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22 CHAPTER FOUR CASE STUDIES OF MEDICAID AND PUBLIC TRANSIT COORDINATION The case studies introduced in this chapter focused on five one such example, where, in 2003, the state legislature transit agencies and were selected based on review of the mandated that the TxDOT in essence assume control data, the literature search, panel suggestions, geography, of all human service transportation. whether a large or small urban area, and general knowledge Eligibility/compatibility--Some agencies have reported that of the subject. Most of the case studies were successful there are complicated eligibility issues associated with examples of coordination, whereas one was not, and many NEMT service. In addition, other agencies have noted lessons can be learned from that example. There were many compatibility concerns in a variety of areas including cus- excellent examples of transit agencies that would have met tomer compatibility (some passengers ride for free, the needs of this effort; however, only five could be selected, whereas others must pay) and technology compatibility. and these are representative of different operating styles and Jurisdictional--These concerns typically include agen- approaches. The case studies reviewed five different agen- cies that cannot or will not transport people outside of cies in five states and how they and the Medicaid agencies their jurisdictions. Medicaid agencies often want a approach coordination of NEMT. The case studies focus on provider that will travel where required by an individ- one agency in each state and how it has coordinated Medic- ual's medical needs. aid transportation with its public transit. The case studies 1915(b)(4) Waiver/Freedom of Choice--Freedom of helped identify the impediments or barriers to coordination, choice is, by its nature, the opposite of coordination in as well as what actions facilitated coordination. that this approach encourages many small providers and little in the way of control. Freedom of choice does The case studies include agencies whose states have various not work as well for transportation as it does for exam- models of service delivery, such as exclusive contracts, a pri- ple the heavily regulated and credentialed medical vate for-profit broker, or a transit system as broker. An attempt field. According to some, the hurdles of overcoming was made to ensure geographical diversity and present a vari- the requirements of the waiver can be extensive. ety of transit settings in urban, small urban, and rural areas. Sur- Local level working relationship--One of the key elements vey respondents were all but one of the case studies. of successful coordination is trust and the ability of local stakeholders to work together. In at least one state, deci- sions were based on the mistrust of the rural operators EMERGING COORDINATION THEMES and a feeling that the operators were overcharging. Based on the results of the literature search and the survey, Need for additional expertise--The kind of transportation themes emerged that suggest a number of identifiable barriers provided through Medicaid is unique and requires a and approaches to coordination at all levels of government. specific expertise. Many of those making transporta- These themes were examined in the case studies. tion decisions for state and local Medicaid agencies do not have the background or the training in these types Service delivery model--It is apparent that certain mod- of transportation issues. Similarly, public transit man- els encourage or foster coordination, whereas other agers do not understand the nuances of NEMT. Deci- models are not coordination friendly. sions, at times, are based on questionable assumptions. Service standards--There are significant differences in This subject suggests that there is a need for additional training and communication for all sides. the service quality requirements of Medicaid contrac- Business sense--From a transit operator's perspective, tors. In some cases, those state and local standards are any coordination arrangement must make business less stringent than the standards typically employed by sense. That is, it cannot negatively affect existing cus- public transit operators. This is a significant problem tomers, must be relatively straightforward to operate, with ADA paratransit agencies, which must maintain and must be financially feasible. rigorous standards of safety and performance that are not required for many Medicaid customers. In one case, the union requirements of a NEMT operator BACKGROUND required higher standards than NEMT. Political--There are a number of states where the legisla- The objective of the following case studies is to provide an in- ture has intervened in the coordination issue. Texas is depth review of five transit agencies and their experiences