do something – unless you’re reimbursing me enough to make it

sensible. If not, sorry – NMP!

5.22 Transportation Provider must maintain a driver’s health record, signed by the driver, that no

physical or health limitation exists that prevents safe, competent operation of the motor vehicle

or ability to assist any passenger in and out of the vehicle, or the performance of any other

passenger assistance services, when a passenger requests such assistance. A copy shall be

provided to MTM upon request. Transportation Provider’s assignment of a trip to a driver, and

the driver’s acceptance of the trip, constitute a representation by both Transportation Provider

and driver that driver has no physical, cognitive or other health limitation that prevents driver

from safely performing the trip and all duties and assistance necessary.



5.23 MTM reserves the right to deny the approval of any driver, or to require a Transportation

Provider to suspend, or otherwise discontinue the use of any driver, in the performance of MTM

services at the sole discretion of MTM.

Joel’s Insight: Man, for a minute there, I thought you were threatening me telling me who I can and

cannot hire. Oh wait, you are! Please enlighten me, who is in charge of my business? Because honestly,

if you (MTM) are in charge, I would really appreciate it if you would start paying my taxes too!

5.24 Transportation Provider must not use any driver who has a pending felony charge, or any other

pending charge, which if the charge were to result in a conviction, would disqualify the driver

under these Guidelines. The driver and Transportation Provider must report all pending felony

charges to MTM, and the final disposition/resolution of such charges.

6.0 Vehicle Requirements

6.1 Transportation Provider must provide the make and model, model year, vehicle identification

number (VIN), license number, and vehicle type (sedan, minivan, paralift, etc.) to MTM for every

vehicle used to transport MTM passengers. This information must be provided no later than the

vehicle’s first day of service. Additionally, the Transportation Provider must notify MTM of any

vehicle permanently added or removed from MTM service. Use of any vehicle prior to approval

of MTM will result in nonpayment for the trip, and assessment of liquidated damages.

Joel’s Insight: This makes sense. And I’m not trying to “pick a fight” on every issue. Tell me, what

happens if I cannot provide this information on the first day? What if I’m so busy that I couldn’t do it

until the third day? Does this constitute “misconduct” and, thus, I’m going to be subject to more

“Corrective Action?”

6.2 All seat belts must be in proper working order and accessible to the passenger.

6.3 Transportation Provider shall provide seat belt extensions when needed.

6.4 All vehicles must prominently display Transportation Provider’s name, and phone number in the

interior of the vehicle.



Joel’s Insight: Mr. Jail Warden, why must I have my company name and phone number “prominently

displayed” on the inside of my vehicle when I already have it posted on the outside of the vehicle? What

if I don’t like the way it looks next to the “No Smoking” sign that is already inside my vehicle? If I don’t

do this, do I have to face “Corrective Action?” Are you going to take trips away from me? Am I still

expected to treat your MTM transports equally as compared to other clients and patients that don’t

insist on all of these frivolous demands?

6.5 All vehicles must be clearly marked showing Transportation Provider’s business name on both

sides of the exterior of the vehicle.

6.6 All vehicles must be equipped with operable heating, air conditioning and ventilation systems so

as to ensure the comfort of the passenger.

6.7 All vehicles in use for MTM services must have:

a) emergency first-aid kit

b) fire extinguisher – (A,B,C)

c) three (3) reflective triangles or similar emergency warning devices

d) blood borne pathogen spill kits

e) extra electrical fuses

f) flashlight

g) ice scraper

h) current insurance card

i) current vehicle registration

j) MTM or Transportation Provider Accident/Incident forms

k) Transportation Provider Accident Procedure



l) such other equipment as may be required by MTM

m) no-smoking sign

Additional equipment is recommended in Appendix C.

Joel’s Insight: MTM requiring that all vehicles are equipped with a first-aid kit makes sense. Requiring a

fire extinguisher, maybe, but extra electrical fuses? Again, I recognize that I might be nitpicking. Yet, if

someone can mandate that all of my vehicles must be equipped with “extra electrical fuses (versus

keeping them in the garage/repair shop), where does it end? Will there be any other redundant and

frivolous mandates that you require in order for me to avoid having trips taken away or being subject to

“Corrective Action” and, thus, adversely affecting my revenue?

6.8 Passenger cars (sedans) must have four (4) doors. Two-door vehicles are not acceptable when

transporting MTM passengers.

6.9 When a Transportation Provider utilizes a high profile/tall vehicle to transport MTM passengers

that has greater ground clearance than an average-sized sedan, Transportation Provider must

provide a sturdy, non-skid, stepping aid to assist the passenger in entering and exiting the

vehicle. This stepping aid must be capable of safely supporting 300 pounds, must be no higher

than twelve inches (12”) above the ground, with a nonskid top surface not less than eight inches

by twelve inches (8” x 12”)

6.10 For all vehicles used for paralift operations, the overhead clearance between the top of the door

opening and the raised lift platform, or highest point of ramp, shall be a minimum of 56 inches,

or such other distance as may be required by ADA or other federal or state laws or regulations.

6.11 MTM requires all wheelchair lifts have a design load of at least 600 pounds.

6.12 All ramps used for the loading and unloading of passengers must meet ADA Accessibility

Guidelines.

6.13 All tie-downs or other securement devices used for paralift operations must meet the ADA

Accessibility Guidelines.



6.14 Vehicles must not be more than eight (8) years old without specific written approval of MTM.

Joel’s Insight: What?! Why? Why can’t I operate a vehicle more than 8 years old? My vehicles are well

maintained. So if I have a vehicle that is 7 years old, in one year I have to take it out-of-service for MTM

transports? OK, please, refresh my memory. How much are you (MTM) reimbursing me again? I just

want to make sure that I’m making a healthy profit with enough margins to compensate for the cost of

new vehicles.

6.15 Vehicles, regardless of age, may be taken out of service for use with MTM passengers at the

discretion of MTM after a vehicle assessment is performed.

Joel’s insight: Oh, silly me! I’m sorry, I should have anticipated this. Of course YOU (MTM) can take any

of my vehicles out-of-service at your “discretion.” After all, I’m here to serve you (MTM)! You can

terminate my employees at your “discretion” so it only makes sense that you can take my vehicles out –

of-service at your convenience! In fact, I appreciate your commands – I didn’t want to run my own

company any ways! I’d rather have you make the decisions so I can say – NMP!

6.16 Vehicles are required to have a form of two-way communication, which enables a central

dispatch to contact the driver at any time.

6.17 Vehicles must be clean, mechanically safe, and road-worthy.

6.18 All vehicles in use for MTM service must have:

a) Functional door handles

b) Accurate speedometers and odometers

c) Functioning interior lighting

d) Adequate side-wall padding and ceiling covering

e) One (1) interior rearview mirror

f) Two (2) exterior rearview mirrors – one on each side of the vehicle



g) Passenger compartments that are clear and free from unsightly and potentially

hazardous, torn upholstery, torn floor covering or dangling seat belts

h) Cell phones are not to be used unless responding to a dispatcher call or making an

emergency call; and use of cell phone must be in compliance with state and federal

laws and regulations.

i) Vehicles must have tire tread-life meeting manufacturer’s minimum specifications

6.19 All vehicles in use for MTM service must not have:

a) Damaged or broken seats

b) Protruding or sharp edges

c) Dirt, oil, grease or litter in the vehicle

d) Broken mirrors or windows (other than small rock chips)

e) Excessive grime, rust, chipped paint or major dents

6.20 Transportation Provider agrees to remove from MTM service any vehicle to be found

unsatisfactory in reference to conditions listed in this section, or is questionable with regards to

safety or roadworthiness until repairs are completed.

Joel’s Insight: “Agree?” Of course I agree. In fact, I insist! This is my company in name only and we are

here to serve you (MTM). So yes, you can take my vehicles out of service at your convenience!

6.21 A vehicle with an inoperative two-way communication system must be placed out of service until

the system is repaired or replaced.

6.22 Daily pre-trip inspections are required, must be documented, and maintained for three (3)

months. See requirements in Appendix D.

6.23 Transportation Provider must maintain documentation that each vehicle has:



a) passed periodic mechanical safety inspections as required by the state in which the

vehicle is licensed and

b) documentation is also to include maintenance of fire extinguishers, first aid kits,

warning devices (triangles, flares, etc.) and bloodborne pathogen spill kits.

6.24 Documentation of regular maintenance procedures and repairs must be available to MTM upon

request.

6.25 All vans and busses shall have accessible emergency exit(s) with appropriate emergency

procedures posted in compliance with Federal Motor Vehicle Standard No. 217.

6.26 All vehicles used to transport passengers who must sit in wheelchairs during transport must have

raised roof or lowered floor.

6.27 For wheelchair transports, if more than minimal assistance is required, a wheelchair lift vehicle

must be provided, which meets all ADA standards.

7.0 Insurance Requirements

7.1 Transportation Provider is required to provide proof of commercial automobile liability insurance

for any vehicle used for MTM service, in accordance with contract terms by means of:

a) Certificate of Insurance from the carrier with MTM named as a Certificate

Holder.

b) MTM named as an “Additional Insured” on a primary, non-contributing basis on

Transportation Provider’s Certificate of Automobile Liability insurance and General

Liability insurance.

c) Certificate of Insurance must be furnished to MTM upon initial application of

Provider, and as insurance coverage renews.

7.2 Transportation Provider’s Commercial Vehicle liability insurance and Commercial General liability



insurance must meet the coverage limits set by MTM, MTM’s Client, or the applicable federal,

state, and local laws and regulations, whichever is greater. MTM may amend the required

minimum coverage limits at its discretion. The minimum vehicle liability insurance coverage

required by MTM is $300,000 combined single limit (CSL), or the state minimum, whichever is

greater. Transportation Provider must also maintain Commercial General liability insurance in the

amount of $300,000 Combined Single Limit (CSL), or the state minimum, whichever is greater.

Vehicle and Commercial General liability insurance must be issued on a primary, non-

contributing basis. MTM strongly encourages increased coverage for the Transportation

Provider’s protection. Higher coverage limits required by specific MTM Clients may limit

Transportation Provider’s ability to take trips for those Clients.

Joel’s Insight: Well of course, I will ensure that my insurance limits meet your (MTM) expectations!

After all, “my cup runneth over” with reimbursements. Oh, if you don’t mind my asking again, how much

are you (MTM) paying me? Because we’re “strategic partners” you (MTM) are going to reimburse me

with healthy premiums to ensure that we remain profitable, right?

7.3 Transportation Provider must comply with State’s coverage requirements for Worker’s

Compensation Insurance. A Transportation Provider that fails to obtain Workers Compensation

for all its drivers, agents and employees must provide MTM with sufficient documentation that

the Transportation Provider is exempt under applicable state law from maintaining Workers

Compensation insurance coverage. A mere statement from the Transportation Provider that it is

exempt is not sufficient. MTM reserves the right to require all Transportation Providers, including

those otherwise exempt, to maintain Workers Compensation insurance.

7.4 Transportation Provider must notify MTM immediately in the event their insurance coverage is

modified or terminated.

7.5 Transportation Provider, at its sole cost and expense, must procure and maintain such policies of

general and automobile insurance liability, both of which policies shall include contractual

liability, Workers Compensation insurance and other insurance as shall be necessary to insure

Transportation Provider, and its agents, employees, subcontractors including subcontracted

transportation companies, owner/operators, drivers and assigns, including volunteer drivers, and



MTM against any claim or claims for damages arising from performance of any services by

Transportation Provider to MTM.

7.6 When proof of insurance is requested by MTM, Transportation Provider must provide

documentation five (5) business days prior to the date of expiration or no future trips will be

awarded. Additionally, MTM will begin canceling all existing trips. Canceled trips will not

automatically go back to the Transportation Provider when they produce current and correct

insurance documentation.

Joel’s Insight: This paragraph alone summarizes everything in regards to Medicaid Brokers. If you don’t

comply with their demands in the allotted time, “no future trips will be awarded.” Further, existing trips

will be “cancelled” and “will NOT automatically go back” to you! Now seriously, who wants to put their

business in such an unstable situation? You have no idea how many transportation providers I encounter

that drool over the opportunity to sign with a Broker, never reading through their Agreement, and when

the Broker makes ANY changes in any capacity their business is shaken if not literally put out of business.

Bottom line, we do NOT go into business with the desire to be in a vulnerable situation. Yet, when you

sign with a Broker and you rely exclusively on them for revenue, that is exactly what you are doing –

putting yourself in a vulnerable situation. If the rates of reimbursement are not adequate to allow you to

cover your operating expenses AND make a profit, you need to tell the Broker to take a hike! Seriously,

this paragraph alone should convince you of the power of NMP!

8.0 Operational Requirements

8.1 Transportation Provider’s dispatch/office must be able to be reached by phone during

Transportation Provider’s regular business hours, and answered by a “live” person, not by an

answering machine or answering service.

8.2 Transportation Provider must maintain all records and documentation, including driver logs, trip

sheets, and billing reports pertaining to MTM services for ten (10) years, from the end of the

calendar year during which services were provided, and retained further if the records are under

review or audit until the review or audit is complete.

Joel’s Insight: Sorry, but if you (MTM) are not paying me enough – NMP! If you are not going to



reimburse me a healthy rate, then I don’t care how many people are on Medicaid, I don’t care how much

of a bind you (MTM) are in, I am not in business to lose money. Sorry, but – NMP!

8.3 Transportation Provider understands records requested by MTM must be original documents

sent at Transportation Providers expense, and will not be returned. Transportation Provider must

maintain copies at their expense.

Joel’s Insight: So I pay to send it to you, at my expense, and you (MTM) don’t have the courtesy to

return what is actually my property, my documents? Sorry, if you (MTM) are not paying me enough –

NMP!

8.4 Transportation Provider must allow on-site general performance evaluation, inspections,

auditing, monitoring, and duplication of records at no charge, of any and all data, billing reports,

trip/log sheets, vouchers and other records maintained by Transportation Provider on MTM

passenger trips, by agents of MTM, MTM Clients or State or Federal government officials during

normal business hours. MTM may conduct such evaluations and inspections unannounced. The

failure of Transportation Provider to timely allow on-site inspections may result in a Corrective

Action Plan (CAP), assessment of liquidated damages, and/or termination of Transportation

Provider at MTM’s discretion.

Joel’s Insight: Do you (MTM) hear yourself? How many more hoops do you want me to jump through?

Who is paying my office staff and associated labor expenses to comply with such laughable demands?

And if I fail to comply, you threaten me again with a laughable “Corrective Action Plan?” Am I in grade

school? Sorry, but if you (MTM) are not paying me enough to make it worth my while – NMP!

8.5 Transportation Provider understands if the Service Agreement (contract) is terminated for any

reason, if requested by MTM, Transportation Provider must forward all required records not

previously sent to MTM for the ten (10) year retention period to MTM. Transportation Provider

agrees that MTM payment for all unpaid claims at time of termination will be withheld until

MTM has received these records, and all transportation provider service records have been

audited by MTM for correctness and accuracy. MTM reserves the right to audit records received

from Transportation Provider within sixty (60) days of final receipt of all such records by MTM.



Joel’s Insight: Oh, well I appreciate your honesty. So if you decide to terminate me, any “unpaid claims

at the time of termination will be withheld?” Huh! Do you think that having payments withheld

(revenue that we already worked for and earned) will adversely affect your revenue? This is why when

working with a Broker you must closely monitor your money and accounts receivables and never allow

Broker reimbursement to run in arrears!

8.6 Transportation Provider must provide transportation services as requested by MTM on an

efficient and timely basis.

8.7 If passenger is delayed due to late pick-up or drop-off by Transportation Provider, and cannot be

seen at appointment, Transportation Provider will not be reimbursed for trip.

Joel’s Insight: You just got threatened to have your money withheld for a passenger being delayed.

Sorry, but – NMP!

8.8 Transportation Provider agrees to notify MTM immediately of any significant delays such as a

breakdown or stopped traffic, which cause the passenger to be 15 minutes or more late for

his/her medical appointment. In addition to MTM notification, Transportation Provider will make

subsequent alternative plans for completing the trip in a timely manner if the medical

appointment can still be attended.

8.9 Transportation Provider agrees to contact the passenger, if phone number is provided by MTM,

to notify of a significant pick-up delay and obtain information as to whether or not the passenger

will still be able to attend the scheduled appointment.

8.10 Transportation Provider understands if they are consistently late for pick-up and/or drop- off by

MTM’s assessment, Transportation Provider may face disciplinary action and be assessed

liquidated damages.

Joel’s Insight: OMG, more threats! The famous “Corrective Action Plan” monster again, sorry – NMP!

8.11 Transportation Provider must not sub-contract with other transportation companies for MTM

services without prior written approval of MTM. If MTM becomes aware a Transportation

Provider uses a sub-contracted company without written approval from MTM, Transportation



Provider will not be paid for any trip for which an unapproved subcontractor was used.

Joel’s Insight: Blah, blah, blah! It’s amazing. MTM’s Service Agreement is half the size of Logisticare’s

Agreement. That means twice the amount of threats from Logisticare as compared to MTM. Sorry –

NMP! If you (Broker) are not paying me enough in reimbursement to make any of this worth my while

then you need to move on to some other schleprock who is a big enough sucker to deal with this crap!

8.12 Approved sub-contracted Transportation Providers must meet the same standards and adhere to

the same “MTM Transportation Provider Guidelines” as does Transportation Provider, and

Transportation Provider must be responsible for their approved subcontracted Transportation

Providers.

8.13 Transportation Provider may not solicit money from MTM Clients or their passengers for

payment of MTM authorized transportation services; except that Transportation Provider may

collect a co-pay amount approved by MTM and MTM’s Client from the passenger, where

applicable.

8.14 Transportation Provider understands that all trips, including recurring trips, may be assigned or

reassigned by MTM in its sole discretion. Transportation Provider has no claim or right to

transport any particular person, nor any claim or right to transport any person attending any

particular health care services facility.

Joel’s Insight: Blah, blah, blah. You (MTM) are a broken record. You already threatened me with this,

remember? Sorry, but – NMP!

8.15 Transportation Provider shall have a MTM approved accident/incident investigation procedure in

writing, and shall follow that procedure to respond to and review all accidents/incidents.

8.16 Transportation Provider must provide a copy of the Transportation Provider’s Accident/Incident

Investigation Procedure to MTM.

8.17 Transportation Provider must report all incidents, accident and injuries occurring while the

Transportation Provider or a sub-contracted Transportation Provider is transporting any MTM

passenger(s).



8.18 Transportation Provider accident/incident reports must be made in writing by the end of the next

business day following an accident/incident while transporting an MTM passenger. If there are

injuries involved, Transportation Provider must also report verbally to MTM within three (3)

hours of the accident/incident.

Joel’s Insight: What if I’m busy? What if I’m out of town? What if I can’t do it when you want? Let me

guess, more of the famous “Corrective Action Plan,” right? LOL!

8.19 At a minimum, the accident/incident report must include the name of the driver, transported

passenger(s), and specific details of the accident/incident and related injuries.

8.20 A copy of the police report must be provided to MTM as soon as it is available.

9.0 Trip Scheduling

9.1 Transportation Provider agrees to check the MTM Daily Fax Summary and/or electronic trip file

to make certain all trip requests have been received by Transportation Provider. Transportation

Provider must contact MTM Provider hotline if a fax has not been received.

9.2 If Transportation Provider knows that the price, designated level of service, mileage, zip codes, or

any other data on the trip request is incorrect, Transportation Provider must notify MTM of the

corrections immediately. Transportation Provider shall have the right to turn back, or refuse any

trip assignment from MTM. If Transportation Provider performs a trip, Transportation Provider

agrees to accept the amount of compensation for that trip that is noted by MTM on the trip

assignment sheet provided in advance by MTM to Transportation Provider. Transportation

Provider agrees not to claim compensation in excess of the compensation noted on the trip

assignment sheet, irrespective of the level of service, or the totality of services provided by

Transportation Provider for the given trip; and payment by MTM of the amount of compensation

noted on the trip assignment sheet shall constitute payment in full and satisfaction of

Transportation Provider’s claim for compensation for services rendered for that trip, and

Transportation Provider, by performing the trip, waives any claim for compensation in excess of

the stated compensation on the trip assignment sheet. “Wait time”, where authorized by

contract, must be approved by MTM at the time of the occurrence of wait time, and prior to



submission of an invoice claim for payment of the trip.

Joel’s Insight: So you (MTM) tell me what I have to agree to and “accept the amount of compensation”

that you deem worthy and that “constitutes payment in full” and to my “satisfaction?” Hmm, that

doesn’t make me feel much like a “strategic partner” as I was hoping! So where is the negotiation?

Where is the open communication to determine win-win solutions to both our advantage? Oh, are you

saying that there is no negotiation with you (MTM)? Sorry, but – NMP!

9.3 Transportation Providers are required to schedule drivers with adequate time allowances so

speed limits are followed and passengers arrive on time for appointments.

9.4 Transportation Provider must establish, where applicable, an internal schedule for the

passenger’s return “will call” trip pick-up which does not impose unreasonable waiting time for

the passenger, not to exceed one (1) hour maximum from time of passenger’s call (see 10.7).

9.5 The wait time for a pre-scheduled return trip, such as dialysis, rehabilitation, etc., after an

appointment, shall not exceed thirty (30) minutes.

Joel’s Insight: So if a driver gets caught in traffic or whatever, what’s going to happen? Let me guess,

more “Corrective Action Plan?”

9.6 If Transportation Provider turns back or refuses a trip assignment, Transportation Provider must

notify MTM as soon as the determination is made the Transportation Provider is unable to take

an assigned trip, and in any event, no later than 48 hours prior to the date and time of passenger

pick up.

9.7 Transportation Provider must not overbook MTM trips.

9.8 Transportation Provider agrees to contact the passenger by phone within a twenty-four (24) hour

window prior to trip, if phone number is provided, to confirm the Transportation Provider’s

estimated arrival time.

Joel’s Insight: There is no question that providing courtesy calls/reminders to passengers within 24-

hours prior to their trip is a great idea. But, my business was averaging 300 trips per day. And, I have



worked with Transportation Providers that have double that per day and more. Do you really think that

such a demand is feasible? Sorry, but who is paying for the extra time and labor to meet such a

demand? If you (MTM) are not paying me enough for the administrative labor to do so, sorry – NMP!

9.9 Transportation Provider shall provide the Transportation Provider’s phone number to the

passenger during the pre-trip confirmation phone call.

9.10 Transportation Provider may give the passenger a ½ hour “window,” fifteen (15) minutes before

and after ideal pick-up time, providing the passenger will arrive on time for the appointment.

9.11 For the Transportation Provider’s benefit, the Transportation Provider must note on the form

what time Transportation Provider made the confirming call and with whom the Transportation

Provider spoke.

Joel’s Insight: How thoughtful, “for the Transportation Provider’s benefit.” I’m flattered!

9.12 If a trip is canceled by the passenger directly, the Transportation Provider must notify the MTM

Provider hotline immediately to document member cancellation of the trip, and document all

cancellation information, using the “MTM Coding System for MTM Canceled Trips,” and report

such on the weekly reconciliation report.

Joel’s Insight: Thank you for telling me how to operate my administrative duties and responsibilities!

9.13 Transportation Provider will not take calls directly from the passenger to arrange for covered

transportation services except for the “will call” telephone call for pick-up for the second leg, or

additional multiple leg trip.

9.14 If passenger calls Transportation Provider directly (except for the “will call” situation),

Transportation Provider must notify them to call the MTM toll-free telephone number or local

number provided to the passenger to arrange and authorize their transportation.

9.15 Transportation Provider will not contact passenger’s medical provider to schedule or re- schedule

appointments.

10.0 Trip Process



10.1 Transportation Provider acknowledges and agrees that where mileage is paid by MTM for a trip,

all mileage will be calculated by MTM’s commercial GPS based mileage system, based on the

shortest distance from the pick-up point to the final destination point, irrespective of the route

actually taken by the Transportation Provider, and irrespective of the actual travel time incurred

in the performance of the trip. MTM’s system determination of mileage shall be final and not

subject to challenge or dispute by Transportation Provider.

Joel’s Insight: This is truly an incredible paragraph. MTM is going to tell you what the mileage is for each

transport “irrespective of the route actually taken!” Think about how audacious this is. It’s crazy! If there

are traffic issues, traffic jams, construction, etc. it doesn’t matter. You will take whatever MTM deems

worthy and NOT what you actually performed and are justified in receiving. Man, “that takes balls” – to

tell someone that is how you are going to treat them. Let me be clear, we are NOT in business to be

sharecroppers! We are NOT in business to just accept what a Broker decided to give us. Sorry, but –

NMP!

10.2 Transportation Provider must not cause a passenger to arrive more than thirty (30) minutes prior

to an appointment, unless requested or pre-authorized by MTM or the passenger.

10.3 Transportation Provider must allow a minimum of five (5) minutes “wait time” at pick-up

locations for scheduled passenger(s) to enter vehicle

10.4 Drivers must make “best effort” to make contact with the passenger notifying them their ride is

waiting outside before leaving the premises without the passenger. This would include, at a

minimum, honking, knocking at door, inquiring at reception desk and calling dispatch to place a

call to the passengers to notify them their ride is outside.

10.5 Transportation Provider agrees to present to the passengers upon leaving the vehicle, a business

card, typed instructions, or a pre-printed sticker, advising the passenger of contact and phone

number to call in order to arrange for a return ride home.

10.6 Transportation Provider must ensure all return and “will call” trips are picked up within a

maximum of sixty (60) minutes of the passenger’s request for a return trip (see 9.5).

10.7 Transportation Provider must maintain that all trips not exceed one (1) hour “in vehicle” riding



time, except in those cases in which an unusual traveling distance is involved.

10.8 In multiple-passenger situations, passengers should not remain in the vehicle for more than

forty-five (45) minutes longer than the average travel time for direct transport. Exceptions may

occur in the circumstance of a long, rural multiple-passenger routed trip – in which case, the

passenger should be notified prior to the trip of the lengthy travel time. Further exceptions could

include pick-up and/or destinations outside of the stated local service area.

Joel’s Insight: I agree. I would never want a passenger to be in a vehicle for more than 45 minutes.

Consider what if there are traffic related issues? Let me guess, more “Corrective Action Plan?”

Also, if you prefer that I don’t take multiple passengers at the same time in an effort to reduce cost, then

you (MTM) better be paying me enough to afford to send individual drivers for individual clients! If not,

and I need to consolidate trips as much as possible to ensure profitability, then take it or leave it.

Otherwise, sorry – NMP!

10.9 Transportation Provider agrees to complete any pre-scheduled round trips even under the

circumstance when the medical service extends past the approximate expected completion time.

10.10 Transportation Provider must maintain a signed trip or log sheet, including passenger’s original

signature and date of transport, listing all passengers’ scheduled rides for each individual day.

Note: All driver trip logs must be maintained for ten (10) years.

Joel’s Insight: First, telling me how to operate my business administratively is bad enough. But what if

the client, through physical condition or mental capacity, can’t sign their name? What if I don’t have

their signature? I know, I know. More “Corrective Action Plan” and/or you (MTM) are going to withhold

payment from me, right? Sorry, but – NMP!

10.11 Transportation Provider must require the passenger to sign the trip/log sheet, or an individual

voucher for each leg of the trip at the time of completion of the trip. The passenger’s signature is

used as part of the trip verification process. Trip signatures obtained by Transportation Provider

at any time after the drop off of the passenger and after completion of the trip will not be

accepted by MTM, and Transportation Provider shall not attempt to obtain such passenger

signatures retroactively. The same rules and procedures shall also apply to obtaining the driver’s



signature for each trip leg.

Joel’s Insight: Again, we face the issue of MTM mandating our administrative procedures. We also have

to ask: what about clients who are unable to sign due to physical and/or mental reasons? Do we fear

non-payment for the transport and/or “Corrective Action?

10.12 Transportation Provider must not require passenger to sign the trip/log sheet on any leg of the

trip which is not completed; to include passenger no-shows. The passenger’s signature must be

obtained contemporaneous with the completion of the trip.

10.13 Transportation Provider understands actual pick-up time and drop-off time must be noted for

each authorized passenger on the trip log sheet. Clearly designate date and time, using either

a.m. or p.m. designation or military time. See Appendix E for all required trip documentation.

10.14 Transportation Provider understands that lack of trip documentation set forth on Appendix E,

including but not limited to, lack of passenger or driver signatures, or date and time of transport

pick up and drop off, submitted at time of invoice/claim, may result in MTM denial of payment to

Transportation Provider and the recoupment of trip charges if MTM has already made payment

to Transportation Provider for the trip. MTM will not accept any passenger or driver signatures,

or other trip documentation, that does not accompany the original invoice/claim submission to

MTM.

Joel’s Insight: Again, threatened with “denial of payment.” This is definitely NOT how you treat

someone you view as a “strategic partner.”

10.15 If passenger is unable to sign, driver must document reason on trip/log sheet. Transportation

Provider understands payment may be subject to verification of noted reason.

Joel’s Insight: Ah, finally we are enlightened about what our drivers must do in the event of a patient

that is unable to sign a Trip/Log Sheet! Despite such circumstance, payment is still “subject to

verification.” So even if you successfully transport a client, you paid for the fuel, you incurred the labor

costs, your efforts are still “subject to verification.” Sorry, but if you (MTM) deny me payment, I’m not

performing your trips. Why, because I’m not in business to operate at a loss. In short, sorry – NMP!



10.16 An adult, accompanying a minor child, may sign the adult’s name on the trip/log sheet as long as

the minor’s name is clearly noted as well.

10.17 Transportation Provider must provide MTM with the trip/log sheets, or the vouchers, upon

request. See Appendix E for trip/log sheet information.

10.18 Transportation Provider/passenger must call for approval prior to taking passenger to an

unscheduled appointment or a pharmacy trip. If Transportation Provider does not obtain prior

approval from MTM, they will not be paid for the trip.

Joel’s Insight: Ah (yawn), more threats and stipulations for denial of payment. You (MTM) continuously

threaten me with denial of payment, you threaten “Corrective Action” at your discretion, and you want

me to treat MTM clients the same as I would other clients? Sorry, but no – NMP!

10.19 If there is a discrepancy on the number of additional passengers noted on the trip faxes,

Transportation Provider must contact MTM before leaving passenger’s home/pick-up location. If

Transportation Provider does not obtain prior approval from MTM, additional passenger fees will

not be paid.

11.0 Trip Requirements

11.1 MTM requires, the Transportation Provider, to call, email or fax MTM with all no-shows at the

time of the no-show. Timeliness of reporting will determine whether the no show is a “member”

or “provider” no show.

11.2 Transportation Provider must also report all passenger no-shows and cancellations, in

accordance with the “MTM Coding System for MTM Canceled Trips,” to MTM on the MTM

weekly reconciliation report.

11.3 MTM recommends the Transportation Provider verify and document no-shows at the

passenger’s home.

11.4 Transportation Provider agrees to verbally notify MTM immediately of any incidents of passenger

misconduct. MTM may require written follow-up from the Transportation Provider.



11.5 Transportation Provider agrees to report to MTM any known or suspected fraud or willful abuse

of MTM services by a passenger, which includes, but not limited to:

a) Passenger asking to be transported to locations other than the trip destination assigned

to the Transportation Provider

b) Verbal or physical abuse

c) Chronic no-shows

d) Evidence, which could include a visual sighting, that the passenger did not attend the

appointment to which they were transported

11.6 Transportation Provider understands all “trips” are defined as one-way trips.

11.7 Transportation Provider understands that, due to disability, age or mental condition, some

passengers utilizing MTM services require assistance and/or the use of an escort/attendant. The

escort/attendant must be recruited by the passenger or MTM, and multiple escorts are not

permitted. Such escort/attendant’s travel is to be provided by the Transportation Provider free of

charge.

11.8 Children under 16 years of age, to be transported without a parent, guardian or attendant, must

have a signed consent by a parent/guardian provided to the driver before the time of service.

Transportation Provider agrees to attach consent to trip/log sheet.

11.9 Transportation Provider agrees the MTM contract requires, at a minimum, two (2) rides, from

the same household ride for the price of one (1) fare, regardless of the age of the riders (such as

husband and wife or mother and child). In the case of an attendant, the two (2) authorized riders

will be the attendant, who does not live in the household but will be picked up there, and the

passenger/patient.

Joel’s Insight: Are you serious? I am all for offering a discount if I transport two passengers from the

same location. To demand that I only get paid for one passenger, when a driver has to load, secure, and

unload two passengers, is an abuse of all common business sense. Demanding that a Transportation



Provider not be reimbursed for the transport of a second passenger clearly projects the mentality of

sharecropping! Sorry MTM, but we are in business to make money. If you don’t plan on reimbursing me

for a second passenger, you guessed it, NMP!

11.10 If the Transportation Provider determines a scheduled trip cannot be performed due to unsafe

driving conditions during inclement weather, the Transportation Provider must contact, in a

timely manner, both the passenger and MTM to notify them of the cancellation.

12.0 Reports and Billing

12.1 Transportation Provider must submit claims to MTM for authorized MTM-scheduled trips only.

12.2 Transportation Provider agrees to bill MTM for the MTM designated level of service, regardless

of the level of service actually provided. Transportation Provider may not accept the trip

assignment at the MTM designated rate, and claim additional compensation after performance

of the trip for a higher level of service or for any other extras.

Joel’s Insight: This is another poignant stipulation that clearly illustrates the level of audacious control

that, if afforded the opportunity, Brokers will demand of you, the Transportation Provider. So if you

agree to transport a Medicaid patient 20 miles, but due to construction, traffic jams, or other

circumstances, the trip takes 26 miles, MTM mandates that you will only be paid for the designated 20

miles. Thus, any additional time, cost in labor, fuel, and more are irrelevant. You, the Transportation

Provider, must absorb such losses. Well, if you (MTM) expect me to absorb such losses then you (MTM)

better be paying me a reasonable rate of reimbursement to ensure that my transportation company can

always absorb such potential losses.

12.3 Transportation Provider agrees there will be no charge to MTM for trips canceled by

Transportation Provider, passenger, or in advance by MTM.

12.4 Transportation Provider may not charge MTM a member no-show charge unless provided for in

Transportation Provider’s contract rate Schedule A.

Joel’s Insight: So, using the example above, if you drove 20 miles to pick up a patient and he/she does

not go, you do NOT receive ANY compensation! In fact, not only will you not receive any compensation,



MTM is so specific that you, the Transportation Provider, “may not charge MTM a member no-show.”

Again, if you (MTM) expect me to absorb such losses, your rates of reimbursement better be good.

Otherwise, you can enlist the help of some other sharecropper! Sorry, but – NMP!

12.5 If a passenger is capable of riding in a sedan type vehicle with their collapsible wheelchair placed

in the trunk of the vehicle, the lower ambulatory rate must apply.

Joel’s Insight: Another example of Brokers trying to squeeze every ounce of profitability out of you.

12.6 If a Transportation Provider uses a wheelchair lift van for ambulatory passengers, the lower

ambulatory rate must apply.

Joel’s Insight: Another example of Brokers trying to squeeze every ounce of profitability out of you.

12.7 Transportation Provider understands that MTM will not pay for:

a) “Waiting time” charges unless specifically authorized in the Transportation

Provider’s contract rate Schedule A, and pre-approved by MTM.

b) Trip charges when Transportation Provider fails to either arrive at pick-up location in

time for timely delivery to passenger’s appointment, or fails to actually deliver the

passenger to his or her appointment on time, the result of which is the appointment

cannot be attended or must be re-scheduled.

c) Any additional charge if the passenger is picked up from, or dropped off at, any

location other than the pre-scheduled MTM authorized addresses.

d) Any additional charge if Transportation Provider diverts to other locations/stops for

passengers other than the pre-scheduled MTM authorized addresses, unless

specifically authorized by MTM.

Joel’s Insight: MTM specifies what they will not pay for in the previous four examples. But if such

circumstances were for a Private-Pay, worker’s comp, or a contracted transport, you would charge for

wait time, no shows, deadhead mileage, multiple pickup and drop-offs, and more. Yet, for some



laughable reason, MTM expects you, the Transportation Provider, to provide equal treatment to their

clientele as you would for clientele from which you will actually be paid! Sorry, MTM, but – NMP!

12.8 The month-end billing total shall be consistent with the same total of the previously agreed-upon

weekly report totals for that month, and shall be submitted only after final reconciliation with

MTM has been completed for the total monthly billing.

12.9 Billing shall only include charges set forth in the predetermined rate set by MTM transmitted to

Transportation Provider.

12.10 Signed Transportation Provider invoices for services provided to passengers must be submitted

after MTM reconciliation has been completed for the month, and in no event more than ninety

(90) days after the actual date of service. Claims for services received by MTM more than ninety

(90) days after the actual date of service will be deemed waived and will not be paid.

12.11 Transportation Provider shall provide invoices to MTM on forms, at times, and in a manner

acceptable to MTM.

Joel’s insight: Uh oh! If what you do is not “acceptable to MTM,” you risk “Corrective Action!”

12.12 Transportation Provider will provide passenger signed trip tickets upon request as part of the

weekly verification process.

12.13 Weekly reports will be used by MTM to verify Transportation Provider/passenger trip records.

Final billing verification at month-end will be based on the information submitted on the weekly

reports.

12.14 Unless otherwise provided by contract, Transportation Provider payments of clean claims will be

mailed U.S. Mail bi-weekly, provided Transportation Provider has timely submitted all reports

and documentation. All claims will be either paid, denied, or suspended within 45 days of receipt

of the claim.

12.15 Transportation Provider agrees to refer to MTM’s individual internal Authorization/Trip Number

on all claims submission paperwork showing the passenger’s information relating to the



scheduled trip, and to also refer to the Authorization/Trip Number in verbal conversations

relating to the passenger’s scheduled trip.

12.16 Transportation Provider understands disputed billings/claims must be resolved before payment

for any disputed bill/claim can occur.

Joel’s Insight: Trust me, in speaking from experience working with many Transportation Providers

around the country, this is another very important stipulation. I have witnessed several instances where

Providers had a dispute regarding payment and their payments were withheld. This IS an intimidation

tactic because Brokers know that you need your payment to preserve your cash flow. Thus, they hedge

their bets that you will simply accept their terms because you desperately need your money to remain

operational. Again, this is very much an abusive, controlling tactic.

12.17 Transportation Provider understands the Transportation Provider’s pricing and MTM’s payment

is contractual and that Transportation Provider will be paid directly by MTM for

covered/scheduled services. Transportation Provider shall not bill, or otherwise seek

compensation for services from the transported passenger (other than collection of a co-

payment authorized by MTM where applicable) or from MTM’s Client, even in the event of

MTM’s failure to pay Transportation Provider for services rendered.

12.18 Transportation Provider understands they are only paid for loaded miles (from passenger’s pre-

scheduled start location to pre-scheduled end location) and not for the distance traveled by

Transportation Provider to arrive at the pick-up location, unless special arrangements are agreed

upon by Transportation Provider and MTM in advance of trip.

Joel’s Insight: Deadhead mileage is one specific stipulation that, yes, you can indeed negotiate! Do NOT

fall prey to the bullying tactic that “Brokers do NOT negotiate.” In more instances that not, deadhead

mileage not only can be negotiated, it MUST be negotiated. If you transport a patient 80 miles to a

medical appointment, you simply MUST charge deadhead miles for the return trip. Sure, your deadhead

miles will typically be less than loaded miles. But you MUST charge deadhead miles for distance

transports. Using the example of an 80 mile trip, that will cost you additional cost in fuel, labor, and

wear and tear on your vehicles. You MUST charge a profitable rate for your loaded miles and you MUST

charge a deadhead mileage fee. If the Broker refuses to reimburse such charges, sorry – NMP! You can



find some other schleprock to become your sharecropper!

Transportation Provider understands that executing a Medical Transportation Services Agreement and

these MTM Transportation Provider Guidelines does not guarantee Transportation Provider any

minimum number of trips and that assignment, withdrawal, and re- assignment of all trips is within the

sole and absolute discretion and control of MTM. Transportation Provider acknowledges that it has no

property rights or legal interests in any particular trip or transported passenger.

Joel’s Insight: As I always say in regards to signing with a Medicaid Broker, if you want to pet an

alligator, that’s on you. You can pet an alligator all day long and hope it won’t tear your arm off. But if

and when the alligator does tear your arm off you can’t get mad at the alligator - you knew that you

were petting an alligator! And nothing is more evident that you’re petting an “alligator” than this

paragraph. MTM clearly articulates that you are guaranteed nothing from them, that you will receive

NO “minimum number of trips,” and those trips you are fortunate enough to receive from them can, at

their discretion, become “withdrawal and re-assign” trips to other transportation providers. In short,

Brokers ONLY need you until they can find a cheaper alternative – bottom line! Why is it important to

understand this critical principle? Because you CANNOT build your business around a Broker! If you do,

your entire business is built on sand and can be washed away in an instant!

Transportation Provider further understands that with any violation of contract terms, MTM can

immediately suspend assignments of passenger trips to Transportation Provider. MTM also has the right

to discipline Transportation Provider for non-compliance with MTM Transportation Provider Guidelines,

by restricting or reducing Transportation Provider trip assignment.

Joel’s Insight: MTM says it all here; they can get rid of you “immediately,” without prior notice. Think, in

an instance, they can completely shut your business down. And yes, I have seen this before!

Transportation Provider warrants by signing this document they have read the document in its entirety

and have full understanding of all terms and conditions, and agrees to same. Transportation Provider

further pledges to abide by all terms and conditions set forth herein, and acknowledges such by signature

on the “Medical Transportation Services Agreement” and on this page of the “MTM Transportation

Provider Guidelines” document. If Transportation Provider does not understand any part of this

document, it is the Transportation Providers responsibility to seek the advice of an attorney for



clarification prior to signing.



Appendix A

Basic First Aid Training must be given by a certified First Aid instructor.

Defensive Driver Training must include one of the following:

a. National Safety Council DDC-8 Training Class

b. National Safety Council DDC-PC Online Training

c. National Safety Council Video Self-Instruction Kit

d. National Safety Council Self-Instruction CD-ROM Kit

e. American Association of Retired Persons (AARP) 55-Alive Driver Safety Program

f. Transportation Provider developed in-house training must include:

i. Pre-Trip Inspections

ii. Professional Avoidability vs. Legal Liability

iii. Motorists/Pedestrians

iv. Backing

v. Intersections

vi. Following Distance

vii. Braking/Skids

viii. Drugs/Alcohol/Sleep Deprivation

ix. Courtesy

x. Routines

xi. Accident Procedures

xii. On-Job Driver Demonstration



Appendix B

Driver training, both pre-service and Annual, suggested in addition to 4.3 requirements could include:

a. Loading and securing persons with mobility assist devices

b. Sensitivity training

c. Working with passengers with all types of mental and physical disabilities

d. Passenger relations

e. On the road in-vehicle practical training, i.e. driving with supervision

f. Pre/post vehicle inspection responsibilities

g. Transporting passengers with frailties and oxygen tanks

h. Safety issues

i. Radio contact

j. Review of State/Federal regulations

k. New laws/regulations

l. Transportation Provider internal procedures

m. HIPAA compliance

Suggested training resources:

a. American Red Cross (ARC) for Basic First Aid and CPR

b. State Department of Transportation (DOT)

c. National Safety Council (NSC)

d. Training given by local or regional transportation providers in your area

e. Local fire departments (often have certified people to teach first aid)

f. Transportation industry video tapes

g. State and local law enforcement agencies



Appendix C

Recommended equipment to carry in vehicles in addition to 6.7 requirements:

a. Hand Cleaner ( a “waterless” cleanser is suggested)

b. Umbrella

c. Tire Gauge and Jumper Cables

d. Rags and Wipes

e. Wisk Broom, Paper Towels, Glass Cleaner

f. Pouch with Maps

g. Safety Manual

h. Pre-Trip Inspection Forms

i. Car Manual

j. Copy of MTM Driver Guidelines

k. Blanket

l. Water

m. Seat belt cutter

Note: It is recommended that aerosol cans not be carried in the trunks of vehicles in hot weather.



Appendix D

Daily pre-trip inspection should include:

a. Directional lights and flashers

b. Headlights/clearance and running lights

c. Brake lights and tail lights

d. Windshield wipers/washers

e. Interior lights

f. Horn

g. Fire extinguisher

h. First Aid Kit

i. Fluid levels

j. Tailpipe/muffler noise

k. Fuel cap in place

l. Mirrors

m. Two-way Communication

n. Tire condition

o. Heat and/or air conditioning units operable

p. Parking brake

q. Door/lift operations

r. Seat belts

s. Door handles

t. Speedometer and odometer

u. General cleanliness, inside and outside

v. Wheelchair securement devices



Appendix E

Daily Trip/Log Sheet Information/Documentation Must Include the Following:

a. Transportation Provider’s Name

b. Driver’s Name Printed

c. Driver’s Signature

d. Driver’s License Number

e. Passenger’s Signature (for each leg of trip)

f. Passenger’s Name Printed

g. Date

h. Pick-up Address

i. Scheduled Pick-up Time

j. Pick-up Arrival Time

k. Pick-up Departure Time

l. Drop Off Time

m. Drop-off Address

n. Identification of whether the leg is a “To” or a “From”

o. Number of Additional Passengers

p. Ages of Additional Passengers

q. Place to Document No-Shows

r. Attendants Name and Signature (if applicable)

s. Ambulatory ______Wheelchair or Stretcher

t. The MTM internal Authorization/Trip number unique to each trip

u. Vehicle ID Number



By now I am sure you are asking a very logical question, “Why would anyone want to sign an Agreement

with a Broker?” And your question is well-founded. I have seen an untold number of instances where

Brokers have bullied inexperienced Transportation Providers to such a degree that it has brought a great

deal of emotional stress and financial loss to owners who were well-intentioned and unsuspecting

entrepreneurs.

On many occasions, I have witnessed Brokers follow through on their threats to withhold and deny

payments. As a result, companies that were heavily dependent and reliant on Brokers had their cash

flow cut off and their businesses essentially destroyed. Some unsuspecting providers fall prey to the

promises of increased trip volume leading them to invest in vehicles, drivers, and assets only to become

financially overextended when the Broker cuts them off in favor of cheaper alternatives. Obviously, we

do not go into business to be abused or treated as sharecroppers with someone we anticipate should be

more of a “strategic partner.” Fortunately, with the help of this resource, you now know better! You

realize when you partner with a Broker you are petting an alligator – pet at your own risk!

The good news, however, is that there are also many success stories, instances where we successfully

forced Brokers to do what they claim they don’t do - negotiate! And yes, when you position yourself

correctly, when your business becomes a fixture within your community and you refuse to operate at a

loss, Brokers not only negotiate with you, they are forced to respect you! You make Brokers realize that

they cannot bully you and that YOU will turn the table and cut them off versus the other way around.

Later in this resource, I am going to share with you information illustrating how some Transportation

Providers are successfully using Subcontractors to service some of their Broker work. Such strategies

can be profitable if structured properly, far more than in-housing some of the infrastructure and

associated overhead expenses. But before sharing such strategies, I am going to share copies of emails

and correspondence illustrating instances where we successfully forced Brokers to negotiate with

Transportation Providers. Allow me to start by sharing a few articles and publications that will further

illustrate and enlighten you about the growth and objectives of Brokers.

Again, in the coming articles I highlight key points and interject comments in color blue font.



MTM RAMPS UP FLORIDA OPERATIONS

- St. Louis Business Journal

All eyes are on Florida’s Medicaid transformation since the federal government approved a

plan this month that lumps certain Medicaid recipients into managed care programs in an

effort to curb rising costs, Kaiser Health News reports. The move to manage care is causing

Medical Transportation Management Inc. to ramp up its efforts to expand its core business

in Florida.

Health plans will now be reimbursed a set amount for each Medicaid recipient in this new

deal (which only includes elderly and disabled in long-term care for now). This payment

model removes the fee for service reimbursement model, Kaiser Health News reports. Since

health plans will be reimbursed on an individual basis, the assumption is they'll have to

create a network of providers to help these Medicaid recipients receive better care that’s

easier to navigate, although critics think it'll lead to worse care.

MTM is hoping to land a subcontract from the health plans that eventually win the contracts

to provide managed care. If MTM is a subcontractor for a health plan, they'll provide non-

emergency medical transportation--their core business, to these Medicaid recipients.

In the first year, the state will set aside nearly $417 million to pay for the care of the 36,795

qualified Medicaid recipients, Kaiser Health News reports. Currently, MTM operates as a

transportation provider in two Florida counties. But this federal approval could open the

door to subcontracts throughout the entire state.

Michele Lucas, a spokeswoman for MTM, said it's too early to tell just how much added

revenue that could mean. But Alaina Macia, MTM's chief executive, said "this is a huge

deal."

MTM reported revenue of $135 million in 2012, up from $132 million in 2011.

Joel’s Insight: To better put things into perspective, Logisticare, the largest Medicaid Broker, boasts

annual revenue in excess of $500 million! As you will see, they are very excited about Obamacare!

http://www.kaiserhealthnews.org/Stories/2013/February/08/florida-medicaid-managed-care-long-term-care.aspx



Joel’s Insight: The following article is actually from 2011. Although outdated, I include it because it

illustrates the financial growth of MTM, and Brokers in general. Compare MTM’s annual revenue in this

article to their revenue reported in the previous article. MTM experienced an increase of $34.2 million in

one year! This article also shows how contracts can literally change annually and, thus, usher in different

Brokers. This means that any “promises” or Agreements that you share with one Broker can be rendered

obsolete with a new Broker. Obviously, this can dramatically affect your business – especially if you

don’t understand how to position your business and negotiate with Brokers.

MEDICAL TRANSPORTATION MANAGEMENT INC. (MTM) LOSES STATE CONTRACT

- Amir Kurtovic, St. Louis Business Journal

Medical Transportation Management Inc. has lost its $26 million contract with Missouri’s

Department of Social Services to provide non-emergency medical transportation for

Medicaid patients. The contract was a significant portion of revenues for the Lake St. Louis

company which had 2010 revenues of $97.8 million.

Michele Lucas, director of marketing for MTM, said the company will continue doing the

work until Oct. 30, when the program will be taken over by MTM competitor LogistiCare.

“We had a contract with the state and within the contract there are yearly renewal

options,” Lucas said. “We were not able to come to terms on rates so they went with a

different company.”

The contract, awarded in 2010, was for one year with the option to renew for two additional

years. This is not the first time the contract is trading hands between two companies. MTM

was Missouri’s first non-emergency medical transportation broker in 1997 and managed the

program for the next eight years. It lost the contract to LogistiCare in 2005 before winning it

back in 2010.

Lucas said MTM is in final negotiations for a contract of a similar size in the Houston area

that could recover most of the lost revenue. MTM President and CEO Alaina Macia

previously said she was hoping for a 20 percent growth in revenues in 2011 and 2012.



Joel’s Insight: Again, this is an older article that I include for a reason. Did you notice how MTM projects

a 20% growth in 2011 and 2012? Well, they achieved that goal! I also appreciate how MTM is

negotiating a “contract of a similar size in the Houston are that could recover most of their lost revenue.”

In short, MTM is practicing NMP! Brokers have their eye on their bottom line. So as a Transportation

Provider, you have to ask yourself if Brokers can be so keen on keeping and ensuring profitability, why

can’t you? If NMP works for them, why shouldn’t you do the same?

The following is another excellent article. I have personally worked with Transportation Providers in

Wisconsin and, long story short, they finally decided to band together and refuse to operate at a loss in

accepting the low rates of reimbursement from Logisticare. The result – Logisticare was a complete flop

and now, legislatures are working to determine if the broker-model is even an effective model! This

entire situation in Wisconsin underscored the value and importance of the United Medical

Transportation Providers Group (UMTPG)!

LOGISTICARE LEAVING WISCONSIN AFTER ALL

- Gitte Laasby, The Journal Sentinel

LogistiCare, the much-criticized company that's been dispatching medical rides for Medicaid

patients in Wisconsin since 2011, will be leaving the state after all.

Chuck DeZearn, senior vice president of operations with LogistiCare, justified terminating

the $38 million annual contract with the state in November: The company had been losing

money in Wisconsin for a while, mainly because the state Department of Health Services

failed to provide accurate data on ridership. LogistiCare officials argued that this led them

to grossly underestimate the number of rides needed and bid half the amount it should

have charged to provide those rides.

Joel’s Insight: Don’t buy into the “inaccurate data” crap. Logisticare was losing money for three

reasons. First, the broker-model is built upon Request for Bids (RFB) which, ultimately, is designed to

award the lowest bidder. Logisticare was the lowest bidder which automatically squeezed their margins.

Second, because of their success in squeezing Transportation Providers in other states on already thin

mailto:[email protected]



margins, Logisticare believed they could duplicate their strategy in Wisconsin. And the third reason,

Logisticare was losing money because when Transportation Providers refused to operate at a loss they

found themselves overpaying unqualified Transportation Providers.

"Data is extremely important. Once you're off as far as we were, with our expectations vs.

what ended up being reality, it's always an uphill climb to recover. That was the biggest

challenge, getting off on the wrong foot and constantly trying to catch up," DeZearn told the

Journal Sentinel Friday. "We stuck through a lot of months of losing money, trying to do this

correctly. It just never worked out to be, I guess, a win-win scenario for everybody. We just

said, 'Enough.' "

Joel’s Insight: Amazing, Logisticare’s own senior Vice President is talking about a “win-win scenario for

everybody?!” Hello, Mr. Senior Vice President, did you not read your own Transportation Provider

Service Agreement? Sorry, but your Service Agreement is far from a “win-win scenario for everybody!”

LogistiCare experienced a sharp uptick in complaints in September 2012, when it extended

its dispatch services to southeast Wisconsin. DeZearn said while the company strove not to

have any complaints, some are inevitable when you dispatch 216,000 trips in a month as

LogistiCare did in January.

Joel’s Insight: This is comical. Logisticare began to experience a “sharp uptick in complaints” when

Transportation Providers had enough of being told that their rates of reimbursement were going to be

further reduced and they stopped transporting Medicaid clients, thus, leaving Logisticare extremely

short-handed and unable to meet the growing demand.

"If we were 99.5% complaint free, you're still going to hear from 1,000 or so people," he

said. "So the volume of complaints was probably a little higher than it should be, (but) it's

just that it's a high number because it's a high number of trips."

Driver complaints

Transportation providers, throughout LogistiCare's tenure, complained that LogistiCare gave

them sloppy data on rides and didn't work with them to solve problems. In order to make up



for the low bid, they said, LogistiCare pressured them into lowering their prices so much

that trips weren't viable, driving mom-and-pop cab companies out of business.

Joel’s Insight: Interesting, the consensus from Transportation Providers is that Logisticare was not

working with them to “solve problems.” Yet, it was Logisticare’s Senior Vice President who was just

talking about finding “win-win scenarios for everyone.”

"We'll work with any broker that gets (the contract), as long as they'll consider providers an

asset rather than a liability," said Red Christensen, general manager of American United Taxi

Cab, which hopes to provide rides for the company that gets the next state contract.

"Unfortunately, LogistiCare had more of an adversarial relationship with providers rather

than working with them."

Joel’s Insight: Because I have worked with a handful of Transportation Providers in Wisconsin, I have a

true affection and appreciation for what has happened in that State. As this transportation provider

indicates, they welcome the opportunity to work with Brokers who consider them “an asset rather than a

liability.” Ultimately, this is the goal of Transportation Providers, to work with Brokers as “strategic

partners” and not as sharecroppers. The irony, Wisconsin is a microcosm of what can happen when

Transportation Providers unite and refuse to operate at a loss. The result, Brokers get run out!

Legislators need to take another look at whether the brokerage model is really saving any

money. Officials have been unable to provide data to quantify how much, if any, money was

saved by converting to a broker, which was supposed to cut down on fraud.

LogistiCare operates in 40-some states across the nation under government contracts or as

business-to-business, DeZearn said.

Joel’s Insight: In Wisconsin, Logisticare learned the hard way what can happen when Transportation

Providers decide to band together and practice NMP! This is exactly what the United Medical

Transportation Providers Group is working to achieve – empowering Independent Transportation

Providers with a common voice.



THE MEDICAID BROKER PLAYBOOK

I share the following email from a Transportation Provider because it does an excellent job setting the

stage for a series of emails between MTM and another transportation provider I worked with in a similar

market. I have removed names for anonymity and legal purposes. As you read through the emails,

harken back to stipulations defined in the “Service Agreement.” Consider for yourself MTM’s tactics.

The more I work with Transportation Providers, the more comical Brokers become because they all

operate from the same playbook – using the same tactics and strategies of intimidation and control.

Joel,

All they [MTM] do is communicate through emails regarding lowering our rates to be more

competitive with other provider's. They take work from us until we feel the squeeze where

we have no choice but to lower our prices. It's being done that way to all of the provider's

here in [State] by MTM. Crappy tactics if you ask me.

We are at $1.50 per mile and agreed to come down to $1.23 per mile and that's when MTM

sent us back a counter offer trying to make us come down to $1.15 per Mile. After that

counter offer I withdrew my offer of $1.23 and I'm leaving it at $1.50 per mile. They can

squeeze all they want with their silly tactics but they won’t pull a fast one on this old man.

Funny thing is MTM is still paying me at the $1.50 rate.

I get some of my work from 2 Major Hospital's here in the area and will ramp up my volume

very soon. I am taking 11 Case Manager's between 2 hospitals out for lunch to introduce

myself and the services I provide along with my pricing. At the most I will spend for lunch is

approximately $400.00. Break that down. Its only 6 wheelchair moves or 4 stretcher moves.

Not a bad investment... kind of like your Course, Knowledge is the Key to Success.

Thank You,

[Name]

Joel’s Insight: This email supports exactly what Brokers say they will do – take away transports until you

bow to their demands! But you will notice, this Provider practices NMP and refuses to be a sharecropper.

The result, MTM is still paying him the full mileage rate of $1.50 per mile. What I also appreciate about

this Provider is that he “knows his numbers” and is actively putting “Personal Promotions” to use to

introduce and connect with decision makers. He’s personally building brand recognition!



The following pages are a series of emails between MTM and a different Transportation Provider that

was also informed that their mileage rates of reimbursement were going to be reduced from $1.50 per

mile to $1.00 per mile. Again, this is a 33% reduction in reimbursement that MTM was attempting to

force Providers to accept or have their trip assignments reduced or eliminated.

As I always tell Transportation Providers, correspond as much as possible via writing/email so that you

have a record, a paper trail, especially in dealing with Brokers, contractors or facilities.

After receiving notice of the forced 33% reduction in reimbursement, this Provider, obviously shocked

and upset, attempted to call MTM. Forced to leave a message, he received a short, brief, and direct

email from MTM the following day (Email 1). Thereafter, the Transportation Provider enlisted my help

for which I drafted a series of replies that we forwarded to MTM via fax and email.

[Email 1 - MTM to Transportation Provider]

[Name],

Reducing reimbursements are a necessity for which all providers will be experiencing. We

are working to give providers as much advanced notice as possible of the coming changes so

that you can plan accordingly.

Regards,

[Name]

Joel’s Insight: There are a few key points that I want you to notice in this email. First, as ridiculous as it

sounds, notice how the Area Liaison from MTM greets the transportation provider – just by name, no

pleasantries. Again, I know this sounds ridiculous, but you will see how this changes later on. It’s

comical!

Second, notice how short and brief the email. MTM definitely doesn’t attempt to parse words (for now).

This is definitely a common practice of Brokers. When they do correspond via email/writing they

attempt to be as brief as possible so as not to expose themselves to potential legalities.



[Email 2 – Transportation Provider to MTM]

[Name], Area Liaison

Medical Transportation Management, Inc.

Fax 800-459-6224

Re: Rates of Reimbursement

Dear [Name]:

We are in receipt of your recent email indicating that MTM is attempting to reduce our

mileage rate of reimbursement by 33.3%. Needless to say, this is very much unexpected

and unanticipated news. But more so, especially considering the amount of miles that

[Name of Company] incurs on a daily basis in transporting clients throughout [State] and

[State], accepting any reduction in reimbursement is not prudent or sensible.

We appreciate your advance notice, but although this reduction in reimbursement may be

“a necessity” for MTM and other providers, it simply is not feasible for [Name of Company].

As you know, we maintain excellent performance standards which are to the benefit of our

shared clientele and a reflection of our strategic partnership. However, maintaining such

high standards do come at a cost for which we are confident that MTM would not

encourage us to compromise.

Thank you again for your correspondence and bringing this issue to our attention. We trust

that you understand that we cannot operate at the proposed rates of reimbursement and

look forward to continuing to provide a superior level of service.

Sincerely,

[Name]

President, [Name of Company]

Joel’s Insight: First, notice how professional our response is in terms of layout and content. It is nothing

like MTM’s correspondence. Second, notice the tone. It is pleasant, yet still direct. It is very “passive

resistant” which subtly begins to convey to MTM that we wish to work with them but we most certainly

are not pushovers willing to operate at a loss! Over the course of this correspondence you will notice

how things begin to change and the level of respect for us from MTM becomes evident.



[Email 3 – MTM to Transportation Provider]

[Name],

We enjoy having you in our network, but all transportation providers are experiencing a

reduction in mileage reimbursement. In order to ensure that [Name of Company] remains

competitive with other transportation providers you will need to agree to the new rates.

Providers that do not accept these new rates will see their number of trips reduced and

assigned to other providers.

Regards,

[Name]

Joel’s Insight: MTM definitely was NOT expecting to receive our response. Their reply came almost

instantantly. But at this point, MTM still assumes that we will cave under pressure like other

Transportation Providers, hence, the continued threats of “trip reductions.” The rebuttal is a slight bit

longer and even includes a simple pleasantry; “We enjoy having you in our network.” But ultimately,

MTM holds true to their posture of intimidation and control. You will need to agree to the new rates or

your number of trips will be reduced and assigned to other Providers.

What I appreciate most about this response is how MTM attempts to make their forced reductions in

reimbursement almost as a favor – “to ensure that you remain competitive with other Transportation

Providers you will need to agree to the new rates.” What an absolute joke! Well, I guess we can

definitely say that MTM does not discriminate and is an equal opportunity Broker in breaking everyone!




[Name], Area Liaison Medical Transportation Management, Inc. Fax 800-459-6224 Re: Rates of Reimbursement

Dear [Name]:

Thank you for your recent correspondence. We have enjoyed working with you and MTM

these past two years and we welcome the opportunity to continue our relationship.

However, based upon the proposed reduction in the rates of reimbursement it appears that

our strategic partnership will conclude at the end of next month when our current

Agreement expires.

At a time when fuel, insurance, labor, and other associated operating expenses are

increasing, MTM is proposing a reduction in reimbursement which would force [Name of

Company] to operate at a loss. Obviously, as a for-profit enterprise, we are not in business

to lose money. Thus, we have no alternative but to reject your proposal and allow both

MTM and [Name of Company] the remaining six weeks as a transitional period to prepare

for the dissolution of our working relationship.

Again, [Name], we thank you for the opportunity to work with you and all of MTM over the

past two years and we wish you nothing but future success.

Sincerely,

[Name]


Joel’s Insight: It’s important to note that we purposely waited three days before sending this email. And

yes, the Transportation Provider was growing impatient! But it definitely paid off. We waited so that (1)

MTM would just assume that we caved on their demands, allowing us to “catch them off guard with our

reply, and (2) to project our lack of concern or panic regarding the overall issue. You will also notice that

we “welcome the opportunity to continue our relationship,” so we’re leaving the door open and put the

ball in MTM’s court. We even refer to MTM as a “strategic partnership.” We also reference continued

increasing overhead expenses in an effort to convey to MTM that we’re not stupid, we understand the

“Laws of Economics,” and we’re not going to violate these “Laws” and operate at a loss under any

circumstances!




Hello [Name],

I tried to call you and left a message with [Name of Office Manager] but have not heard back

from you. I would like to schedule a time when we can further discuss the rate of

reimbursement circumstances and explain in greater detail what MTM is trying to do. Based

upon market expansion, there is a very good possibility that we will be assigning [Name of

Company] an increased volume of trips.

Let me know when you will be available or call me directly to discuss. I look forward to

sharing more details with you.

Regards,

[Name]

Joel’s Insight: This is when things heated up and did so quickly and MTM’s stalwart and dismissive

posture came to an abrupt halt! Upon receiving our response, Email 4, as predicted, MTM’s Liaison

called the Transportation Provider – immediately! But as I instructed the provider, do not take the phone

calls. Correspond only via email so that you have a paper trail in addition to allowing the lack of verbal

response to weigh on MTM’s concerns.

Why was MTM in a state of panic, calling the provider immediately? Because in this Transportation

Provider was averaging in excess of $28,000 per month and growing with MTM, so the stakes were

pretty high for everyone. Although this Transportation Provider literally risked losing half of his monthly

revenue, he definitely had a high degree of leverage - and that is what we were working to exploit. In

our second rebuttal we reaffirmed that we would no longer be performing MTM transports. Needless to

say, this was definitely of concern to MTM (and the Transportation Provider) as losing this experienced

and proven provider would be a huge logistical liability to MTM. This Provider is located on a border

state and operates MTM transports throughout both states. So again, this is a very knowledgeable and

experienced Provider that MTM was at risk of losing.

I trust that you noticed the pleasantries, the “Hello” and “I look forward to sharing.” Did you notice how

the Liaison was a bit more talkative and encouraged verbal conversation? Brokers are so predictable!






Fax 800-459-6224


Dear [Name],

Thank you for your messages and your email. I apologize for my delayed response as we

have been very busy, so much so that I have been on the road and unable to return your

calls. So if you don’t mind, please feel free to contact me via email as my time is limited

during the day and I can’t afford to neglect our clients. I trust that you understand.

In regards to the forced reductions in reimbursement, although unfortunate, as a business

owner I do understand strict budget controls to remain viable. So please know that I fully

understand and can appreciate that a company as large and expansive as MTM must be

financially prudent.

As far as receiving a trip volume increase, please provide me with more clarification as I am

a bit confused. If [Name of Company] were to accept and provide transportation at the

forced rates of reduction we would be operating at a loss. Please pardon my ignorance, but

why would we want to take on the burden of even greater losses?

Again, thank you for contacting me, [Name]. If you could respond via email with greater

clarification to resolve my confusion I would greatly appreciate it.

Sincerely,

[Name]


Joel’s Insight: By this time, our confidence was further growing because prior to this email being sent,

MTM’s Liaison had left three voice messages over two days; obviously illustrating their eagerness and

sense of urgency to keep this Transportation Provider in their network. You will notice that we used the

word “forced” reductions in reimbursement and we project an almost naïve sense of confusion, further

playing our strategy of “passive resistant.” We’re kind, we’re polite, yet we continue to be firm and

stand our position. In borrowing the boxing slogan, I refer to this strategy as “Rope-a-dope.”




Hello [Name],

It’s good to hear from you and thanks for getting back to me. I know that you guys are busy

so I do understand. I do have good news, though. I explained to [Name of Director] how

long you have been in our network and the great relationship that we have with [Name of

Company]. Over the last few days we have been able to put a package together that would

give you guys an increase from $1.00 to $1.25 per mile. I explained to [Name of Director]

how many trips you are doing between [State] and [State] and he agreed that we should

work with you to get you an increased mileage rate. This is an exclusive opportunity for

[Name of Company] so definitely contact me as soon as possible so that we can sign

everything which will give you a premium rate as compared to other providers.

Regards,

[Name]

Joel’s Insight: I trust that by now you are realizing how comical this situation is becoming and how,

clearly, MTM does not want to lose the services of this Transportation Provider. Notice how the emails

continue to grow in pleasantries and length. But most of all, note how MTM is now positioning

themselves as doing “exclusive” favors for this provider by offering them a “premium rate as compared

to other Providers.” What a progression, a stark difference from the initial emails that were short

directives.

Something else that you need to note and learn from is the comment “contact me as soon as possible so

that we can sign everything.” This is one of the most predictable tactics straight out of Broker’s Playbook

101! I can’t tell you how many times I have seen this - Brokers always developing this false sense of

urgency, the unnecessary push to sign an Agreement ASAP. And in most instances it works because

naïve, inexperienced Providers do just that, sign contracts that are less than advantageous to their

interests. During this entire negotiation process we purposefully delayed some of our responses so that

WE controlled the timing and sequence of events.






Fax 800-459-6224


Dear [Name]:

Thank you again for your continued correspondence. I appreciate your assistance in

conveying to [Name of Director] the circumstances regarding our trip volume and dynamics.

However, under our existing Agreement which expires January 31st, our mileage rate is

$1.50 per mile. Thus, agreeing to $1.25 per mile is most definitely not an increase and far

from “premium.” Rather, $1.25 per mile is a net loss; something that [Name of Company]

simply cannot risk when considering uncertain variable costs such as fuel, insurance, and

labor.

Again, [Name], I thank you for your help and consideration. But to be clear, [Name of

Company] will not be renewing our contract with MTM should you insist on any forced

reductions in reimbursement or trip volume. Like MTM, we must do everything possible to

ensure organizational profitability and sustainability.

Please feel free to contact me should you have any questions.

Sincerely,

[Name]


Joel’s Insight: Although cordial and gracious, you will notice that this email takes a more firm posture

and sends a final and clear message. A clear line in the sand has been drawn; either MTM forces

reductions in reimbursement in which case we will not renew our contract, or MTM abandons their

attempts and we proceed.




Hello [Name},

Attached is an updated agreement reflecting reimbursements. Please sign and return as

soon as possible so that we do not risk delays and or interruptions.

Let me know if you have any questions.

Regards,

[Name]

Joel’s Insight: Well, well, well. Although we do get a fine “Hello,” we are back to the short, direct

emails. But if that’s the price of victory, oh how sweet it is! This email was received three days after

sending the previous email reaffirming that we will not agree to mileage rates less than $1.50 per mile.

Attached was an updated Agreement reflecting the existing rates including $1.50 per loaded mile.

The entire process took a couple of weeks and included some high anxiety for the Transportation

Provider. However, it was definitely a worthy investment and a moral victory. Although there is no net

gain in terms of increased reimbursement, the good news is that there is no reduction in reimbursement

as MTM is forcing upon other Providers. Additional good news is that we have sent a clear message to

MTM which I am sure will serve this Transportation Provider long-term.



KEYS TO THRIVING IN BROKER INFESTED WATERS

I know that I have bombarded with you a LOT of information and insight regarding Brokers. And trust

me, I have a LOT more in which I could share, but that would literally fill volumes! I also know that much

of what I have put before you appears negative and may have you discouraged about the prospects of

working with a Broker(s). But do not be disheartened. My intentions are solely to be honest with you

and to provide you with road guards that help to protect and navigate your venture moving forward.

I can’t tell you how many Transportation Providers enlist my help AFTER signing a “loser” Agreement

and then realize (1) their finances are hemorrhaging, (2) their sources of revenue are one dimensional

and completely dependent on an overbearing Broker, and (3) prospects for recovery appear bleak

because the Broker is prepared to strictly enforce the “loser” Agreement.

But the good news is that I can also boast of many successful NEMT businesses that are very prosperous

to include their relationships with Medicaid Brokers. There are several key reasons for their success

with Brokers which you need to learn and follow:

KNOW YOUR NUMBERS. Rarely, if ever, are Medicaid reimbursements as profitable when

compared to Private-Pay or other forms of reimbursement. But in knowing your operating

expense ratios you can more easily and accurately determine profitable rates of reimbursement.

Let me be clear. Brokers do not care about your operating expenses. They only care about

getting your rates down as low as possible while ensuring that you still provide reliable service

so that they can boost their profit margins – bottom line. In Hawaii, Brokers recently proposed a

$6 reimbursement for a wheelchair pickup. Why? Because Transportation Providers allowed

them to! Providers kept relenting and relenting and Brokers kept pushing and pushing down

reimbursements. The result, providers went out of business! Know your numbers – sorry, but

you shouldn’t even put the key in the ignition and attempt to turn over the engine for only $6!

KNOW YOUR VALUE AND YOUR WORTH. I’m not referring to your net value, which is important.

Rather, I am referring to what your market can sustain. How much are people willing to pay for

your professional service?



If customers are willing to pay $85 for a stretcher transport and Brokers are suggesting a $25

reimbursement for a stretcher of equal distance you instantly know that such a proposition is

unsustainable! Further, it doesn’t matter how much volume the Broker proposes, if you cannot

turn a profit on a single transport then you most certainly cannot turn a profit on more

transports! If I’m drowning in 10 feet of water the last thing I need is 5 more feet of water!

DO NOT BE ONE DIMENSIONAL. One of the greatest mistakes is when Transportation Providers

become one dimensional and rely exclusively or disproportionately on Brokers for their source

of revenue. As expressed in their Service Agreement and illustrated in their emails, Brokers will

take away trips away and reassign them to other providers willing to serve as sharecroppers.

Thus, any movement and trips/revenue can have immediate and disastrous effects on your

business. One of your primary goals should be to build diversified clientele with various sources

of reimbursement. When you are diversified, you are empowered!

FORCE NEGOTIATIONS. The email correspondence between the Transportation Provider and MTM

clearly illustrates that, yes, Brokers DO negotiate. I have witnessed and contributed in countless

negotiations with various Brokers. But understand and be realistic. If you are new to the NEMT

industry you have very limited leverage and negotiating power, especially if you are in a large

market. Thus, you need to focus on building your Private-Pay and contracted work. When you

build brand recognition and become a fixture within your community you then have leverage

and negotiating power.

In business, you don’t get what you deserve, you get what you negotiate!

PRACTICE NMP, AND ALWAYS BE WILLING TO WALK AWAY. I know that NMP sounds a bit comical –

it’s a bit of a play on words. With all seriousness, if you wish to build a viable and profitable

business you need to be able to say “NO” and walk away without remorse or second-guessing.

Trust me, Brokers first priority is their profit margins and you too are entitled to the same focus.



SUBCONTRACTING TO INCREASE PROFITABILITY

A strategy that is continuing to grow, if for no other reason than financial necessity, is Transportation

Providers subcontracting to Independent Operators for servicing Medicaid recipients. I continue to

witness this with Transportation Providers in competitive and growing markets. What was once a

strategy rarely used and not permitted by most Brokers, is now becoming an accepted strategy and

suitable to meet the growing demand.

As I have mentioned several times before in my Newsletter and email correspondence, the way we are

doing business today in the medical transportation and home care industries has definitely changed

from years past. I trust that you realize this after reading the many articles and publications I have

presented in this resource.

Brokers too are recognizing and adapting by adjusting their considerations to meet the growing demand

of dramatically increasing number of Medicaid recipients via Obamacare. Especially considering what

we have accomplished in the State of Wisconsin (Logisticare losing the contract and essentially getting

evicted), Brokers know they can’t afford the possibility of becoming short-handed when Transportation

Providers refuse to provide transports for meager reimbursements. Although Brokers are not stumbling

over themselves to increase rates of reimbursements, they do recognize that more flexibility on

particular issues is critical to their best interests.

Don’t misunderstand, Brokers remain far from a pleasure in terms of policy and practice! But ultimately,

they know that Transportation Providers are their life blood. Without us, they are out of business!

We all understand the basic principle of subcontracting – outsourcing work to Independent Operators.

Essentially, what makes this strategy financially viable for the NEMT industry is that the Independent

Operator, often referred to as a “gypsy service,” uses their own vehicle, maintains their own insurance,

and pays for their own fuel. In all practicality, they are operating their own vehicle. Additionally, rather

than paying labor costs, worker’s compensation and associated tax burdens, you compensate via

straight reimbursements and then issue a Form 1099 as Independent Operators are responsible for their

own taxes.



Subcontractors can definitely add to your bottom line. However, if not managed properly, there can be

areas for concern. Before deciding that subcontracting is suitable for your business model, you need to

be aware of some key elements as follows:

Command and Control: Subcontractors are not your employees. As such, you can risk sacrificing a

degree of “ownership” over your level of service. Think practically. Employees driving your vehicles,

wearing your uniforms, and operating under your company policy and procedures tend to have a

greater sense of obligation to their job. Their performance is expected to contribute to the building of

your company’s reputation and brand recognition. As such, you have greater autonomy to train your

employees, implement expectations, and create policies.

The reasons for those preferring to serve as Independent Operators versus working as employees are,

like individual personalities, wide and varied. However, I would cite the overwhelming consensus is that

an Independent Operator wishes to remain just that – independent! Just as we seek freedom and

fulfillment through entrepreneurship and owning businesses, so too do Independent Operators. The

difference, however, is that Independent Operators essentially “own their job.” Unlike an employee, on

days that Independent Operators cannot or prefer not to work, they simply tell you. Ultimately, if they

don’t want to work, they don’t have to!

Undercutting and Undermining: Over the years, we have had an untold number of Independent

Operators contact our office in an effort to learn how to start their own business. They believe they can

gain greater reward serving directly as a Subcontractor to Medicaid Brokers versus Independent

Operators for you. Especially when Independent Operators are desperate for money to remain

operational, your customers are prospect number one!

You should definitely have a Non-Compete Agreement with your Independent Operators. Such

Agreements are an initial deterrent and clearly articulate your intentions and expectations to the

Operator. However, you have to keep things in proper perspective. At this level and at such modest

price points, a Non-Compete Agreement serves only as a form of intimidation than a realistic course of

action. If an Independent Operator violates a Non-Compete Agreement it is a civil matter only. The cost

in legal fees, time, and effort would far exceed any potential reward. Yes, your attorney could send a

few threatening letters to a violating Independent Operator and you would be out of $500 – $1000. But



ultimately, such idle threats amount to nothing more than expensive toilet paper. Similarly, based upon

what you have learned about Brokers, do you really think they would be an advocate for such

complaints? - No, of course not. Unless there is evidence of unacceptable service, Brokers will always

go with the cheapest option.

Undercutting and undermining are always potential possibilities with subcontracting. Independent

Operators have informed us of such intentions and Transportation Providers have complained of such

occurrences. Because Independent Operators are literally the ones “making face time” and assisting

your clients, they essentially perceive your customers to be their customers. Understanding that

undercutting is always a possibility, it is all the more important that you find, secure, and adequately

compensate reliable and responsible Independent Operators.

When Independent Operators venture off and apply directly to Brokers, there exists the possibility that

they may lure away some of your clientele. Because Brokers make primary decisions based on price, if

the Independent-Operator-turned-Medicaid-Provider offers to perform transports at a reduced rate

chances are very good that they will receive transports. The first moral of the story is that Brokers are

not loyal to you - they are loyal to the lowest price. The second moral of the story is that Independent

Operators are not loyal to you – they are loyal to the highest reimbursement.

Suitable Clientele: Because Independent Operators use their own personal vehicles, typically a sedan or

minivan, the only clientele that you can suitably subcontract are ambulatory clients or those in a

wheelchair able to transfer into the seat of a car. Personal vehicles cannot accommodate para-lift

transports and they obviously cannot accommodate stretchers.

Subcontracting can be profitable because you are not paying the fixed and variable overhead expenses

associated with transporting ambulatory Medicaid recipients. However, to make money worth your

while you need volume. You need many Independent Operators for which you make a percentage of

each reimbursement. Consider the following reimbursements offered by MTM in the state of Florida:

A. Ambulatory trips will be paid at the following rate:

Base rate fee for cab/sedan per one way trip:

$11.00 includes the first five (5) miles

Mileage rate for trips:



5.01 to endless loaded miles: $1.25 per mile

B. Para-lift trips will be paid at the following rate:

Base rate fee for para-lift per one way trip:




C. Stretcher trips will be paid at the following rate:

Base rate for stretcher per one way trip:




Special Rates

Wait time – must have prior authorization

Ambulatory: 40 or more loaded miles: $5.00 an hour

Para-lift: 40 or more loaded miles: $10.00 an hour

I have to include MTM’s wait time rates because they are so comical. If a driver is “approved” to wait

for a patient that has to travel 40 or more miles, you will be reimbursed at a rate less than minimal

wage! It’s laughable that Brokers propose such a rate, but even more so, it’s scary to think that there

are many uninformed and inexperienced Providers that actually agree to such rates.

Think about it. If you agree to a $5.00 or $10.00 per hour wait time and you are paying a driver an

hourly wage to wait, you are literally agreeing to lose money. You are being reimbursed at a rate that is

less than what it costs. This is why you have to love Medicaid Brokers – they have the balls to propose

the audacious and even bigger balls to enforce it!

MTM’s proposed wait time alone illustrates why you need to outsource, subcontract, your ambulatory

Medicaid recipients to Independent Operators. With MTM’s rates of reimbursements, you cannot

afford to have drivers, on your payroll, waiting for $5 – 10 per hour. You cannot afford the overhead

expenses of vehicles, insurance, fuel, and labor expenses.

Managing Independent Operators: In addition to saving money and reducing overhead expenses,

subcontracting to Independent Operators allows you to operate in more remote and distant locations.



Realistically, because Independent Operators are not your employees and they operate their own

vehicles, technically, you rarely, if ever, need to see them! With the help of technology, you can literally

forward trip-related information to your Operators and manage them from a distance.

Transportation Providers with whom I work incorporate Subcontractors into their business model; they

use Dispatching Made Easyi (DME) to send the Independent Operators trip related information. Using

DME’s Mobile Functionality, dispatchers assign and convey trips to Independent Operators and, using

their own phones at their own expense, Operators relay trip status to dispatch. Dispatchers don’t even

talk to the Independent Operators – everything is done electronically via Dispatching Made Easy. If

additional trips are received from Brokers throughout the course of the day, dispatchers simply send

Operators their trips electronically. For Brokers who require signatures, DME allows you to email Trip

Manifests to Independent Operators to be printed from their home computers. This technological

convenience is significant leverage that saves you a lot of money while making you even more!

In regards to policy compliance, according to the Medical Transportation Service Agreement that we

evaluated earlier in this resource, you will recall the various driver expectations to include background

checks, drug screening, CPR training, Motor Vehicles Reports and more. Subcontracting work to

Independent Operators does not absolve you, “The Company,” from complying with Broker related

policies. However, you can pass along these financial obligations to the Independent Operators. In fact,

it is to your advantage to ensure that Independent Operators cover such expenses because it serves as a

filtering mechanism, weeding out those who are not serious, and it ensures their vested interest in your

Provider-Operator Agreement.

The Medical Transportation Service Agreement also reserves the right for Annual Inspections of Vehicles.

Needless to say, Independent Operators must agree to and comply with annual inspections by Broker

representatives if they are to work for your company. In this regard, subcontracting to Independent

Operators makes policies and procedures as dictated by Brokers more helpful than harmful. Especially

for Operators that you don’t see regularly, annual vehicle inspections, drug screening, and Motor

Vehicle Reports can actually contribute to ensuring higher standards.

Profiting from Independent Operators: How do YOU actually make money from subcontracting? There

are two options. You either take a percentage of the Operator’s total earned reimbursements or you



offer a flat fee reimbursement. One strategy is not necessarily better than the other. The right solution

for you is really determined by what is best for your accounting procedures and your financial goals.

Using the MTM rates as an illustration, MTM reimburses $11.00 for an ambulatory pickup. You, the

Provider, will receive this reimbursement and compensate your Independent Operator $8.00, keeping

$3.00 as profit. Likewise, where MTM’s mileage reimbursement is $1.25 per mile, you would

compensate the Operator $.85 per mile, profiting $.40 per mile.

As I mentioned previously, subcontracting ambulatory Medicaid work is a volume-based business

model. Profiting from $3.00 pickups and $.40 per mile is an example where “nickels and dimes add up.”

Obviously, these numbers will vary depending on the various rates of reimbursements in different states

and with different Brokers.

Another benefit to subcontracting Medicaid work is what Brokers often refer to as Liquidated Damages.

When a customer is picked up late, late for an appointment, or encounters other inconveniences, the

Broker reserves to the right to seek Liquidated Damages – code word for the Broker is not paying you!

The good news with such inconvenient circumstances, Liquidated Damages, is that it does not come out

of your pocket - it gets passed along to the Independent Operator.

Another benefit to using Dispatching Made Easy is that the moment your dispatcher receives a call

indicating that a patient is ready to be returned and selects “Customer Awaiting Return,” the trip is time-

stamped, marking the exact time which cannot be changed. Such confirmation serves as an additional

form of checks and balances should protesting any Liquidated Damages to Brokers become necessary.

Motivation for Independent Operators: A logical question is why would anyone want to serve as an

Independent Operator? Why don’t Operators just apply to Brokers directly to become an approved

Provider? I am sure that there are personal motivations that I cannot speak to as they are unique to

each Operator. However, as I work with Transportation Providers who use subcontractors, I cite a few

primary reasons.

First, many Independent Operators cannot afford to go 30-45 days without payment as is sometimes the

norm with Brokers when first applying to become a Provider. Practically speaking, there are many

people who live “week to week” and “paycheck to paycheck.” They simply cannot afford a sustained



period of time without money. Second, by joining with an approved and established Provider, an

Independent Operator can gain more trips and more money much more quickly than going through the

enrollment process with Brokers. Third, an Independent Operator has no desire to deal with any

potential headaches or administrative hassles from Brokers. They just want to obtain their trips, do

their job and get paid without potential complications. The more you can provide consistent work,

without hassle and with generous compensation the more likely you are to retain worthy Operators.

Suitable Applicants: Finding reliable and responsible Independent Operators is obviously important.

Although they are not your employees, Independent Operators still serve and represent your company.

One might think that finding experienced taxicab drivers are ideal candidates. However, not so

surprising, Transportation Providers using Independent Operators have discovered this is not so.

According to many Providers, taxicab drivers tend to be less reliable, easily distracted, and more

interested in pursuing “fast cash” versus providing assistance befitting the elderly. A consensus of

Providers indicate that, overall, many taxicab drivers are less willing to take the time to leave the vehicle

to assist elderly people in and out of the vehicle, up and down stairs, and open and close doors.

In the event that someone reading this is a former taxicab driver, please don’t take offense and “kill the

messenger.” Again, this less than desirable opinion of taxicab drivers serving the role of assisting the

elderly comes from experience via a consensus of Providers. Needless to say, I trust that there are many

exceptions and many former taxicab drivers can provide exceptional service. So do not be disheartened.

There are, however, two types of people that serve as prime candidates for Independent Operators.

The first, we will be discussing in the Home Care section of this resource; middle-aged women, possibly

single mothers, looking for additional money. Multiple Providers have mentioned such candidates,

middle-aged women, because (1) they tend to be more mature as compared to younger women, (2) if

they have children, then definitely need the money and are desirous of some type of stable cash flow,

and (3) they have an instinctive nurturing nature that is ideal for serving the elderly.

Speaking of women employees, especially if you already have or you plan on diversifying into Home

Care, you may already have them. As we discussed, Obamacare is changing the way we employ people.

We cannot afford to have more than 50 employees or we will be paying unsustainable taxes and health

benefits. Our businesses will not be profitable! Further, because of Obamacare, full-time employees



are considered working 30 hours per week, no longer 40 hours. Thus, more and more employers are

laying people off and hiring part-time help.

Because your Transportation Business and Home Care Agency are two separate legal entities providing

mutually exclusive services, you have some creative options. Middle aged women are prime candidates

for your Home Care Agency, working 20-30 hours per week depending on demand, and then serving as

reliable Independent Operators for your Transportation Company. As an employee of your Home Care

Agency, they will draw a steady paycheck. As an Independent Operator for your Transportation

Company they will receive steady compensation and receive a 1099 at the end of the year.

Various reminders that make using Caregivers as Independent Operators more enticing and

economically feasible are as follows:

Workers compensation for Home Care Providers is relatively cheap, especially when compared

to Workers Compensation for NEMT drivers. In your Transportation Company, you will not pay

Workers Compensation for your Independent Operators

Your Caregivers have reliable vehicles and are experienced in assisting and transporting elderly

people to medical appointments. Further, if you use some of the strategies discussed in “How

to Build a Million Dollar Home Care Agencyii,” they have magnetic signs with your company logo.

While on duty as a caregiver in your Home Care Agency and while serving as an Independent

Operator in your Transportation Company they will be advertising your business.

The second type of candidate is older, retired men – and I understand why. Personally, I always

welcomed the opportunity to hire such persons. Older retirees obviously (1) have a proven job history

demonstrating their reliability, (2) most are receiving pensions and social security so that they literally

cannot be compensated too much or it could conflict with their retirement benefits, and (3) their

motivation for working is simply to stay busy, engaged in life, and create some supplemental income.

Located in Upstate New York, we had a big IBM presence so I always welcomed the opportunity to hire

retired IBMers looking to stay active and engaged in life.

Insurance and Liability: Independent Operators are responsible for their own insurance because they

will be using their own personal vehicle. Thus, Operators can have standard insurance; something like



Geico, State Farm, All-State, etc. By using Independent Operators and not having to insure vehicles with

livery insurance, you are saving a small fortune!

You do, however, need to carry a General Liability policy, one that lists your Independent Operators

individually. So you do need to make sure that your Independent Operators have good driving records

and clean Motor Vehicle Reports. But again, the good news is that the cost of a General Liability policy

is a minute fraction of the cost in carrying livery insurance for each vehicle. Feel free to visit us at

http://www.umtpg.org/umtpg-benefits/insurance-savings to learn more and enter your contact

information. One of our lead insurance brokers will contact you with pricing and more information.

http://www.umtpg.org/umtpg-benefits/insurance-savings



MANAGED CARE CONSORTIUM AGREEMENT

Now that we have gone into excessively great detail discussing the Medicaid Broker system and

particulars thereof, let me share with you an Agreement that Transportation Providers are required to

sign when providing services to Kaiser Permanente, an integrated Managed Care Consortium that

provides services to Medicaid recipients. Kaiser Permanente was founded in 1945 by industrialist Henry

J. Kaiser and physician Sidney Garfield.

We need to review this contract for two specific reasons. First, the possibilities of working with

Managed Care Consortiums or similar-type structures in the near future are very real possibilities.

Second, this Agreement will give you an unbelievable sense of perspective when you compare this

Agreement to that of the Broker Service Agreement. Kaiser’s Agreement is ONLY 8 pages as compared

to the 38 page MTM Agreement and 75 page Logisticare Agreement. Third, the rates of reimbursement

from Kaiser are dramatically higher and more favorable as compared to the peanuts that Brokers

attempt to offer!

Consider, the non-profit Kaiser Foundation Health Plan and Kaiser Foundation Hospitals entities

reported a combined $1.6 billion in net income on $47.9 billion in operating revenues last year. Kaiser

Permanente has 8.9 million health plan members, 167,300 employees, 14,600 physicians, 37 medical

centers, and 611 medical offices. As of 2006, Kaiser Permanente operates in nine states and the District

of Columbia, and is the largest Managed Care Organization in the United States.

In short, although we are comparing apples to oranges, Kaiser is HUGE as compared to individual

Medicaid Brokers. And Kaiser only operates in 9 states! Needless to say, Kaiser is a serious “player”

versus the archaic and caveman tactics as practices by Brokers.

Kaiser’s Agreement with Transportation Providers is in stark contrast to the Service Agreements

proposed by Medicaid Brokers. Clearly, by the language and amicable tone of the contract, Kaiser

actually understands that they need Transportation Providers in an effort to accomplish their daily

missions. Thus, they treat Transportation Providers much more like strategic partners versus

sharecroppers as do Medicaid Brokers!



MANAGED CARE CONSORTIUM SERVICE AGREEMENT

This Letter of Agreement (“Agreement”) sets forth the basic terms for non-emergency wheelchair

and/or gurney van transport services negotiated on behalf of [Name of Transportation Provider]

("Contractor"), a ____________________________, and Kaiser Foundation Health Plan, Inc. (“Health

Plan”), a California nonprofit, public benefit corporation.

Contractor is a provider of wheelchair and/or gurney van, transport services. Contractor is duly

licensed and approved by applicable Federal, State, local laws and regulations to provide such services.

Contractor shall provide authorized gurney and/or wheelchair non-emergency ground transportation

services (“Services”) to certain members (“Members”) of Health Plan who are Medicaid beneficiaries

(“Members”) and referred to Contractor by Health Plan or The Permanente MediCal Group (“Medical

Group”). Contractor may make use of subcontractors in its performance of Services under this

Agreement, as long as subcontractors are pre-approved by Health Plan to meet the requirements stated

in this Agreement. Contractor is fully responsible for adhering to all of the terms and conditions of this

Agreement regardless of whether it uses subcontractors in performance of the services stated. Health

Plan is licensed as a health care service plan by the California Department of Managed Health Care

(“DMHC”).

Joel’s Insight: It’s only the second paragraph and Kaiser is already demonstrating the freedom and

flexibility afforded to Transportation Providers. Kaiser has no problem with Providers using

Subcontractors as long as they are “pre-approved by Health Plan to meet the requirements” of this

Agreement.

Health Plan and this Agreement are subject to the Knox-Keene Health Care Service Plan Act of

1975 (“Knox-Keene Act”) located at California Health & Safety Code Sections 1340, et seq. and

regulations promulgated thereunder. All federal, state and local laws and regulations applicable to the

provision of Services hereunder are incorporated by reference herein and shall be binding on the

parties, including but not limited to the laws, regulations and directions governing the Medicare

Advantage and regular Medicare and Medicaid Programs, and applicable provisions of Knox-Keene Act,

and such other laws that are mandated as a result of Health Plan’s contractual relationship with

government funded healthcare programs. All applicable provisions of the accrediting standards and



requirements of The Joint Commission, the National Committee for Quality Assurance and any other

applicable accrediting organization shall also apply to this Agreement.

This Agreement will be for a term of two (2) years, commencing June 1, 2013 (“Effective Date”) and

expiring, with an option for Health Plan to extend the agreement for (2) one (1) year periods (the

“Term”). This Agreement may be terminated, with or without cause, during its stated two year term by

either party giving sixty (60) days prior written notice to the other party of its intention to terminate.

Either party may terminate this Agreement effective immediately upon breach by the other party of any

material provision of this Agreement, provided such breach continues for fifteen (15) days after receipt

by the breaching party of written notice of such breach from the non-breaching party. Termination or

suspension of the Agreement without any future obligations owed by either party to the other shall

result during the occurrence of any force majored.

Joel’s Insight: First, especially when using MTM’s Broker Agreement as a point of reference, the

language in Kaiser’s Agreement is much more amicable and respectful of the needs of both parties.

Second, Kaiser’s Agreement allows either party to terminate this Agreement without future obligations

owed by either party to the other – what a stark difference from that of MTM’s Agreement!

Contractor hereby agrees to provide gurney and/or wheelchair ground transportation services

to Member Patients by Health Plan under this Agreement as reasonably requested by Health Plan.

Contractor’s drivers and all personnel who assist in providing the said service will each have all

permits, licenses, and certifications required by applicable federal, state, municipal and county laws

and regulations now or hereafter in force and effect. Such permits, licenses and certification will be

current and in possession of Contractor’s drivers and other personnel at all times for inspection by

Hospitals upon request. Contractor will notify Health Plan immediately of any changes in regard to its

license status (e.g. suspensions, cancellations, updates, etc.).

Joel’s Insight: MTM and other Brokers require that drivers have proper licensing available for inspection.

But all throughout this Agreement you will notice that Kaiser refrains from including the ridiculous

threats of “Corrective Action Plan” should a provider fails to be compliant with any stipulations.



Service Locations:

Services are to be provided within the KP California Region, defined as within the

following counties: [Name of Counties].

Contractor is committed under this Agreement to coordinate its efforts with the requirements

of Health Plan and Medical Group to assure the quality of all care and services provided to Member

Patients. In accord with a mutually agreed upon quality management program as outlined in Exhibit B,

which is attached hereto and incorporated herein by this reference, Contractor, Health Plan, and

Medical Group Contractor hereby acknowledges that the quality assurance, risk management, and

utilization review programs of Health Plan and Medical Group require that Health Plan and Medical

Group monitor the quality assurance, risk management, and utilization review programs of Contractor

and all of its personnel. Contractor agrees that Contractor, Health Plan, and Medical Group shall

cooperatively pursue opportunities to continuously improve the care provided under this letter of

Agreement in accord with the provisions of Exhibit B. Contractor shall allow representatives of Health

Plan and Medical Group to participate actively in the conduct of Contractor's quality assurance and

utilization review programs. The parties hereto will perform utilization reviews as part of their efforts to

achieve the objectives of quality assurance and utilization review.

Joel’s Insight: Wow! Look at the difference in tone between this Agreement and that of MTM! In

Kaiser’s Agreement, we see “mutually agreed” and “cooperatively pursue opportunities” – underscoring

the strategic partnership between Kaiser and Contractor. No such language exists in MTM’s Agreement

because, in the perspective of MTM, Transportation Providers serve the role of servant.

Services provided under this Agreement may or may not be a covered benefit under the

Member’s membership agreement (the “Membership Agreement”). If Services are a covered benefit

under the Member’s Membership Agreement (“Covered Services”), Health Plan shall be responsible for

payment to Contractor, as set forth in greater detail in Section 1 below. If Services are not a covered

benefit under the Member’s Membership Agreement (“Non-Covered Services”), Health Plan shall not be

responsible for payment to Contractor; however, the Member will be notified that the Services are not

covered and that the Member will be personally responsible for the Non-Covered Services if the

Member elects to have them provided; in which case, if the Member agrees to be personally responsible



for the Non-Covered Services, Contractor shall be so notified, and the payment shall be as set forth in

Section 2 below. If the Services are Non-Covered, and the Member does not agree to be personally

responsible therefor, Contractor shall not provide Services.

Joel’s Insight: Kaiser demonstrates further good will by specifying that the cost of transportation

services for Members may or may not be covered under their Health Plan. In the instances when such

transportation is NOT covered, Kaiser will notify the Member in advance and, thus, the Member will be

responsible for such expenses.

For Covered Services, Health Plan shall pay to Contractor according to the rates included in

Exhibit A, which is attached hereto and incorporated herein by this reference. Contractor shall submit

its claims for Covered Services to:

Joel’s Insight: As you will notice in the attached rate sheet, the rates of reimbursement from Kaiser are

dramatically higher and more reasonable as compared to the rates proposed by Medicaid Brokers –

further evidence illustrating that Kaiser understands that Contractors need to remain profitable and

solvent in order to continue supporting the mission of Kaiser.

KP NCAL Member GV/WCV Claims Mailing Addresses

Gurney Van/Wheelchair Van claims must be billed on a standard CMS-1500 form, indicating the KP

authorization number in Box 23, and sent to:

EMI-Gurney Van/Wheelchair Van Claims

PO BOX 853915

Richardson TX 75085-3915

Overnight packages and expedited mail should be sent to EMI’s street address:

EMI-Gurney Van/Wheelchair Van Claims

1200 Riverplace Blvd. Suite 600

Jacksonville, FL 32207



Customer Claims Service Department

Hours: Monday through Friday 8:00 am to 5:00 pm Pacific Time

Telephone: 1-888-[Number]

FAX: 1-[Number]

1. Payment shall be made to Contractor for services rendered within forty-five (45) days of

receipt of a completed HCFA 1500 form. Except as expressly stated elsewhere in this

Agreement and for an applicable co-payment, Contractor shall look solely to Health Plan for

compensation for Covered Services rendered to Member Patients under this of Agreement.

Contractor agrees that in no event, including, but not limited to, non-payment by Health

Plan, insolvency, or breach of this Agreement, shall Contractor bill, charge, collect a deposit

or surcharge from, assert a lien on a Member’s settlement or judgment against a third party

tortfeasor, or have any recourse against any Member Patients for Covered Services provided

pursuant to this letter of Agreement. Contractor further agrees that this provision shall

survive the termination or expiration of this letter of Agreement and shall be construed to

be for the benefit of Members.

Joel’s Insight: The only downside to this Agreement is that Kaiser reserves the right to pay Net 45.

However, if you maintain a healthy cash flow, this stipulation will not be a long-term problem.

2. If a Member elects to continue receiving Non-Covered Services from Contractor after such

Member’s coverage benefits under his or her applicable Membership Agreement have been

exhausted or after Health Plan disallows coverage for such services, Contractor shall seek

compensation solely from such Member (or such Member’s representative) for such

services, and Health Plan and Medical Group shall not be liable to Contractor for any charge

in connection with such services rendered by Contractor to such member. Contractor shall

submit invoices for services provided under this letter of Agreement to the Member, unless

indicated otherwise.

Joel’s Insight: If transportation service is no longer covered for a Member of the Health Plan, Kaiser not

only informs the Member, but they also allow the Member to continue using the Transportation Provider



of their choice. Medicaid Brokers do NOT do this – afford Members such autonomy. Kaiser further

makes it clear to the Member and to you, the Transportation Provider, that the Member will be

responsible for the cost of transportation service.

Contractor shall maintain, and shall require its subcontractors providing Services hereunder to

maintain, in full force and effect, at its sole expense, insurance covering its obligations under this letter

of agreement for professional liability, bodily injury and property damages at limits of not less than $1

million per occurrence and motor vehicle liability insurance with a combined single limit of not less than

$1 million to cover the scheduled autos vehicles used in performance of Contractor’s duties hereunder.

Contractor shall cause such insurance policies to name Health Plan as an additional insured. Upon

request, Contractor shall provide Health Plan with satisfactory evidence of its compliance with these

insurance requirements.

Contractor agrees that all information, records and data maintained or collected about Member

Patients shall be confidential and Contractor's agents and employees shall not discuss or transmit such

information except as a necessary part of providing services to Member Patients. Neither Contractor

nor Health Plan shall disclose to any person not a party to this letter of agreement in any manner

whatsoever any information about this Agreement, including without limitation, information about

either party’s duties or benefits hereunder or the contents of Exhibit A without the prior written

consent of the other party. Notwithstanding anything to the contrary stated herein, Health Plan, in its

own discretion, may disclose to Health Plan or Medical Group any information about this Agreement

obtained as a result of this Agreement. The parties recognize and acknowledge the importance of

protecting the privacy rights of Members, including, but not limited to those rights in the Health

Insurance Portability and Accountability Act of 1996, Public Law 104-191, together with the regulations

promulgated thereunder (collectively, “HIPAA”).

Contractor agrees to indemnify and hold harmless (and at Health Plan’ request, defend) Health

Plan and all other persons or organizations cooperating in the conduct of the “Kaiser Permanente

Medical Care Program” and each of their officers, partners, employees and agents from and against any

and all claims, losses, damages, liabilities, costs, expenses, or judgments for or in connection with injury

or damage (including, but not limited to, death) to any person or property that such injury or damage

results from or is any way connected with any acts, failure to act, or the performance of or failure to



perform obligations under this interim agreement by Contractor, its officers, partners, employees, or

agents. Health Plan agrees to indemnify and hold harmless (and at Contractor’s request, defend)

Contractor from any and all claims, losses, damages, liabilities, costs, expenses or judgments for or in

connection with injury or damage (including, but not limited to, death) to any person or property that

such injury or damage results from or is any way connected with any acts, failure to act or the

performance of or failure to perform obligations under this Agreement by Health Plan, its officers,

employees or agents. Neither termination or expiration of this Agreement nor completion of acts to be

performed under this Agreement shall release either party from its obligations to indemnify as to any

claim or cause of action asserted so long as the event upon which a claim or cause of action is

predicated shall have occurred prior to the effective date of any such termination or completion.

Joel’s Insight: There is no other paragraph in this Agreement that illustrates how Kaiser attempts to

create an amicable and mutually beneficial arrangement for both parties. First, Kaiser insists that both

parties indemnify and hold each other harmless. Second, they specify that such an arrangement shall

not terminate or expire. This is a good will stipulation that you rarely see in Broker Agreements.

Contractor agrees that if this Agreement is determined to be subject to the provisions of

Section 952 of P.L. 96-499, which governs access to books and records of contractors of services to

Medicare providers where the cost or value of such services under the contract exceeds $10,000 over a

twelve (12) month period, then Contractor will permit representatives of the Secretary of the

Department of Health and Human Services and of the Comptroller General to have access to this

Agreement and books, documents and records of Contractor, as necessary to verify the costs of this

Agreement in accordance with criteria and procedures contained in applicable federal regulations.

Contractor will provide services to Member Patients without discrimination on account of race,

sex, sexual orientation, color, religion, national origin, age, physical or mental handicap, or veteran’s

status. Contractor recognizes that Health Plan, as a federal government contractor is subject to various

federal laws, executive orders and regulations regarding equal opportunity and affirmative action which

may also be applicable to subcontractors. Contractor, therefore, agrees that any and all applicable

equal opportunity and affirmative action clauses shall be incorporated in this Agreement with Health

Plan as required by federal laws, executive orders, and regulations, which include the following: Title VI

of the Civil Rights Act of 1964, the Age Discrimination Act of 1975, the Genetic Information



Nondiscrimination Act of 2008, and the Rehabilitation Act of 1973, all as amended; shall provide

reasonable access and accommodation to persons with disability to the extent required of a health

services provider under the Americans with Disabilities Act of 1990, or any applicable state law or

regulation; and shall not unlawfully discriminate, harass, or allow harassment against any employee or

applicant for employment on the basis of any factor prohibited by law including, without limitation,

those already delineated in this Section. Contractor also agrees to comply with any and all applicable

equal opportunity and affirmative action clauses from the Federal Acquisition Regulations (FAR) at 48

CFR Part 52, which shall be incorporated in this Agreement by reference as required by federal law,

including, without limitation, the following FAR clauses: (1) Equal Opportunity (April 2002) at FAR

52.222-26; (2) Equal Opportunity for Special Disabled Veterans, Veterans of the Vietnam Era, and Other

Eligible Veterans (September 2006) at FAR 52.222-35; (3) Affirmative Action for Workers with

Disabilities (June 1998) at FAR 52.222-36; and (4) Utilization of Small Business Concerns (May 2004) at

FAR 52.219-8. In addition, Contractor agrees to comply with the provisions of Executive Order 13496

(codified at 29 CFR Part 471, Appendix A to Subpart A) concerning the obligations of federal contractors

and subcontractors to provide notice to employees about their rights under Federal labor laws. If

Contractor is not otherwise subject to compliance with the laws and executive orders specified in this

Section, the inclusion of this Section shall not be deemed to impose such requirements upon Contractor.

Notwithstanding any other provision of the Agreement, if Health Plan reasonably determines

that a modification of this Agreement is necessary to cause it to be in conformity with state or federal

law, or the requirements of an accrediting or regulatory agency, or in order for Health Plan to

participate in government-funded health plan products, then Health Plan shall give Contractor written

notice of the proposed modification, and the date on which it is to go into effect, which shall not be less

than thirty (30) days following the date of the notice, and the modification shall go into effect on that

date. Health Plan shall consider any objections made by Contractor concerning the proposed

modification during the notice period.

Any notice or demand required under this Agreement will be in writing; will be sent by certified

mail, return receipt requested, postage prepaid or by a recognized overnight carrier which provides

proof of receipt; and will be sent to the addresses below. Either party may change the address to which

notices are sent by sending written notice of such change of address to the other party in accordance



with the provisions as stated in this paragraph. The addresses for the parties for the purposes of such

communication are:

KAISER FOUNDATION HEALTH PLAN, INC.

Attn: _____________________________________________

THE ABOVE TERMS HEREBY ARE AGREED TO AND UNDERSTOOD

KAISER FOUNDATION HEALTH PLAN, INC.

By :______________________________

Print Name :_______________________

Title :_______________________________

Date:_______________________________

Provider: [COMPANY NAME]

By :__________________________________

Print Name :___________________________

Title :______________________________

Date :______________________________



EXHIBIT A

to

Letter of Agreement for Wheelchair/Gurney Transportation Services

Description of Services

Service

Wheelchair Transport Services (WCS):

(1) Driver (Certified CPR, First Aid Only). No medical services provided (only assistance or equipment, no lights or sirens. Can accommodate oxygen or allow portable oxygen tanks.

Gurney Van Transport Services (GVS):

(1) Driver (Certified CPR, First Aid Only). No medical services provided (Only assistance or equipment), no lights or sirens. Can accommodate oxygen or allow portable oxygen tanks.

RATES

Base

Rate

Mileage

(Per Mile)

Wait Time

(per 15

min.)

Oxygen

(Per Trip)

Stairs

(Per

Trip)

Service

Offerings RATES (Business Hours)

GVS $124.00 $4.00 $13.00 $0.00 $5.00

WCS $44.00 $2.00 $7.50 $0.00 $4.00

Service

Offerings RATES (Nights & Weekends)

GVS $0.00 $0.00 $0.00 $0.00 $0.00

WCS $0.00 $0.00 $0.00 $0.00 $0.00

Business Hours: 7:00am - 6:00 pm Mon-Fri

Nights & Weekends: 6:01 pm - 6:59 am Fri-Sun

GVS (Gurney Van Services)

WCS (Wheelchair Services)



EXHIBIT B

Letter of Agreement for Wheelchair/Gurney Transportation Services

AGREEMENT FOR QUALITY MANAGEMENT PROGRAM

Health Plan agrees that all information, records and data collected or maintained about Members shall

be confidential. Health Plan, its employees and agents shall maintain the confidentiality of all Member

information received in the course of providing services under this Agreement. No employee or agent of

Health Plan shall discuss, transmit or narrate in any manner any Member information of a personal,

medical or other nature except as a necessary part of providing services to the Member.

Contractor agrees to the following:

A. Sentinel events: Report within 12 hours, any unexpected occurrence or variation involving death

or serious physical or psychological injury or the risk thereof to a Member. Serious injury

specifically includes loss of limb or function. A “sentinel” event is an event where there is a

serious or immediate threat/risk to patient safety; leads to patient deterioration or patient

harm, and requires medical director review.

B. Upon request, provide:

Patient assessment records (i.e., LOC (level of consciousness), etc.)

Written responses in support of quality case reviews

Documentation justifying abnormal arrival times (i.e., >15 minutes of quoted real time

Estimated Time of Arrival)

C. Any additional mutually agreed upon ongoing monitoring

Kaiser Foundation Health Plan Quality

Contact: Medical Transportation Department

1950 Franklin Street, 8th floor

Oakland, CA 94612

Phone: 510-987-2336

Fax: 510-873-5393

Attention: Senior Quality/Utilization Analyst

Progress Reporting and Communications:

Monthly activity reports to be provided by supplier to KP, format and content to be

agreed upon by KP and supplier

Performance reports to be provided by supplier to KP when requested, format and

content to be agreed upon by KP and supplier



OBAMACARE, THE BIG PICTURE

"I predict future happiness for Americans if they can prevent the government from wasting

the labors of the people under the pretense of taking care of them."

- Thomas Jefferson

Let me preface everything by telling you that I am from the People’s Republic of New York (named in

honor of communist China, Cuba, and other socialist states). Trust me - I definitely don’t say this to

boast! As of this writing, New York has officially become the number one most highly taxed and

regulated state in the Union. We are like a true socialist state, great in taxes, unfulfilled promises,

welfare, and burdensome regulations! So despite any of the commercials you may have seen

advertising “The new New York” in an effort to encourage new business in New York, I can assure you, it

is a load of crap! And yes, I am absolutely speaking from first-hand experience. Needless to say, I will

only be in New York for a short time longer and then I’m definitely moving to a more business friendly

state.

Now that I have adequately expressed my displeasure with The People’s Republic of New York, I share

with you a handful of articles from the New York Times, easily one of

the most liberal, left-leaning newspapers in the country. Why is this

important? Because if the New York Times is writing about the

precarious situation of our economy due to overspending,

Obamacare, welfare, and more, then you KNOW it has to be serious!

Again, I want you to consider all sources and information so that you

can draw your own conclusions. And if The People’s Republic of New

York Times is acknowledging this growing disaster, you know that we

are heading for a financial cataclysmic event! And yes, this absolutely has everything to do with your

business!



WHAT IS DRIVING GROWTH IN GOVERNMENT SPENDING?

- NATE SILVER, THE NEW YORK TIMES

It’s one of the most fundamental political questions of our time: What’s driving the growth

in government spending? And it has a relatively straightforward answer: first and foremost,

spending on health care through Medicare and Medicaid, and other major social insurance

and entitlement programs.

In the long run, the overall economic health of the country is the most important constraint

on fiscal policy. A growing economy gives us a lot of good choices: maintaining or expanding

government programs, cutting taxes or holding them at a moderate level, reducing or

managing the national debt. A stagnant economy means that everything gets squeezed.

Another surprise is how little we are paying in interest on the federal debt, even though the

debt is growing larger and larger. Right now, interest payments make up only about 6

percent of the federal budget.

The growth in federal government spending relative to inflation is because of the increased

expense of entitlement programs. Spending on welfare programs like food stamps and

unemployment insurance is the most cyclical – or technically the most countercyclical, since

much of it kicks in automatically during an economic downturn. And health care spending

has been increasing at the fastest rate.

Health care spending increased at 5.7 percent per year (and federal government spending

on health care increased at a 6.7 percent pace). In contrast, the gross domestic product

grew at a rate of 2.7 percent over this period, with tax revenues increasing at about the

same rate as the G.D.P.

Spending on infrastructure and government services, excluding defense, has kept pace with

gross domestic product growth.

http://fivethirtyeight.blogs.nytimes.com/author/nate-silver/



Spending on entitlement programs was about $500 billion per year in 1972 in today’s

dollars. If it had increased at the same rate as the gross domestic product, it would now be

about $1.4 trillion. Instead, it is now about $2.9 trillion per year. What this means is that

there has been about a $1.5 trillion increase in entitlement spending above and beyond

gross domestic product growth. This is actually slightly larger than the overall increase in

government spending relative to gross domestic product. But essentially all of the increase

in spending relative to economic growth, and the potential tax base, has come from

entitlement programs, and about half of that has come from health care entitlements

specifically.

The growth in health care expenditures, for better or worse, is not just a government

problem: if we can’t slow the rate of growth in health care expenditures, we’ll either have to

raise taxes, cut other government spending or continue to run huge deficits. Or we could



hope to grow our way out of the problem, but health care expenditures may be impeding

private-sector growth as well.

Slowing the growth of entitlement spending will not be easy. Particularly in the case of

health care, it has become substantially more expensive for individuals with both public and

private insurance to purchase the same level of care.

And on a political level, cuts to entitlement programs are liable to be more noticeable to

individual voters than cuts to things like infrastructure spending. A 10 percent cut to Social

Security or Medicare benefits will surely draw the ire of voters. A 10 percent reduction in

the amount allocated to bridge repair, or in the amount of government-sponsored energy

research, will affect individual citizens less directly.

Joel’s Insight: What do huge deficits, over-spending, and all other factors leading to our down economy

have to do with your business? Um, only everything! Think long-term. Where will you be financially

three, five, ten, twenty years from now? What will be the status of our economy and your money? We

are in the business to make money – bottom line. Anything that influences our ability to create and build

wealth and gain financial independence is of concern. Needless to say, a down economy leads to high

inflation, high unemployment, diminished sales and services, low returns on investments, and much,

much more. Thus, by understanding what is happening on a macro scale, we can, as Entrepreneurs,

better plan, prepare and adjust our businesses and finances so as to limit our exposure to risk.

Again, if the New York Times, of all sources, is admitting the growing precarious financial situation

regarding our economy versus advancing a socialist agenda, then it has to be serious!



FEDERAL WELFARE SPENDING TO SKYROCKET 80 PERCENT IN NEXT DECADE

- DANIEL HALPER, THE WEEKLY STANDARD

Federal welfare spending will skyrocket 80 percent over the next decade, according to new

analysis by the minority side of the Senate Budget Committee. Here’s a chart, provided by

the committee, detailing the growth in spending:

“This chart displays projected federal spending on federal welfare programs over the next

ten years, based on data from the Congressional Research Service and Congressional Budget

Office,” the Republican side of the Senate Budget Committee explains. “These figures do not

count state contributions to federal welfare programs (primarily on low-income health

assistance) which brought total welfare spending in FY2011 to more than $1 trillion—

dwarfing any other budget item including Medicare and Social Security, and totaling enough

to mail every household in poverty a check for 60k each year.”

Currently, 95% of spending on means-tested poverty assistance falls into four categories:

cash assistance, health assistance, housing assistance, and social and family services.

http://www.weeklystandard.com/blogs/federal-welfare-spending-skyrocket-80-percent-next-decade_696026.html



Welfare spending has increased on a year-over-year basis regardless of whether the

economy has improved or unemployment has declined, and is projected to continue this

dramatic rise indefinitely. Spending on these poverty programs will rise approximately 80%

from FY2013-FY2022, representing a total cost of $11 trillion—roughly one quarter of

cumulative federal spending. Slowing the growth rate from 80% to a still massive 60%

would thus result, according to standard congressional budget accounting, in a $1 trillion

savings over ten years.

Part of the large increase in welfare spending is driven by a series of controversial

recruitment methods that include aggressive outreach to those who say they do not need

financial assistance. Recruitment workers are even instructed on how to “overcome the

word ‘no’” when individuals resist enrollment. The USDA and Department of Homeland

Security also have promotions to increase the number of immigrants on welfare despite

legal prohibitions on welfare use among those seeking admittance into the United States.

"The democracy will cease to exist when you take away from those who are willing to work

and give to those who would not."

- Thomas Jefferson



In the event you thought that the previous article was an exaggeration, I encourage you, take a moment

to study and let the message of this image sink in. And yes, this is very much a “real” image that I took

on my cell phone. It was featured on a billboard about 100 yards from my church. I had another image

that I took near the main entrance of a supermarket featuring two representatives from the “Family

Enrichment Network.” Unfortunately, that image did not come through on my phone, but it featured a

recruiting booth for prospective applicants as they frequented the supermarket. Upon entrance,

customers were solicited by smiles, greetings, brochures, handshakes, and associated solicitations to fill

out applications for Food Stamps. And in the event you’re wondering why a supermarket would allow

such solicitations of their customers, you have to remember, we’re talking about Food Stamps; a “feel-

good” service that, if denied, would have you labeled uncompassionate!

This truly is an incredible message, “Food stamps help keep Broome County Strong.” The concept of

hard work, persistence, and self-reliance is quickly fading from the American conscience and is replaced

by increasing social services. Effective marketing and recruiting strategies are making welfare a more

popular and viable option as compared to workfare. Again, what does this have to do with your

business? Everything! Such unsustainable policies and institutions are contributing to the rapid

bankruptcy of our economy which, in turn, directly affects your ability to make and protect your assets!



Before anyone begins railing me with accusations that I am not compassionate because I am of the

opinion that our current welfare-state is more harmful than helpful, please, don’t waste your time! I am

very much compassionate and a firm believer in giving. In fact, I am not only a generous giver, I am a

cheerful giver! Why – because the more we give the more we receive is promised in Proverbs 11:24-25:

24 One person gives freely, yet gains even more; another withholds unduly, but comes to poverty. 25 A

generous person will prosper; whoever refreshes others will be refreshed.

I recognize that my money is not of my own. Rather, I am only a good steward of God’s money as it all

belongs to Him. Because I give, He blesses me with more. The more I give, the more He blesses me! So

too will God bless you when you give generously. What does giving and welfare have to do with your

business specifically? Everything!

I believe in two things, relief and restoration. There are people who need temporary relief, maybe in

the form of money, time or other assistance. However, when someone continuously requests

assistance for the same problem, they no longer need relief. They need restoration! For example, when

someone continuously asks to borrow money because they can’t pay their bills, they need immediate

relief. But more so, they need long-term restoration. You can give them money to relieve them of their

immediate problem, but soon thereafter they will be back for more. They need long-term restoration.

Such is the scenario with our welfare state, Obamacare, and associated social mechanisms that are

making people more dependent on the Government. Welfare was originally designed to offer short-

term relief for those in need. However, under the guise of “helping people,” such institutions have

become more of an enslavement mechanism, making people dependent on the Government long-term,

versus helping to restore people to personal growth, development, and independence.

In the event that you think that I am wrong, I echo back to 1968 when Lyndon B. Johnson traveled to

West Virginia as a backdrop of poverty to declare “Today, we declare a war on poverty!” Well, Mr.

Johnson, well Mr. Obama, with ever increasing welfare numbers and by increasing the ceiling for

Medicaid recipients over 50 years, we can officially declare that poverty has absolutely kicked our ass!

What’s this have to do with your business? Everything! A bankrupt economy has everything to do with

your business and your ability to make money!



JP MORGAN’S FOOD STAMP EMPIRE

- PETER SCHWEIZER, THE DAILY BEAST

In 2010, President Obama signed into law the Healthy, Hunger-Free Kids Act. It received

bipartisan support, and was hailed as a compassionate victory for America’s poorest

children. The bill was also a potentially good development for mega bank JP Morgan Chase.

Why, you may be wondering, would one of the nation’s biggest banks benefit from a bill

meant to feed poor children? A closer look at the legislation reveals the answer. The bill

mandates that “all state agencies implement Electronic Benefit Transfer (EBT) systems by

October 1, 2020” for those receiving money through the Women, Infants, and Children

(WIC) program. And which company administers nearly half of all states’ EBT programs?

You guessed it: JP Morgan Chase.

We seldom think of poverty programs as profit centers, preferring to discuss them as

matters of ideology. Liberals view programs like WIC—which provides food to both

pregnant mothers and mothers of young children—as the mark of a compassionate nation.

Conservatives see them as a gateway to government dependency. Arguably, they may fit

either of those descriptions. But as with so many other government programs in

Washington, both WIC and its close cousin, the federal food stamp program, have morphed

into something else: cash cows for powerful corporate interests.

“This business is a very important business to JP Morgan,” Christopher Paton, the

company’s managing director of treasury services, told Bloomberg News. “It’s an important

business in terms of its size and scale. We also regard it as very important in the sense that

we are delivering a very useful social function. We are a key part of this benefit delivery

mechanism. Right now volumes have gone through the roof in the past couple of years or so

… The good news from JP Morgan’s perspective is the infrastructure that we built has been

able to cope with that increase in volume.”

18 of the 24 states JP Morgan handles have been contracted to pay the bank up to

$560,492,596.02 since 2004. Since 2007, Florida has been contracted to pay JP Morgan



$90,351,202.22. Pennsylvania’s seven-year contract totaled $112,541,823.27. New York’s

seven-year contract totaled $126,394,917.

These contracts are transactional contracts, meaning they are amendable based on changes

in program participation. Each month, the three companies that administer EBT receive a

small fee that can range from $.31 to $2.30 (or higher depending upon the number of

welfare services on an EBT card and state contractual requirements) for each SNAP

recipient.

With states paying EBT processors so much, one might think that these companies would be

expected to tenaciously prevent and investigate fraud and abuse. That job is left to states’

EBT fraud investigation units which, according to the USDA’s website, the federal food

stamp program has “over 100” inspectors to police the nearly 200,000 retailers nationwide

that accept EBT cards.

The rapid growth of welfare enrollments can be attributable to the fact that, in recent years,

more and more states have begun to operate under “broad-based categorical eligibility”

rules. That means households which were previously ineligible to receive SNAP benefits may

now receive them.

But there may be one more reason the food stamp industrial complex continues to balloon:

because wealthy corporate interests have been filling the campaign coffers of politicians

who control the program’s trajectory. Prior to the 2002 EBT implementation mandate, JP

Morgan’s political donations to members of the House and Senate agriculture committees

were modest. But since 2002, they’ve been on a steady climb upward.

"I believe that banking institutions are more dangerous to our liberties than standing armies.

If the American people ever allow private banks to control the issue of their currency, first by

inflation, then by deflation, the banks and corporations that will grow up around the banks

will deprive the people of all property - until their children wake-up homeless on the

continent their fathers conquered."

- Thomas Jefferson



THE INFLUENCE OF OBAMBACARE IN A CHANGING INDUSTRY

At this point, I think it necessary to reiterate the purpose of this resource. My goal is to educate you on

the overall status of what we, as Entrepreneurs, face in a changing economy and a changing social

system in addition to the various strategies to grow and diversify your business. Education is absolutely

critical, as I mentioned in the very beginning, the way that we have done business is the past is now

obsolete. If for no other reason, Obamacare, and the associated burdens, will have lasting affects

throughout all businesses and industries. It has changed everything.

The most fundamental reason why entrepreneurs start their own business is independence. We seek

financial independence without cap or ceiling on our profit earning potential. We desire more time,

freedom and flexibility. We seek creative and managerial independence to build what we envision.

After learning more about Brokers, I trust that you can see how, if allowed, Brokers can severely stifle

your entrepreneurial independence. Nothing in their Agreement or business practices favors you.

The good news with Brokers, you only yield control as you choose. If you wish to be more selective and

not transport Medicaid recipients then you will never deal with Brokers. If you wish to use Brokers more

selectively and subcontract portions of your work to Independent Operators that can prove to be more

profitable. Many successful Transportation Providers only provide Private-Pay and contracted

transportation services. By choice, they do no work with Brokers. Other Providers transport Medicaid

recipients on a limited basis, essentially supplementing their existing revenue. Regardless of the level of

Medicaid services, as a Provider you should choose the degree to which you wish to work with Brokers

(hence, NMP). When the choice is yours, you’re empowered!

Now that we have journeyed down the pathway of Broker-ism, which I trust has been enlightening, it is

time to travel a parallel path for which I provide even greater insight from various articles and

publications. Again, rather than my telling you what I know and see developing, I prefer that you hear

from doctors, economists, professors, analysts, journalists and more, on both sides of the political aisle,

so that you can draw your own informed conclusions. I strongly encourage you to read everything as

the information is of great impact on your business. As you read, I suspect your entrepreneurial

perspective will again be challenged as it is with the Broker system.



INCREASING THE SIZE OF MEDICAID AND IMPENDING EFFECTS

Obamacare is not just a change within the industry, Obamacare IS changing the industry! It is now an

institution and unlike working with a Broker, you have no choice but to comply. You cannot negotiate.

Through Obamacare, the government has heightened control. Failure to adhere will bring fines, audits

and the full weight of the Internal Revenue Service and the Federal Government. Furthermore, despite

political promises, Obamacare affects everyone, business owners and employees alike, in all industries.

Medicaid is the lifeblood of the Broker system and as you will continue to discover, under Obamacare,

the size and enrollment of Medicaid recipients is exploding. Knowing the tactics, strategies, and

mentality of Medicaid Brokers, it’s important that we consider the landscape of the medical industry

with such expansion. How much more emboldened and enthusiastic will Brokers be with such “job

security?”

In 1964, President Lyndon B. Johnson traveled to Martin County, Kentucky, to declare what he called a

“War on Poverty.” As an expansion of the Great Society, Johnson believed in expanding the

government’s role in social programs, welfare, and health care. Here we are 50 years later. As you read

the following articles illustrating how Obamacare is increasing the Medicaid ceiling, ask yourself who’s

won this war; prosperity or poverty?

LET’S MEET ON MEDICAID, MR. PRESIDENT

- BOBBY JINDAL, THE WASHINGTON POST

As the implementation of Obamacare nears, every governor must decide whether to expand

Medicaid. This is not a simple question. Expanding Medicaid will significantly burden state

budgets across the country. The Kaiser Family Foundation and the Urban Institute, estimate

that such an expansion would cost Louisiana more than one billion dollars over the first 10

years. The Obama administration heralds this as a tremendous bargain for states. That’s

simply not the case. The administration overlooks that Medicaid is largely failing current

enrollees with its outdated model that costs billions of taxpayer dollars and produces poor

outcomes.

http://www.kff.org/medicaid/8384.cfm



Medicaid operates under a 1960s model of medicine, with inflexible, one-size-fits-all

benefits and little consumer engagement and responsibility. Expanding the entitlement

program as it stands would further cement a separate and unequal tier of health coverage.

Without fundamental reform, Medicaid will continue to deliver what it has for decades:

limited access, poor quality and budget deficits.

Fortunately, states know the problems and how to address them. Our ideas to fix Medicaid

target several areas for reform: eligibility, benefit design, cost-sharing, use of the private

insurance market, financing and accountability.

The process to determine eligibility should be simple, accurate and fair. States should have

the flexibility to set eligibility standards that make sense for residents, instead of the rigid,

one-size-fits-all approach dictated by Washington. States should be allowed to design their

programs to promote value and individual ownership in health-care decisions. This includes

using consumer-directed products, flexible benefit design, and reasonable and enforceable

cost-sharing requirements. States must be freed from decades-old rules that are no longer

relevant to 21st-century health care.



RIGHT CALL ON MEDICAID

- NICK PANDELIDIS, YORK DAILY RECORD

Since announcing that Pennsylvania would not be participating in the Obamacare Medicaid

expansion, Gov. Corbett has been excoriated by Obamacare supporters. Gov. Corbett is

being accused of being unsympathetic to the plight of the uninsured, denying them "good"

healthcare insurance with Medicaid coverage. In addition, his critics claim that the Medicaid

expansion is "free money" that would not only pay for Pennsylvania's Medicaid expansion

but also stimulate our commonwealth's economy.

While the federal government is "picking up" the cost of the Obamacare Medicaid

expansion for three years and 90 percent going forward, Pennsylvania's Medicaid spending

has already reached a critical level. Since 1980, Pennsylvania's Medicaid expenditure has

grown from 12 percent to 24 percent of the state budget. As the Medicaid burden has

grown, it has crowded out other state expenditure including education and infrastructure.

Joel’s Insight: If Medicaid expenditures currently account for 24% of Pennsylvania’s state budget, how

much more will this burden increase as Obamacare expands annually as projected? What impact will

this have on state and national economies?

Expanding Medicaid at the national level worsens an already dangerous and untenable

federal fiscal situation. With a $16-plus-trillion debt that exceeds our GDP, we no longer are

a prosperous nation. There is no "free money." More spending can only come from three

sources: confiscating more taxes out of the private sector further suppressing our listless

economy; borrowing, which really means more taxes out of the future economy; or simply

printing more money, devaluing our earnings and savings.

“We need earmark reform, and when I'm President, I will go line by line to make sure that we

are not spending money unwisely.”

- Barack Obama

http://www.brainyquote.com/quotes/quotes/b/barackobam409216.html




Because Medicaid reimburses physicians so poorly, many doctors restrict the number of

Medicaid patients they can see, or don't participate at all. Studies have shown that even

individuals with no insurance can more easily get an appointment with a physician than can

Medicaid recipients. As a result, Medicaid patients use the emergency room for care twice

as frequently as those with private insurance.

Through Obamacare, Medicaid expansion extends eligibility for Medicaid to those who have

incomes between 100 percent and 138 percent of the poverty level. Obamacare also

qualifies this same population for substantial taxpayer subsidies to obtain private insurance

in the new insurance exchanges.

Nick Pandelidis is a local physician and a regular contributor to Viewpoints.

Joel’s Insight: What makes this article more profound is that it is authored by a physician. In discussing

anything regarding the medical industry, health care systems and procedures, and the like, I trust the

opinion and experience of a physician before I do any politician!



CANCER CLINICS ARE TURNING AWAY THOUSANDS OF MEDICARE PATIENTS

- SARAH KLIFF, THE WASHINGTON POST

Cancer clinics across the country have begun turning away thousands of Medicare patients,

blaming the sequester budget cuts. Oncologists say the reduced funding, which took effect

for Medicare on April 1, makes it impossible to administer expensive chemotherapy drugs

while staying afloat financially. Patients at these clinics would need to seek treatment

elsewhere, such as at hospitals that might not have the capacity to accommodate them.

“If we treated the patients receiving the most expensive drugs, we’d be out of business in

six months to a year,” said Jeff Vacirca, chief executive of North Shore Hematology Oncology

Associates in New York. “The drugs we’re going to lose money on we’re not going to

administer right now.”

Joel’s Insight: Amazing! Here you have cancer clinics turning people away because they are at severe

risk of losing money? Talk about NMP! This is the foreshadowing of what is to come with Obamacare

and the impending rationed care policies take effect.

After an emergency meeting Tuesday, Vacirca’s clinics decided that they would no longer

see one-third of their 16,000 Medicare patients. “A lot of us are in disbelief that this is

happening,” he said. “It’s a choice between seeing these patients and staying in business.”

Joel’s Insight: Wow! Cancer clinics are actually turning away one third of their clientele to ensure

profitability and survivability. Yet, where are the cries and labeling of these clinics as uncompassionate?

The fact of the matter is they’re not uncompassionate. They’re just reacting to changes in the market

just as we need to do with our businesses. As markets rise and fall, inflation and interest rates fluctuate,

we need adjust accordingly.

The federal government typically pays community oncologists for the average sales price of

a chemotherapy drug, plus 6 percent to cover the cost of storing and administering the

medication. Since oncologists cannot change the drug prices, they argue that the entire 2

http://www.washingtonpost.com/sarah-kliff/2011/07/28/gIQAoLzSfI_page.html



percent cut will have to come out of that 6 percent overhead. That would make it more akin

to a double-digit pay cut.

“If you get cut on the service side, you can either absorb it or make do with fewer nurses,”

said Ted Okon, director of the Community Oncology Alliance, which advocates for hundreds

of cancer clinics nationwide. “This is a drug that we’re purchasing. The costs don’t change

and you can’t do without it. There isn’t really wiggle room.”

Joel’s Insight: Talk about slim profit margins! Clinics only have 6 percent margin on a drug that is

absolutely critical to cancer patients? They’re right. There is very little “wiggle room” or margin for

error. Any fluctuations in the market could definitely affect these clinics’ ability to administer this drug

as we are learning in this article. What would/will happen if the economy bottoms out completely due to

the impending bankruptcy as predicted by many economists?

Cancer patients turned away from local oncology clinics may seek care at hospitals, which

also deliver chemotherapy treatments. The care will likely be more expensive. Those costs

can trickle down to patients, who are responsible for picking up a certain amount of the

medical bills. Medicare patients ended up with an average of $650 more in out-of-pocket

costs when they were seen only in a hospital setting.



WHAT DOES OBAMACARE MEAN FOR YOUR BUSINESS?

The influence of Obamacare on your business depends on the size of your labor force, employee

salaries, whether you provide benefits and how much employees are required to contribute. As

business owners, our challenge is to reach the greatest amount of customers with quality products or

services, and to do so as cost effectively as possible. Needless to say, for any business in any industry,

the challenges for achieving profitability are numerous and diverse. There are research, production, and

development challenges. There are marketing challenges. There is hiring, training, and associated labor

related issues. And the list of challenges continues.

Ironically enough, the government does play a very important role in business and industry. But the

government’s role is NOT to be IN business. Rather, the government’s role is designed to serve a type of

mediator and road guard to ensure a legal and “level playing field” that ensures equal opportunity for

everyone. Notice I did not say equal guarantee or entitlement! Unfortunately, when an overactive or

overbearing government exceeds their intended purpose and intrudes in the process it becomes more

of a hindrance than a help – for everyone. An intrusive government creates more obstacles and barriers

versus solutions and opportunities.

“Government is not a solution to our problem, government is the problem.”

- Ronald Reagan

Needless to say, no such obstacle is more burdensome to growth, prosperity, and entrepreneurial

innovation than excessive taxation. Consider the following articles and draw your own conclusions. Do

we have an overactive, intrusive government process? Are such taxes stimulating or stifling growth and

opportunity? How will these impeding tax increases affect your ability to grow, build, and save?



RINGING IN 2013 WITH OBAMACARE TAXES

- KATE ROGERS, FOX BUSINESS

Small businesses may be ringing in the New Year with a dose of optimism, as well as a reality

check. Taxes and fees associated with Obamacare are beginning to take effect, and the

countdown begins to 2014, when many small businesses across the country will have to

decide whether to start offering employer-sponsored health insurance or pay a penalty.

Curtis Dubay, senior tax policy analyst at the Heritage Foundation, said on January 1, several

tax increases went into effect that stand to potentially impact smaller companies,

depending on annual income levels. The medical device surtax of 2.9% became law,

although Dubay said the vast majority of medical device manufacturers are larger

companies. Another potential hit to entrepreneurs is the new 3.8% surtax on all capital

gains and dividends. An increase to the Medicare payroll tax is also likely to pinch small

business, according to Dubay.

“This further compounds the damage from the fiscal cliff,” Dubay said. “Now the total top

income tax rate is 39.6%, plus that uncapped 3.8% on every dollar of income. President

Obama has said he wants to return to the rates we had under the Clinton Administration,

but under Clinton the Medicare tax was 2.9%.”

Now the big tax to watch for is a penalty for employers with more than 50 workers who

chose not to offer coverage to their workers. Edmund F. Haislmaier, senior research fellow

on Health Policy Studies at the Heritage Foundation, said the tax will impact different

industries in different ways. Small businesses in the food service and hospitality industry will

be more likely to pay the fee of $2,000 per worker annually for failing to offer coverage to

workers, because they rely more heavily on low-wage employees. “They will drop coverage

or not offer coverage because the penalty costs will be less than the insurance would cost,”

Haislmaier said.

For example, for a worker making $10 per hour, if you shift the costs to them for health

care, their compensation would drop to about $7.50, the national minimum wage. Or if the

http://www.foxbusiness.com/archive/author/kate-rogers/index.html



business absorbs the costs, that hourly rate goes up to about $13 an hour, he said. Another

industry to watch will be the nursing and home health-care sector, which relies on low-wage

workers as aids, often making between $9 and $12 hourly.

Haislmaier said small businesses are also waiting on regulations from the Treasury

Department on what will actually be considered adequate coverage. That $2,000 fee will

also be charged for companies not offering coverage that is up-to-par with the Affordable

Care Act’s standards. “That is going to determine how much you have to upgrade your

[health] plan for workers,” he said.

The companies to be affected by the new requirements will be those right above and below

that 50-worker threshold, he said. “This isn’t an issue if you have 10 employees, or if you

have 200 employees,” he said. “It’s when you are running something with 40 employees

that is where you have to be careful, because there are significant costs for crossing the

threshold.”

“The last thing you want to do is raise taxes in the middle of the recession because that

would just suck up and take more demand out of the economy and put businesses in a

further hole.”

- Barack Obama



OBAMA'S $264 BILLION TAX FOR 2013 MAY SPARK NEW RECESSION

- DAVID A. PATTEN, NEWSMAX

With the fiscal cliff deal and many Obamacare taxes taking effect, Americans will be

slammed with an estimated $264 billion in new taxes this year alone — making 2013

memorable for delivering one of the largest one-year tax increases in American history. In

2013 alone, the new tax revenues would include:

$160 Billion Hike in Payroll Taxes. This is due to the expiration of the payroll tax

“holiday,” which increases the payroll tax that helps fund Social Security from 4.2

percent to 6.2 percent. According to the Tax Policy Center, this increase will actually hit

lower and middle-income taxpayers harder, in percentage terms, than the wealthy.

“I can make a firm pledge, under my plan, no family making less than $250,000 a year will

see any form of tax increase. Not your income tax, not your payroll tax, not your capital

gains taxes, not any of your taxes.”

- Barack Obama

$39.5 Billion in Income-Tax Rate Hikes. President Obama insisted on letting the Bush tax

cuts lapse on high-income earners. The tax impacts many high-spending professionals

and successful small business owners who pay taxes on the personal returns.

$15 Billion from Limiting Deductions. The new law calls for a “personal exemption phase

out,” or PEP, affecting the exemptions and deductions that wealthier families can claim.

$5.5 Billion in Capital Gain and Dividend Taxes. The new tax rate for capital gains and

dividends will rise from 15 percent to 20 percent.

$2 Billion in Estate Taxes. The law increases the top rate for gift and estate taxes from

35 to 40 percent. The Tax Policy Center reports taxes will go up for over 77 percent of

American households.






$21 Billion in Medicare Taxes. The healthcare law calls for a nine-tenths of 1 percent

increase in Medicare payroll tax paid by couples earning more than $250,000 a year, or

$200,000 per year for single filers.

$11 Billion from Surcharge on Capital Gains and Dividends. Married couples earning

more than $250,000 per year, or single filers earning $200,000 will be slapped with a 3.8

percent surcharge in the tax rate for capital gains and dividends in addition to the

compromise that hiked taxes on capital gains and dividends from 15 to 20 percent.

$2 Billion in Excise Fees. A 2.3 percent excise tax on manufacturers and importers of

medical devices, which is expected to be passed along in higher costs to consumers.

$2 Billion in Limiting Healthcare Itemized Deductions. This reflects a reduction in the

amount that middle-class families facing high medical expenses can deduct from their

income taxes.

The tax burden associated with healthcare reform will climb even higher next year, when

the tax penalty for not complying with the mandate to purchase healthcare insurance

begins to kick in. Some experts predict millions of Americans may opt to pay the tax

penalty, rather than comply with the mandate. The CBO estimates the U.S. Treasury will

get $167 billion in such fines over the next 10 years. Some observers also argue that the

rising private insurance premiums due to Obamacare mandate are a hidden tax that will

directly hit insured individuals and companies. Overall, the House Ways and Means

Committee has estimated that all 21 tax increases associated with the healthcare law will

bring in over $675 billion over the next decade — an average of over $67 billion each year.



NEW YORK TIMES: MIDDLE CLASS TAX INCREASE ‘NECESSARY’

- EDDIE SCARRY, NEW YORK TIMES

President Obama campaigned on raising the tax rate for the “top 2 percent” of income

earners. The New York Times editorializes today that eventually, the government will need

to tap into the middle income earners as well:

To reduce the deficit in a weak economy, new taxes on high-income Americans are a matter

of necessity and fairness; they are also a necessary precondition to what in time will have to

be tax increases on the middle class. …

Raising taxes at the top is neither punitive nor gratuitous. It is a needed step, both to

achieve near-term budget goals and to lay the foundation for a healthy budget in the future.

As the economy strengthens and the population ages, more taxes will be needed from

further down the income scale, both to meet foreseeable commitments, especially health

care, as well as unforeseeable developments, from wars to technological challenges. But

there will never be a consensus for more taxes from the middle class without imposing

higher taxes on wealthy Americans, who have enjoyed low taxes for a long time.

“I will cut taxes - cut taxes - for 95 percent of all working families, because, in an economy

like this, the last thing we should do is raise taxes on the middle class.”

- Barack Obama

Joel’s Insight: Commonly known for their liberal perspectives, even the New York Times acknowledges

that as “the population ages, more taxes will be needed from further down the income scale.” Thus, we

are no longer limited to just making wealthier Americans pay their “fair share.” Obviously, tax increases

are going to directly influence all working Americans earning a paycheck, especially the “middle class”

which politicians on both sides of the aisle claim they are fighting to defend.

http://www.theblaze.com/blog/author/eddiescarry

http://www.nytimes.com/2013/02/22/opinion/why-taxes-have-to-go-up.html?ref=opinion&gwh=14099DFD7C8DB03248F62917543E60F3





HOWARD DEAN: HONESTLY, EVERYONE'S GOING TO HAVE TO PAY HIGHER TAXES SOON

- GUY BENSON, POLITICAL EDITOR, TOWNHALL.COM

This candid assessment from former DNC Chairman Howard Dean comes after the election,

but better late than never. The truth comes out:

Whether or not they'll say so publicly, most recognize that across-the-board tax hikes are a

necessary ingredient in their broader project of unending government expansionism.

Beating up on "the rich" is a politically-convenient ploy for the moment, but the math

doesn't lie: Taxing only the upper echelons of income earners and small businesses would

reap an insufficient pittance in the final analysis. The government's unsustainable spending

will soon require many more people to pay their "fair share" to the federal government.

“But let me be perfectly clear, because I know you'll hear the same old claims that rolling

back these tax breaks means a massive tax increase on the American people: if your family

earns less than $250,000 a year, you will not see your taxes increased a single dime. I repeat:

not one single dime.”

- Barack Obama

Some voters who are currently on board with the Left's soak-the-rich crusade will one day

discover that they themselves are the new "rich," with their livelihood and income suddenly

in Big Government's crosshairs. Dean is at least doing everyone a favor by serving notice

early. He is very enthusiastic about middle class tax increases and deep defense cuts, but

very protective of all other spending.

When the accrued expenses of the government's entitlement programs are counted, it

becomes clear that to collect enough tax revenue just to avoid going deeper into debt would

require over $8 trillion in tax collections annually. That is the total of the average annual

accrued liabilities of just the two largest entitlement programs, plus the annual cash deficit.

Nothing like that $8 trillion amount is available for the IRS to target.

http://townhall.com/tipsheet/guybenson/

http://www.mrctv.org/node/118889

http://townhall.com/tipsheet/guybenson/2012/12/06/california_teachers_union_video_depicts_rich_people_urinating_on_the_poor

http://washingtonexaminer.com/how-much-deficit-reduction-would-obamas-tax-on-the-rich-accomplish/article/2513252#.UMD4O4PAcrc

http://www.npr.org/2011/09/24/140748420/defense-leaders-make-their-case-against-budget-cuts



According to the most recent tax data, all individuals filing tax returns in America and

earning more than $66,193 per year have a total adjusted gross income of $5.1 trillion. In

2006, when corporate taxable income peaked before the recession, all corporations in the

U.S. had total income for tax purposes of $1.6 trillion. That comes to $6.7 trillion available to

tax from these individuals and corporations under existing tax laws. In short, if the

government confiscated the entire adjusted gross income of these American taxpayers, plus

all of the corporate taxable income in the year before the recession, it wouldn't be nearly

enough to fund the over $8 trillion per year in the growth of U.S. liabilities.

Generally speaking, functioning societies make good-faith efforts to raise what they spend,

subject to fluctuations in economic fortune: Government spending in the United States is

42.2 percent, but revenues are 24 percent — the widest spending/taxing gulf in any major

economy.

Joel’s Insight: Oh dear, it looks like we have a serious mathematical problem! Surprise, it appears that

our government spends more than what we receive in revenue. And somehow increasing taxes, making

people pay their “fair share,” is going to resolve this double digit shortfall? Can you imagine how

successful your business would be if you managed your business in like manner as politicians do our

government?

Again, continue to evaluate and digest all of this information and draw your own conclusions. Consider

the political climate, the status of the economy, and the direction of policies that influence your business.

Using even the most basic laws of economics, if nothing changes and our economy continues on current

course, how long is it realistically sustainable? If and when a financial “day of reckoning” arrives, how

will your business affected?



DO YOU NEED TO PROVIDE HEALTH BENEFITS TO YOUR EMPLOYEES?

The following are key terms and definitions to further understand the particulars of Obamacare

followed by a chart to help you further navigate the effects of Obamacare on your business.

Affordable: Employer-based coverage is considered affordable if the lowest cost single-coverage option

does not exceed 9.5 percent of an employee’s W2 wages. If the coverage doesn’t meet the affordability

requirement the employee could be eligible for a tax credit for health premiums – and the employer can

be hit with a $3,000 penalty for any full-timer who gets the credit.

Common Control: No, you can’t break your 60-person into two 30-person companies in order to avoid

the large-employer mandate. For purposes of determining “large employer” status, the Affordable Care

Act (ACA) makes clear that a group of companies under common control are to be treated as a single

company.

Dependent: The ACA requires large employers to offer health coverage to the dependents of

employees. According to the IRS proposed regulations put out in January 2013, dependents are defined

as children under the age of 26. There is no requirement to offer coverage to an employee’s spouse.

Full-Time Equivalent: A full-time employee is anyone on your payroll who works an average of 30 hours

or more per week. But under the ACA, you also must include part-timers in your company head count.

For example, two half-timers equal one full-timer, so a business with 40 full-timers and 20 half-timers

would have 50 full-time-equivalent employees, or FTE’s and, thus, would have to offer health benefits or

pay a penalty. The ACA does not require employers to cover part-time workers, only to count them in

determining their “large employer” status.

Grandfathered Plan: Employer health plans that were in effect on March 23, 2010, and haven’t

significantly reduced benefits or increased employee costs may be considered ‘grandfathered” and

exempted from certain provisions in the health care law, such as the requirement to provide 100

percent coverage for preventative care.



Large Employer: A company with 50 or more full-time-equivalent employees is considered large. Only

large employers are subject to the ACA’s “play or pay” mandate to provide affordable health coverage

or pay a range of penalties.

Look-Back Provision: An employee’s status as a full-timer is determined by looking back at a defined

period of three to 12 months, as chosen by the employer. Any employee on your payroll for an average

of 30 hours per week or more during that period is considered full-time.

Minimum Value: The ACA requires large employers to cover at least 60 percent of an employee’s total

health care costs – not just premiums but copays, deductibles, and other qualified out-of-pocket

spending. If coverage does not meet that minimum value, the employee could be eligible to receive a

premium tax credit – and the employer could be hit with a $3,000 penalty for any full-timer who gets

the credit.

Shop Exchange: Beginning in 2014, each state is supposed to offer small employers access to a Small

Business Health Options Program, or SHOP, exchange that offers a variety of qualified health plans.

Note, different states define “small” differently.

Small-Business Health Care Tax Credit: Businesses that cover at least half of the cost of single coverage

for their employees, have fewer than 25 full-time-equivalent workers, and have average wages of less

than $50,000 a year may qualify for a tax credit of up to 50 percent of employer-paid premiums.



Do you have 50 or more full-time-equivalent (FTE) employees?

YES NO

Do you offer health coverage to employees? You are not responsible. The AFA does not

require companies with fewer than 50 FTE

employees to offer health insurance.

However, you may be eligible to buy insurance

on a state exchange.

Do you have fewer than 25 FTE workers?

YES NO

YES NO

Does your plan

pay at least 60

percent of

coverage health

costs?

Will any

employee buy

coverage on a

state-based

insurance

exchange?

If the average wage of your

employees is below $50,000,

you may qualify for a small-

business tax credit of up to 50

percent of employer-paid

premiums, for up to two years,

if you buy insurance through a

SHOP exchange.

YES YES NO NO

Must any

employee pay

more than 9.5%

of W2 income for

single coverage?

Employees could qualify for

a tax credit or subsidy to

buy coverage on a state

exchange. You will be

responsible for an annual

penalty of $3,000 per FTE

worker receiving the credit

or subsidy, or $2,000 per

total number of FTE

workers, excluding the first

30, whichever is less.

YES

NO

Will any such

employee qualify

for a tax credit or

federal cost-

sharing subsidy?

You don’t

qualify for

federal

credits or

subsidies.

Congratulations, you provide what the

Feds consider affordable coverage and

will not face any ACA-related penalties.

YES NO

You will not be

penalized for failing

to offer health

insurance.

You must pay a penalty for not providing coverage.

The penalty is up to $2,000 a year per FTE employee,

not counting the first 30 employees.



IRS TO EMPLOYERS: PAY OBAMACARE 'SHARED RESPONSIBILITY' OR ELSE

- MERRILL MATTHEWS, FORBES

As if concerns about the fiscal cliff, debt ceiling, higher taxes and a potential recession

weren’t enough to scare employers, the Obama administration has just handed them one

more headache: an IRS warning that any efforts to avoid the ObamaCare mandate to

provide coverage or pay a penalty (or is it a tax?) will not go unpunished.

Yes, the Internal Revenue Service has just released its “proposed regulations providing

guidance under section 4980H of the Internal Revenue Code (Code) with respect to the

shared responsibility for employers regarding employee health coverage.”

Of course, there has been a lot of confusion among employers about implementing the

coverage mandate and their responsibilities, just as there has been a lot of confusion among

states about the rules and regulations associated with the health insurance exchanges.

Just so everyone is clear, what the IRS says is:

Section 4980H generally provides that an applicable large employer is subject to an

assessable payment if either (1) the employer fails to offer to its full-time employees (and

their dependents) the opportunity to enroll in minimum essential coverage (MEC) under an

eligible employer-sponsored plan and any full-time employee is certified to the employer as

having received an applicable premium tax credit or cost-sharing reduction (section

4980H(a) liability), or (2) the employer offers its full-time employees (and their dependents)

the opportunity to enroll in MEC under an eligible employer-sponsored plan and one or more

full-time employees is certified to the employer as having received an applicable premium

tax credit or cost-sharing reduction (section 4980H(b) liability). Generally, section 4980H(b)

liability may arise because, with respect to a full-time employee who has been certified to

the employer as having received an applicable premium tax credit or cost.

Everybody got that?

http://www.forbes.com/sites/merrillmatthews/

http://www.forbes.com/sites/merrillmatthews/2013/01/10/irs-to-employers-pay-obamacare-shared-responsibility-or-else/www.irs.gov/pub/irs-drop/n-12-58.pdf



Essentially, employers with 50 or more employees must provide health coverage to their

employees. If they don’t they will have to pay an “assessable payment” of up to $2,000 per

employee.

The problem is that not all employer-worker relationships are that simple.

Some employees work part time, and some part-timers can put in full-time hours during

peak times for the company. Other companies often fill gaps with temporary employees.

And some companies have so many part-time workers that they equal 50 full-time workers.

Not to worry, the IRS has rules for all of them; and they are every bit as clear as the passage

cited earlier.

Basically, the IRS is skeptical that all employers will be as excited about these mandates as

the Democrats implied they would be early on. So the IRS is issuing these proposed

regulations as a way to keep employers from avoiding their shared responsibility. As the IRS

warned on December 28, “The Treasury Department and the IRS are aware of various

structures being considered under which employers might use temporary staffing agencies

(or other staffing agencies)… to evade application of section 4980H [the employer insurance

mandate].”

Joel’s Insight: As of this writing, I have a number of Transportation Providers with whom I have worked;

they have well in excess of 150 employees and vehicles. Needless to say, they are deeply concerned

about the ramification of Obamacare. Their initial instinct was to separate and fragment their business

in an effort to avoid paying health benefits that would bankrupt their business or warrant costly

penalties. However, as this article clearly articulates, the IRS is looking for just such strategies and is

ready and waiting to bring the full brunt of the Federal Government down upon you! One of the

Providers has resorted to hiring a team of attorneys to help them evaluate their business and develop

effective strategies that will keep them compliant with Obamacare. As of this writing, they have paid in

excess of $12,000 in legal fees for this endeavor and counting. Sorry, but when government policy

warrants that you spend money just to ensure your compliance, that is definitely an intrusive,

overbearing, and out of control Government!

http://cnsnews.com/news/article/irs-warns-employers-do-not-try-avoid-obamacare-insurance-mandate

http://cnsnews.com/news/article/irs-warns-employers-do-not-try-avoid-obamacare-insurance-mandate



HEALTH INSURANCE BROKERS PREPARE CLIENTS FOR OBAMACARE STICKER SHOCK

- DR. SCOTT GOTTLIEB, M.D., FORBES

A California insurance broker, who sells health plans to individuals and small businesses,

told me that she’s prepping her clients for a sticker shock. Her local carriers are hinting to

her that premiums may triple this fall, when the plans unveil how they’ll billet the full brunt

of Obamacare’s new regulations and mandates. California is hardly alone. Around the

country, insurers are fixing to raise rates by double digits. They’re privately briefing

politicians in Washington on what’s in store. Those briefings are leaving a lot of folks up and

down Pennsylvania Avenue jumpy.

What’s gives? President Obama, after all, said he’d prevent these sorts of prices. His new

health law gave state regulators the power to block premium increases. It even created a

federal agency to oversee insurance rates. But these bureaucrats are spectators to the price

hikes. They’re mere wallflowers. Even in the bluest of states.

Their silence is the best evidence of who is culpable for the increases. It’s the policymakers.

It’s Obamacare. The President is accepting the premium hikes as an allowable consequence

of his healthcare policies. There’s buzz in Washington that to ease the price hikes, the

Obama team may slow down some of the most expensive regulations. This might include

the law’s mandatory community rating. One approach they’re said to be considering is

allowing some of the historically based underwriting to stay in place for a time.

But premiums will still rise because, in the end, everything has a price. The law’s prohibition

against traditional insurance underwriting is just one of its costly provisions. Washington can

try to force health plans to price insurance below the cost of these mandates. But then the

health plans will simply lose money and move out of markets. To keep the insurers whole,

and accommodate new rules, the cost of insurance must get re-priced higher. That re-

pricing is what’s coming this fall.

This lesson was learned by Massachusetts, after it adopted its own skinny version of

Obamacare. To meet the law’s costs, insurers hiked premiums. Massachusetts’s regulators

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blocked the increases. All the plans reported losses the very next quarter. This simple

economic axiom doesn’t mean the higher premiums were tolerated in Massachusetts, or

will be embraced by Washington. What Massachusetts did afterwards is a lesson for where

the entire nation is heading under Obamacare.

Massachusetts regulators went after the underlying source of spending – peoples’ use of

medical services. First and foremost, that meant taking on the providers. Massachusetts

moved to regulate the prices that doctors and hospitals could charge and the kind of

services that they could offer. Rates are rising nationally because, like Massachusetts,

Obamacare guarantees more free medical services while doing nothing to make the market

for these things more efficient, or competitive. Like Massachusetts, some form of price

controls is the next political chapter.

“Contrary to the claims of some of my critics and some of the editorial pages, I am an ardent

believer in the free market.”

- Barack Obama

The Obama team can’t merely squeeze the insurers. That’s why our political elite will

tolerate many of the looming premium hikes. In the end, health plans are mostly just

passing along the costs of the underlying services. That’s even truer today now that

Washington is directly regulating insurance company profit margins.

The prices Washington pays for medical services will gradually fall below the rates where

things will be readily supplied. That’s the legacy of Medicaid, and increasingly Medicare as

well. Don’t worry, though. The medical services that you’ll have a hard time accessing are

mostly the stuff you’ll only need if you get really sick.

Dr. Gottlieb is a physician and Resident Fellow at the American Enterprise Institute.

http://www.forbes.com/enterprise/



RAMIFICATIONS OF OBAMACARE

The following articles are very important in helping you to understand the impending fallout of

Obamacare. My staff and I continuously invest in research to ensure that we are abreast of shifts and

changes in our industry. Of the thousands of news and trade articles, publications, and briefs that I have

reviewed in just the last few months, I have chosen these articles because they accurately articulate and

illustrate the impeding ramifications from Obamacare. It is imperative that you read the following pages

to better understand how Obamacare is going to affect you and your family in addition to your business:

AFFORDABLE CARE ACT TO PRESENT NEW CHALLENGES FOR MEDICAL PROFESSIONALS

- LEIGH IRVIN, DAILY TIMES

FARMINGTON — Implementation of the "Patient Protection and Affordable Care Act," more

commonly known as "Obamacare," has local physicians and administrators conjecturing

about what reform will mean for the future of healthcare.

While Rick Wallace, chief executive officer at San Juan Regional Medical Center, believes

healthcare reform will present new challenges, he says the act's push for better physician

accountability is a good one. "The focus behind the act is provider accountability," said

Wallace. "But the challenge is that there will be more patients and a shrinking availability of

physicians."

The demand for physicians will likely increase dramatically in early 2014, when the

individual insurance mandate of the act takes hold. This means that most Americans will

need to have insurance and will also have greater access to affordable health insurance

options. These factors will change the way many Americans access healthcare.

"Whereas many uninsured people particularly younger people have used urgent care

centers or the emergency room when they needed a doctor, people will now have to have a

medical home," he said. "The Affordable Care Act wants people to take responsibility for

their own health care and be proactive in managing their care."



While Wallace acknowledges that requiring people to be responsible for their health care is

moving in a positive direction, it means a lot more people will be looking for doctors. And

many of those doctors already have full schedules.

The law also adds accountability measures for the quality of health care while lowering

reimbursement rates, Wallace said. "Reimbursements are reducing, but the cost of

healthcare is constantly rising," he said. "So now we're talking about the perfect storm,

which will hit around January 2014. I don't think they thought through these issues."

Under the act, hospitals are judged by the quality of care given, using 176 different "core

measures," as well as on the patient's hospital experience. If these factors are determined

to be superior, the hospital could receive a ten to fifteen percent bonus in reimbursement.

The flip side is that if service is judged to be sub-standard, the hospital could be penalized.

One of the stricter standards is that if a patient is treated at the hospital and released, but is

re-admitted within thirty days of discharge, the hospital will lose all of the reimbursement it

received for providing the first treatment.

"This sounds bad, but accountable care is not all bad," said Wallace. "People do need to be

accountable, and we (the hospital) have already been doing that. The challenge will be in

keeping track of all the numerous rules and making sure we check all the boxes the

government requires. It creates a lot of redundancy, and I don't' know if they considered the

amount of extra work that would require. We will just have to be better at what we do to

meet the expectations."

Though medical providers can be penalized under the new act for providing substandard

care, the actual patient, who may have been responsible for creating his or her own health

problems in the first place, cannot. For this reason, it will be imperative, Wallace said, to

spread the message that patients need to start taking more responsibility for their own well-

being.

"Unfortunately, the state of New Mexico is not a healthy state. There is a high incidence of

diabetes and hypertension," he said. "How can we convey to the public that we (medical



personnel) can't take care of everything, and that people have to start taking responsibility

for their own health? It's important to reduce the actual need for healthcare by getting

people to take responsibility to become healthier, and people have to accept that."

Joe Pope, a physician with Pinon Family Practice on 30th Street, shares many of Wallace's

views on the health care changes. The dearth of family practitioners will become a major

issue as implementation of the federal law proceeds, he said.

"There have never been enough physicians, so we'll have to find other ways to increase our

capacity," he said, adding that a shift from doctors providing direct care to mid-level

practitioners such as physician assistants and nurses may be imminent.

"Physicians will not be able to keep up with the primary care need, and may take more of a

supervisory role, with physician assistants and nurses providing most of the care," he said.

Pope also believes that the act neglected to address some vital issues, such as the need for

medical liability reform.

"This was a glaring omission of the act in my opinion, and the fact that physicians are

paranoid and having to sometimes order unnecessary tests because they're afraid of being

sued," he said. And that, he said, is part of what is driving up costs.

In fact, a 2008 survey of Massachusetts doctors found that 83 percent admitted to

practicing defensive medicine — ordering tests and consultations as a way to protect

themselves from potential liability — resulting in an estimated $281 million in unnecessary

physician costs in that state.



CALIFORNIA REDEFINES 'DOCTORS' TO COMPENSATE FOR OBAMACARE SHORTAGES

- DR. SUSAN BERRY, BREITBART

As a result of Obamacare and its expansion of coverage to millions, many states will begin to

experience doctor shortages. California is dealing with this problem by redefining who is a

“doctor.”

State lawmakers are working on legislation that would permit physician assistants and nurse

practitioners to set up independent practices. Pharmacists and optometrists could now act

as “primary care” providers. These role changes will be common in the age of Obamacare,

when even teachers will be “trained” to diagnose mental health and behavioral health

problems in “school-based healthcare centers.”

As State Senator Ed Hernandez (D) says, “What good is it if they are going to have a health

insurance card but no access to doctors?” The solution, to those who support Obamacare,

is to permit more people to do what “doctors” have done in the past.

California’s Health and Human Services Agency secretary, Diana Dooley, states, “We’re

going to have to provide care at lower levels. I think a lot of people are trained to do work

that our licenses don’t allow them to.”

Beth Haney, president of the California Association for Nurse Practitioners, said, “We don’t

have enough providers… so we should increase access to the ones that we have.” Turf wars

are becoming standard fare with Obamacare, as will questions of accountability. The big

question, of course, is where does the buck stop when the government is in charge of

healthcare?

http://www.breitbart.com/Columnists/Dr-Susan-Berry

http://www.latimes.com/health/la-me-doctors-20130210,0,1509396.story

http://www.breitbart.com/Big-Government/2012/05/12/ObamaCare-Coming-to-a-Public-School-Near-You

http://www.latimes.com/health/la-me-doctors-20130210,0,1509396.story



WILL ONLY SUCKERS BUY OBAMACARE INSURANCE

- JOHN MERLINE, INVESTOR'S BUSINESS DAILY

For years, Obamacare critics focused on its least popular feature — the mandate that

everyone buy insurance — taking their fight all the way to the Supreme Court. But as

Obamacare's official launch date approaches even its backers are beginning to admit that

the law could actually create powerful incentives for millions of people and thousands of

businesses to drop their coverage, despite the mandate.

There is growing concern, for example, that the law's market reforms will cause a huge "rate

shock," particularly for those young and healthy. A February survey of major health

insurance companies in five cities across the country found that they expect premiums for

this group to climb an average 169%.

Aetna CEO Mark Bertolini said late last year that he expects premiums to double for some

small businesses and some individuals as a result of the law. And state insurance

commissioners are worried as well.

"We are very concerned," California Insurance Commissioner Dave Jones told federal health

officials at a December meeting, "if there is so much rate shock for young people that

they're bound not to purchase (health insurance) at all." The cause of this rate shock is

simple: Obamacare imposes what is called "community rating" on insurance companies,

effectively forcing them to charge the young and healthy more so they can charge older and

sicker consumers less.

The five-city survey, for example, found that while the law will jack up rates for the young, it

will lower them an average 22% for older and sicker customers. At the same time,

Obamacare also forbids insurance companies from turning anyone down — a reform called

"guaranteed issue" — which also will provide an incentive for some to drop coverage,

knowing they can get it back any time.

"Even with the tax penalty ... some healthy people would avoid purchasing coverage until

they are sick," Howard Shapiro, director of public policy at the Alliance of Community Health

http://www.investors.com/search/searchresults.aspx?source=filterSearch&Ntt=+JOHN+MERLINE&Nr=OR(Author%3a+JOHN+MERLINE%2cAuthor%3a+John+Merline)

http://americanactionforum.org/topic/premiums-and-aca-survey

http://www.bloomberg.com/news/2012-12-12/aetna-ceo-sees-obama-health-law-doubling-some-premiums.html

http://capsules.kaiserhealthnews.org/index.php/2012/12/state-insurance-officials-raise-concerns-about-rate-shock-for-young-people/

http://capsules.kaiserhealthnews.org/index.php/2012/12/state-insurance-officials-raise-concerns-about-rate-shock-for-young-people/



Plans, told regulators . The problem is that if the young and healthy drop coverage, the

result would be what the industry calls a "death spiral." Premiums will climb as the pool of

insured gets sicker, causing still more to cancel their policies.

This is just what happened in states that imposed strict community rating and guaranteed

issue reforms in the past. In fact, of the eight states that did so, most ended up either

dropping the reforms or loosening the rules after they saw enrollment decline and

premiums climb.

Obamacare backers say the law's subsidies will keep premium costs down, while the

mandate to buy insurance will keep the young and healthy in the market. But even they

admit that the subsidies won't protect everyone from Obamacare-caused rate shocks, and

the mandate is likely to prove too weak to be very effective.

In fact, the annual penalty for not buying insurance will be as low as $95 in 2014, and even

when the mandate penalty is fully phased in by 2016 it will be modest relative to the cost of

buying insurance.

In one illustrative example provided by the IRS, a family earning $120,000 in 2016 would

owe just $2,400 in "shared responsibility payments" — the administration's new euphemism

for the penalty — while buying insurance would run them, in the IRS example, at least

$20,000.10

In addition, after 2016, the penalty amounts will be indexed to inflation, even though

insurance premiums have consistently risen much faster than the CPI, which means "shared

responsibility payment" will be less of a deterrent over time.

On top of all this, the IRS has virtually no ability to collect the penalties from those who

don't pay them. As the IRS itself explains, the law forbids the agency from imposing liens or

criminal penalties, leaving it few options beyond deducting the penalty from tax refunds.

The Obama administration knows this poses a potential problem. In fact, in late November it

asked the industry to offer ideas on how it could "discourage consumers from abusing

guaranteed availability rights." The industry's response: Make the penalties even tougher,

http://www.regulations.gov/#!documentDetail;D=CMS-2012-0141-0437

http://www.ahipcoverage.com/wp-content/uploads/2012/03/Updated-Milliman-Report.pdf

http://www.ahipcoverage.com/wp-content/uploads/2012/03/Updated-Milliman-Report.pdf

http://www.irs.gov/PUP/newsroom/REG-148500-12%20FR.pdf



something lawmakers are unlikely to want to do. The same problem threatens to

undermine Obamacare on the business side, if companies decide that paying a penalty is

cheaper than providing an increasingly expensive benefit to workers.

The Congressional Budget Office now expects that employers will dump coverage for 7

million workers as a result of Obamacare, nearly double its previous forecast. And it says the

figure could be as high as 20 million. At the same time, small companies will have an

incentive to cut their full-time workforce to below 50 to avoid the mandate altogether. In

fact, the IRS recently had to issue a warning to companies about using various tricks to

dodge the employer mandate.

Estimated Increases in Individual Market Premiums Due to Obamacare, by State

State Premium Increase State

Premium Increase State

Premium Increase

Alabama 61% Louisiana 56% Ohio 55% to 106%

Alaska 30% to 80% Maine 40% Oklahoma 65% to 100%

Arizona 65% to 100% Maryland 34% to 39% Oregon 27% to 55%

Arkansas 61% to 100% Massachusetts 39% Pennsylvania 39%

California 42% to 61% Michigan 35% to 65% Rhode Island 8% to 39%

Colorado 19% to 41% Minnesota 29% to 56% South Carolina 61%

Connecticut 39% to 64% Mississippi 61% South Dakota 56%

Delaware 61% Missouri 61% to 106% Tennessee 61% to 100%

Florida 61% Montana 61% Texas 35% to 65%

Georgia 61% to 100% Nebraska 61% Utah 56% to 90%

Hawaii 56% Nevada 50% to 56% Vermont ***

Idaho 65% to 100% New Hampshire 19% to 39% Virginia 75% to 82%

Illinois 61% New Jersey 39% Washington 39%

Indiana 61% to 106% New Mexico 56% West Virginia 56%

Iowa 56% to 100% New York *** Wisconsin 34% to 106%

Kansas 61% North Carolina 61% Wyoming 61% to 100%

Kentucky 65% to 106% North Dakota 56% ***Since these states already hyper regulate their insurance market, their significantly higher premiums are unlikely to change.

http://news.investors.com/020513-643239-obamacare-subsidy-cost-hiked-233-bil-in-new-cbo-score.aspx?p=full

http://news.investors.com/020513-643239-obamacare-subsidy-cost-hiked-233-bil-in-new-cbo-score.aspx?p=full

http://www.forbes.com/sites/merrillmatthews/2013/01/10/irs-to-employers-pay-obamacare-shared-responsibility-or-else/



BRACES FOR THE KIDS JUST GOT MORE EXPENSIVE: OBAMACARE TAX HIKE CASE STUDY

- AMERICANS FOR TAX REFORM

In 2013, the tax increases in Obamacare will increasingly conspire against kitchen-table

family healthcare decisions.

As just one example, below are some of the taxes that will impact the purchase of dental

braces:

Obamacare Medical Device Tax: As of Jan.1, Obamacare imposes a new tax of 2.3 percent

on medical device manufacturers, including those who make dental braces. The tax is

imposed on gross sales -- even if the company does not earn a profit in a given year. While

the tax will be paid to the IRS by the manufacturer, the tax will be passed along as a higher

cost of the product, ultimately to be borne by the parent buying the braces for their child.

With the cost of braces being as high as $7,625 this new tax could raise the cost of these

braces by $175.

Obamacare Flexible Spending Account Cap: As of Jan. 1, the 30-35 million Americans who

use a pre-tax Flexible Spending Account (FSA) at work to pay for their family’s basic medical

needs face a new government cap of $2,500. This will squeeze $13 billion of tax money from

Americans over the next ten years. (Before Obamacare, the accounts were unlimited under

federal law, though employers were allowed to set a cap.) A parent looking to sock away

extra money to pay for braces would find themselves quickly hitting this new cap, meaning

they would have to pay some or all of the cost with after-tax dollars. Needless to say, this

tax will especially impact middle class families.

Obamacare “Haircut” to the Medical Itemized Deduction: Faced with higher prices for

braces and a reduced ability to pay for them with their FSA, parents might decide to deduct

the cost of braces on their tax returns. Unfortunately, Obamacare makes this harder, too.

Before Obamacare, Americans facing high medical and dental expenses were allowed a

deduction to the extent that those expenses exceeded 7.5 percent of adjusted gross income

(AGI). As of Jan. 1, Obamacare imposes a threshold of 10 percent of AGI. Therefore,

http://health.costhelper.com/braces.html



Obamacare not only makes it more difficult to claim this deduction, it widens the net of

taxable income.

According to the IRS, 10 million families took advantage of this tax deduction in 2009, the

latest year of available data. Almost all are middle class. The average taxpayer claiming this

deduction earned just over $53,000 annually. Americans for Tax Reform estimates that the

average income tax increase for the average family claiming this tax benefit will be $200 -

$400 per year.

This is just a small example of how a simple, everyday kitchen table decision has been

fundamentally altered by the tax hikes in Obamacare. It does not even take into account

the indirect effects of the rest of the tax hikes in the law, which will reduce family income

and kill jobs.

http://www.irs.gov/file_source/pub/irs-soi/09in21id.xls



A TAX EVEN CHUCK SCHUMER HATES

- SALLY C. PIPES, NEW YORK POST

The tax will also put a damper on medical innovation. Most new medical devices are

invented by small, venture-backed companies that invest heavily in research and

development — and so run losses for years before getting their device approved by federal

regulators and ultimately turning a profit. If they come up with a promising prototype, their

financial futures are still not secure. Bringing a new, low-risk medical device from concept to

market can cost around $31 million — $24 million for activities related to gaining regulatory

approval. Yet the tax applies to gross sales of applicable devices, regardless of a company’s

profitability or ability to pay. So companies with weak balance sheets (innovative small firms

among them) may face bankruptcy.

The tax will also precipitate a slowdown in a manufacturing sector where America still leads

the world. The medical-technology industry exports $5.4 billion more than it imports. And in

2008, the United States accounted for 40 percent of the world’s medical-technology market.

Congress has long known about the tax’s ugly impact on the economy — and on patients. In

2010, Richard Foster, the chief actuary at the Centers for Medicare and Medicaid Services,

wrote that the device tax “would generally be passed through to health consumers in the

form of higher drug and device prices and higher insurance premiums.” He predicted that

annual health-care spending would increase $18.2 billion by 2018 thanks to the tax and

other similar fees in Obamacare.

None of this — not even the pleadings of his own party — has moved President Obama to

reconsider the device tax. He explained in a recent interview, “The health care bill is going to

provide those medical device companies 30 million new customers . . . so this additional tax

essentially comes back to them as new customers.” Problem is, most of the new customers

who gain coverage through Obamacare will be young, healthy Americans — hardly the

device industry’s core customers.

http://www.nypost.com/p/news/opinion/opedcolumnists/tax_even_chuck_schumer_hates_RuP7IgxTDnDpHB75yQjPWP



CONCIERGE CARE MEDICINE

As mentioned, Obamacare is not a change within the industry, Obamacare IS changing the industry!

One such change is literally the way doctors practice medicine. Like entrepreneurs, doctors are desirous

and deserving of making money. Doctors have endured years upon years of rigorous medical school and

are obligated to paying back small fortunes in student loans. Many are highly skilled in specialized fields,

further enhancing their value.

With Obamacare ushering in ever increasing policies and bureaucratic red tape, more and more doctors

are leaving direct primary care medicine in favor of offering concierge medicine. Concierge physicians

care for fewer patients than in a conventional Practice, ranging from 100 patients per doctor to 1,000,

instead of the 3,000 to 4,000 that the average physician sees annually. The annual fees vary widely,

ranging from several hundreds of dollars to $5,000 per individual.

Some Concierge Practices are cash-only and do not accept insurance of any kind. By refusing to deal

with insurance companies, these Practices can keep overhead and administrative costs low, thereby

providing affordable healthcare to patients. They become "Concierge" only if the Practice assesses an

annual or monthly fee instead of or in addition to a fee for each medical service. Other Concierge

Practices do take insurance, even Medicare, but ask for an annual fee for services beyond those covered

by insurance plans. This annual fee is not a substitute for medical insurance and generally does not

cover consultations outside the Practice, laboratory procedures, medicines, hospitalizations, or

emergency care from other Providers.

Without question, Concierge Medicine’s growing popularity is in response to Obamacare.

Unfortunately, it is further taking primary care physicians out of “circulation” from the general public at

a time when Obamacare is grossly expanding the Medicaid system. Needless to say, the coming years

are going to be very interesting! But honestly, can you blame doctors? Do the math. They can see a

fraction of the patients, make equally as much if not more money, and never have to deal with the

threats, headaches, and hassles associated with Obamacare? That’s not a difficult decision! We as

Entrepreneurs would do the same, why should Doctors be any different?



A short-list of many of the benefits of Concierge Medicine is as follows:

Guaranteed same-day appointments

24/7 access to the physician - no waiting

Longer appointment times - quality time with physicians

Phones are answered by staff who know you personally

Annual preventive care physical examination - comprehensive wellness plan

Coordination and assistance with hospital care, if needed

Expedited testing results - lab work checked prior to complete physical

Support personnel dedicated exclusively to concierge medicine patients

Convenient prescription services

Enhanced coordination of any physician referrals

Travel medical services

Consider the following article illustrating the allure and convenience of Concierge Medicine:

A YEAR LATER, UTAH DOCTOR REFLECTS ON HER SWITCH TO CONCIERGE CARE MEDICINE WITH FEWER PATIENTS, UTAH DOC FORGES DEEPER RELATIONSHIP WITH THEM

- KIRSTEN STEWART, THE SALT LAKE TRIBUNE

It’s not every day that Hanlon makes house calls. But she’s making more exceptions these

days, now that she’s seeing a fraction — about 350 — of the 2,500 patients she had a year

ago. In late December 2011, Hanlon and another internist at Alpine Medical Group, Yong

Hui Ahn, joined a growing number of doctors embracing "concierge" health care.

Hanlon closed her traditional practice. She reopened at the same location under the banner

of MDVIP, a "concierge" company. Hanlon’s patients pay a $1,500 annual membership fee

on top of copayments for their regular insurance, if they have it. In return, she promises

them more personalized care and round-the-clock access.



Twenty years into her career, Hanlon is professionally recharged, practicing medicine the

way she had always hoped – "the quintessential internist, always there when you need her,"

she says.

Proponents say concierge medicine could heal what ails the health care system. For all the

money that Americans pour into health care, the country has the worst health outcomes of

any developed nation, says Tom Blue, executive director of the American Academy of

Private Physicians, a professional association. It’s on the shoulders of primary care doctors

to reverse that through better preventive care, but too many suffer from "burnout," Blue

says. "They complain of the costs of indulging insurer chart audits and billing to collect a

fraction of what they charge. They can’t stay afloat. I hear it in every state."

Indeed, nine out of 10 physicians say they are unwilling to recommend health care as a

profession, according to a 2012 poll by The Doctors Company, the nation’s largest liability

insurer. Faced with new requirements to go digital and other federal health-reform rules,

many are closing their practices and hiring on with hospital groups. Based on current hiring

trends, hospitals will account for more than 75 percent of physician hires within two years,

predicts physician-recruiting firm Merritt Hawkins.

Blue predicts retainer-based practices will salvage the solo practice. There are about 4,400

concierge doctors in the U.S., up 30 percent since 2011. "The election results really fanned

the flames," Blue says. "But the true potential will be unleashed when people realize the

access and white-glove treatment is a byproduct of the business model, not the price."

Members don’t have to have insurance, though MDVIP recommends it for emergencies and

acute specialty care. Hanlon works with some single working moms whose employers don’t

offer health benefits and whose pre-existing conditions make it impossible for them to buy

coverage.

She has room for more patients, but she has met her enrollment goal. About half her

patients are retirees on fixed incomes and Medicare; all but a few renewed their

memberships this year.



"People are investing in their health," says Murrison, noting MDVIP added 100 doctors to its

portfolio last year, which now spans 600 practices in 40 states. He predicts growth will

remain strong as the Affordable Care Act prods millions to buy insurance, taxing the nation’s

shortage of primary care doctors.

"Issues that have plagued primary care, such as the ability to get into a doctor quickly, will

be exacerbated. We’ll see more midlevel physician’s assistants providing care and longer

waits, which will set us apart."

Critics say by winnowing their patients, concierge practices will worsen the shortage,

especially for the poor. Proponents argue primary care doctors are running out of choices.

As insurance prices soar, more people are moving to high-deductible plans, which cover only

big-ticket surgeries and emergencies.

In December, MDVIP published data showing its patients are hospitalized 79 percent less

than the average Medicare beneficiary and 72 percent less than the average commercially

insured adult.

I fully appreciate and understand why an increasing number of doctors are practicing Concierge

Medicine. As I discuss in my “How to Land Private-Pay Clients in Your NEMT Businessiii” Report, doctors

are doing nothing more than practicing Select Profitability to transform their entire business model to

ensure profitability. Especially when you consider the many ramifications of Obamacare, are Doctors

not doing what we ourselves must do as business owners? We need to be even more prudent and

selective in the clients we service and the business opportunities we pursue. Just because a particular

demand exists, does not automatically mean that all demand is for YOU! More specifically, just because

Obamacare is expanding the size of Medicaid, a population that needs your services, it does NOT

automatically mean that they should be your client(s)!

Understanding Concierge Medicine presents you with potentially outstanding strategic partners.

Because their clientele are primarily Private-Pay, finding and befriending such doctors can provide you

with a very exclusive clientele.



WHY YOU NEED TO DIVERSIFY YOUR BUSINESS

As I have said repeatedly in my Newsletter and associated correspondence, times have changed. The

way we have done business in the past is no longer feasible. Previously, there was no limit to the size

and depth we could build our business. Many Providers started with a single vehicle and grew fleets and

labor forces well into the hundreds. Our only limitations were self-imposed limitations.

Unfortunately, Obamacare and overbearing Government policies have changed everything. We risk

increased taxes, penalties and even potential IRS reprisal if we become too large; exceeding 50 full-time

employees. No longer can we focus on building our business vertically without limitations, adding more

vehicles and employees to meet our growing demand. Now, out of necessity, we need to focus on

building our venture horizontally – diversifying and offering complementary services to increase

additional sources of revenue and profit earning potential.

Consider the following article from the “Huffington Post,” an ardent left-leaning news source, illustrating

how Obamacare is backfiring and causing layoffs within the very industry it is targeted to help – the

medical industry! When the “Huffington Post” admits that “Obamacare is having some negative

effects,” you know there are inherent problems.

AURORA HEALTH CARE SAYS IT WILL LAY OFF EMPLOYEES BECAUSE OF OBAMACARE

- HARRY BRADFORD, THE HUFFINGTON POST

It looks like Obamacare is having some negative effects on the industry it was intended to

help.

Dr. Nick Turkal, CEO of Wisconsin-based non-profit Health Care Provider Aurora Health Care,

announced earlier this month that his employer would be cutting jobs due to Obamacare,

The Journal Times reports. In a letter to employees he wrote that the company would be

receiving $13 million less in government reimbursements forcing it to make “position

eliminations plus discontinuation of some positions in the coming weeks.”

http://www.huffingtonpost.com/harry-bradford

http://journaltimes.com/news/local/aurora-ceo-cites-obamacare-as-partial-cause-of-job-cutbacks/article_2a607054-6742-11e2-b5bb-001a4bcf887a.html



The cuts will be small considering Aurora’s 30,000 current employees but things could get

worse in the future. Already, staff has been instructed to cut costs by avoiding making color

copies; physicians serving Medicare patients may receive a cut in payments.

“We don’t want people to be afraid, but things are different,” Aurora spokeswoman Myrle

Croasdale told the Journal Times.

Aurora isn’t the only one in the Health Care Industry to claim Obamacare is forcing layoffs.

Orlando Health, a Florida network of community and specialty hospitals, said it would be

laying off 400 employees due to new Obamacare costs, One News Now reports. Likewise,

small medical device company ADM Tronics says Obamacare will mean the company will

have to lay off employees for the first time in over a decade.

Because many people reading this material voted for Obamacare, I know that some will take offense

when I say that Obamacare is an absolute disaster! I don’t apologize because overwhelming evidence,

statistics, professional opinions and historical failures of similar socialistic systems supports this reality.

Further compounding Obamacare’s dismal creation, it is going to grow worse in the coming years. What

is most offensive, though, is that such overburdening policies and government intrusion inflicts the most

harm on small business owners; the backbone of our economy. The good news, however, is that

Entrepreneurs are the resourceful engines that, despite being taken for granted, will always find creative

ideas, strategies, and solutions to solve problems and create wealth.

In presenting you with strategies for expanding and diversifying your business, I offer you a “choose

your own adventure.” To increase your profit earning potential, I put before you proven business

models that Providers from all over the country are using to enhance their brand recognition and

integrate their services into the daily lives of their clientele. In coming chapters, I present you with ideas

and information - you choose what is most feasible for you, meets your personal and business goals and

expectations, and satisfies the needs within your local community.



http://www.onenewsnow.com/business/2012/11/30/hospitals-will-see-massive-layoffs-decline-in-2013

http://www.foxnews.com/politics/2012/12/13/medical-companies-brace-for-devastating-obamacare-tax-prepare-for-layoffs/



LEVERAGING NEW OPPORTUNITIES, WAIVER PROGRAMS

After enduring the hardship of learning about the grim realities of Obamacare, it’s time to share some

good news. Despite Obamacare’s manifesto of expanding the size and scope of the Medicaid and

welfare systems, the good news is that Medicaid Waivers are unique programs that are administered at

the County level.

Medicaid Waivers are designed to be a cost-saving strategy to pay for long-term care services. For

Nursing Home qualified persons who choose to live at home or in a residential community, Medicaid will

pay for various services if they can be obtained at a lower cost. Because funding and management

varies between States and Counties, various names for such Waivers include Home and Community

Based Services, Waiver Funded Services, Medicaid Waivers. Regardless of all such names, they’re all the

same – Waivers!

Because so few entrepreneurs know about, let alone understand how Waiver programs work, this

section alone should excite you about your investment in this resource. The following email is from a

close friend, a very experienced and well-established Transportation Provider in Pennsylvania. In asking

him about his application for the Pennsylvania Department of Aging (PDA) Wavier program he

responded with the following very enlightening email:

Every state has an online submission process and that is the reason I don't have my original

application. All of the new programs have been opened up for Providers to apply. In PA they

provide FREE software to allow companies to submit all claims electronically. I believe most

states have that ability because the funding for the specific programs is from the Federal

Government.

Waiver Programs are different county to county based on the services. Remember PDA

(Pennsylvania Department of Aging) Waiver as well as MHMR (Mental Health Mental

Retardation) Programs are all funded by the State DPW (Department of Public Welfare). All

billing goes through the state DPW Program so the first step to getting enrolled to PDA,

MHMR, etc. is to apply for a billing code and approval through the state program. After



approval they will send information on how to bill through their free site. At that point they

would need to log on to the site to get a username and password.

Our site has a tutorial and training and I am certain most do. They would need to learn a

little about Coding claims which for Para-transit they only use about 3 procedure codes, and

then a diagnosis code as well when submitting, but honestly, this is simple because PDA or

MHMR will provide this information. Billing is extremely simple. Once submitted it tells you

whether it was approved or not and payment is 2-3 weeks to process. We submit large

batches at a time so 50,000 to 70,000 a month.

They establish a "base" for each rate (ambulatory, wheelchair, stretcher, extra attendant, lift

assist) and this rate is different in each area because it is solely based on the "cost reporting"

by each contractor. Rate proposals can be submitted and they can be changed but it can

sometimes be time consuming but they are worth it. The rates I have established in several

counties are very lucrative and I have setup the transports on a "Share Ride" basis which is

making over a million dollars a year just on this program alone. I would tell your people to

start by contacting the County MHMR Unit.

Needless to say, my friend’s email should excite you – with even more good news to come! The irony is

that there are many creative ways to make money with Waivers in addition to Non-Emergency Medical

Transportation. In discussing such particulars in greater detail, consider the following article illustrating

the situation of an unsuspecting elderly couple, also from Pennsylvania, in need of relief and assistance:

ELDER LAW: UNDERUSED PROGRAM HELPS SENIORS STAY AT HOME

- JULIAN GRAY AND FRANK PETRICH, PITTSBURGH POST GAZETTE

Mr. Harris receives the bulk of the family income through his Social Security and pension

while Mrs. Harris receives around $600 a month in Social Security retirement benefits.

Absent any emergencies, they can live comfortably on their income and within their means.

Mr. Harris has taken on an increased role as his wife's caregiver, but realizes that with his

own bad back and other physical ailments from years of physical labor, he, too, may be



limited in the care he can provide as time goes on. In addition, he is becoming concerned

about leaving his wife at home alone safely.

Mr. Harris has done some research and attended local events to learn about Home Health-

Care options in the event that his wife's needs escalate to more than he can handle.

However, with their limited savings and income, he feels that such home care would not be

financially sustainable for the long term. He also inquired with local government agencies as

to the availability for assistance in their home, only to be told that they did not qualify for

financial reasons.

The Harris' situation is quite common as many seniors are not prepared to take on the

financial burden of Private Home Health-Care costs. For many, the alternative of Facility

Care is a last resort. Fortunately, there are programs in Pennsylvania to assist those in need.

One such program is the Aging 60+ Waiver Program; more commonly referred to as the

"PDA Waiver" program. This program is funded through Pennsylvania's Medicaid program,

called Medical Assistance, as an alternative to Nursing Home Care.

A wide range of services is available under this program, including: personal care services,

Home Health Aides, medical equipment and supplies, transportation and home health visits,

to name a few. Generally, a person's situation dictates a formal care plan. Once the care

plan is established, the recipient will receive the designated services in her home at no cost

to the recipient. Depending on the number of hours per week prescribed in the care plan,

this can amount to thousands of dollars in benefits each month. Sounds too good to be

true? There are a few considerations that warrant further discussion.

Joel’s Insight: In “putting the cart before the horse,” can you see the opportunity for Home Care? “The

recipient will receive the designated services in her home at no cost to the recipient….this can amount to

thousands of dollars in benefits each month.” If this doesn’t scream diversification into Home Care, I

don’t know what will convince you!

Medicaid-funded programs such as PDA Waiver are tested for medical and financial

eligibility. The financial test for the PDA Waiver program is quite similar to the eligibility for

Nursing Home covered Medicaid, with one twist. Under the Pennsylvania Department of



Aging (PDA) Waiver program, the applicant's income must not exceed the level prescribed

by the Department of Public Welfare, which is the gatekeeper for Medicaid benefits in

Pennsylvania.

Currently, the monthly income limit for the PDA Waiver program is $2,022. The spouse's

income is not counted. Therefore, Mrs. Harris would be income eligible for the program

because her income is only $600/month. In addition to the income test, there is an asset

test. The asset test is a bit more complicated, but there are many exemptions available to

assist applicants and their spouses to achieve eligibility.

Joel’s Insight: Because “The spouse’s income is not counted,” Waivers offer exceptional opportunities for

Entrepreneurs because it, essentially, expands our potential client base.

Unfortunately, most applicants are unaware of the options and the government cannot

provide legal advice to obtain the sought-after benefits. In the situation of Mr. and Mrs.

Harris, they feel that they would not be financially eligible for this program because they

own a home, a car, Mr. Harris' IRA worth $50,000 and have various CD's totaling about

$100,000. However, upon closer inspection, the Harrises would be surprised to learn that

eligibility for this program to help Mrs. Harris would not require them to "spend down" all of

their savings. In fact, there are federal spousal protections enacted for this very purpose.

Moreover, new legislation and recent case law in Pennsylvania now provide more options to

obtain eligibility for the PDA Waiver program.

Because the previous article discusses the PDA Waiver program and my friend who generates over

$1,000,000 per year in NEMT is from Pennsylvania, allow me to focus on Waivers in Pennsylvania. With

50 States and an untold number of Counties in the US, it is obviously not feasible to share Waiver

programs from across the country. Thus, one of your first tasks after reading this resource is to begin

researching the particulars of Waiver programs in your State/County.

Pennsylvania Department of Aging (PDA) Waiver Overview: This Medicaid Waiver provides home and

community based services to seniors who require nursing facility care but elect to live in their own

homes or in other community living arrangements and receive care in those locations. It is also referred



to as the PA Council of Aging Waiver, the PDA Waiver or the Home and Community-Based Waiver for

Individuals Aged 60 and over.

Under this waiver, certain goods, supports and services can be participant directed or self-directed. This

means the individual chooses from whom they purchase goods or care services. Such freedom of choice

is ideal because, unlike the Broker system, customers are empowered; they have a choice of Provider

and it is not determined exclusively by lowest price. This also empowers you, the Provider, because in

providing a higher quality service you have the potential for increased clientele. Pennsylvania also has a

more robust program which allows the individual even greater control of their care Providers called the

Services My Way Program.

Aging Waiver Eligibility Guidelines: In addition to living in PA, residents must be at least 60 years old

and require the level of care typically provided in a nursing home. They also must qualify financially for

Medicaid in Pennsylvania, which is sometimes called "Medical Assistance" or abbreviated MA.

Pennsylvania Medicaid Eligibility Requirements: The income limit for an individual applying for

Medicaid is $2,130 / month. If one spouse is applying for Medicaid and the other is not, joint income can

be shifted to help the applicant qualify.

The asset limit for the PDA Waiver is $8,000. Resources in excess of that amount will need to be spent

down or re-allocated into exempt (non-countable) assets. In the situation previously described, where

one spouse of a married couple is applying, resources in excess of $8,000, up to a maximum of $115,920

can be allocated to the non-applicant spouse. This is referred to as the Community Spouse Resource

Allowance.

Applicants exceeding these Limits: Pennsylvania has a Medically Needy Medicaid program that enables

residents with unusually high care costs to qualify for the program. Alternatively, Medicaid planning

professionals can work with a family to arrange their assets and income into annuities and trusts so that

they meet the eligibility requirements. For example, by pre-funding a funeral using an irrevocable

funeral trust, one can reduce their countable assets by up to $15,000. Persons in this situation should

find Medicaid planning help.

http://www.payingforseniorcare.com/cash-and-counseling/pa-services-my-way.html



Services & Benefits: The services provided under Waivers are determined on a needs basis. Individuals

can be approved for a wide variety of services, so prepare for new ideas on diversification. Services

highlighted in red are specific strategies that we will be discussing because, under Waivers, individuals

can be approved for any of the following:

-Adult Daily Living Services (Adult Day Care)

-Attendant Care (Personal Care)

-Community Transition Services (Moving Assistance)

-Companion Services (Escort)

-Counseling

-Environmental Accessibility Modifications (Home and / or Vehicle)

-Financial Management Services

-Home Health Services

-Home Medical Equipment and Supplies

-Meal Delivery (Hot or Prepared)

-Non-Medical Transportation

-Personal Emergency Response (PER) System

-Respite Care Services (Temporary Caregiver Relief)

In the event you might think that such opportunities sound too good to be true under such Waivers,

consider the following article from the great State of Florida:

BIG CHANGES IN LONG-TERM CARE

- SUN SENTINEL EDITORIAL BOARD

The Obama administration last week gave Gov. Rick Scott one of the two Waivers he's

requested for managing Medicaid, the federal-state health program for the very poor. The



Waiver affects long-term care for 87,000 low-income seniors and disabled people who now

receive Nursing Home or In-Home Care under Medicaid.

Given that Medicaid consumes about $21 billion of the state's $74 billion budget — and that

long-term care accounts for about 18 percent of Medicaid's budget — we all have a stake in

the efficient management of the program's long-term care services for our most frail

citizens.

Gov. Scott is certain that by contracting with a limited number of private companies, Florida

can deliver better services at a lower cost. Now, he's got the chance to prove it.

If Nursing Home patients, or those trying to stay out of Nursing Homes, get into a plan that

offers more meaningful coordination of care, they will be better off for this Waiver. For it

gives the state more flexibility in providing alternatives to Nursing Home Care, such as

attendant care, adult day care, homemaker and respite services, transportation, and much

more.

It's imperative that the state Agency for Health Care Administration provide strict oversight

of the companies selected to manage the In-Home Care of our poorest elderly and disabled

neighbors. For starters, The Agency should get much more aggressive about communicating

what the Waiver means for real people, including those now in Nursing Homes.

Gov. Scott scored a win in convincing the federal government to give Florida more flexibility

in managing nursing home and in-home care for low-income seniors. We hope it's a win for

patients and taxpayers, too.

Joel’s Insight: Only one word adequately speaks to the previous articles and Waiver programs in general

– Opportunity!

http://articles.sun-sentinel.com/2013-02-11/news/fl-dlyons-editorial-medicaid-20130211_1_long-term-care-medicaid-recipients-medicaid-patients

http://articles.sun-sentinel.com/2013-02-11/news/fl-dlyons-editorial-medicaid-20130211_1_long-term-care-medicaid-recipients-medicaid-patients



LEVERAGING NEW OPPORTUNITIES, SCHOOL DISTRICTS & UNIVERSITIES

A niche market that very few Transportation Providers consider pursuing is the assisted transportation

needs of School Districts, Colleges and Universities. When I mention this niche to Providers, most have

never considered such possibilities. This is surprising because, depending on the size and number of the

school districts, they can be highly profitable! I can only assume that Transportation Providers simply

overlook this market; focusing more on elderly and disabled seniors. Rarely do Providers consider the

needs of children and students with disabilities. But you have to consider, how do students in

wheelchairs or with special needs get to and from school? Someone is taking them; why not you? You

need to contact surrounding School Districts to request potential future RFP’s.

Locally, we have a large State University, SUNY Binghamton, and a junior college, Broome Community

College. Over the years, we have transported an untold number of college students to and from school.

Reimbursement amounts were very good and typically came from the University or College, an

academic-related grant, or a combination of both. Initially, we received various Requests for Proposals

(RFP). Once we established a good reputation with the schools, we were rarely, if ever, offered another

RFP. Rather, they simply kept referring more and more students each semester. The best part,

reimbursements from New York State were very good and always on time.

The following several pages is an actual RFP awarded to a Transportation Provider to provide services to

and from elementary, middle, and high school. This is a great illustration of the content featured in a

standard RFP. I also include this RFP for other reasons to include:

1. You will notice that the date of this RFP is in the middle of the second semester. Why – because the

School District discontinued the previous Provider after several years in search of a more reliable

Service. This reinforces the principle that you never take providing exceptional service for granted.

2. The last page features the rates of reimbursement - which are outstanding! They are per student, per

one-way transport. When you consider this Provider transports multiple students in a single vehicle, it is

easy to see the profit-earning potential. How the previous Provider allowed this contract to be lost is

unbelievable. The new Provider is making very good margins on this contract.



STATE OF [NAME]/[NAME] COUNTY PUBLIC SCHOOLS REQUEST FOR PROPOSAL:

RFP #: 1213-0000

TITLE / PROJECT: Transportation for Students

USING AGENCY: [Name] County Public Schools

ISSUE DATE: February 27, 2013

Proposals subject to the conditions made a part hereof will be received until 2:00p.m., on Wednesday,

February 27,2013 for furnishing the services incidental and implied, described herein.

SEND ALL PROPOSALS DIRECTLY TO THE ISSUING AGENCY ADDRESS AS SHOWN BELOW:

DELIVERED BY US POSTAL SERVICE HAND DELIVERY RFP #: 1213-0000

[Name] County Public Schools [Street Name & Number] Avenue West [City], [State] [Zip Code] Attn: [Name], Purchasing Agent

RFP #: 1213-0000

[Name] County Public Schools [Street Name & Number] Avenue West [City], [State] [Zip Code] Attn: [Name], Purchasing Agent

Bids submitted via facsimile (FAX) machine, or e-mail, in response to this Request for Proposals will be

accepted. Fax to: [Number], Attn: [Name], CLGPO, Purchasing Agent, or e-mail to:

[Name]@[emailaddress].us

Bids submitted after the above referenced deadline will not be accepted under any circumstance.

Direct all inquiries concerning this RFP to:

[Name], CLGPO, Purchasing Agent Phone: [Number], Ext: 2232

"It is the policy of the [Name] County Public School System not to discriminate on the basis of race, ethnic origin, sex, or

disability in its educational programs, activities, or employment policies."

Board of Public Education [Name], Chairperson [Name], Vice Chairperson [Name] [Name] [Name] [Name] [Name]

[Name] Superintendent

[Street Name & Number] Avenue West [City], [State] [Zip Code]

Fax [Number] or [Number] www.[name]countypublicschools.org



THE PROCUREMENT PROCESS

The following is a general description of the process by which a firm will be selected to provide services.

1. Request for Proposals (RFP) is issued to prospective contractors.

2. A pre-proposal conference (if applicable) and/or deadline for written questions is five days prior to due date.

3. Proposals in one original will be received from each offeror in a sealed envelope or package. The original shall be signed and dated by an official authorized to bind the firm. Unsigned proposals will not be considered.

4. All proposals must be received by the issuing agency not later than the date and time specified on the cover sheet of this RFP.

5. At that date and time the package containing the proposals from each responding firm will be opened. The purchasing division will furnish bid tabs upon request.

6. At their option, the evaluators may request oral presentations or discussion with any or all offerors for the purpose of clarification or to amplify the materials presented in any part of the proposal. However, offerors are cautioned that the evaluators are not required to request clarification; therefore, all proposals should be complete and reflect the most favorable terms available from the offeror.

7. Proposals will be evaluated according to completeness, content, experience with similar projects, ability of the offeror and its staff, and cost. Award of a contract to one offeror does not mean that the other proposals lacked merit, but that, all factors considered, the selected proposal was deemed most advantageous to [Name] County Public Schools.

8. Offerors are cautioned that this is a request for offers, not a request to contract, and the [Name] County Public Schools reserves the unqualified right to reject any and all offers when such rejection is deemed to be in the best interest of [Name] County Public Schools.

GENERAL INFORMATION ON SUBMITTING PROPOSALS

1. EXCEPTIONS: All proposals are subject to the terms and conditions outlined herein. All responses shall be controlled by such terms and conditions and the submission of other terms and conditions, price lists, catalogs, and/or other documents as part of an offeror's response will be waived and have no effect either on this Request for Proposals or on any contract that may be awarded resulting from this solicitation. Offeror specifically agrees to the conditions set forth in the above paragraph by signature to the proposal.

2. CERTIFICATION: By executing the proposal, the signer certifies that this proposal is submitted competitively and without collusion (G.S. 143-540), that none of our officers, directors, or owners of an unincorporated business entity has been convicted of any violations of Chapter 781A of the General Statutes, the Securities Act of 1933, or the Securities Exchange Act of 1934 (G.S. 133-



59.2), and that we are not an ineligible vendor as set forth in G.S. 144-59.1. False certification is a Class I felony.

3. ORAL EXPLANATIONS: The State/[Name] County Public Schools shall not be bound by oral explanations or instructions given at any time during the competitive process or after award.

4. REFERENCE TO OTHER DATA: Only information which is received in response to this RFP will be evaluated; reference to information previously submitted shall not be evaluated.

5. ELABORATE PROPOSALS: Elaborate proposals in the form of brochures or other presentations beyond that necessary to present a complete and effective proposal are not desired.

In an effort to support the sustainability efforts of the State of [Name] we solicit your cooperation in this effort.

It is desirable that all responses meet the following requirements:

All copies are printed double sided.

All submittals and copies are printed on recycled paper with a minimum post-consumer content of 30% and indicate this information accordingly on the response.

Unless absolutely necessary, all proposals and copies should minimize or eliminate use of

non-recyclable or non re-usable materials such as plastic report covers, plastic dividers,

vinyl sleeves, and GBC binding. Three-ringed binders, glued materials, paper clips, and

staples are acceptable.

Materials should be submitted in a format which allows for easy removal and recycling of

paper materials.

6. COST FOR PROPOSAL PREPARATION: Any costs incurred by offerors in preparing or submitting

offers are the offerors' sole responsibility; the State of [Name]/[Name] County Public Schools

will not reimburse any offeror for any costs incurred prior to award.

7. TIME FOR ACCEPTANCE: Each proposal shall state that it is a firm offer which may be accepted

within a period of 45 days. Although the contract is expected to be awarded prior to that time,

the 45 day period is requested to allow for unforeseen delays.

8. TITLES: Titles and headings in this RFP and any subsequent contract are for convenience only

and shall have no binding force or effect.

9. CONFIDENTIALITY OF PROPOSALS: In submitting its proposal the offeror agrees not to discuss

or otherwise reveal the contents of the proposal to any source outside of the using or issuing

agency, government or private, until after the award of the contract. Offerors not in compliance

with this provision may be disqualified, at the option of the State/[Name] County Public Schools,



from contract award. Only discussions authorized by the issuing agency are exempt from this

provision.

10. RIGHT TO SUBMITTED MATERIAL: All responses, inquiries, or correspondence relating to or in

reference to the RFP, and all other reports, charts, displays, schedules, exhibits, and other

documentation submitted by the offerors shall become the property of [Name] County Public

Schools when received.

11. OFFEROR'S REPRESENTATIVE: Each offeror shall submit with its proposal the name, address,

and telephone number of the person(s) with authority to bind the firm and answer questions or

provide clarification concerning the firm's proposal.

12. SUBCONTRACTING: Offerors may propose to subcontract portions of the work provided that

their proposals clearly indicate what work they plan to subcontract and to whom and that all

information required about the prime contractor is also included for each proposed

subcontractor.

13. PROPRIETARY INFORMATION: Trade secrets or similar proprietary data which the offeror does

not wish disclosed to other than personnel involved in the evaluation or contract administration

will be kept confidential to the extent permitted by NAC T01:05B.1501 and G.S. 132-1.3 if

identified as follows: Each page shall be identified in boldface at the top and bottom as

"CONFIDENTIAL". Any section of the proposal which is to remain confidential shall also be so

marked in boldface on the title page of that section. Cost information may not be deemed

confidential. In spite of what is labeled as confidential, the determination as to whether or not it

is shall be determined by [State] law.

14. HISTORICALLY UNDERUTILIZED BUSINESSES: Pursuant to General Statute 133-38 and Executive

Order #140, the State/ [Name] County Public Schools invites and encourages participation in this

procurement process by businesses owned by minorities, women, disabled, disabled business

enterprises and non-profit work centers for the blind and severely disabled.

15. PROTEST PROCEDURES: If an offeror wants to protest a contract awarded pursuant to this

solicitation, they must submit a written request to the Purchasing Agent, [Name] County Public

Schools, [Street Address] Avenue West, [City], [State] [Zip Code]. This request must be received

by the Purchasing Division within thirty (30) consecutive calendar days from the date of the

contract award. Protest letters must contain specific reasons and any supporting documentation

for the protest. Note: Contract award notices are sent only to those actually awarded contracts,

and not to every person or firm responding to this solicitation. Contract status and award

notices are available through the Purchasing Division or the project designer with contact

information as shown on the first page of this solicitation. All protests will be handled pursuant



to the [State] Administrative Code, Title 1, Department of Administration, Chapter 5, Purchase

and Contract, Section 5AB.15219.

16. TABULATIONS: Offeror's may call the Purchasing Division to obtain a verbal status of contract

award.

17. VENDOR REGISTRATION AND SOLICITATION NOTIFICATION SYSTEM: Vendor Link [State] allows

vendors to electronically register free with the State to receive electronic notification of current

procurement opportunities for goods and services available on the Interactive Purchasing

System. Online registration and other purchasing information are available on our Internet web

site: http://www.webaddress.us/pandc/.

18. RECIPROCAL PREFERENCE: G.S. 1433-519 establishes a reciprocal preference law to discourage

other states from applying in-state preferences against [State] resident offers. The "Principal

Place of Business" is defined as the principal place from which the trade or business of the

offeror is directed or managed.

[STATE] GENERAL CONTRACT TERMS AND CONDITIONS (Contractual and Consultant Services)

1. GOVERNING LAW: This contract is made under and shall be governed and construed in accordance with the laws of the State of [Name].

2. SITUS: The place of this contract, its situs and forum, shall be [State], where all matters, whether sounding in contract or tort, relating to its validity, construction, interpretation and enforcement shall be determined

3. INDEPENDENT CONTRACTOR: The Contractor shall be considered to be an independent contractor and as such shall be wholly responsible for the work to be performed and for the supervision of its employees. The Contractor represents that it has, or will secure at its own expense, all personnel required in performing the services under this agreement. Such employees shall not be employees of, or have any individual contractual relationship with the Agency.

4. KEY PERSONNEL: The Contractor shall not substitute key personnel assigned to the performance of this contract without prior written approval by the Agency's Contract Administrator. The individuals designated as key personnel for purposes of this contract are those specified in the Contractor's proposal.

5. SUBCONTRACTING: Work proposed to be performed under this contract by the Contractor or its employees shall not be subcontracted without prior written approval of the Agency's Contract Administrator. Acceptance of an offeror's proposal shall include any subcontractor(s) specified therein.

http://www.webaddress.us/pandc/



6. PERFORMANCE AND DEFAULT: If, through any cause, the Contractor shall fail to fulfill in timely and proper manner the obligations under this agreement, the Agency shall thereupon have the right to terminate this contract by giving written notice to the Contractor and specifying the effective date thereof. In that event, all finished or unfinished deliverable items under this contract prepared by the Contractor shall, at the option of the Agency, become its property, and the Contractor shall be entitled to receive just and equitable compensation for any satisfactory work completed on such materials. Notwithstanding, the Contractor shall not be relieved of liability to the Agency for damages sustained by the Agency by virtue of any breach of this agreement, and the Agency may withhold any payment due the Contractor for the purpose of setoff until such time as the exact amount of damages due the Agency from such breach can be determined.

In case of default by the Contractor, [Name] County Public Schools may procure the services from other sources and hold the Contractor responsible for any excess cost occasioned thereby. [Name] County Public Schools reserves the right to require a performance bond or other acceptable alternative performance guarantees from successful offeror without expense to [Name] County Public Schools.

In addition, in the event of default by the Contractor under this contract, [Name] County Public Schools may immediately cease doing business with the Contractor, immediately terminate for cause all existing contracts [Name] County Public Schools has with the Contractor, and de-bar the Contractor from doing future business with [Name] County Public Schools.

Upon the Contractor filing a petition for bankruptcy or the entering of a judgment of bankruptcy by or against the Contractor, [Name] County Public Schools may immediately terminate, for cause, this contract and all other existing contracts the Contractor has with it, and de-bar the Contractor from doing future business.

Neither party shall be deemed to be in default of its obligations hereunder if and so long as it is prevented from performing such obligations by any act of war, hostile foreign action, nuclear explosion, riot, strikes, civil insurrection, earthquake, hurricane, tornado, or other catastrophic natural event or act of God.

7. TERMINATION: The Agency may terminate this agreement at any time by 15 days notice in writing from the Agency to the Contractor. In that event, all finished or unfinished deliverable items prepared by the Contractor under this contract shall, at the option of the Agency, become its property. If the contract is terminated by the Agency as provided herein, the Contractor shall be paid for services satisfactorily completed, less payment or compensation previously made.

8. PAYMENT TERMS: Payment terms are Net not later than 30 days after receipt of correct invoice(s) or acceptance of services, whichever is later, or in accordance with any special payment schedule identified in this RFP. The using agency is responsible for all payments to the contractor under the contract.

9. AVAILABILITY OF FUNDS: Any and all payments to the Contractor are dependent upon and subject to the availability of funds to the Agency for the purpose set forth in this agreement.



10. CONFIDENTIALITY: Any information, data, instruments, documents, studies or reports given to or prepared or assembled by the Contractor under this agreement shall be kept as confidential and not divulged or made available to any individual or organization without the prior written approval of the Agency.

11. CARE OF PROPERTY: The Contractor agrees that it shall be responsible for the proper custody and care of any property furnished it for use in connection with the performance of this contract or purchased by it for this contract and will reimburse [Name] County Public Schools for loss of damage of such property.

12. COPYRIGHT: No deliverable items produced in whole or in part under this agreement shall be the subject of an application for copyright by or on behalf of the Contractor.

13. ACCESS TO PERSONS AND RECORDS: The State Auditor shall have access to persons and records as a result of all contracts or grants entered into by State agencies or political subdivisions in accordance with General Statute 1417-641.7. The Contractor shall retain all records for a period of three years following completion of the contract.

14. ASSIGNMENT: No assignment of the Contractor's obligations nor the Contractor's right to receive payment hereunder shall be permitted. However, upon written request approved by the issuing purchasing authority, Henderson County Public Schools may: a. Forward the contractor's payment check(s) directly to any person or entity designated by

the Contractor, or b. Include any person or entity designated by Contractor as a joint payee on the Contractor's

payment check(s). In no event shall such approval and action obligate [Name] County Public Schools to anyone other than the Contractor and the Contractor shall remain responsible for fulfillment of all contract obligations.

15. COMPLIANCE WITH LAWS: The Contractor shall comply with all laws, ordinances, codes, rules, regulations, and licensing requirements that are applicable to the conduct of its business, including those of federal, state, and local agencies having jurisdiction and/or authority.

16. AFFIRMATIVE ACTION: The Contractor shall take affirmative action in complying with all Federal and State requirements concerning fair employment and employment of people with disabilities, and concerning the treatment of all employees without regard to discrimination by reason of race, color, religion, sex, national origin, or disability.

17. INSURANCE: During the term of the contract, the contractor at its sole cost and expense shall provide commercial insurance of such type and with such terms and limits as may be reasonably associated with the contract. As a minimum, the contractor shall provide and maintain the following coverage and limits:

a. Worker's Compensation - The contractor shall provide and maintain Worker's Compensation Insurance, as required by the laws of [State], as well as employer's liability coverage with minimum limits of $500,000.00, covering all of Contractor's employees who are engaged in any work under the contract. If any work is subcontracted, the contractor shall



require the subcontractor to provide the same coverage for any of its employees engaged in any work under the contract.

b. Commercial General Liability - General Liability Coverage on a Comprehensive Broad Form on an occurrence basis in the minimum amount of $1,000,000.00 Combined Single Limit. (Defense cost shall be in excess of the limit of liability.)

c. Automobile - Automobile Liability Insurance, to include liability coverage, covering all owned, hired and non-owned vehicles, used in connection with the contract. The minimum combined single limit shall be $1,000,000.00 bodily injury and property damage; $150,000.00 uninsured/under insured motorist; and $1,000.00 medical payment.

Providing and maintaining adequate insurance coverage is a material obligation of the contractor and is of the essence of this contract. All such insurance shall meet all laws of the State of [Name]. Such insurance coverage shall be obtained from companies that are authorized to provide such coverage and that are authorized by the Commissioner of Insurance to do business in [State]. The contractor shall at all times comply with the terms of such insurance policies, and all requirements of the insurer under any such insurance policies, except as they may conflict with existing [State] laws or this contract. The limits of coverage under each insurance policy maintained by the contractor shall not be interpreted as limiting the contractor's liability and obligations under the contract.

The Contractor shall furnish a Certificate of Insurance as proof of the above coverages. Certificate will contain provision that the insurance coverages cannot be canceled, reduced in amount or coverage eliminated without 30 days written notice to Henderson County Public Schools. Owner's Protective insurance must list [Name] County Public Schools as "Additional Insured" as its interest may appear. Owner's approval of Certificate of Insurance does not decrease or relieve the contractor's responsibility for maintaining insurance coverage as required in this Request for Proposal.

18. ADVERTISING: The offeror shall not use the award of a contract as part of any news release or commercial advertising.

19. ENTIRE AGREEMENT: This contract and any documents incorporated specifically by reference represent the entire agreement between the parties and supersede all prior oral or written statements or agreements. This Request for Proposals, any addenda thereto, and the offeror's proposal are incorporated herein by reference as though set forth verbatim.

All promises, requirements, terms, conditions, provisions, representations, guarantees, and warranties contained herein shall survive the contract expiration or termination date unless specifically provided otherwise herein, or unless superseded by applicable Federal or State statutes of limitation.

20. AMENDMENTS: This contract may be amended only by written amendments duly executed by the Agency and the Contractor.

21. TAXES: G.S. 1413-519.1 bars the Secretary of Administration from entering into contracts with vendors if the vendor or its affiliates meet one of the conditions of G. S. 1105-1164.8(b) and refuse to collect use tax on sales of tangible personal property to purchasers in [State].



Conditions under G. S. 1105-1164.8(b) include: (1) Maintenance of a retail establishment or office, (2) Presence of representatives in the State that solicit sales or transact business on behalf of the vendor and (3) Systematic exploitation of the market by media-assisted, media-facilitated, or media-solicited means. By execution of the proposal document the vendor certifies that it and all of its affiliates, (if it has affiliates), collect(s) the appropriate taxes.

22. YEAR 2000 COMPLIANCE/WARRANTY: Vendor shall ensure the product(s) and service(s) furnished pursuant to this agreement ("product" shall include, without limitation, any piece of equipment, hardware, firmware, middleware, custom or commercial software, or internal components, subroutines, and interfaces therein) which perform any date and/or time data recognition function, calculation, or sequencing, will support a four digit year format, and will provide accurate date/time data and leap year calculations on and after December 31,1999, at the same level of functionality for which originally acquired without additional cost to the user. This warranty shall survive termination or expiration of the agreement.

23. GENERAL INDEMNITY: The contractor shall hold and save the [Name] County Public Schools, its officers, agents, and employees, harmless from liability of any kind, including all claims and losses accruing or resulting to any other person, firm, or corporation furnishing or supplying work, services, materials, or supplies in connection with the performance of this contract, and from any and all claims and losses accruing or resulting to any person, firm, or corporation that may be injured or damaged by the contractor in the performance of this contract and that are attributable to the negligence or intentionally tortious acts of the contractor provided that the contractor is notified in writing within 30 days that the Henderson County Public Schools has knowledge of such claims. The contractor represents and warrants that it shall make no claim of any kind or nature against the [Name] County Public Schools agents who are involved in the delivery or processing of contractor goods to [Name] County Public Schools. The representation and warranty in the preceding sentence shall survive the termination or expiration of this contract.

24. OUTSOURCING: Any vendor or subcontractor providing call or contact center services to the State of [Name] shall disclose to inbound callers the location from which the call or contact center services are being provided.

If, after award of a contract, the contractor wishes to outsource any portion of the work to a location outside the United States, prior written approval must be obtained from the State agency responsible for the contract.

Vendor must give notice to the using agency of any relocation of the vendor, employees of the vendor, subcontractors of the vendor, or other persons performing services under a state contract outside of the United States.



Title: Transportation for Students

Term of Contract: The initial contract period shall be for a period of 4 months, beginning March 1, 2013

and ending June 30, 2013. The contract may be renewed for 2 additional 1 year terms if mutually agreed

upon by both parties.

Pricing: Pricing shall be guaranteed for the initial term of the contract. There shall be no additional

charges billed to HCPS other than those listed on the bid form.

Default: [Name] County Public Schools may, by 15 days written notice of default to the Contractor,

terminate the contract if the Contractor fails to perform the services as listed in this agreement. [Name]

County Public Schools reserves the right to make determinations as to whether service is being

performed satisfactorily. Failure to satisfactorily perform any or all services outlined in the contract will

be grounds for cancellation of the contract.

In the event [Name] County Public Schools terminates this contract as provided herein, they may

procure, in such manner as seems appropriate services similar to those so terminated.

Contractor's Responsibility: The Contractor shall be responsible for performing the services as described

in this RFP on school premises during the hours which have been mutually agreed-upon by CPS and

Contractor.

Certificate of Insurance: The contractor is responsible for issuing a Certificate of Insurance as proof of

the coverages as specified on Page 6, Section 17 of the RFP.

Scheduling: The successful contractor will coordinate with the CPS Homeless Liaison or designated

employee in regards to scheduling of services required.

Minority Business: [Name] County Public Schools promotes and encourages participation by Historically

Underutilized Businesses. Historically Underutilized Businesses (HUB) consist of minority, women,

disabled business firms, and socially and economically disadvantaged individuals or corporations that

are at least fifty-one percent owned and operated by persons of the aforementioned categories. Please

indicate on your proposal bid sheet if your company does, or does not, fall within one of these

categories. If applicable, specify classification.

References: List below references where your company has provided services similar to those listed in

this Request for Proposal. [Name] County Public Schools may contact these individuals to determine the

level of services provided. Such information may be considered in the evaluation of the bid.

COMPANY CONTACT PERSON TELEPHONE #

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________



SCOPE OF SERVICES TO BE COMPLETED:

[Name] County Public Schools (CPS) is seeking transportation services to transport students to and from

schools, as requested, for the remainder of the 2012-2013 school year.

During this period, the Contractor will insure that the following requirements are met;

Motor vehicles used to transport student shall meet all [State] Division of Motor Vehicles Safety Inspection requirements.

Drivers shall have a minimum of 3 years driving experience, have maintained a good driving record, and must hold a valid [State] Driver's license.

It is required by CPS that all drivers who are assigned to transport students must pass a criminal background check. Contractor is responsible for having background checks completed and for all costs incurred.

Contractor shall provide to CPS;

a. A complete list of all drivers responsible for transporting students. b. A copy of the [State] Driver's License for each driver.

c. A copy of background check for each driver.

If Contractor hires new drivers, CPS must be notified and a background check completed prior to driver transporting students.

Drivers shall be experienced, professional individuals who are of good character.

Contractor shall notify CPS whether or not random drug testing is required for their drivers.

Contractor shall provide and maintain the proper liability insurance coverage required to transport individuals (See Section 17, page 5 of the attached [State] General Terms and Conditions for types and limits required).

Contractor shall furnish a Certificate of Insurance as proof of the above coverages prior to the effective date of this contract. CPS shall be listed as the Additional Insured on the Certificate.

Contractor shall assume total responsibility for the safety of the Student during the time the Student is being transported.

Contractor shall be familiar with, and required to, follow all Child Passenger Safety Laws for the State of [Name] when transporting students.

Current Law: All children ages 7 & under who weigh less than 80 pounds must be secured in an appropriate child passenger restraint system.

CPS will provide car and/or booster seats to Contractor if needed.

Contractor may not transport any student of CPS in a vehicle which is classified as a Van.



Detailed invoices shall be submitted to the school system every two weeks. Detailed billing shall include; the date of each trip, name of student/s, pick-up and drop-off locations with mileage per trip, and total cost per trip.

If more than one student is picked up at the same location, Contractor shall not duplicate charges from pick up location to drop off location for first student.

Contractor shall notify HCPS immediately if they cannot provide transportation at the times designated so there is sufficient time to contract with an alternative Contractor.

Mileage count begins from Contractor's place of business, or at location of taxi if closest to pick up area.



(NOTE: THIS PAGE MUST BE FULLY EXECUTED AND RETURNED FOR CONSIDERATION OF PROPOSAL)

COST PROPOSAL/EXECUTION OF PROPOSAL

Transportation for Students - RFP# 1213-0000

By submitting this proposal, the potential contractor certifies the following:

This proposal is signed by an authorized representative of the firm.

It can obtain insurance certificates as required within 10 calendar days after notice of award.

The cost and availability of all equipment, materials, and supplies associated with performing the services described herein have been determined and included in the proposed cost.

All labor costs, direct and indirect, have been determined and included in the proposed cost.

The offeror has attended the (if applicable) conference/site visit and is aware of prevailing conditions associated with performing these services.

The potential contractor has read and understands the conditions set forth in this RFP and agrees to them with no exceptions.

Therefore, in compliance with this Request for Proposals, and subject to all conditions herein, the undersigned offers and agrees, If this proposal is accepted within 45 days from the date of the opening, to furnish the subject services at prices listed below:

Charge per mile: $_________/mile OR $_________/trip (attach list) **Please Indicate whether or not drug testing is required for drivers ** Yes_____ No_____

OFFEROR: _____________________________________________________

ADDRESS: _____________________________________________________

CITY, STATE, ZIP: ________________________________________________

TELEPHONE NUMBER: ___________________ FAX: ___________________

FEDERAL EMPLOYER IDENTIFICATION NUMBER: _______________________

E-MAIL: _________________________ MBE Status:____________________

Principal Place of Business if different from above (See General Information on Submitting Proposals, Item 18.):________________________________________________________________

BY: _____________________________ TITLE: ____________________ DATE: _________________ (Signature) _____________________________________ (Typed or Printed name)



[Name] Middle School 18.50 each way

[Name] Elementary School 20.50 each way

[Name] School 18.50 each way




[Name] High School 18.50 each way


















DIVERSIFYING YOUR BUSINESS MODEL, STRATEGY 1

If I were challenged to start a new business with the goal of becoming operational and generating

revenue within 6-8 weeks, I would definitely start a Non-Medical Home Care Agency. A Non-Medical

Home Care Agency is not complicated and the synergy with NEMT is phenomenal.

The Home Care Industry is the fastest growing segment of Health Care in America. Due to our aging

population and the desire of older Americans to remain in their homes for as long possible, Home Care

Agencies continue to increase in demand and popularity. With population and life expectancy

increasing, more and more families find themselves seeking outside assistance in the form of Home Care

Professionals to assist in essential services. Consider the following article:

HOME HEALTH AIDES SERVE A GROWING POPULATION; HERE’S WHAT YOU NEED TO KNOW

- CONSUMERS UNION OF UNITED STATES, THE WASHINGTON POST

The demand for home-care aides — also known as personal-care aides and home health

aides — is skyrocketing as the number of seniors continues to grow. The Department of

Labor projects that in-home assistance will be the nation’s fastest-growing occupation by

2020. Those workers help seniors, the infirm and people with intellectual or developmental

disabilities with personal hygiene, taking medication, preparing meals, doing household

chores and other tasks.

Getting help

To find the right help for a family member, ask his or her doctor for a referral to a social

service worker. The doctor also may be able to provide a list of home-care agencies that

serve your area. If the services required are primarily medical, such as wound care or home

chemotherapy, the best choice might be a visiting nurse; to learn more, contact one of the

organizations affiliated with the Visiting Nurse Associations of America.

If necessary services are more personal than medical, a home-care aide might be best. He or

she can help with shopping, cooking, cleaning and laundry as well as personal activities such



as dressing, eating, bathing and using the toilet. A homemaker aide might be the right

choice if needs are housekeeping, laundry, shopping and meals, but not personal hygiene.

Who will pay?

Once you’ve determined what type of aide is best and you’ve established that your relative

is on board, check to see whether he or she is covered for home care through a private

health or long-term insurance policy, the Veterans Administration, Medicare or Medicaid.

Note that Medicare typically covers home health aides for just 60 days at a time and only if

patients are housebound and require a certain level of care (for instance, intermittent,

skilled nursing care). It won’t pay for personal or homemaker services if that’s the only care

needed. In contrast, some states allow Medicaid recipients to hire almost anyone for home

care, including relatives. Eligibility and benefits vary by state, so check with your state

Medicaid office.

Home care becomes important whenever a person needs

assistance that cannot be readily provided by a family member

or friend. There are many situations and conditions for which

home care and hospice are especially appropriate. Advances in

treatment and technology have allowed more people to leave

or never even enter nursing facilities and institutions. They can

be cared for effectively and efficiently at home even with illnesses that once were only treatable in a

hospital or institutional setting.

According to Colleen Teixeira Moffat of the US Bureau of Labor and Statistics, who studies the

occupation of personal and Home Care Aides, “Increasing health care costs partly explain this growing

demand for a shift in need to more in-home care. It's a lot more cost-effective to leave a hospital

sooner when all a senior might need is assistance with daily activities," she said. "A visiting Nurse, Home

Health Aide, and personal and Home Care Aide all will be cheaper than a stay in a residential care

facility."



In discussing this particular business model it is important for me to mention a few things. At least 50-

60% of the business owners I work with own a Home Care Agency. Thus, in working with this many

successful entrepreneurs in this industry and having access to their Profit & Loss Statements and

associated strategic details, I can definitely confirm the data and statistics provided in the following

chart:

When you consider the margins both in dollars and percent, it is easy to see why a Non-Medical Home

Care Agency is a great business investment. I have several clients who have started and sold Home Care

Agencies multiple times over. In fact, one particular client with whom I continue to work has built and

sold not one, not two, but three multi-million dollar Non-Medical Home Care Agencies. Each time they

have moved to a different State where they continue to experience compounding success.

It’s also important to reiterate that the statistics provided by the “Private Duty Benchmarking and State

of the Industry Report” are averages. This means that many Non-Medical Home Care Agencies are even

more profitable, especially those that operate an NEMT business and can consolidate associated

overhead expenses.

Non-Medical Home Care versus Home Healthcare: “Home care” is a very broad and generic term

encompassing various levels of care. Therefore, it is essential that we distinguish between “Non-

Medical Home Care” and “Home Healthcare.”

Terminology does fluctuate between States, but generally speaking, Non-Medical Home Care is a type of

“custodial" care focusing on helping individuals with their activities of daily living. Although there



remains very little oversight and regulation for custodial care, some States distinguish between hands on

assistance offered by a “Caregiver” such as dressing, grooming, and bathing, with that of “Homemaker”

assisting with meal preparation, errands, housekeeping, and companionship. Essentially, anyone can

serve as a Homemaker. But in regulating States, where clients need hands-on assistance it must be

performed by experienced Home Health Aides.

Home Healthcare, however, is typically physician-prescribed care involving skilled nursing, physical

therapy, speech therapy, social work, dieticians, nutritionists or other treatments performed by licensed

medical professionals.

Why Non-Medical Home Care? There are a handful of key reasons why I focus on Non-Medical versus a

Home Healthcare Agency. However, it is important to mention that in an effort to expand their services

and profit earning potential, some entrepreneurs who start out as a Non-Medical Home Care Agency do

expand into becoming a Home Healthcare Agency. So by all means, as I continue to discuss this

particular business model, I do not want you to gather the impression that one type of Agency is better

than the other. Both Agencies serve very important roles in meeting the needs of the elderly and

disabled.

The first reason why starting a Non-Medical Home Care Agency is so appealing is because it doesn’t

require skilled care. This makes getting started in the industry much easier and more cost effective. It is

easier to find, recruit, and train your caregivers. Also, as of this writing, there are approximately 28

states that have some form of licensing and registration for starting a Non-Medical Home Care Agency.iv

The remaining 22 states require no formal licensing or registration which means you can literally start

laying the foundation almost immediately!

Second, Non-Medical Home Care Agencies play an undeniably large role in filling gaps in Home Care

Services which further increase demand. Un-skilled Home Care services such as personal care assistance,

cooking, cleaning and companionship assistance are often what many seniors need the most in order to

remain in their homes. These types of services are perfect for families needing temporary relief, or

respite care. Agencies afford family members time away while ensuring that loved one’s receive safe,

reliable assistance and companionship in their absence.



Offering respite care leads to a very important third reason for starting a Non-Medical Home Care

Agency, you can literally earn money 24 hours a day, 7 days a week! There are many seniors or people

with disabilities who need assistance in turning over in bed or help getting to the bathroom in the

middle of the night. Such assistance requires Caregivers throughout the night, on weekends and

holidays. Thus, your business will literally be generating money 365 days a year.

Fourth, roughly 80% of reimbursements in the Non-Medical Home Care industry are derived from

Private-Pay. Similar to what we discussed in the NEMT business model, Private-Pay clients in the Home

Care industry are ideal because they tend to be more profitable and require far less bureaucratic

regulation.

Another appealing factor that makes starting a Home Care Agency a great opportunity is that it is a

service based business that goes out into the community to meet the demand. This means that, like an

NEMT business, you don’t need expensive or lavish office space or store front. The easiest way to make

money is to save money and when you can limit your overhead expenses you are in great position to

increase your profit margins.

What Forms and Rates of Reimbursement for Non-Medical Home Care? Much like the NEMT industry,

there are many sources of reimbursement. However, more great news about this specific business

model is that, according to the “Private Duty Benchmarking and State of the Industry Report,” roughly

80% of reimbursement for Non-Medical Home Care is Private-Pay.



As we discussed previously, Private-Pay clientele are ideal because the rate of reimbursement tends to

be higher and it requires less hassle to collect your money. Such a staggering number, 80.4% Private-

Pay, makes focusing your marketing efforts easy. Obviously, the bulk of your marketing efforts and

resources should be towards the recruitment of Private-Pay clients. However, this doesn’t mean that

you should neglect the possibilities of other sources of revenue. Especially if you are already in the

NEMT industry, recruiting clients and gaining approval from other sources of revenue such as Medicaid

and the Veterans Administration is much easier.

In terms of hourly rates of reimbursement, they will vary depending on the economic conditions and

market dynamics of your local community. Also, like any business, the more a client uses your service

the more inclined you are to offer discounts.

For example, in using random numbers for demonstration purposes, if you charged a client $20 per hour

with a three hour minimum ($60 total) you would offer a discount for more hours. So if a client needed

8 consecutive hours of care you could offer them a 10% discount or $18 per hour for a total of $144. If

your standard hourly rate is $23 per hour, for an 8 hour period with 10% discount you would charge

$165.60.

As you can see, this is a volume based business. The more clients you have, the more hours you will

serve and, thus, the more revenue-generating potential. When you consider the exponentially growing

elderly population, it’s easy to see why the average Private-Pay Home Care Agency generates almost

$1,500,000 in annual revenue. Some clients need round-the-clock care. Others may need a full shift on

a daily basis. When you have a growing number of at home clients, this can add up to a lot of money.

The good news, you’re still saving clients a lot of money because the alternative, a nursing home, is

significantly more expensive! Consider the following article published in the great State of Ohio:

MORE ‘FISCAL CLIFFS’ TO COME AS POPULATION AGES

- MARY MCCARTY, DAYTON DAILY NEWS

By 2050, analysts predict two-thirds of Ohio’s counties will have an over-60 population that

is greater than 30 percent. In urban counties like Montgomery and Clark, where that

percentage was around 17 or 18 percent two decades ago, that represents a major shift.

http://www.daytondailynews.com/staff/mary-mccarty/



But it will be even greater in high-growth counties like Warren, which saw many young

families move in during the 1990s, a trend that continued over the first decade of this

century.

“If things continue at the present rate, Medicaid would contain the largest part of the state

budget, and that’s simply not feasible,” said Suzanne Kunkel, director of the Scripps

Gerontology Center. “We should be worried about these demographics. They should be a

wake-up call to take action and think differently about the way we do things. Now is the

time to look at what does and doesn’t work with the existing system.”

Fifteen years ago, 90 percent of Medicaid reimbursements for long-term care went toward

nursing homes; today that figure has been reduced to 58 percent, with more and more

seniors staying in their homes with the help of home health care and other direct services.

Joel’s Insight: These are staggering statistics. In a highly populated state like that of Ohio, 15 years ago

90% of their Medicaid reimbursements went towards long-term care in nursing homes. This number is

down to 58%, illustrating the huge shift towards a rapidly growing in-home care industry! Again, this is

only in one state, Ohio. Imagine the growth for in-home care in other, more populated states such as

Texas, Florida, California, and more.

“That’s very significant when you compare the cost — $60,000 a year for nursing homes

compared with less than $20,000 for home health care,” said McGarry, whose agency serves

seniors in Champaign, Clark, Darke, Greene, Logan, Miami, Montgomery, Preble and Shelby

Counties. “It’s the seniors’ preference and it’s what taxpayers should want because it is

already saving the state $1 billion annually.”

Joel’s Insight: The Private-Pay savings for families deciding on the type of care to offer a loved one

doesn’t compare; Nursing Home versus in-home care, $60,000 versus $20,000 per year? An increasing

elderly population coupled with an obviously growing transition from Nursing Home to Home Care

presents huge opportunities.

As the population ages, more jobs are created in the health care field, said Kantor-Burman.

But more importantly, she said, “It enriches families when we are able to care for our elders,



and the family unit is strongest when generations are able to interact with each other. We

want our society to think about aging as an exciting, normal part of life where decline is not

inevitable.”

What Qualifications Do My Caregivers Need? Many times, when people think of Home Care they

associate it with Skilled Care which requires the help of nurses, therapists and more. But to reiterate,

one of the greatest appeals and attractions to starting a Non-Medical Home Care Agency is that you are

not providing direct medical assistance, therapy or treatment. Therefore, a Non-Medical Home Care

business model does not require Caregivers to be nurses or therapists. In sharing with you primary job

responsibilities, I am not exaggerating on the overall level of simplicity. Yet, these tasks are very much

beneficial and essential for clients and profitable for you. Some of these various non-medical tasks that

your Caregivers will provide are as follows:

Personal Care Services - Personal care services provide non-medical hands-on assistance with daily

activities such as bathing, dressing, eating, and a range of other daily tasks. In essence, the personal

Caregiver does tasks for the individual that patients are unable to independently do for themselves

because of disability due to illness, disease, trauma, or the natural progression of aging.

Companionship/Sitter Services - Provide multiple services such as reminding patients of dates, routines,

and when to take medication. Companions monitor patient’s comfort level, assist with meals and

feeding, converse with and entertain the client. They also monitor patient’s activities such as ensuring

the patient stays in bed, perform prescribed exercises, and more. Companions ensure family members

that their loved one is safe when they are unable to be there personally.

Homemaker/Home Management Services - A Homemaker handles household responsibilities to

maintain the home environment. Services include cooking, housekeeping, laundry, and simple home

repairs and maintenance.

Caregiver Respite - Respite care is the provision of short-term, temporary relief to those who are caring

for family members who might otherwise require permanent placement in a facility outside the home.

Home Care Agencies are in high demand for respite care. Such programs provide planned short-term

breaks for families and Caregivers while providing a positive experience for the person receiving care.



Live-In Care Services - Live in-care Providers reside in the home of the client to provide services for a set

number of hours or a 24 hour period. Live-in care can help with a variety of tasks including domestic

responsibilities, personal care, shopping services, home administration, medication reminders,

transportation, providing companionship and much more. Although clients in need of 24 hour care may

receive a per-hour discount, overall, round-the-clock clientele can be very profitable for your Agency

and Caregivers.

Where can you find competent Caregivers? One of the best aspects about Non-Medical Home Care is

that not all Caregivers need to be full-time employees. Especially for those starting a new business, this

is a significant convenience both financially and logistically. Unlike an NEMT business where you will

send drivers from one appointment to the next for the duration of their shift, with Home Care,

Caregivers will spend several hours at each appointment. Therefore, it is very realistic to have a number

of part-time employees that work a few days a week, a few mornings, or maybe just the weekends to

attend to the needs of particular clients.

Because we can leverage part-time employees, especially in a down economy, it allows us greater

flexibility in finding competent and qualified applicants that meet our expectations. Certified and Non-

Certified Aides are prime applicants for Non-Medical Home Care. Even if they are working full-time

elsewhere, they may need additional work to supplement their income.

In working with many business owners, consensus indicates that ideal applicants for Caregivers and

Homemakers are middle-aged women. First, consider modesty issues. An elderly woman needing

hands-on assistance typically prefers the help of another woman. Likewise, elderly men also prefer the

help of women. For this reason, in excess of 90% of caregivers are female! Second, middle-age women

and single mothers tend to be more responsible and in need of stable and reliable work.

Another great source for part-time Caregivers is nursing students. Because they’re in school, they

obviously can’t work full-time, but they most likely can use the extra money in working part-time.

Further, many prospects such as Aides, nursing students, and the like may have prior experience.

Nursing Homes and hospitals are full of excellent prospects, Aides in need of earning additional money.

What is very common throughout the medical industry in general is the degree of transient staff. It’s

very common for nurses, Aides, social workers, and associated staff to move to different positions or



altogether different facilities in seeking promotions or change of environment. Especially when some

facilities are understaffed and overworked, this willingness to change jobs makes it very possible to find

experienced Aides that, for comparable wages, would welcome the opportunity to work for a smaller,

more intimate Agency.

Networking is important. As mentioned, employees are transient. Sure, you want a good employee to

work for your company indefinitely. But that’s not realistic. Thus, in seeking qualified applicants you

want to further build and expand your network of strategic partners. If you have a Nursing School or

Trade Schools in your area, these could be excellent resources for reliable Caregivers. Another popular

resource for finding applicants is faith based venues such as churches and outreach programs.

One recruiting venue that I have always appreciated for convenience, cost, and presence is Craigslist.

Yes, there are the traditional forms of print marketing and recruiting such as newspapers, mailing lists,

and direct mail. Speaking from first-hand experience and in working with other business owners,

Craigslist can provide you with an overwhelming number of prospects. What I have seen several

business owners do, which has even surprised me at how well it works, is schedule a job fair for a

specific date and time at their office. They will post their ad on Craigslist several times and applicants

show up to fill out applications, discuss job particulars and more.

The Synergy between Home Care and NEMT: If you already own and operate a medical transportation

company, not only do you have the “hot market” in terms of potential clientele, but you probably

already have some awesome contacts at doctor offices, social workers, hospitals, dialysis centers, senior

centers, Office of the Aging, and a host of other community based organizations. These will be excellent

initial sources of potential referrals, as well as clients who can benefit from your Home Care service

directly. The good news about these contacts is that you have already established what is essential for

successful networking; you have already proven to be reliable, dependable, and hard working. You have

already been establishing brand recognition that you’re going to continue to expand via your Home Care

Agency. Doctors, nurses, social workers, secretaries, and various other representatives are infinitely

more likely to take your calls and solicitations when you contact them to discuss your new business

because of your proven track record and reputation. What you have accomplished in one business gives

you infinitely increased chances for networking success as compared to someone without.




After discussing the profitable possibilities associated with a Non-Medical Home Care Agency, let us now

consider another synergistic business model that of Residential Care Homes. Momentarily, I am going to

share with you an outstanding approach to Residential Care Homes. We will discuss one particular

husband-wife team who is leveraging to exponentially increase their net worth. It’s awesome! But first,

let’s discuss the particulars of this specific business model the ways how Assisted Living bridges the gap

between living independently and needing Nursing Care.

Residential Care Homes serve a variety of populations ranging from elderly and disabled to troubled

youths and adults. Especially for seniors - whose family members reside out of state - who need daily

assistance, Residential Care Homes are proving to be an increasingly ideal living arrangement. Facility

staff is better trained to care for seniors suffering from mild cognitive impairment to Alzheimer’s, heart

disease, stroke, cancer, Parkinson’s, diabetes, and those seniors undergoing rehabilitation.

As diverse as the population of each Residential Care Home, so too are the names of such facilities;

Adult Family Homes, Shelter Homes, Board & Care Homes, Transition Homes, Group Homes, Hospice

Homes, Respite Care Homes, and more. Although the names are diverse, the mission of each Home is

similar - to provide lodging in a comfortable home setting, meal preparation and service, dressing,

bathing, rehabilitation, medication monitoring, housekeeping and laundry in addition to personal

assistance with other daily living activities. Residential Care usually offers local transportation to Non-

Emergency Medical appointments and social activities.

Living expenses in a Residential Care Home are often half the cost of Nursing Home Care. However, cost

can vary significantly depending on the geographical location of the Home and the level of care provided

in the Home. Cost also varies depending on room accommodations - single or shared. Rent for a typical

Residential Care Home ranges between $2,500 and $5,000 per month and includes cost of care, meals,

laundry, and general services.

Most Residential Care Homes are located in traditional homes and neighborhoods and provide care for

fewer patients than Assisted Living Communities; typically between 6-12 seniors. Staff to resident ratios

of 1:3 is very common making Residential Care Homes an ideal choice for mentally and physically



challenged seniors. Staff is highly trained to care for seniors with memory loss from mild cognitive

impairment to Alzheimer’s, heart disease, stroke, cancer, Parkinson’s, diabetes, and those seniors

undergoing rehabilitation.

The Supply of Residential Care Services

Assisted Living Facilities grew rapidly starting in the 1990s and continues today with exponential growth.

It is estimated that three quarters of all senior housing built during the 1990s were Assisted Living or

Supportive Housing Units. Large, for-profit facilities account for only a portion of the supply. Most

facilities are small, independent, for-profit operations that are often run by independent business

owners. Another component of the industry is Residential Care Homes owned and operated by not-for-

profit organizations. Growth in the small for-profit and not-for-profit sectors has been slower as

compared to large for-profit chains as these types of facilities do not have the same access to capital.

However, a lack of capital does not reduce market opportunity and demand.

Not-for-profit facilities can receive loans from banks under the Community Reinvestment Act for

construction of moderate-income housing for the elderly in addition to loan subsidies under programs

run by the U.S. Department of Housing and Urban Development (HUD). In addition, not-for-profits can

engage in community fundraising.

The Demand for Residential Care Services

While comprehensive data is not available on residents in all forms of supportive housing, a recent

survey by the American Seniors Housing Association suggests that the average age of a Residential Care

Home resident is roughly 83, and that 60 percent of residents need help with one or more activities of

daily living. Along with favorable demographics, increasing wealth among the elderly is likely to provide

a further impetus for growth in the demand for Assisted Living Facilities. It is estimated that between 40

and 60 percent of individuals over the age of 75 have the financial resources to live in an Assisted Living

Facility of some type for at least two years.



Regulatory Trends

State governments play the primary role in regulating the Residential Care Industry. They influence the

supply, demand, and quality of care in these facilities through a number of policies and regulations. A

recent survey conducted by the National Academy of State Health Policy offers insights into several

areas including the following:

Stimulating demand for services through income-subsidy programs, most often through the

State Medicaid program

Setting resident eligibility criteria by defining allowable levels of care and resident acuity within

Residential Care Homes

Setting reimbursement rates for State-Funded payments to Residential Care Homes (primarily

through Medicaid)

Increasing supply of Residential Care Home beds by encouraging the conversion of Nursing

Home beds to Assisted Living Facilities

Maintaining adequate levels of quality through quality assurance processes

Protecting residents by mandating disclosure of the terms of residencies, including move-out

requirements

Income Subsidy Programs

While the predominant source of payment for Residential Care and Assisted Living Services is Private-

Pay, the federal government and virtually all States provide some level of subsidy to assist low-income

individuals in accessing these services. The most common public income subsidy program available is

the combination of the Federal Supplemental Security Income (SSI) program with State Supplemental

Payments (SSP). SSI/SSP directly pay the rent for low-income residents, at a payment level below the

market rate for Residential Care Housing. This inadequacy of the SSI/SSP payments has led most States

to apply for Waivers, allowing the use of Medicaid funds to financially support low-income individuals in

need of Residential Care Housing care.

As we discussed, Medicaid Waivers are popular for two reasons. First, they are considered a strategy for

reducing Nursing Home expenses by encouraging movement to lower-cost facilities. Second, they



provide more choices to beneficiaries. Are you seeing how the various strategies we continue to discuss

are interrelated and synergistic? You would be amazed how the majority of Providers have no

understanding of these opportunities.

Types of Group Homes

Although there are variations between regulation and terminology between States, there are many

commonalities. In general, there are four types of Residential Care Homes that State governments will

license and regulate. Type 1, the least restrictive, is synonymous with Boarding Homes. An example is

an “Adult Foster Care Home.” These Homes provide shelter, daily personal grooming and meals. This is

referred to as a Type 1 Facility.

Type 2 provides a higher degree of services. An example is a Home for mentally disabled adults that

provide shelter and a homelike atmosphere. It also provides social and therapeutic programs for

residents. These residents can share chores and hold employment outside of the Home. Although the

residents are self-sufficient, they do not live independently. The Residential Care Home is their home

address, but they often go to their job during the day.

A Type 3 Facility requires 24/7 staff. Such a Home may house residents with emotional or mental

disease or issues requiring shelter, monitoring, therapy, and social programs. Some States require a

Type 3 Facility to be locked, not allowing residents to move freely in and out of the Home.

The most restrictive Residential Care Home, Type 4, is for residents considered to be severely disturbed

individuals. These residents could hurt themselves or others. Such a Facility must provide an intense

social and therapeutic program, a locked facility with 24/7 staff and possibly even a locked room.

Again, the Type of Home depends on the level of needs of the resident population and State regulations.

As expected, the reimbursement for residents is higher for those needing greater assistance. As

demand for Residential Care Homes continues to increase so too does the range of services. However,

individual Residential Care Homes serve a single resident Type; a single population of common need.

For example, a Type 3 Residential Care Home will not cater to the needs of residents needing only Type

1 level of care. Serving a single residency type is more convenient for the residents and staff and is

more cost-effective. Additionally, focusing the level of care helps to provide the best possible care and



environment for the residents.

Licensing and Reimbursement Policies

As levels of care and services increase with Residential Care Homes, so also do changes in licensing and

reimbursement policies. In researching the licensing and registration requirements within your State,

start by contacting the Department of Aging and Disability Services within your County. In regards to

Medicaid reimbursements, historically, States used flat daily rates of reimbursement. However, an

increasing number of States are creating tiered categories where licensing and reimbursement are

adjusted to reflect the level of service of individual Residential Care Homes.

Nursing Home Conversions and Transfers to Assisted Living

Proponents of Residential Care Homes and Assisted Living Facilities, including policymakers and industry

advocates, believe that such facilities can serve as a substitute for higher-cost Nursing Homes without

having a negative effect on the health status of residents. The Agency for Health Care Policy and

Research estimated that between 25 and 35 percent of Nursing Home residents are in such facilities

primarily because of limitations in their ability to perform personal care tasks such as bathing, dressing,

and ambulating - that a number of these individuals could potentially live independently or in supportive

Housing settings with community-based support. This is leading to increasing changes that include an

increased investment and growth in for-profit corporations.

A handful of States are trying different strategies to stimulate the movement of qualified residents from

Nursing Homes to more appropriate Assisted Living Facilities. One approach used by States with an

excess supply of Nursing Home beds is to make funds available to convert them to Assisted Living

Facilities.

Some states, such as Oregon, are explicitly following a policy of diverting Nursing Home-certifiable

residents from Nursing Homes into residential settings. In fact, as early as 1991, Oregon reported

relatively little difference in the functional characteristics of those in Nursing Homes and those in

Assisted Living Facilities.



Consider the following two articles:

A BETTER WAY TO SERVE SENIORS

- MICHELLE NORRIS, MCKNIGHT’S LONG-TERM CARE NEWS & ASSISTED LIVING

The struggle to lower healthcare costs, especially Medicare and Medicaid, affects us all –

from Congress to long-term Providers to the very seniors we serve. As an Affordable

Housing Provider for low-income seniors, we know first-hand that many senior residents

could live more independently if only they had the right support. When I joined National

Church Residences 20 years ago, our goal was to combine practicality and caring with a

successful housing approach – and that's been the goal since our founding in 1961.

Our experience, especially when we began offering health care services, demonstrated that

housing with support services wouldn't cost more at all. In fact, it would cost less. Today,

we know that Affordable Housing with services is a viable, successful platform to deliver

healthcare more cost-effectively — and with better results. How? We were so certain of

our care model (especially at a time when families were asking for alternatives to a nursing

home bed), that we tested it by developing attractive, safe and affordable housing paired

with support services.

The proof came when the Kresge Foundation provided National Church Residences and the

Ohio State of Office of Health Transformation with a $150,000 cost-study grant to study cost

savings at our affordable assisted living communities (created with HUD grants). The result:

not just cost savings. Substantial cost savings.

The study, conducted by Health Management Associates, found that our model provided a

49% savings over the cost of a nursing home bed — all while saving the state $73.08 per

person per day vs. living in a Nursing Facility. For perspective, a Nursing Home bed cost

(including other medical costs incurred outside the bundled rate) averaged $149.44 per

person per day. The average cost for individuals in an Assisted Living apartment, including

other medical costs incurred outside the waiver rate, was $76.37 per person per day.



Additionally, the report concluded that the affordable, assisted-living environment allows

seniors to live in communities more independently. This is incredibly exciting news for all of

us providing the continuum of housing services and long-term care. It's a road map for

substantially reducing Medicaid costs while also improving health outcomes.

Here's the reality. About 20% of those in skilled Nursing Facilities could actually live in

affordable senior housing, but they don't. Why? Almost all of Ohio's Assisted Living

Facilities are Private-Pay and don't accept Medicaid-eligible residents. The truth is if

Medicaid committed even a small percentage of the dollar difference to community-based

housing with services, more seniors could move to a much more cost-effective model – with

improved results.

Now that we can demonstrate the initial Medicaid savings, we all must work in collaboration

with others to seek creative financing options to expand such lower cost, high-quality

solutions.

Michelle Norris is the senior vice president of business development & public policy at

National Church Residences.

AGING POPULATION DRIVES DEMAND FOR SENIOR HOUSING

- CHELSEA SCHNEIDER, NWI.COM

When Frances Wulf, 92, made the decision to stop driving and sell her car, she began to look

for her next step. Wulf, who moved to Valparaiso from Wisconsin to be near her kids about

three years ago, had lived independently until the age of 91. One day Wulf surprised her

daughter by saying she wanted to look at the rooms at Rittenhouse Senior Living in

Valparaiso. Wulf moved in late September after picking the facility, because she said it felt

like she was checking into a hotel and not a hospital.

Statewide, one in five Hoosiers will be older than 65 by 2030, and the number of seniors is

expected to grow locally in the next 20 years as well. In 2010, seniors comprised 13 percent

http://www.nwitimes.com/search/?l=50&sd=desc&s=start_time&f=html&byline=Chelsea%20Schneider%20Kirk%20%0Achelsea.schneider%40nwi.com%2C%20%28219%29%20933-3241










of Lake County’s population and 12 percent of Porter County’s population. Those numbers

jump to 20 percent for Lake County and 21 percent for Porter County by 2030, according to

state estimates.

“In regards to the industry, there is still a tremendous demand that is needed and supply is

not there,” Fairbanks said. “I think what's happened, there is a tremendous influx of supply

on your primary, large markets and your big cities have a lot of supply. There are still a lot

of pockets in and around the country where the demand far outpaces the supply.”

Growth in Senior Industry

Construction of Assisted Living Facilities has returned to pre-recession levels, notching up

activity for the overall industry, McGraw said. In the first three months of this year,

construction of new units represented 2.5 percent of the existing inventory for Senior

Housing. While the percentage is down from the pre-recession peak of 4.8 percent in 2008,

it’s up from the 2 percent recorded in early 2011.

Following the recession, the center is seeing fewer freestanding independent living

properties break ground but instead more developments that bundle together independent

living, assisted living and memory care.

Affordable Housing a Challenge

The Indiana Housing and Community Development Authority, which oversees the

distribution of tax credits for new construction and remodeling of affordable rental housing,

saw a high demand among senior projects in its latest round of funding, authority

spokeswoman Emily Duncan said. Of the 20 projects that got such tax credits this year, 14

competed in the elderly category of housing developments serving residents 55 and older,

Duncan said.

In Gary, a 38-unit senior housing project — Gardens on Carolina — by Volunteers of America

is in the final stages of construction. The organization is the leading nonprofit to provide




























affordable housing for seniors in the country, said Tim Campbell, president and CEO of

Volunteers of America of Indiana. “With the aging of the baby boomer generation, we see

this as a real area of focus,” Campbell said. “There are going to be so many individuals go

into retirement not financially prepared, and having the availability of low-cost, decent

housing is something we think many folks will need.” In trying to address that need, some

communities have developed policies that privately developed housing must set aside a

percentage of units that meet affordability standards, Stafford said.

With this understanding about the Assisted Living business model, as promised, let me share how one

husband-wife team, John and Renee, are creatively customizing their Residential Care business to

exponentially increase their net worth. Note, John and Renee are not their real names. Because they

have a long-term strategy for increasing their number of community-based Residential Care Homes,

they have requested that I protect their anonymity and location. In assisting with their NEMT and Home

Care businesses, I have discovered and definitely appreciate John and Renee’s unique strategy.

Starting in 2008, with a Non-Medical Home Care Agency, as of this writing, John and Renee employ

more than 80 Caregivers - and yes, they are very much concerned about how Obamacare is going to

affect their business and bottom line. They have been working to restructure their entire Human

Resources in an effort to limit their exposure to Obamacare penalties and taxation.

Needless to say, with the success of their Home Care Agency, John and Renee are skilled in providing

care to seniors and in managing Caregivers. Thus, expanding into Residential Care Homes becomes a

relatively seamless progression. Intent on increasing their portfolio, in September 2012, John and Renee

invested in their first Residential Care Home. The following are some of the particulars of this Facility:

John and Renee purchased a 4 bedroom, 3 ½ bath suburban home for $234,000

Their Residential Care Home is dedicated to serving seniors diagnosed with Alzheimer Disease

This Care Home is staffed 24/7 by a single Caregiver working eight hour shifts

John and Renee assist with daily care as needed, but primarily serve as support service in

keeping the Facility operational

Unlike typical Residential Care Homes that house between 6-12 residents, John and Renee limit

their Home to four residents











John and Renee accept only Private-Pay clients drawing prospects from their Home Care Agency

As of this writing, rent for each of the three residents is $4,200 per month for which each

resident has their own room

What makes this Care Home unique and, in my opinion, ingenious, is illustrated in John’s response when

I asked him why he limits this Residential Care Home to only four residents. John explained, “We are not

just in the relationship business, we are also in the real estate business.” In explaining their business

model, John and Renee shared the following goals and objectives:

John and Renee are dedicated to finding quality homes in suitable neighborhoods that will

continue to appreciate in value

They limit the number of residents to four because they wish to leave a “small footprint” on the

property. Focused on the resale value of the property, John and Renee are very conscientious

with any remodeling or upgrades

Because of the financial success of their Home Care and NEMT businesses, John and Renee use

all profits from their Residential Care Home to aggressively pay down the principal on their 30

year note. They anticipate having this property paid off in between 6-7 years!

With a growing waiting list of prospective residents, John and Renee’s goal is to leverage each

Facility to purchase and start a new Residential Care Home each year for the next 7-10 years.

This will allow them to serve the needs of their community while passively increasing their net

worth to well in excess of $2,000,000

What I really like about John and Renee’s strategic approach to Residential Care Homes is what they are

leveraging. First, they are leveraging demand, a growing elderly population and their associated

essential needs and services. Second, they are leveraging what they already do, providing Non-Medical

Home Care and managing Caregivers. Third, they are leveraging time, aggressively paying off mortgages

while allowing their properties to appreciate in value – Awesome!




While achieving success in the NEMT industry, I diversified into a

Courier and small package Delivery Service for the two hospitals we

were contracted. It was a natural and seamless progression as the

hospital’s Support Services initially enlisted our help to deliver files,

oxygen tanks, wheelchairs and sometimes linen between the two

hospitals and surrounding facilities. Over time, these services naturally progressed and expanded to

delivering blood, lab results, and on occasion, human organs!

For my company, diversifying by adding the courier business was easy because we already had the core

infrastructure; a fleet of vehicles, drivers and hospital contracts and an established reputation to

leverage. This courier work was an excellent and welcome source of additional revenue. With a few

exceptions that included bulk mail delivery services for a Business Process Outsourcing (BPO) and

Consulting Firm, most of our courier work was primarily dedicated to servicing hospital and medical

facilities. However, you definitely do not need to limit yourself to serving only as a Medical Courier.

Many of you may recognize the name, Carlos Banks, author of the popular ebook “How to Start a

Successful Courier & Small Package Delivery Servicev.” With 20 years of experience in working for UPS,

Carlos took his own courier service to an even more advanced level, one in which he became a

Subcontractor for large delivery companies in addition to serving local businesses. Because most courier

entrepreneurs do not have a fleet of vehicles or drivers for which to leverage, Carlos explains that the

easiest way to enter the courier industry is to start as an Independent Operator or Freelance Courier.

Ironically enough, in the midst of a recession and down economy, Carlos explains how it is actually an

ideal time to start a courier service. Why? Because as the economy slows, more and more companies

are outsourcing work and transportation needs in an effort to reduce overhead expenses. With

fluctuations in fuel, insurance, and labor costs, companies and services are enlisting the help of smaller,

Independent Operators because of their specialized versatility and ability to make numerous deliveries.

Consider the following email that I recently received from Carlos explaining how his courier business is

continuing to expand into growing freight opportunities:



I want to give you a little insight on the type of freight deliveries that exist. My first

opportunity is with a courier broker which hires Independent Operators. They needed

someone to take over a daily route delivering office supplies. This contract is for roughly

$850.00 per week, $3,683 per month, or $42,000 per year.

My second opportunity is with a company that supplies lighting for restaurants and other

commercial properties. The lighting is palletized and they were looking for someone that

could be a little more flexible and readily available than the bigger trucking companies. This

contract is for $1,200.00 per month or about $14,000 per year.

A third opportunity is with a textile plant that makes twine and threads wrapped on bobbins.

The owner needs someone more flexible than the "Big trucking" companies that could

handle about 2,000 lbs. of palletized freight per trip. This contract makes roughly $400.00

per month on a low end or about $4,800 per year.

As you can see, this is only three companies that produce more than $60,000 per year in

revenue of which I make roughly $40,000 in profit on the low end.

We will discuss Carlos’ email in greater detail momentarily. But as you can see, there are other

attributes that attract hospitals, corporations, law firms, banks, and businesses of all industries to local

courier services versus global delivery services such as UPS, Fedex, and USPS. These attributes include

(1) same day delivery, (2) reduced cost, (3) flexibility, (4) multiple deliveries and pickups per day, and (5)

fewer regulation or shipping procedures. But even more interesting, most people don’t realize that

larger global delivery services outsource portions of their work in strategic locations. Yes, it’s true, even

the popluar FedEx, UPS, USPS, and many trucking companies seek Independent Operators to

strategically assist their exhaustive operations.

Think of the massive infrastructure and routes of distribution required for these large companies. Do

you really believe that they can service every corner of the country and beyond? Absolutely not! Now,

coupled with rising overhead expenses compounded with a recession, it screams subcontracting. Even

these large, industrial sized delivery operations need to cut costs. When large delivery services can

subcontract work, especially in more rural areas, they reduce their fuel, vehicle and labor related



overhead expenses. Think back to the Broker-Subcontracting section of this resource. Much the same

way, it is ideal for global delivery services to subcontract to smaller, more Independent Courier Services.

Large delivery services have global brand recognition. However, you do not have to worry about your

courier service being overshadowed because, as Carlos explains, there are fewer direct competitors than

you think – especially as you build strong, strategic relationships within your local community. As we

experienced in working with local hospitals and medical facilities, there is always room for local, smaller

Delivery Services that offer same day delivery with much more flexibility.

Becoming a Subcontractor for Larger Delivery Services: Large Delivery Companies subcontracting work

to your service will require you to sign an Independent Operator Agreement identifying you as “The

Courier“ instead of an employee of “the Company.” This is a very common practice for the legal and

liability protection of both parties in addition to defining expense responsibilities.

Stipulations of such Agreements usually include some or all of the following:

1. You, The Courier, own or lease your own vehicle. The lease or loan payments are not contingent

upon your performing services for The Company

2. If you need any equipment to service deliveries, you are required to purchase or rent any auxiliary

equipment required

3. You are paid based on deliveries accomplished and not by the hour or fixed time period. You are not

paid if the customer doesn’t pay because of your failure to deliver or a late delivery

4. Subject to applicable insurance requirements, you are free to substitute another driver to complete

deliveries

5. You pay for all vehicle expenses (fuel, maintenance and repair, insurance, etc.) to include possible

tolls or tickets

6. In most instances, you are free to set your own hours and subcontract for multiple companies

provided you fulfill all accepted delivery requests for The Company

7. You may accept or reject available dispatch requests without penalty



8. You can wear your own uniform but may be required to carry identification as rquired by The

Company

9. You are not required to sign a Non-Compete Agreement. The company may require you to sign a

confidentiality or nondisclosure agreement that includes provisions prohibiting you from using The

Company’s confidential information such as customer list for personal benefit

10. Subject to customer requirements, The Company does not specify particular routes that you must

follow or the order in which deliveries are to be made

Reimbursements for Subcontractors: When serving as a Subcontractor for a large Delivery or Trucking

Company one of two things is going to happen. Either they are going to dictate how much they

reimburse you or they are going to ask you for your proposed rates. If the company tells you how much

they are willing to pay, it is usually because they already have predetermined and negotiated rates with

their clients whom you will serve. Thus, in turn, The Company will reimburse you a sizeable percentage

of the delivery. If The Company asks you how much you plan to charge, that is an open invitation for

negotiation. However, this is where “knowing your numbers” is very important. You need to know your

cost to provide service plus how much money you need to make on each transport to make it worth

your time and effort.

Never be afraid or intimidated to negotiate. I know that it can be more uncomfortable in the beginning

when you’re first starting out and you don’t have much of a track record. But be honest with your

prospective client, the Company. Work to create open dialogue and get a sense from them in regards to

“ball park figures.”

Some more important advice, regardless of the type of business or industry, whenever you’re

attempting to subcontract and you are meeting with the Company, you are interviewing them just as

much as they are interviewing you! The relationship is a two-way street. If it is not feasible and

profitable for you, then the deal is not worthwhile. Likewise, if there are any conditions or stipulations

that put you at a disadvantage, then the deal should not be pursued. As I always say, “Some of the best

deals are the deals that don’t happen!”



Flat Fee Rates of Reimbursement: When discussing rates with a client, always keep it as simple as

possible. This is not only for your benefit, but also your customers. Think in terms of your customers.

Whether you’re subcontracting for a Company or providing direct services to a business or facility, the

last thing they want to do is struggle when trying to calculate their cost for your services. Furthermore,

you don’t want to confuse yourself when trying to calculate how much a client owes you!

Many Courier Services charge a flat fee plus mileage. This is a very convenient process for both you and

your clients. For example, if you have a flat pickup fee of $12.00 plus $1.50 a mile and your delivery is

10 miles then your total invoice is $27. This flat fee rate strategy is very convenient and easy to itemize.

The only “problem” is making sure that you always monitor and calculate your mileage. Obviously, your

charges are based upon mileage so you need to be diligent in documenting your start and end mileage.

The common practice is to round up and round down. If the ending mileage is 10.3 you only charge $15

for mileage (10 miles). If the ending mileage is 10.7 then you will charge $16.50 (11 miles).

Payment Arrangements: Depending on your client and the type of deliveries, you will typically bill your

clients weekly or monthly. Should your client’s customer fail to pay them, it is your client’s responsibility

to absorb the loss – not yours - unless failure to pay is due to your non-performance. In such an event,

you will absorb the loss.

Startup Vehicles: Obviously, if you already own and operate a NEMT

business, using your existing vehicles is ideal. There is no reason to

incur additional cost in new vehicles and assets. Leverage what you

already have. However, in the event you are entering the

transportation industry via a Courier Service it is most cost effective to

start with your own vehicle. If your primary deliveries entail messages, small packages, and the like,

then the type of vehicle you use is relatively inconsequential. You do not need a big vehicle that will

incur excessive fuel or maintenance costs. This also means that finding a great deal on vehicles is never

going to be a chore since deals on smaller more fuel efficient vehicles are endless.



However, if you anticipate delivering larger products such as mail tubs, auto parts, luggage, and more,

then you will need, as a minimum, a small truck, a cargo van, or an open bed minivan. If given the

choice, I recommend using an extended cargo van with an open bed. Some companies will not consider

subcontracting to you unless you operate a van-type vehicle. The company wants to ensure that,

relatively speaking, you are not limited in the number of packages you can transport.

Especially with a down economy, you need to be all the more pragmatic and financially prudent as you

pursue any business venture. For this reason, starting a courier and small package delivery service can

be a very cost effective way to penetrate your local transportation market. Especially if you already

have a reliable and presentable vehicle, getting started can be relatively easy and very cost effective. I

say a “presentable” vehicle because the last thing you want to do is start a business, promote your

name, and begin building brand awareness with a “rust bucket.”

In going back to Carols’ email that we discussed previously, a personal vehicle, let alone his existing

NEMT and courier cargo vans would not accommodate his three freight contracts. Consider how Carlos

resolved the problem in the second half of his email:

I wasn't prepared with the right vehicle for these freight jobs. I regularly us my NEMT and

cargo vans for courier work, but these vehicles don’t adequately serve the purpose of hauling

freight. I considered renting a box truck, but honestly, you just can’t always rent such a truck

on short notice to do a job. When some calls for a same day delivery or pick up, box trucks

especially may not be readily available. Rental companies also charge a basic rate, a

mileage fee, potential fuel charges, and insurance deposit. Rental fees are fine in the short-

term, but not long-term. All the additional costs add up and can cut into your profit margin.

I searched Craigslist feverishly and, lo and behold, I found a box truck for around $3,700

dollars. It was a 14 foot vehicle, Non-CDL meaning I didn’t need a commercial driver’s license

to operate this vehicle. This van was perfect for what I needed and the insurance is much

more cost effective than NEMT insurance. Insurance requirement is 100/300/50 and I also

purchased $60,000 cargo insurance for only $1,100 per year – not bad compared to the

insurance on NEMT!




A few years ago, a client named Devon enlisted my help to work with him One-on-One in building his

NEMT business. After experiencing years of success in the Durable Medical Equipment industry, Devon’s

business of equipment sales and rentals was heading in reverse because of reduced rates of

reimbursement and continued increases in bureaucratic “red tape” from insurance companies,

Medicare, and Medicaid. Not only were rates of reimbursements decreasing, but in an effort to fight

fraud, Medicare and insurance companies continued to increase collection policies and procedures. As a

result, he “saw the writing on the wall” and knew that transformation and diversification of his business

was essential.

In learning more about Devon’s Durable Medical Equipment business and reviewing his Profit & Loss

Statements for the previous years it was easy to see his plight and concern. His overall volume of sales

and rentals continued to increase annually which was an outstanding testament to his efforts as a

business owner. The problem, however, is that his profit margin and overall bottom line continued to

decrease for three consecutive years! Volume was increasing but, due to reduced premiums and

demanding collection procedures, profits were decreasing. Obviously, this is not the pattern that we

aspire to achieving as business owners!

The good news, however, is that there were specific elements and portions of Devon’s business that

were very much successful and, if dissected and re-branded, could prove to be very lucrative. More

specifically, when we analyzed the various

portions of his business, it was obvious that his

Private-Pay clientele was highly profitable –

much more profitable than his Medicare and

insurance-based business. This was for a few

reasons. First, the increase in time and

overhead expenses to process claims for reimbursement were dramatically increasing. The paperwork

and bureaucratic hurdles were growing. Second, the lengthy delays in awaiting payment were also

increasing. At the time I was working with Devon, some of his “Approved” transactions remained

almost six months in arrears! Third, the number of reimbursement denials for “technicalities” were



increasing. Thus, Devon and his staff were forced to spend additional time contacting and coordinating

with doctors and processors, chasing down signatures and authorization, and more in an effort to collect

reimbursement. Fortunately, with Private-Pay clientele, there were no such hassles, policies or

procedures.

In response to these growing problems, Devon and I developed a well-devised two-prong strategy to

transform his entire business. Although it was a dramatic change in Devon’s business model, it was

essential for his survivability and profitability. While leveraging many of his existing contacts, clients,

and relationships to build his NEMT business, Devon was going to systematically wean his Medical

Equipment business out of the Medicare and insurance sector and focus exclusively on profitable

Private-Pay clientele. In so doing, we also reduced the overall number of items featured in inventory.

Items that statistically sold or rented the least in volume were not restocked in inventory and were no

longer featured. Essentially, all of “the fat” from his business was being eradicated; we were

streamlining. All efforts were focused on targeting and expanding profitable sources of revenue -

exclusively!

Working with Devon and studying his business was a great opportunity to witness first-hand the

profitable and almost passive source of revenue that equipment rentals can produce. After sharing

Devon’s story at one of my live Seminarsvi, ironically enough, Carlos Banks, the entrepreneur we

discussed in the previous chapter, took the inspiration and started his own medical equipment business

when the opportunity essentially fell into his lap.

When purchasing a used NEMT vehicle, Carlos acquired two FREE used electric wheelchairs; equipment

that the seller no longer needed nor wanted. Thus, free of charge, Carlos quite literally had two

excellent pieces of equipment that would serve as seeds of his rental business. After having the

wheelchairs refurbished and prepared for money-making use, Carlos established his rental rates and

created professionally designed brochures featuring his power wheelchairs along with manual

wheelchairs.

Carlos’ marketing efforts started by distributing his brochures and associated information to key

facilities and contacts where he provides medical transportation. Needless to say, by leveraging existing

contacts and relationships, it wasn’t long before Carlos needed to expand the number of wheelchairs in

his inventory to keep up with demand.



As Carlos’ rental business grew he began to test and add new items and types of equipment to his

inventory. However, unlike Devon who eventually found himself overwhelmed with excessive inventory

and unable to readily determine which items were profitable, Carlos kept a keen eye on his sales and

statistics. As his business grew, Carlos was able to determine which items were most popular and

profitable. Items that were less popular were removed from inventory. Because Carlos’ rental business

remains exclusively Private-Pay, he does not have to wait to collect his money or comply with excessive

bureaucratic “red tape.”

There are two additional key points worth mentioning regarding Carlos’ rental business model that

demonstrates additional possibilities. First, by having an NEMT business and courier service, Carlos is

able to market equipment delivery and pickup services. This helps Carlos to generate additional revenue

as well as provide added value and convenience to customers. Second and ironically enough, because

he already has a fleet of vehicles and drivers, a much larger and more diverse equipment company has

enlisted Carlos’ help by subcontracting some of their deliveries through his transportation business!

Thus, Carlos continues to diversify his sources of revenue as well as his referrals.

The following pages feature a handful of screen-captured images that illustrate the level of ease and

convenience required to begin a rental business. The pictures are from a website that offers a select

number of mobility rentals in addition to delivery options. When you consider the infrastructure that

you already maintain via your NEMT business, possibly your courier business, your vehicles and

personnel, you will see how starting a rental business, even if only limited in size and inventory, is very

feasible. Further, when you consider the growing demand for Home Care and Assisted services, I trust

that you will see nothing but great opportunity.








During the many years of working with entrepreneurs and Transportation Providers, I have been privy to

many interesting and profitable possibilities. As I mentioned previously in this resource, creative and

motivated entrepreneurs will always find profitable solutions to satisfy demand. I believe I am skilled in

predicting many opportunities associated with the NEMT industry, yet I can honestly say I never

anticipated the synergistic possibilities between a Non-Emergency Medical Transportation Company and

a Moving Service. To my surprise, I was completely enlightened when I learned the particulars of how

Dexter, a Provider I had worked with previously in starting his NEMT business, began doubling his

monthly profit in less than one year with his new venture. Further, Dexter quite literally discovered the

idea of starting an Elderly Moving Service by complete accident.

Some of you may be asking “What’s an ‘elderly’ moving service? What distinguishes an ‘elderly’ moving

service from a typical moving service? What does it have to do with the medical industry?” Those are all

valid questions – questions that I was asking when Dexter

was first explaining his growing success.

An elderly moving service is simply another exclusive niche

business that is helping meet the needs of seniors. In a

very unique resource that Dexter and I recently published,

“How to Build a Local Moving Company with 69.1% Profit

Marginvii,” Dexter shares his story - how he has diversified his NEMT business into a moving service that

started by helping seniors downsize and move into Independent Living Facilities.

Now, before you dismiss this idea or, like I did, you question the market potential of an elderly moving

service, let me share with you the following article published in a New Jersey newspaper:



INCENTIVES HELP N.J. SENIORS GET MOVING, RETIREMENT COMMUNITIES REACH OUT WITH A HOST OF SERVICES

- DAN GOLDBERG, THE STAR-LEDGER

As people sell their homes and look for new ones, some continuing-care retirement

communities across the state are offering new services and incentives to entice senior

citizens. These services include personal moving consultants, lists of preferred real estate

agents and cash loans, all offered to seniors, who make up about 20 percent of the seller’s

market.

These communities are part independent-living, part assisted-living and part-skilled nursing

homes, providing care that progresses as the needs of an individual resident increase. There

are 27 such communities in the state, with more than half concentrated in five counties:

Burlington, Camden, Monmouth, Ocean and Somerset, according to a state report.

Earlier this year, when Bob and Marilyn Macrae were ready to sell their home in North

Haledon where they had lived for 38 years, they were aided by Margaret Semezko, a

personal moving consultant employed by Cedar Crest Village, a 130-acre continuing care

retirement community in Pompton Plains.

"She meets with everyone," said Ray Guarino, director of sales at Cedar Crest. "She acts as a

quarterback and helps them through this process." The Macraes credit her with their

success. In six weeks, the Macraes, both 79, had put their home on the market, sold it,

signed the paperwork and moved into their new apartment in Cedar Crest. And they cleared

more than $50,000 more on their home than they had asked.

There are no statistics tracking the market for these continuing-care communities, but as

more homes sell across the state, Sales Directors report increased interest. "We are

definitely seeing a trend recently in Monmouth and Ocean counties," said Rick Kiernan,

Director of Sales at Seabrook Village, a scenic 98-acre campus in Tinton Falls. "The real

estate market has picked up, and the homes for our perspective residents are selling much

quicker."



Some of this trend has as much to do with real estate sales as it does with demographics.

From 2000 to 2010, New Jersey’s population grew by 4.5 percent, according to the U.S.

Census. But the 55-and-older population grew by nearly 20 percent. The demographic

realities and some improvement in the real estate market have breathed new life into the

Continuing-Care Industry, which is still trying to rebound from the worst of the recession.

In Somerset County, Fellowship Village recently partnered with Moving Station, a company

that provides seniors with a list of preferred real estate agents who can help sell the home.

Nina Updegrove, Fellowship Village’s vice president of marketing, said the partnership is

meant "to get people to overcome their fears of listing their home, and fears of not being

able to sell it."

About a year ago, Monroe Village, a Continuing-Care retirement community in Monroe

Township, partnered with a "financial concierge," said Bill Brottman, Director of Sales and

Marketing. They will price a home and loan the owners up to 70 percent of what they deem

to be a realistic sale price, which can be used to cover the cost of moving into Monroe

Village, which pays the interest.

Again, I probably never would have thought of this niche business, helping seniors downsize and

transition into independent living facilities. Ironically enough neither did Dexter! But ultimately, you

can’t argue with his results. Dexter has been taking a $2,000 per week salary from his growing NEMT

business. However, within eight months of incorporating his moving service, Dexter was generating

over $8,000 per month in additional profit. He went from a monthly salary of roughly $8,000 to $16,000

in less than eight months!

As Dexter explains in “How to Build a Local Moving Company with 69.1% Profit Margin,” this opportunity

literally “fell into my lap.”

One day one of the Social Workers, Grace, contacted me and asked if we could help one

of their former residents move from her home into one of their independent living

facilities. This particular nursing home is part of a chain or family of facilities and

independent living facilities that we have a great relationship with. We do a lot of

business with them. Well, at first I didn’t understand what she was talking about. I



thought that maybe Grace wanted us to help a moving company to carry stuff. Then I

realized she actually wanted us to be the moving service. My initial reaction was to

kindly say no because you can only do so much with an ambulette. But out of respect

because we have a great relationship with Grace and this facility, I asked what all she

needed moved. Grace told me that it was a lady that we transported a few months ago

and we had gone back later in the evening to move some of her stuff. When she

mentioned the name I remembered because I was the one to go back and pick up her

stuff later in the day and deliver it to her residence.

Grace went on to tell me that this elderly woman’s daughter lived out of state and that

the daughter asked her for help in coordinating her mother’s move from her residence

into their independent living facility. The mother was obviously downsizing. The

daughter was going to be in town to pack things up and help supervise the move. Like I

said, I remembered this lady and her house because I’m the one that went there to drop

stuff off.

Now, a few years ago when my wife and I were moving we rented a U-Haul truck and

between us and my brother we moved our entire house in a day. So long story short, this

same idea popped in my head. I told the Grace that if the daughter was interested I

would rent a U-Haul and one of my drivers and I would do the job. I told her I would call

her back later on and let her know how much we would charge. So I called U-Haul and

asked about their pricing to help figure out my game plan. I then called Grace back and

told her we would do it for $120 per hour which included both drivers and the cost of the

U-Haul plus $2 per mile over 20 miles with a minimum of 4 hours. Grace said that she

would pass along the info to the daughter and let me know. The following day Grace

called me back and said that she spoke to the daughter and that we got the job.

Without exaggeration, this is exactly how we got started. I’m not exaggerating. It was

that simple. I know it’s not an exciting story, but that really is how it happened.

After successfully completing this specific job with great satisfaction, Grace, the social worker, contacted

Dexter later that same month to see if he could do another move for another senior moving into their

Independent Living Facility. Using one of his NEMT drivers, between the two separate jobs Dexter made



$1,680 in total revenue. According to Dexter, “that’s when the light went on.” He began brainstorming

how he could make this a viable business.

Following his October success, Dexter sat down with Grace to inquire into the possibilities and prospects

of expanding and creating a more formalized moving service for the seniors moving into their chain of

facilities. With the message and opportunity well received, Dexter had a handful of additional moves in

the months of November and December. He then incorporated his new business for the first of the year

and began marketing to the general public.

Needless to say, according to Dexter’s numbers below, his efforts and this entire business opportunity

have proven to be a great success.



As you can see, the success of Dexter’s moving business should serve as motivation for any

entrepreneur seeking a profitable business opportunity in a potentially short period of time. Again,

within eight months of his incorporating Dexter was literally doubling his personal profits.

We couldn’t have predicted any of this. So I don’t ever proclaim I’m some genius that

came up with this idea. All this really came about by accident - just trying to provide

added value to our customers. The next thing you know I’m renting a U-Haul to help a

client, then doing it again and again and now I own my own moving truck and run two

crews. So did we anticipate any of this? No, absolutely not. But so far, it’s been an

awesome year because [Name of NEMT Company] continues to grow and now we’ve

built a second business with even higher profit margins that’s doubling our personal

income.

What Type of Truck Should You Use for a Moving

Service? Starting in the month of May, Dexter began

using his own truck. He kept track of his truck expenses

which included his monthly U-Haul rental fees. Once this

number exceeded the cost of operating his own truck,

Dexter purchased a used GMC 3500 Savana 14' box

moving truck with a ramp.



Despite operating his own moving truck, twice in the month of July and three times in the month of

August Dexter had to again rent a U-Haul because he had multiple jobs requiring two different moving

crews operating at the same time! As can be expected, when these additional rental fees exceed the

cost of another moving truck, Dexter will invest in another.

Why a 14 Foot Truck Versus a Smaller or Larger Size? According to Dexter, there are actually a couple

reasons as follows:

First, when I rent from U-Haul the 14’ trucks are very cheap. Overall, I think the 14’

trucks have the best price-point in terms of cost. It costs me $19.95 for a day for rental

fees and $.99 per mile from the time I pull off the lot. Plus I also have to top off the gas.

So just off of price alone you can’t go wrong with this size truck.

A second reason is because 14’ trucks are very manageable to operate, park, backup,

and maneuver in driveways. Years ago when my wife and I were moving we rented a 24’

truck and it was a pain in the butt because of where we lived. We didn’t have the widest

of streets and between the cars parked on the street and passing traffic we had to play

traffic cop half the time. It was a pain in the ass - a hassle and a distraction that I have

no desire to deal with again. So just from personal experience, a 14’ truck is more

convenient and manageable. And now that I’ve been using a 14’ truck for business I’m

even more used to it and find it to be an ideal size.

Another reason is because 14’ trucks are big enough that you can move a lot of stuff yet

small enough that it requires more trips – and more trips means more time and more

money.

And remember, my company is still very young right now. I’m just shy of one year and

this will be my fifth month with owning my own truck. So I’m still very much learning

things and working to come up with creative ideas to better build my business. As we

grow, which I fully intend to explore all options, I may determine that bigger size trucks

are needed. But I will cross that bridge when I get there. For now, I’m doing great with

a 14’ trucks. I definitely think that anything less than that is too small and anything

bigger than this is really not necessary as of right now. So if I had to suggest a particular

size of truck for anyone thinking about expanding into this business I would definitely say



go with a 14’ to 17’ truck to start with and then go from there. If you think you need

something bigger then go bigger, but only after you feel more comfortable and you see

the need for larger trucks.

There a few reasons, in my opinion, that makes diversifying into a local Moving Service so appealing.

First, moving trucks are versatile and give you various revenue-generating options. When discussing the

Courier business model, Carlos mentioned his $3,700 investment for a used 14 foot truck for his freight

deliveries. As of this writing, Carlos has been significantly expanding his freight clientele to include

making local furniture deliveries for Big Lots, a national retailer. Another Transportation Provider I have

worked with started with NEMT and expanded into Courier. Using a box truck, he landed an exclusive

Agreement with a company that manufactures wooden pallets. Today, he has a small fleet of box trucks

and delivers all over the Northeast.

Dexter invested $11,000 for a truck similar to Carlos’ for residential moving. After gaining experience

working with one Independent Facility, Dexter began marketing to and servicing other facilities.

I’m trying to build a common brand that includes both my moving service and NEMT, I’m

actively marketing our service to other independent living facilities – and it’s paying off. I

actively started to market to other independent living facilities. We actually have a

government subsidized chain of facilities that’s pretty big in our State. They have 27

independent senior living facilities across the State with 9 of them being in our county. Most

of these 9 facilities are rehabilitated old schools and office buildings. So in January I met

with the “Director of Resident Services” to introduce our services and to see if they could do

something similar to what Grace has done for us. But because they receive government

funding she said they can’t actively promote our service – they can use us, but according to

her they cannot show favoritism by endorsing any particular service.

The irony is that they actually do use us, but not like I anticipated. I went in there thinking

that they could refer us to some of their prospective elderly tenants that would be moving in.

So far I think we have only done one of those moves – moving someone into their facility.

But if you look at our P/L, you’ll see quite a few of those 4 hour jobs. A lot of those 4 hour

moves are the [Name of Independent Living Facilities] hiring us to move residents out of their

facility. So when I went to meet with the “Director of Resident Services” I was hoping that



they’d use us to move people in yet they’re pretty much using us to move people out. It’s

funny, but I’ll take it.

Are you seeing the synergistic possibilities between all of these various business opportunities?

A second reason why I applaud the moving business model is because, like Dexter, you can reimburse

your movers as Independent Contractors and issue them 1099’s at the end of the year. When asked

how he reimburses his movers, Dexter says the following:

I basically pay them straight wages by check. I don’t have them on payroll. I don’t withhold

any taxes or anything like that. This was an issue that I consulted with my accountant on a

while back and basically, because my movers are not working regular hours or scheduled

regular hours like my drivers are, they aren’t regular employees – as of yet. Because our

moving jobs are not scheduled regularly I can basically hire movers when jobs come up. This

is how I’m able to pay them as independent contractors.

Think in terms of Obamacare and the impending labor-related burdens thereof. Any business

opportunity that allows you to make money while avoiding such burdens should be of serious

consideration.

A third reason why I like the prospects of a moving business is, despite the opportunity to assist elderly

people, Independent Living Facilities, and the like, a moving service is mutually exclusive from the NEMT

industry! Yes, the elderly population is booming. Yes, the demand for NEMT is continuing to increase.

But the NEMT industry still remains a niche market. Conversely, people of all ages, marital status, job

status, location, and more are all potential clients for a moving service. Essentially, your prospective

market is significantly greater – especially when you consider that the average family moves once every

four years!

Consider Dexter and how empowered he is in having two separate businesses that net $8,000 per

month respectively. Should anything happen to or cause revenue fluctuations in either business, Dexter

will remain stable and profitable. Such diversity offers significant leverage and peace of mind.



WHY YOU NEED TO BUILD, GROW, SAVE AND CREATE WEALTH

I truly enjoy working with entrepreneurs from around the country for many reasons. Two primary

reasons: first, helping people to improve their business, increase efficiency, create new opportunities,

and ultimately, make more money changes people’s lives -- nothing is more rewarding or gratifying!

Second, working with such a diverse group of people, blesses me with a unique opportunity -- a macro

perspective with insight into evolving trends and strategies.

One growing and common concern that I continue to receive from entrepreneurs, regardless of location,

education, years of experience, or level of success, is fear of the unknown. Their concerns and

apprehension are not about market demand. To the contrary, the growth potential of our market, the

elderly population and the medical industry in general, is undeniable. In fact, the future of our industry

is paved with opportunity. The problem, however, is actually much greater. Over the past few years, an

increasing number of entrepreneurs express anxiety and concern over their ability to not only make

money, but to keep, build and create wealth. Why -- because business owners of all industries are under

continuous assault on many fronts.

We’re facing increased taxes, increased inflation, increased regulation, a devalued dollar, an economy

on life support, and a climate where policies of mediocrity are the norm versus a drive and expectancy

of excellence. Sadly, we’re in a climate where successful business owners are almost vilified, accused of

being mean-spirited and tyrannical, taking advantage of employees versus being congratulated for

empowering people through employment.

“They keep telling us that if we just let business pollute more and treat workers and

consumers with impunity, that somehow we’d be better off. We’re told that when the

wealthy become even wealthier and corporations are allowed to maximize their profits by

whatever means necessary, it’s good for America.”

- Barrack Obama

I have worked with an untold number of business owners from a variety of industries. In so doing, I can

assure you, I have never encountered a business owner who seeks to “pollute more” or “treat workers

and consumers with impunity.” To the contrary, I regularly encounter optimistic business owners who



seek nothing more than to create profitable solutions to improve the lives of all of those around them,

including their employees and consumers!

Further, I have yet to meet a successful business owner who is not committed to honest, hard work. As

we all know, especially in the early stages of your business, it is the business owners who arrive early

and leave late. It is business owners who, during startup phases, work without pay yet, accept all

financial and legal responsibility. Unfortunately, in similar slanderous fashion, wealthy people, most of

them successful business owners, are accused of not doing enough - not “paying their fair share." Yet,

nothing could be further from the truth. Consider the following article revealing the “fair” and equitable

situation of our current tax structure:

WHAT IS YOUR ‘FAIR SHARE’? OBAMA THINKS HE KNOWS BEST

- MATT WALSH, FLORIDA’S BUSINESS OBSERVER

If there is one issue that surely has the attention of Florida business owners, you can bet it is

Barack Obama’s rants about “the rich” paying “their fair share.” As noted in his speech to a

room full of America’s daily newspaper editors, we “as a country” cannot succeed if you do

well and others struggle. As the president told the editors, “Everyone” must get “a fair

shot” and “everyone” must do “their fair share.”

Surely you note that Mr. Obama is never specific on what he means by “fair shot” and “fair

share.” He cleverly avoids explicit definitions. In one breath: “I believe deeply that the free

market is the greatest force for economic progress in human history.” And yet, in his next

sentence, he said “… through government we should do together what we cannot do as well

for ourselves.”

“Through government?”

Through “the state,” through the force of law, through central planning in Washington,

through collectivism, and socialism the state will decide what is “fair” and “just?”



In Mr. Obama’s beliefs, you and all Americans acting in your day-to-day self-interests

apparently are not morally driven or capable of taking care of those in need — in spite of

the historical record to the contrary, which shows Americans are the most charitable and

generous people in the world.

Mr. Obama asked in another speech last week: To extend existing tax rates — or, give

another tax break to “the rich”? To raise taxes on those that “invest in” schools, teachers,

more police officers and alternative energy sources?

Unless we tax more, Mr. Obama infers, there won’t be enough teachers, schools and cops.

In his vision, government spending is untouchable and its growth should be unstoppable.

This is scary for Americans — Obama’s vision of what is required to “succeed as a country.”

His is a vision that shows disdain for you, your efforts and fruits of your labor, your ingenuity

and success.

While you believe in the self-evident truths that all Americans are created equal and

endowed by their Creator with the unalienable rights of Life, Liberty and the pursuit of

Happiness, unfortunately our incumbent president clearly does not.

LOOK WHO’S PAYING HIS ‘FAIR’ SHARE

The figures below are based on adjusted gross incomes (AGI) for 2009, the most recent data

available:

Percent Income Income Threshold Percent of Federal Taxes

Top 1% $343,927 36.73%

Top 5% $154,643 58.66%

Top 10% $112,124 70.47%

Top 25% $66,193 87.3%

Top 50% $32,396 97.75%

Bottom 50% <$32,396 2.25%

Source: IRS, National Taxpayers Union



When you consider that 50% of our working population pays almost 100% of the tax base and the top

10% pays more than 70%, it is nothing short of astonishing! “Fair” – most definitely not! Further, the

statistics and the associated verbal assaults on equitable distributions are equally appalling. Such

numbers, coupled with high unemployment, the changing dynamics in population and the growing

reduction in the labor force, are simply not sustainable long-term. All of these variables lead to an

already weak economy morphing into an even more precarious and potentially disastrous situation.

Thus, you have no alternative but to diversify and maximize your profit-earning potential. You need to

make, grow, and save money now! As mentioned previously, times have changed. No longer can you

focus exclusively on just building your business vertically. Now, you need to explore all options for

building your business horizontally. Again, don’t just take my word for it. Listen to what “experts”

suggest about the status of the economy and prospects for the future:

U.S. IS ALREADY BROKE

- PIERRE LEMIEUX, THE FINANCIAL POST

Many analysts believe that the U.S. federal government is bankrupt. They include, among

others, economists Jeffrey Hummel of San Jose State University and Laurence Kotlikoff of

Boston University. As early as 2006, Kotlikoff wrote an article in the journal of the Federal

Reserve Bank of St. Louis, asking the question “Is the United States Bankrupt,” to which he

answered affirmatively.

Even official government agencies such as the Congressional Budget Office (CBO) and the

Government Accountability Office (GAO), which have each produced scenarios of their own,

are less optimistic.

Social Security (the federal public pensions system) faces increased expenditures over the

next 20 years due to population aging. Even more consequential, is the weight of federal

health programs. U.S. governments, and especially the federal government, spend more on

public health care (Medicare for the old, Medicaid for the poor, and CHIP for children) as a

proportion of GDP than the average country. The new public health insurance system,

http://opinion.financialpost.com/author/specialfp/



dubbed Obamacare, will likely fail at reducing the growth of these expenditures, as the

CBO’s and GAO’s realistic scenarios admit.

These realistic scenarios calculate that maintaining the federal debt at 70% of GDP would

(without different tax policies than those pursued in the past) require an immediate and

permanent cut of about one-third in non-interest federal expenditures compared to their

current trajectory. Any delay would mean still larger cuts in the future. This is a tall order.

The CBO’s and GAO’s realistic scenario estimates that closing the fiscal gap with taxes would

actually require the equivalent of increasing by 50% all federal tax rates on everybody,

bringing to European levels the total tax burden in America. It is far from sure that

Americans would accept this.

The financial liabilities on the U.S. federal government’s official balance sheet are already

five times the amount of its financial assets, not counting its future commitments on

entitlements (Social Security, Medicare, etc.). This government is technically bankrupt.

When investors realize this, a fiscal crisis will develop.

The goal of all my resources is to equip, educate and enable you with techniques and strategies to build

new opportunities, to keep more of your earned income, to build wealth, and to increase your net

worth. My hope is that you will structure your business model to sustain and increase you versus

exposing you to undue risk or liability. I understand that some of the information presented in this

resource can be quite disturbing. Especially when it comes to discussing the economy, impending taxes

and healthcare laws; I apologize for being the bearer of bad news. For me, the actual research and

creation of this resource has, in many ways, been very difficult and troubling. I am a true capitalist and

believe that our country was designed to provide equal opportunities for one and all – not guarantee

equal results via wealth redistribution. For those in disagreement or believe I am exaggerating, I simply

point to the previous article expressing how 50% of our population is burdened with almost 100% of our

tax revenue. Sorry, but that is fiscal abuse and most definitely wealth redistribution!

Despite the policy barriers and regulatory burdens that we face, as business owners, it is essential that

we focus on doing what we do best – press forward and use our God-given creative abilities to build,

grow and develop creative ideas and workable solutions. I realize impending circumstances can be



discouraging, but there are several reasons why growing, diversifying, and integrating your business is

absolutely essential:

Can you afford not to? We are under continued assault via higher taxes, increased inflation,

rising operation and variable costs and more. Seriously, can you really afford not to build, grow,

save and create wealth?

Every business experiences a natural loss of customers regardless of the quality of service. In

the medical industry, clients will pass away, some will transition into full-care facilities, and

some may simply choose another provider. Therefore, it is imperative that you remain on

offense and actively grow, promote, and build your clientele

Competition is a part of a healthy market. You need to remain competitive and provide

exceptional service or your competition can eliminate you

You cannot afford to become vulnerable in any capacity! Being dependent on a single source of

revenue, such as a Broker, puts your business in a very precarious situation. We choose

entrepreneurship in pursuit of self-determination, not to consciously increase our vulnerability

Do NOT allow your business portfolio to become dependent on a single business

In building your business, always remember, anyone can make money. Making money is not hard,

especially when you engage in the growing demand such as we have in our industry. Making and

keeping money are two totally different skills. I can't tell you how many people say "Joel, we're making

$50,000 a month" - or whatever the amount. When I ask, "How much money are you keeping?" a hush

grows over the room. Or, sadly, when I ask "What is your profit margin," all too often I hear "I don't

know, I will have to check with my accountant." If you can't articulate how much money you're keeping

or your profit margin, it is probably because you're not making any profit! As an entrepreneur, you

should knowledgeably know your numbers - it is not the responsibility of someone else! You should

always know the amount of money coming in, going out, how much you’re keeping, and your margins.

Equally important is understanding that keeping money is not the same as building and creating wealth.

When entrepreneurs are profitable; their businesses afford them very comfortable and convenient

lifestyles. But when asked about their net worth, sadly, a hush grows over the room. Essentially, as

quickly as money comes in, so too does it go out. Their savings become limited as is their net worth.



They rely on cash flow to sustain their lifestyle. Needless to say, such a strategy is highly precarious.

Should anything adverse happen to your business it will directly influence your lifestyle.

Consider the strategy of John and Renee, the husband-wife team diversifying into the Residential Care

Home industry. They are not focused exclusively on cash flow. Rather, they are committed to

increasing their net worth via tangible assets, the actual properties used as Care Homes. Should

anything happen to the cash flow of one or all of their three businesses, they still have tangible

appreciating assets. Again, I applaud John and Renee for their excellent, consistent wealth-building

strategy. Their strategies illustrate the old adage “Success is the corner where opportunity meets

preparation. Commitment counts. Great job, John and Renee!

i Dispatching Made Easy, www.dispatchingmadeeasy.com ii “How to Build a Million Dollar Home Care Agency,” www.milliondollarhomecare.com

iii “How to Land Private-Pay Clients in Your NEMT Business,”

http://milliondollartransportation.com/privatepay.html iv “How to Build a Million Dollar Home Care Agency, www.milliondollarhomecare.com

v “How to Start a Successful Courier & Small Package Delivery Service,” www.startcourierservice.com

vi “Joel’s Million Dollar Transportation Seminar,” www.mdtseminar.com

vii “How to Build a Local Moving Company with 69.1% Profit Margin,” www.startprofitablemovingcompany.com

http://www.dispatchingmadeeasy.com/

http://www.milliondollarhomecare.com/

http://milliondollartransportation.com/privatepay.html

http://www.milliondollarhomecare.com/

http://www.startcourierservice.com/

http://www.mdtseminar.com/

http://www.startprofitablemovingcompany.com/

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Joel Davis’ State of the Industry Report of the... · 2019. 9. 6. · Why You Need to Build, Grow, Save and Create Wealth 214 . Joel Davis’ State ... industries will benefit could