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Transit Agency Participation in Medicaid Transportation Programs (2006)

Chapter: Chapter Three - Survey of State Medicaid Agencies, Departments of Transportation, and Transit Agencies

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Suggested Citation:"Chapter Three - Survey of State Medicaid Agencies, Departments of Transportation, and Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2006. Transit Agency Participation in Medicaid Transportation Programs. Washington, DC: The National Academies Press. doi: 10.17226/13961.
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Suggested Citation:"Chapter Three - Survey of State Medicaid Agencies, Departments of Transportation, and Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2006. Transit Agency Participation in Medicaid Transportation Programs. Washington, DC: The National Academies Press. doi: 10.17226/13961.
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Suggested Citation:"Chapter Three - Survey of State Medicaid Agencies, Departments of Transportation, and Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2006. Transit Agency Participation in Medicaid Transportation Programs. Washington, DC: The National Academies Press. doi: 10.17226/13961.
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Suggested Citation:"Chapter Three - Survey of State Medicaid Agencies, Departments of Transportation, and Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2006. Transit Agency Participation in Medicaid Transportation Programs. Washington, DC: The National Academies Press. doi: 10.17226/13961.
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Suggested Citation:"Chapter Three - Survey of State Medicaid Agencies, Departments of Transportation, and Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2006. Transit Agency Participation in Medicaid Transportation Programs. Washington, DC: The National Academies Press. doi: 10.17226/13961.
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Suggested Citation:"Chapter Three - Survey of State Medicaid Agencies, Departments of Transportation, and Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2006. Transit Agency Participation in Medicaid Transportation Programs. Washington, DC: The National Academies Press. doi: 10.17226/13961.
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Suggested Citation:"Chapter Three - Survey of State Medicaid Agencies, Departments of Transportation, and Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2006. Transit Agency Participation in Medicaid Transportation Programs. Washington, DC: The National Academies Press. doi: 10.17226/13961.
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Suggested Citation:"Chapter Three - Survey of State Medicaid Agencies, Departments of Transportation, and Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2006. Transit Agency Participation in Medicaid Transportation Programs. Washington, DC: The National Academies Press. doi: 10.17226/13961.
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Suggested Citation:"Chapter Three - Survey of State Medicaid Agencies, Departments of Transportation, and Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2006. Transit Agency Participation in Medicaid Transportation Programs. Washington, DC: The National Academies Press. doi: 10.17226/13961.
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Suggested Citation:"Chapter Three - Survey of State Medicaid Agencies, Departments of Transportation, and Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2006. Transit Agency Participation in Medicaid Transportation Programs. Washington, DC: The National Academies Press. doi: 10.17226/13961.
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Suggested Citation:"Chapter Three - Survey of State Medicaid Agencies, Departments of Transportation, and Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2006. Transit Agency Participation in Medicaid Transportation Programs. Washington, DC: The National Academies Press. doi: 10.17226/13961.
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Suggested Citation:"Chapter Three - Survey of State Medicaid Agencies, Departments of Transportation, and Transit Agencies." National Academies of Sciences, Engineering, and Medicine. 2006. Transit Agency Participation in Medicaid Transportation Programs. Washington, DC: The National Academies Press. doi: 10.17226/13961.
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SURVEY METHODOLOGY To understand the real and perceived barriers to the coordi- nation of NEMT and public transportation, three types of stakeholders were surveyed: transit agencies, state DOTs (transit divisions), and corresponding state Medicaid agencies. Thirty surveys in three different versions were distributed, 10 each to state Medicaid agencies and their corresponding state DOTs, and an additional 10 to transit systems—rural, small urban, and urban. Copies of these surveys are provided in Appendix A. States were selected based on a variety of considerations, including information derived from the literature and sug- gestions from the Topic Panel. Unique and innovative approaches were reviewed, such as the pioneering use of large-scale brokerages in Georgia and Florida’s innovative approaches to county level coordination. California (Medi- Cal) uses a freedom of choice model, which although not exactly in Medicaid, is unique among large states. A wide variety of other service models were considered including contracted single operators in each service area as in Texas and Maryland and a variety of brokerages—statewide as in Virginia and local community-based brokerages such as those in Massachusetts and Oregon. Geographic considera- tions were also essential to avoid under- or over-representation in any geographic area. SURVEY RESULTS The survey results are detailed here. For the purpose of analysis, the survey responses have also been organized into a series of four tables. The first three tables present information about how NEMT is provided and monitored in the different states and the fourth table provides a listing and categorization of the barriers to coordination that were cited by the respondents. The tables have a wealth of detailed information and should be reviewed in conjunction with the narrative. The first part of this section reviews the approaches used by the different entities to coordinate services, provide ser- vice (service models), conduct intake of NEMT trips, and set standards and monitoring requirements. The second part reviews barriers and challenges. 10 Description of Respondent Approaches to Non-Emergency Medical Transportation State Level Coordination An important consideration when looking at the coordination of Medicaid and public transportation is the level of coordi- nation that exists between state agencies; that is, state DOTs and state Medicaid agencies. Survey questions explored the working relationship of the state agencies. In all but one of the states that responded to the survey, the coordination of transportation services between NEMT and public transit has been discussed and is encouraged at the state level. Among these states there were four general levels of coordination: (1) periodic contact (Missouri), (2) regularly scheduled meetings (Colorado, Maryland, and Michigan), (3) formal coordination agreements (Kentucky, North Carolina, and Oregon), and (4) legislative mandates (Florida and Texas). Although Florida is currently an example of a state in which public transportation and NEMT are highly coordinated, some Medicaid health maintenance organizations in the state requested permission to provide transportation for their enrollees, effective November 1, 2005. Also, under a Medic- aid Reform Pilot Project starting in 2006, transportation ser- vices may become part of capitated networks. These changes will affect the state-coordinated transportation system. The 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 provided in the case study section of chapter four. Service Model The survey data show that brokerages play a significant role in the delivery of NEMT in 9 of the 10 states. The term “bro- kerage” can be used to describe a wide variety of service models. Most states that use a brokerage approach have a regional or county system, whereby the state is divided into regions (or counties) for the delivery of NEMT. The regional and community-based broker is typically in charge of all aspects of the local program, including trip and client eligi- bility verification, trip assignment, scheduling, billing, and monitoring. Missouri, Texas, and Virginia are the only states among those surveyed that use a single statewide broker. In the singular case of Texas, the TxDOT operates the brokerage CHAPTER THREE SURVEY OF STATE MEDICAID AGENCIES, DEPARTMENTS OF TRANSPORTATION, AND TRANSIT AGENCIES

State Is There State Level Coordination? Is There Local Level 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. TABLE 1 COORDINATION (continued)

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. State Is There State Level Coordination? Is There Local Level Coordination? What Is the Level of Coordination? If Not, Why Not? TABLE 1 (continued) COORDINATION

13 in-house. Georgia has five regions; however, these regions are combined so that there are two brokers covering the entire state. Florida, Maryland, Massachusetts, Oregon, and Vermont all use community-based brokers. The use of brokerages for the provision of NEMT can work in favor of the coordination of services or, depending on the brokerage model, can also be an obstacle to coordina- tion. For example, if a NEMT brokerage only handles NEMT, then the coordination of transportation services is not as likely, as only one trip purpose is served by the bro- ker. In these cases, the public transit operators may or may not participate as a provider within the brokerage. It was determined that in Georgia and Virginia a significant major- ity of service providers are entities other than public transit operators. For example, in Georgia the number of participat- ing transit operators includes 13 of the 126 transit agencies (36 small and large urban and 90 rural providers). Eight of these coordinated agencies are in urban areas and include the use of fixed-route services (in such cases, the broker has a financial interest in coordinating with fixed-route), whereas, as of September 2005, 5 of the 90 rural transit operators were participating in the Medicaid program. In Virginia, in 2002, the brokerage utilized very few transit agencies with the exception of fixed-route transit in urban areas (information provided by the Virginia Department of Medical Assistance Services). However, in states where the brokers serve multi- ple funding agencies and/or is the transit agency (e.g., Florida, Oregon, and Vermont), the brokerage system can foster the coordination of transportation services. Table 2 shows the survey respondents’ various methods of providing NEMT, describes how services are delivered, and indicates what entities are responsible for eligibility, screening, and verification. Standards and Monitoring of Service NEMT is a federal/state program that has a set of basic federal guidelines. The standards that guide the NEMT service—from standards for paperwork to standards for vehicles and operation of the service—are determined at the state and/or local level. These standards in large part determine the cost of the service. One of the key issues for coordination is that of often dissimi- lar service and operating standards. The subject of standards was disclosed in a number of surveys and in anecdotal evidence offered by a Medicaid provider in New York State. Because one of the perceived barriers to coordinating was that there are different (typically lower) standards for service for NEMT providers as compared with public transit providers, the survey asked the Medicaid state program managers to indicate if they had standards and, if so, to describe them. The results indicated that in about half of the responding states there are state- mandated standards in place with regard to driver training, driver qualification, vehicles, and, in some cases, insurance levels. These standards typically follow state motor vehicle laws and relate to the type of vehicle being driven. Some states have very specific and more far-reaching stan- dards (e.g., Georgia includes standards for the broker) and the requirements are set forth in state regulations (Kentucky). In the remaining states, the standards are locally determined. These results indicate that although there are standards in place for NEMT providers, they are often not as inclusive and standardized as those that are in place for public transit providers. For example, in Portland, Oregon, the broker, Tri- County Metropolitan Transportation (TriMet), determines the standards, which are higher than the state-mandated requirements. States use a variety of mechanisms to monitor the qual- ity of service and guard against fraud. These mechanisms include electronic and paper reporting, field monitoring, customer surveys, inspection of driver and vehicle records, various types of audits, and complaint information. Unlike school bus requirements, which are highly regulated, there is little in the way of a formalized process in some states. There are also indications that, in at least one state surveyed, there was very little monitoring of service. Some states sur- veyed have not tracked on-time performance and some did not routinely collect safety and accident data. Table 3 pro- vides the survey results with regard to service standards and monitoring of service. BARRIERS AND CHALLENGES The major focus of this synthesis is to report on real and per- ceived barriers and challenges to the coordination of NEMT and public transportation. Barriers or challenges stop the efforts of some, while impeding progress for others. With this focus in mind, respondents were provided with various categories of challenges to choose from. The results indi- cated a number of real and perceived challenges across many categories. Some challenges could be included in several cat- egories; however, for the purposes of analysis they were assigned to just one. Table 4 presents these challenges, which are highlighted and discussed here. Regulatory, Legal, and Compliance Issues Regulatory, legal, and compliance issues relate to a variety of requirements. Regulatory and legal barriers included the Managed Care/Freedom of Choice waiver requirements, whereas compliance included issues related to service moni- toring and standards. This category of challenges generated many responses, from both the transit and Medicaid perspec- tives. One theme that emerged from the urban transit providers and Medicaid representative’s responses is that there are different levels of service that are required for trips provided under the ADA; for example, as compared with those required for NEMT. Furthermore, these levels of ser- vice are different in different areas, because some transit agencies go above and beyond what is required by the ADA and others do not. Trying to fit the two services in one system

State and FFP Method and Waiver Method of Providing NEMT Decision Makers Description of How Services Are Delivered Eligibility and Screening California Medical Private transportation providers enroll as Medi-Cal providers and determine their own service area. State level staff and upper management Medi-Cal recipients contact the provider directly. The provider requests prior authorization. Medi-Cal pays for w/c vans, guerney vans, and nonemergency ambulance service under NEMT. Authorization is approved if the Medi- Cal recipient has a functional limitation that precludes their use of public or private transportation. Colorado Medical Several approaches are used, including local and regional brokerages, locally arranged contracts with private transportation providers, and public fixed-route transit. State level upper management and local level staff There is a broker for the metro area counties and individual county administration through local departments of social services for the remaining counties. Broker or local department of social services checks with a statewide verification system that is available through the fiscal agent. Florida 1915(b) Medical Agency for Health Care Administration (AHCA) contracts with the Commission for the Transportation Disadvantaged for the statewide coordination of NEMT. AHCA pays the Commission a fixed amount each month for services. State and local level staff There are local community transportation coordinators/brokers that arrange or directly provide NEMT for clients in their service areas. Local county coordinators or their contractors handle eligibility and screening. Kentucky 1915(b) Medical Statewide brokerage. NEMT program is operated under a 1915(b) waiver, allowing the state to restrict freedom of choice. State level staff and upper management Legislature State and local level staff Medicaid recipients contact regional broker, and then the broker either approves or requests denial of the trip. If approved, the broker schedules the trip with a provider that has contracted with the broker to provide transportation. Regional brokers have access to eligibility information via Internet connection. If the broker has a question about eligibility, it contacts the Office of Transportation Delivery, which then verifies the eligibility. Maryland Administrative Local brokerages, locally arranged contracts with public and private transportation providers, public fixed- route transit, gasoline vouchers, and agency vehicles and staff. Marylandís 24 jurisdictions are provided funds to arrange for NEMT. In 23 jurisdictions these funds go to the local health departments. In one county the funds go directly to the public transit agency, which is a county DOT. Either the local health department or the vendor screens for eligibility. The state mandates specific screening questions that must be asked. Michigan Administrative Local brokerages, locally arranged contracts with private and public transportation providers, and public fixed-route transit. State level staff and local level staff The Michigan Medicaid Program has an intradepartmental agreement with the Michigan Department of Human Services (MDHS) to administer the provision of NEMT for the fee-for- service beneficiaries. The qualified health plans are responsible for NEMT for their enrollees. MDHS coordinates NEMT through its local offices and bills Medicaid for the transportation expenses on a monthly basis. Local MDHS offices are responsible for eligibility and verification. Legislature TABLE 2 GENERAL STATE NEMT CHARACTERISTICS (continued)

Missouri Administrative (is changing to medical) Statewide brokerage and state cooperative agreements with public transit and other agencies and schools. State level upper management Missouri ensures NEMT through a statewide brokerage. There is one statewide broker that provides transportation arrangements and ancillary services for eligible recipients. There are also state cooperative agreements with public transit and other agencies and schools to draw federal NEMT funds on current funding sources. Broker verifies eligibility on the date of transport through one of three mechanisms: (1) state agency’s interactive voice response system, (2) agency’s fiscal agent via the Internet, or (3) point of service terminals that provide a paper printout of eligibility information on a specific date of service. North Carolina Medical NEMT is arranged locally through each county’s Department of Social Services (DSS). Each DSS has a coordinator who is in charge of the local NEMT transportation program. State and local level staff Local DSS coordinators use the least expensive modes that meet the needs of the clients. They are strongly encouraged to use the local public transit agencies. State has an Executive Order in place to encourage coordination. The local DSS offices are responsible for eligibility and verification. Oregon 1915(b) Medical There are nine transit systems serving as medical transportation brokerages. State and local staff State level staff and upper management Legislature Designated regional broker determines the best approach for NEMT using the least expensive appropriate mode. The regional brokers and their contractors determine eligibility. Texas Medical State contracts with private transportation providers and public transit agencies. Recent legislation mandates that the Health and Human Services Commission (HHSC) contract with TxDOT for the provision of transportation services to clients of eligible health and human service programs, including Medicaid. Transit association TxDOT manages nine call centers with state employees. TxDOT headquarters contracts with a wide variety of providers across the state, including both public and private operators. All trips are prior authorized through TxDOT Medical Transportation Program intake workers. The program was recently changed to allow for a pass-through entry between TxDOT and the operator. HHSC shares (electronically) Medicaid eligibility information with TxDOT. TxDOT’s call centers conduct eligibility and screening. Vermont Administrative Regional brokers coordinate services locally, with oversight from the Vermont Public Transportation Association. Local brokers arrange the trips, which are provided with a variety of modes. There is an extensive network of volunteers who participate with the local brokers. Eligibility and screening is conducted by the local brokers. Washington Administrative Regional brokerage—through competitive procurements. State level staff and upper management Brokers are responsible for delivering transportation services in their regions. State provides eligibility information weekly; brokers also have medical eligibility verification as backup if the weekly information is inadequate. State and FFP Method and Waiver Method of Providing NEMT Decision Makers Description of How Services Are Delivered Eligibility and Screening TABLE 2 (continued) GENERAL STATE NEMT CHARACTERISTICS

16 State State or Local Monitoring Contractually Required Service Standards How Are Services Monitored? California Both state and local Driver training, driver experience, and vehicle standards are set in accordance with established state regulations pertaining to the type of vehicle and the transportation involved. Services are monitored through electronic and paper reports, field monitoring, customer surveys, and the inspection of driver and vehicle records. Colorado 90% state and 10% local There are very specific standards in the provider contracts. There are standards for the type of driver training required and the type of drivers hired (with regard to type of license, driving record, criminal record, etc.). There are also specific requirements with regard to vehicles and their accessibility, maintenance, upkeep, and cleanliness. Every vehicle must be insured for a minimum $500,000 combined single limit. Services are monitored through electronic and paper reports, customer surveys, and program integrity audits. Florida 100% state There are specific standards that are defined in the contract between the Agency for Health Care Administration (AHCA) and the Commission. Local coordinators often add to these minimums to make them compatible with public transit. Services are monitored through electronic and paper reports, field monitoring, and the inspection of driver and vehicle records. Local coordinators conduct their operational monitoring. Kentucky 50% state and 50% local There are specific requirements in a number of areas (i.e., drivers, training, vehicles, broker responsibilities, etc.). These requirements are set forth in Kentucky State Regulations—603 KAR 7:080: Human Service Transportation Delivery. Services are monitored through electronic and paper reports, field monitoring, customer surveys, and the inspection of driver and vehicle records. Maryland 30% state and 70% local Contractually required service standards are locally determined. Services are monitored through annual customer surveys, field monitoring, and the quarterly submission of complaint logs. Michigan Local Contractually required service standards are left to the discretion of the local Michigan Department of Human Services offices. Services are monitored through electronic and paper reports. Missouri State There are specific requirements with regard to driver training, driver experience/driving record, vehicle maintenance and inspections, as well as first aid and safety requirements. Services are monitored through electronic reports and customer surveys (quarterly). North Carolina Local There are required standards with regard to safety and risk management. Local transit systems set higher standards. Services are locally monitored through different mechanisms including examining the trips for a particular date and/or random sampling of trips. TABLE 3 SERVICE STANDARDS AND MONITORING (continued)

17 has proven difficult. Broward County Transit (Florida) and TriMet (Oregon) both operate ADA and Medicaid services in their regions; however, each is a separately managed and operated program within the organization. Another barrier cited was that different laws and rules apply to public transit operators than to NEMT providers; specifically, drug testing, vehicle (ADA compliance), and Commercial Drivers License requirements. These require- ments typically result in higher costs for the transit agencies, making it difficult to compete against those operating under a less stringent set of policies and procedures. One state found that the Centers for Medicare and Medic- aid Services (CMS) process for requesting waivers is a major barrier that requires a significant amount of administrative work. One state did not actually use a waiver and eliminated the freedom of choice requirement. Jurisdictional Issues There were two jurisdictional issues indicated that could be considered real challenges to the coordination of services. The first is that, in some rural areas, the public transit provider does not have enough vehicles to allow one to leave the ser- vice area for an entire day to provide a long distance medical trip. Another real barrier can be found in small cities where the service mode is fixed-route and the operator does not have the proper authority to travel outside the service area. In North Carolina, the many rural county transit agencies (typically coordinated with Medicaid) often cross two or three jurisdictional lines to transport passengers to a regional medical facility, often without coordinating with the agen- cies in the counties they cross. The North Carolina DOT has begun an initiative to identify and coordinate those services. Financial Issues The financial issues listed by the respondents appear to be real and significant challenges to the coordination of services between NEMT and public transportation. One major issue in urban areas, which has been discussed for many years with- out resolution, is the question of which agency should pay for the trip of an ADA paratransit-eligible Medicaid client to travel for a medical need—the state Medicaid agency or the local transit agency. Following this same issue, should the Medicaid agency pay the regular fare (which includes federal, state, and local subsidies, but not in urban areas where only local money is used), the entire local share of the cost, or the fully allocated cost? One NEMT manager did not understand that large urban areas (more than 200,000 population) do not receive federal operating subsidies. Some state transit agen- cies require that their transit grantees collect the fully allo- cated costs for human service agency trips (e.g., Virginia) rather than the general public fare, whereas one state attorney general ruled that Medicaid can only pay the regular general public fare (Idaho). CMS has determined that it is appropriate for NEMT to pay a rate higher than the general ADA fare. Other financial concerns listed included the business deci- sion of whether the reimbursement rate is too low for Medic- aid trips and would cause transit agencies to lose money by subsidizing the trip. In cases where a third-party administrator State State or Local Monitoring Contractually Required Service Standards How Are Services Monitored? Texas All Requests for Proposals and contracts with individual providers are handled through TxDOT headquarters. A new process is pending. Previous standards for drivers, vehicles, safety, and other requirements were well below standards for public transit. New requirements have stronger standards. An annual assessment of the Medicaid Medical Transportation Program is scheduled to begin in FY2006. It is anticipated that the assessment will include the following elements: Review trip eligibility determination Surveys Review of safety Review of telephone service Fixed rate usage Quality review Driver and vehicle records. Washington Both state and local There are standards with regard to driver training, driver experience, and vehicles. Services are monitored through electronic and paper reports, field monitoring, customer surveys, and the inspection of vehicle records. TABLE 3 (continued) SERVICE STANDARDS AND MONITORING

18 Regulatory/Legal/ Compliance Issues • The level of service required for paratransit trips provided under the ADA is higher than the level of service required for Medicaid trips, thus making it difficult to coordinate these trips together in a cost-effective manner. • The transit system is subject to more stringent standards than those required by Medicaid with regard to vehicles, equipment, driver licensing, drug testing, and training, etc. These regulations result in higher costs than would be found among providers that exclusively carry Medicaid clients. • Drug testing makes ADA service cost more than Medicaid service. • Coordinating Medicaid transportation with general public service is a challenge because the state human service agency staff does not understand the complexity of transit regulations. For example, for vehicle fleet size the state DOT uses the FTA-funded services as the guide to peak need. Contracted services (including Medicaid) are not included, which leaves the impression that the state DOT has a negative view of Medicaid transportation. • Some public transit agencies see the drug testing and commercial drivers license requirements as a means for establishing standards for quality mobility providers (not as a barrier). • The 27 different transit agencies in the state have very different ADA structures and regulations. • The regulatory/legal/compliance issues attached to transit funding sometimes prohibit coordination. The belief is that $1 of federal money in a coordination project compels compliance with all FTA regulations. • Many of the local transit agencies and human service agencies believe that they cannot coordinate because of regulatory issues who can and cannot ride on the bus. • The Centers for Medicare and Medicaid Services process for requesting waivers is a major barrier. It is a lot of administrative work to pull together all of the information that is necessary to request a waiver. Jurisdictional Issues • The transit boundaries are much smaller than the Medicaid transportation brokerage region boundaries. • Some rural transit agencies are unwilling to provide long distance NEMT to urban areas for specialized care. • The state Medicaid agency requires prior approval to transport clients out of the county for services. Obtaining this approval is an administrative burden. • There are different standards for vehicle and driver licensing and permits in the different counties. • There are jurisdictional issues for small urban transit providers who operate in towns where there are not major medical facilities—the small fixed-route providers are not always able to travel out of their service area. Financial Issues • The state’s billing and reimbursement mechanism requires expensive software customization, contractual services for electronic eligibility verifications, full- time monitoring, and the payment for services is not always processed in a timely manner. • The state Attorney General ruled that Medicaid can only pay the regular fare for the purchase of transit service (instead of the cost). • The Medicaid system is cumbersome and efforts to reduce costs result in no or inadequate payment to providers. • The brokers and third-party administrators of the NEMT program, especially in the capitated rate scheme, have included penalty provisions in their contracts with mobility providers (transit providers) to shift some of the financial risk to the providers. These penalty provisions include minor irregularities such as late reporting or incomplete reporting as determined by the broker. Several mobility providers have made a business decision not to participate in NEMT as a result of those disadvantageous contract provisions. • The reimbursement for brokers and providers. • Low reimbursement rates limit the number of available NEMT providers. • The transit system is required to carry a higher level of insurance than is required for Medicaid trips, thus increasing the cost of the ADA service. • Fleet needs and the sources to fund them. • Dual eligibility—Medicaid and ADA paratransit. When an ADA customer requests a medical ride, Medicaid should pay for the trip instead of the transit agency. TABLE 4 CHALLENGES (continued)

Information/ Technology Barriers • The Medicaid agency has electronic billing requirements that can be difficult for transit agencies to meet without significant software expenses. • Combining ADA and Medicaid would tax the ability of the paratransit scheduling program that is currently in place. • The different record keeping requirements add to the overhead cost of providing mobility services. This is especially the case when coordinating many human service transportation programs, just one of which is NEMT. • Health Insurance Portability and Accountability Act is a potential barrier. • Many agencies do not want to share client information. • Technology varies between private and public programs. Different Goals • Transit is interested in meeting ADA requirements, which are narrower in scope than Medicaid requirements. • From the transit agency perspective it is more effective to issue Medicaid clients a monthly bus pass. The cost of the monthly pass is less than the cost of one door-to-door round trip, resulting in savings for the program and an increase in the quality of life for the client. Some state Medicaid staff believed that only single-trip passes should be issued for Medicaid-funded appointments, but the administrative costs and staffing required to administer these trips would have a negative financial impact on the program. • Medicaid agencies are interested in transporting their clients and not overall public transportation. Eligibility • The eligibility process is difficult and time consuming. The transit agency does not always have the needed information to determine a client’s eligibility status. • Ensuring the eligibility is in place before providing the trip is a major challenge. • Penalizing the transit provider for performing a noneligible trip when that trip was ordered by the NEMT broker is unfair. Eligibility ought to be the sole responsibility of the broker and once the trip is assigned by the broker to the transit provider; no inquiry into the eligibility of the client by the transit provider should be needed. • The state recently increased the client eligibility requirements for NEMT, which has increased the number of people seeking medically related rides under other programs, such as general public transit. This cost shifting has led to transit vehicle capacity problems, especially for rural transit providers. • Medicaid limits eligibility to those with no other means of transportation. • Mixing of funding streams—one bus may carry five different types of clients with different funding sources. • The different funding sources have different service requirements and eligibility. • Dual eligibility between ADA and Medicaid—who should pay for the trip? Operational Barriers • The provision of NEMT service can cause significant disruption to all facets of an established paratransit system owing to the following: the eligibility process, the billing system, the customer service staffing, the no-shows and cancellations, and the database maintenance. • Medicaid clients share rides with ADA clients, which prompts them to request paratransit trips for which they are not eligible. A high level of monitoring is necessary to deal with this issue. • Educating transit systems on how to schedule and dispatch fully coordinated services is challenging. • Some clients need a higher level of personal care than the (public transit) staff is prepared to provide. • Some agencies expect the transit provider to be the liaison for the client with the medical provider. • NEMT has a 30-min pick-up and will-call return pickup requirement that require most transit providers to have their drivers wait with the client rather than use the driver’s time more productively by delivering trips for other programs or even other NEMT trips to different destinations. • Medically fragile people have different service needs than able-bodied people. • With a central dispatch center and shared vehicles there are issues with regard to which agency should pay for maintenance, which agency should provide the local match, etc. • The hours of operation are different, the frequency of service is different, and all public transit vehicles must be ADA-compliant. • Transit agencies have higher standards with regard to driver training. TABLE 4 (continued) CHALLENGES (continued)

exists, there are penalty provisions for minor irregularities and difficulties with invoices that make participation by public transit agencies difficult. Another financial concern, which is also a technology issue, is that some states’ billing and reimbursement mech- anisms require expensive software customization, contrac- tual services for electronic eligibility verifications, and full-time monitoring. Also, the payment for services is not always processed in a timely manner. This makes partici- pation in NEMT difficult for smaller rural public transit agencies. Intake Responsibility The responsibility for trip intake is expensive and time con- suming in both urban and rural areas. The functions of trip intake are complicated and require the following multistep process: • Verification of Medicaid eligibility, • Assessment of need (in some states, the intake is required to determine if the individual requesting service has a car or can get a ride elsewhere), • Verification of trip purpose (is the individual requesting service going to an eligible service?), and • Determination of what mode of services the individual is eligible for; fixed-route, paratransit, volunteer, etc. Often, the responsibility for trip intake rests with the bro- ker or directly with the service provider. In some states, the transportation vendor (sometimes this is the public trans- portation operator) performs these functions, whereas in other states, the broker or local health or Department of Social Ser- vices handles eligibility, screening, and verification (in Texas it resides with TxDOT). Regardless of where this function occurs, this information is typically available electronically, although not always in a timely manner (as noted in the barriers section). Transit agencies reported that the intake process is diffi- cult and time consuming and that the agency does not always have the required information before the trip. This could pose difficulties for those smaller transit agencies that do not have the staff to manage this effort. This prob- lem can have financial implications if the trip is provided, but then is not reimbursed. Another concern for transit agencies, particularly those in rural areas, is that the same vehicle may have clients from six different agencies on board, each of which has a different set of eligibility crite- ria. In one state it was noted that the Medicaid eligibility verification requirements were increased, resulting in addi- tional costs for public transit. Operational Barriers One transit agency reported that the provision of NEMT can cause significant disruption to all facets of an established ADA paratransit agency for a number of reasons, including the intake process, the billing system, the customer service staffing, the no-shows and cancellations, and the database maintenance. It was also reported in one state that NEMT has a 30-min will-call/return pick-up requirement that requires that transit providers have their drivers wait with the client, rather than using the driver’s time more productively by undertaking trips for other programs or by taking other NEMT trips to different destinations. In addition, some Medicaid clients require a higher level of care than what the public transit agency staff is able or willing to provide. Information and Technology Barriers The requirements for the use of technology in billing and oper- ational areas make participation by smaller agencies difficult. These agencies have difficulty investing in the technology and often cannot afford the staff necessary to maintain it. One sig- nificant barrier that could be classified under “information technology” is that there are significantly different record keeping requirements for NEMT when compared with public transit. This is particularly true in urban areas, where the only information collected from a general public passenger is the fare that was paid. This is less of a barrier in rural areas oper- ating demand-response service, because the public transit agencies are already collecting information needed to provide the trip. 20 Other Barriers • Transit agencies are typically not just coordinating NEMT, but also senior transportation programs, mobility programs for persons with developmental disabilities, Head Start transportation, and many others. Each of these programs has their own, and sometimes conflicting rules, requirements, and limitations. • There are information barriers to the extent that clients as well as sponsoring agencies are not aware of all the existing mobility services that are available to them. • Identification of entities. Medicaid agencies’ documentation requirements versus public transit’s personnel and time constraints. TABLE 4 (continued) CHALLENGES

21 Other Challenges One major barrier is that Medicaid agencies have the single goal of ensuring that beneficiaries can access their medically necessary appointments for the lowest cost that meets the clients’ needs. In urbanized areas, this goal can often be achieved in a cost-effective manner by issuing bus passes to Medicaid-eligible clients. However, in some states this does not occur because the Medicaid focus is single-trip oriented. Medicaid agencies do not always realize that the administra- tive costs associated with issuing single-trip passes are equal to or greater than the cost of a multiride pass. Confidentially of records is also a potential barrier, because public transit agencies may not be equipped to keep the medical information necessary to provide the trip as confidential. One survey respondent indicated that the Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a potential barrier. However, this is a misunder- standing, because transit agencies do not come under this requirement, although at least one agency reported problems in this area. Finally, many rural transit agencies are typically coordi- nating not just NEMT, but also senior transportation pro- grams, mobility programs for persons with developmental disabilities, job access, and other programs. Each of these programs has their own, and sometimes conflicting rules, requirements, and limitations.

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TRB's Transit Cooperative Research Program (TCRP) Synthesis 65: Transit Agency Participation in Medicaid Transportation Programs explores the tasks that may help develop successful public transit-non-emergency medical transportation (NEMT) partnerships. The report examines real and perceived barriers to NEMT and public transit coordination and includes case studies of Medicaid transportation program participation by transit agencies.

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