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TRANSIT AGENCY PARTICIPATION IN MEDICAID TRANSPORTATION PROGRAMS SUMMARY Non-Emergency Medical Transportation (NEMT) has existed since the mid-1970s. From the beginning of the program, coordination was employed to maximize scarce resources in rural areas. During this period, many rural agencies and some urban agencies successfully coor- dinated NEMT service with public transit and/or other human service programs. However, opportunities still exist for public transit agencies in both urban and rural areas to participate in the NEMT program as providers of service or as brokers. Although rural transit agencies have historically taken advantage of coordination opportunities, there are a growing number of urban transit agencies that are seeing opportunities for coordination with benefits for customers, transit agencies, and state Medicaid agencies. Medicaid is a large funding resource for transportation across the country. In rural areas, NEMT funding is often greater than public transit funds and virtually dwarfs other human service transportation programs in terms of funding and priorities. Any coordination effort that does not include Medicaid risks omitting the largest participant. TCRP requested this synthesis to examine the tasks necessary for a successful public tran- sitNEMT partnership. This review is conducted to assist transit agencies in exploring opportu- nities to coordinate services with NEMT programs. The report identifies and examines barriers and actions (at all levels) that can foster or inhibit coordination at the local level. The overall focus of this effort is on how transit agencies coordinate services with NEMT. A literature review was undertaken to examine coordination efforts between medical transportation and public transportation; NEMT service models (which have a significant effect on the potential for coordination); administrative/management/monitoring issues; and other pertinent concerns, such as cost allocation. Most of the coordination literature focused on state level efforts, although a handful of documents addressed local level coordination with transit agencies. The literature included articles on fixed-route bus service; cost trans- ferring onto Americans with Disabilities Act paratransit; working relationships between NEMT and public transit and among state and local Medicaid officials, state departments of transportation (DOTs), and transit system officials; and uniform service standards. Next, surveys were conducted to understand the real and perceived barriers to the coordi- nation of NEMT and public transportation, Thirty surveys were distributed to three types of stakeholders; 10 each to transit agencies, state DOTs (transit divisions), and corresponding state Medicaid agencies. A total of 22 stakeholders responded, including 8 state Medicaid agencies, 6 state DOTs, and 8 transit agencies. The survey results indicated a variety of barriers and challenges at all levels of govern- ment. A number of issues emerged, some new and some recurring. It is apparent from the surveys that certain service delivery models encourage coordination, whereas other models do not. Operational issues included the complicated and time-consuming process of trip intake for NEMT, with some agencies indicating that this was such a difficult process that their participation was inhibited. Jurisdictional barriers of crossing service area boundaries and the cost of taking vehicles long distances were discussed as well.

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2 Other issues raised included the need for additional expertise, suggesting that there is a need for additional training and communication for all parties; service standards and the lack of common safety and operational standards; and coordination. Five case studies were undertaken that reflected geographical diversity; urban, small urban, and rural agencies; and different service delivery models. Problem areas as well as successes were examined. For each case study, a transit system and its relationship with the state Medicaid agency, as well as the relationship between the state Medicaid agency and the state DOT were reviewed. A number of coordination concerns were evident throughout the study. These concerns can either foster or impede coordination, and some dictate the level of coordination. Key fac- tors that can foster or inhibit coordination as expressed through the literature review, surveys, and the case studies are listed here: Success factors--these must be present for coordination to succeed. Helpful factors--these elements can help foster coordination; however, without them coordination may still be possible, albeit with more difficulty. Challenges--some activities and policies are clear impediments or barriers to coordination. Where these are in place, coordination is more difficult.