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10 CHAPTER THREE SURVEY OF STATE MEDICAID AGENCIES, DEPARTMENTS OF TRANSPORTATION, AND TRANSIT AGENCIES SURVEY METHODOLOGY Description of Respondent Approaches to Non-Emergency Medical Transportation To understand the real and perceived barriers to the coordi- nation of NEMT and public transportation, three types of State Level Coordination stakeholders were surveyed: transit agencies, state DOTs (transit divisions), and corresponding state Medicaid agencies. An important consideration when looking at the coordination Thirty surveys in three different versions were distributed, 10 of Medicaid and public transportation is the level of coordi- each to state Medicaid agencies and their corresponding state nation that exists between state agencies; that is, state DOTs DOTs, and an additional 10 to transit systems--rural, small and state Medicaid agencies. Survey questions explored the urban, and urban. Copies of these surveys are provided in working relationship of the state agencies. In all but one of Appendix A. the states that responded to the survey, the coordination of transportation services between NEMT and public transit has States were selected based on a variety of considerations, been discussed and is encouraged at the state level. Among including information derived from the literature and sug- these states there were four general levels of coordination: gestions from the Topic Panel. Unique and innovative (1) periodic contact (Missouri), (2) regularly scheduled approaches were reviewed, such as the pioneering use of meetings (Colorado, Maryland, and Michigan), (3) formal large-scale brokerages in Georgia and Florida's innovative coordination agreements (Kentucky, North Carolina, and approaches to county level coordination. California (Medi- Oregon), and (4) legislative mandates (Florida and Texas). Cal) uses a freedom of choice model, which although not Although Florida is currently an example of a state in which exactly in Medicaid, is unique among large states. A wide public transportation and NEMT are highly coordinated, variety of other service models were considered including some Medicaid health maintenance organizations in the state contracted single operators in each service area as in Texas requested permission to provide transportation for their and Maryland and a variety of brokerages--statewide as in enrollees, effective November 1, 2005. Also, under a Medic- Virginia and local community-based brokerages such as aid Reform Pilot Project starting in 2006, transportation ser- those in Massachusetts and Oregon. Geographic considera- vices may become part of capitated networks. These changes tions were also essential to avoid under- or over-representation will affect the state-coordinated transportation system. The in any geographic area. details concerning the various levels of coordination activi- ties between NEMT and public transportation are provided in Table 1. Additional discussion of Florida's activities is SURVEY RESULTS provided in the case study section of chapter four. The survey results are detailed here. For the purpose of analysis, the survey responses have also been organized Service Model into a series of four tables. The first three tables present information about how NEMT is provided and monitored The survey data show that brokerages play a significant role in the different states and the fourth table provides a listing in the delivery of NEMT in 9 of the 10 states. The term "bro- and categorization of the barriers to coordination that were kerage" can be used to describe a wide variety of service cited by the respondents. The tables have a wealth of detailed models. Most states that use a brokerage approach have a information and should be reviewed in conjunction with the regional or county system, whereby the state is divided into narrative. regions (or counties) for the delivery of NEMT. The regional and community-based broker is typically in charge of all The first part of this section reviews the approaches used aspects of the local program, including trip and client eligi- by the different entities to coordinate services, provide ser- bility verification, trip assignment, scheduling, billing, and vice (service models), conduct intake of NEMT trips, and set monitoring. Missouri, Texas, and Virginia are the only states standards and monitoring requirements. The second part among those surveyed that use a single statewide broker. In reviews barriers and challenges. the singular case of Texas, the TxDOT operates the brokerage

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TABLE 1 COORDINATION Is There State Is There Local Level Level State Coordination? Coordination? What Is the Level of Coordination? If Not, Why Not? California No No None Medi-Cal covers NEMT when services that DOT provides do not meet the medical needs of the Medi- Cal recipient. The DOT reports that Medicaid trips are provided (by law) only by "for-profits" and social service trips are provided by nonprofits. Colorado Yes Partial Some services are coordinated. The DOT sponsors a coalition and the Medicaid agency is a participant in the coalition. Florida Yes Partial Some services are coordinated, depending on the arrangement in each county. There is a formal coordination agreement. The Florida Commission for the Transportation Disadvantaged procures local brokers to arrange/provide trips for a number of human service agencies, including Medicaid. Kentucky Yes Yes The brokers coordinate a variety of services. There is a formal coordination agreement and there are regularly scheduled meetings. Maryland Yes Yes Virtually all of the rural operators coordinate Medicaid. Separate services in Baltimore. There are regularly scheduled meetings of the Maryland Coordinating Committee for Human Services Transportation. Michigan Yes Partial Regularly scheduled meetings. The coordination program was formalized through the United We Ride Project in 2004. Missouri Partial No Broker periodically coordinates service with public systems. Occasional contact at state level. North Carolina Yes Yes Virtually all rural systems coordinate, some urban. The state of North Carolina has an Executive Order in place that created the North Carolina Human Service Transportation Council. The council is comprised of representatives from human service agencies and the state DOT. The basic premise of the coordinated arrangements is that the DOT provides financial support for capital equipment and administrative assistance associated with human service transportation, whereas transportation funds from the other state agencies are used primarily for operating assistance. (continued)

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TABLE 1 (continued) COORDINATION Is There State Is There Local Level Level State Coordination? Coordination? What Is the Level of Coordination? If Not, Why Not? Oregon Yes Yes Operationally, Oregon is fully coordinated through the designation of transit systems as regional brokers. Oregon's governor formalized a coordination project in 2001. ODOT and Department of Human Services were directed to coordinate, and they dedicated one transit agency staff person and one human service agency staff person to develop opportunities and reduce barriers. The ODOT discretionary grant program includes the option for state special transportation funds to match local nonmedical transportation projects and coordinate some trips with medical transportation trips. Texas Yes Yes Many rural systems coordinate service, few urban systems do. There is a formal coordination agreement and occasional meetings. Recent legislation mandates that the Health and Human Services Commission contract with TxDOT for the provision of client transportation, including Medicaid. Vermont Yes Yes The local brokers typically coordinate public transit and human service agency transportation in their respective service areas. There are regularly scheduled meetings between the DOT, state Medicaid agency, and Vermont Public Transit Association (the program administrator). Washington Yes Partial Some of the brokers are transit operators (mostly rural). Formal coordination agreement and regularly scheduled meetings.