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Transit Agency Participation in Medicaid Transportation Programs (2006)

Chapter: Chapter Four - Case Studies of Medicaid and Public Transit Coordination

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

23 with NEMT. These studies test the findings from the literature review and surveys previously conducted. The case studies were selected to reflect a balance of operators in terms of geographical diversity (as many regions of the country as possible and urban, small urban, and rural agencies), demo- graphics, coordination level, and service delivery model. Successes as well as coordination efforts that were less than successful were examined. For each case study, the transit agency and its relationship with the state Medicaid agency, as well as the relationship between the state Medicaid agency and the state DOT were reviewed. The case studies • Review relationships between stakeholders, • Describe the state service delivery model, • Provide a description of the transit agency and approach to NEMT, and • Review the activities that foster or inhibit coordination. The five case studies can be summarized as follows: 1. Broward County Transit (Florida)—Florida has long been a model for coordination at the county level as mandated by the state. This case study focused on Broward County and examines why the county ulti- mately ended its relationship with the state Medicaid agency. 2. North Georgia Community Action Agency (Jasper, Georgia)—An early practitioner of the large-scale bro- kerage, Georgia has fine-tuned its approach and serves as an excellent case study to examine how this type of brokerage affects coordination. A multicounty rural transit agency that has a good relationship with its broker is profiled. 3. TriMet (Portland, Oregon)—Oregon has designated regions where local brokers manage all aspects of NEMT. Each of the brokers are transit agencies. Here the focus is on Portland. 4. Texoma Area Paratransit System (Texas)—The Texas Legislature mandated coordination by placing most human service transportation operations under the control of TxDOT. This review examines their progress 30 months after the legislation was passed. The Texoma Area Paratransit System (TAPS), a mul- ticounty system, was examined. 5. Chittenden County Transportation Authority (Ver- mont)—Vermont’s Medicaid agency uses the state transit association to administer the Medicaid trans- portation program. Contracts are local and typically with transit agencies. Burlington’s transit agency will be reviewed. FLORIDA—BROWARD COUNTY TRANSIT Introduction Broward County is a large urban/suburban county (population 1.7 million) with sizable cities such as Ft. Lauderdale and rapidly growing suburbs. The county manages the transit agency directly and contracts the day-to-day operation of its paratransit to a number of private providers. Broward County Transit (BCT) operates throughout Broward County provid- ing 36 million fixed-route trips and 1.3 million paratransit trips annually. Florida has been a leader of the coordination effort since the advent of its Transportation Disadvantaged (TD) pro- gram. BCT was selected for this synthesis, not because of its success, but rather to examine why Broward County decided that coordinating the service in the manner required was not in BCT’s best interests. It should be noted that Florida has had a number of successful urban transit coordination efforts. However, the researchers believe, in this case, that there are more lessons to be learned from the county’s experience than from a more successful effort. Relationship Between Stakeholders Florida, by legislation, created the Florida Commission for the TD as part of the Florida DOT (FDOT). The TD Com- mission is responsible for the coordination of a wide variety of human service transportation programs including Medic- aid. To that end, the TD Commission has a contract with the Agency for Health Care Administration (AHCA), which is the state agency charged with the responsibility of the Med- icaid program, to provide oversight and management of the NEMT program. This arrangement has reduced costs by 30% during the past 10 years. Much of the savings was attributed to the expanded use of bus passes. Although AHCA has ceded day-to-day operating author- ity, it continues to look at different ways of managing and controlling the service. The 1915(b) waiver submitted by the agency allows the use of the local county Community Trans- portation Coordinators (CTC) to control expenditures to the NEMT. AHCA is now considering a change in the program. The agency previously tried to eliminate the county brokers from the NEMT and procure a statewide broker, but the pro- curement was rescinded. Recently, AHCA determined that it needed to reduce fund- ing for NEMT by $11 million in one year and this resulted in at least one large transit agency opting out of the program. Oth- ers are considering reducing their role as well. The TD Com- mission is also considering a termination of the relationship with AHCA as the funding continues to be reduced. State Medicaid Service Delivery Model As stated previously, AHCA contracts with FDOT’s TD Commission to manage the statewide program. The TD Commission designates a CTC for each county. The CTC functions in a role as coordinator (or broker) of services; actively addressing coordination, monitoring, and reporting.

24 There are a wide variety of approaches used by the CTCs in Florida’s counties. Flexibility at the local level is considered one of the keys to success. The designated CTC can be a tran- sit agency, county government, Metropolitan Planning Orga- nization (MPO), nonprofit agency, or other entity. Typically, the transit agency is given an opportunity to participate. Broward County Transit—Coordination Efforts BCT, an arm of county government, is the public transit operator for the county. BCT is also the designated CTC for the county and between 2002 and 2005 successfully managed and operated the NEMT program in the county as well. BCT had integrated ADA paratransit with NEMT. Customers called BCT to register for the NEMT program. For rides, customers called their designated contract provider who verified eligibility (monthly) and then determined trip eligibility before scheduling and providing the trip. According to BCT management, NEMT was a difficult program to operate in conjunction with ADA paratransit. The programs were separate, but were operated by the same group of contractors who coordinated service at the contrac- tor level. BCT did not have the staff available to certify NEMT customers for paratransit versus fixed-route service. Consequently, fixed-route ridership was low (although it increased from 90 passes per month to 1,000). The large numbers of new riders (averaging 500 per month) were taxing staff ability to keep pace with applications. BCT man- agement chose not to expand their ADA eligibility certifica- tion staff and instead provided paratransit for those who requested the door-to-door service. Ultimately, at the highest level of county government, decisions were made to discontinue the county’s involve- ment in the NEMT program. BCT continues to act as the CTC, coordinating a variety of other human service trans- portation services. Activities That Affect Coordination • Communication with AHCA—BCT cited difficulty in communicating with AHCA and being unable to provide input into the funding changes. The TD Commission echoed those remarks. AHCA is proposing a number of changes, and both AHCA and the TD Commission are considering termination of the agreement. • Local control and flexibility—Services are brokered at the county level, allowing for significant local control in how services are delivered, the development of stan- dards, and other functions that allow flexibility and can encourage coordination. Throughout the state there are many models of local service delivery. • Business/financial sense—The county was clear that its primary reason for terminating its participation in the NEMT was financial. The county was unwilling to provide a subsidy to the program in the face of shifting funding by AHCA. • Difficulty of operating in conjunction with ADA— ADA and NEMT are demanding services that are both (individually) difficult to operate successfully. Adding additional (and also demanding) service can overwhelm an agency. In this case, the eligibility certification staff (determining the use of fixed-route or paratransit ser- vice) was not able to conduct NEMT certifications while simultaneously dealing with significant growth in its ADA certification. • HIPAA interpretations—There were misperceptions of confidentiality issues limiting vital information to the contractors. One interpretation was that certain client groups cannot mix with others, lest these riders discover where the first group is going (confidential information). • Different service standards—BCT provided an ADA level of service that is higher than the requirements for Medicaid. The higher level of service costs more money than a service that does not meet these stringent requirements. This creates two separate agencies with different standards of safety and quality. GEORGIA—NORTH GEORGIA COMMUNITY ACTION AGENCY, JASPER Introduction Thirteen transit agencies in Georgia coordinate with Medicaid. Several transit agencies have successfully coordinated the programs of all three state agencies and one of these will be reviewed here. This agency, the North Georgia Community Action Agency (NGCAA), operates public transportation, has an agreement to provide social service transportation (Title III—Aging), and also has a contract with one of the brokers to operate Medicaid service. NGCAA operates in six counties of north Georgia (population—310,000), with its base in the town of Jasper. They provide a variety of para- transit services, typically within each county, with vehicles infrequently traveling out of county. The FY 2004–05 rider- ship was 240,000 one-way trips. Approximately 40,000 trips are provided for NEMT through the regional broker. Relationship Between Stakeholders Georgia has been working recently to coordinate services on the state level. The state has three separate transportation pro- grams in three agencies, two of which are actively engaged in coordination activities. The local level has also seen significant coordination of two of the programs. The three major pro- grams—all administered separately by three agencies—are: • Georgia Department of Transportation (GDOT)—pub- lic transportation, • Department of Human Resources (DHR)—social ser- vice transportation and management of the FTA Section

25 5310 program that provides funding for transporta- tion for the elderly and persons with disabilities (the funding is used to purchase vehicles in support of their programs), and • Department of Community Health (DCH)—Medicaid transportation, which is managed by one of two brokers. Public transit funding is distributed at the county level. There are some regional multicounty transit agencies; however, most service is provided and coordinated at the county level. DHR and public transit are coordinated frequently, yet only 10% of the transit agencies in the state coordinate with NEMT. There had been little in the way of coordination efforts at the state level in the past. However, this is changing, as GDOT and DHR have been discussing further coordination of their services. DCH operates a separate set of brokerages for its service. The NEMT Request for Proposal (RFP) used in 2004 by DCH called for coordination of services with pub- lic transit to the maximum extent feasible. State Medicaid Service Delivery Model Georgia’s DCH uses a capitated brokerage to manage its NEMT program. That is, the brokers are given a set rate based on the number of Medicaid-eligible clients who reside in their service areas. There are five regions that were avail- able for firms to place bids using an RFP process, resulting in two for-profit firms being selected to operate the capitated brokerage in the five regions. These firms then contracted with a variety of public and private entities. The service model used by at least one of the brokers is designed to maximize fixed-route usage. Clients call the broker who then verifies eligibility for NEMT and determines the most appropriate/lowest cost provider to meet the client’s needs. The broker then contacts the provider and informs them of the trips for the next day. North Georgia Community Action Agency Activities That Affect Coordination NGCAA is under contract to one of Georgia’s two brokers. The broker takes all trip requests, verifies eligibility and trip purpose, and distributes the trips to their providers, one of which is NGCAA. NGCAA’s sole responsibility is to pro- vide the trips as requested by the broker. The broker in the NGCAA service area uses them for service in-county during NGCAA’s operating hours (7:00 a.m. to 4:00 p.m., Monday through Friday). Trips going out of county or during hours that NGCAA does not serve will go to another local provider. The transit agency is paid by the trip with one rate for ambu- latory and a second for nonambulatory riders. NGCAA operates using its public transit and GDOT stan- dards, which are higher than Medicaid according to NGCAA management. NGCAA has operated NEMT in various ways for more than 20 years and as long as it has been providing transportation it has coordinated its service. Management is pleased with the current arrangement and appreciates that it only does trips in its regular service area and does not have to conduct the intake. Activities That Affect Coordination • Local level initiatives—NEMT coordination, when it does happen, is, in large part, a result of activities initiated and successfully implemented by the local participants. There are some fully coordinated agencies in the state (agencies that operate all three major programs for the three agencies). The decision to coordinate or not was, in large part, a result of actions taken at the local level. • Capitated brokerage—By its nature, the large-scale capitated brokerage model is dependent on receiving the lowest cost per trip possible. This is compounded by the playing field set by the broker and/or the state Medicaid agency. The broker attempts to contract with as many providers in an area as possible, often encour- aging small providers to initiate service. This makes coordination with public transportation difficult to achieve, because public transit must compete for service on price, rather than quality. • Lack of coordination of NEMT at the state level— GDOT and DHR have made significant efforts to coor- dinate their services and their models are compatible at the local level. DCH has chosen a capitated brokerage model that does not encourage coordination. • Service standards—The NEMT program maintains a high level of standards for drivers and vehicles, ensuring a reasonably level playing field. OREGON—TRIMET, PORTLAND Introduction TriMet, the large urban transit agency in the Portland, Ore- gon, area (population 1.3 million), operates fixed-route bus service, various light-rail lines, ADA paratransit, and NEMT. Fixed-route and light-rail ridership is approximately 98 million passenger trips, with a paratransit ridership of 920,000 annually. TriMet entered into its brokerage arrange- ment in 1994 as the first transit agency broker in Oregon and provides one of the best examples of coordination of public transit and Medicaid in an urban area. It also serves as an excellent example of a public–private partnership because the operations are contracted to private providers. Oregon’s Office of Medical Assistance Programs (OMAP), in conjunction with the Oregon DOT (ODOT), chose to work directly with a variety of transit agencies that serve as brokers of service. This de facto coordination serves as an excellent example of how state agencies can work with

26 transit professionals to provide service that meets local needs. The first brokerage was initiated in 1994 after two years of discussion, with others following over the next few years. All of the brokerages are public transit operators. Relationship Between Stakeholders In 1991, OMAP initiated discussions with TriMet, which cul- minated with an agreement for management of the brokerage that has been in place since 1994. TriMet management stated that relations among OMAP, ODOT, and TriMet were excel- lent, because all parties have a common goal. Communication is rarely a problem, because all parties work closely together to solve problems. ODOT provides seed money to brokers as needed to ensure successful implementation. State Level Service Delivery Model OMAP has placed control of the service at the local level. By allowing these regional brokers the flexibility to operate a pro- gram that meets the needs of the community, coordination has flourished. The regional brokerages are all operated by transit agencies. Each agency uses its own approach to the provision of NEMT. Brokers are paid based on an average trip cost, which is calculated quarterly. All billing is done electronically. TriMet Coordination Activities TriMet maintains a separate “contact center” for each program and a separate contracted operation owing to the complexities and differences of each program. Until recently, the services were managed by two different entities. Last year, both cen- ters were contracted to one management firm. The centers are on TriMet property with TriMet staff working alongside the contractor, allowing for ease of service monitoring. Customers call the NEMT Contact Center, which then assigns trips to one of 50 subcontractors (some are exclusive to TriMet, whereas others, such as taxicabs, pick up other passengers). Selection of the contractor and mode is depen- dent on need (most appropriate mode) and cost. Fixed-route ridership for NEMT is 35% of total ridership, down from 50% as a result of the elimination of certain groups from the Medicaid program. These groups had a very high level of fixed-route use. TriMet does not conduct a formal assess- ment of the ability of Medicaid clients to ride fixed-route transit (unlike the ADA program), preferring to “take the word” of the customers. Management feels that this approach, coupled with communication with case workers and field observation, is more effective and less intrusive. Activities That Affect Coordination • Communication and trust—OMAP, TriMet, and ODOT have an excellent working relationship and work toward a common goal of continuing to improve the brokerages. • Interagency agreements—By contracting with other governmental entities, as opposed to a competitive pro- curement, OMAP has been able to ensure coordination by involving transit agencies as brokers. • Local level flexibility—As with most large and diverse states, Oregon has a wide variety of transportation needs. Solutions in Portland may not work in the cities of Bend or Salem. This approach recognizes that the local level is the best place to determine needs and a ser- vice model(s). In addition, TriMet works directly with caseworkers to ensure the most appropriate mode. • Cost-effective—The broker is always seeking the low- est cost per trip and has a variety of options available. • Use of fixed-route service—The brokers appear to be taking advantage of fixed-route services and this has resulted in significant savings. • Service standards—TriMet determines the service stan- dards for the NEMT program (over and above state minimum levels). TriMet uses its own standards to ensure a quality service. • Contract oversight—TriMet is aggressive in monitor- ing service—frequent field observations, inspections, and communication with caseworkers can only be done at the local or regional level. • Fair/reasonable payment for service—The cost of the service is closely monitored to ensure that the payment per trip is reasonable for all parties. TEXAS—TEXOMA AREA PARATRANSIT SYSTEM, SHERMAN AND DENNISON Introduction The Texoma Area Paratransit System (TAPS) is a nine- county rural transit agency and a small urban operator for the cities of Sherman and Dennison in north Texas. The service area population is approximately 110,000. The agency is pre- dominantly demand-response with a series of commuter fixed-route services serving various employment sites in the Dallas/Ft. Worth metropolitan area and the Dallas Area Rapid Transit’s (DART) light rail station in Plano. TAPS contracts with the Medicaid Transportation Program (MTP) in nine counties (four under subcontract) and has coor- dinated a wide range of types of human service transportation for more than 20 years. TAPS is similar in size and coordina- tion levels to a number of other rural agencies in Texas. Texas has a long history of coordination at the local level, especially in rural areas, where many of the agencies have a 30-year history of coordinating Medicaid, Title III Aging transportation, job access, and other programs with public transit. Almost all of the rural transit agencies in the state coordinated at least one other human service program, and most more than one.

27 Relationships Between Stakeholders The Texas Legislature has taken a unique approach to the coordination of transportation at the state level. In 2003, the state legislature passed legislation requiring the Texas Health and Human Service Commission (HHSC) (responsi- ble for Medicaid, Title III, and other programs) and the Texas Workforce Commission (TWC) to cede control of their transportation programs to TxDOT. However, HHSC and the TWC retain policy control over their programs (i.e., HHSC is still the single state agency responsible for Medic- aid). To date, TxDOT has transferred the entire MTP staff (more than 150 individuals operating the 8 call centers), as well as seven staff members to support the software used by TxDOT. The program has remained basically the same as it was when it was at HHSC. No other programs have been affected at this time. State Medicaid Service Delivery Model TxDOT operates the regional brokerages directly (using state employees), and each region uses multiple operators to cover their regions. In essence, TxDOT is directly involved in the day-to-day operation. Clients call their designated TxDOT regional broker who verifies client and trip eligibility and then determines the most appropriate mode. The MTP office then schedules the trip and contacts (or posts on the web) the most appropriate service operator at 5:00 p.m. the day before the trip. Use of fixed-route service by TxDOT is low in the major cities where most of the population resides. In the 1980s, more than 50% of urban Texas Medicaid clients using MTP rode on fixed-route; currently, it is below 15%. The previous approach implemented in the late 1990s by the Texas Department of Health was to conduct competitive procurements throughout the state. The RFP standards devel- oped previously by the Department of Health for drivers, vehicles, maintenance, and safety were considerably lower than that of most of the public transit operators. As a conse- quence, some of the rural public transit agencies that had been operating MTP service for 20 years lost their contracts based on price. This resulted in a net loss of coordination in parts of the state, whereas other rural operators continued to operate in a coordinated manner. This loss continued with the most recent procurement (discussed here). The new RFP issued as this study was being completed indicates that TxDOT is beginning to level the playing field by making operating requirements more stringent. The RFP does not require coordination, although it is encouraged. TxDOT has designated the 24 council of government regions as MTP regions. It is conducting a competitive procurement to select one operator or sub-broker who will receive the calls from TxDOT (the broker) to be responsible for all service in the region. These trip requests will then be forwarded to the service operator. It is not clear at this point how this procure- ment will affect coordination with public transit, nor is it clear how fixed-route usage will be increased. State Level Coordination As stated previously, the rural transit agencies have evolved into very highly coordinated transit agencies that compare favorably with other states. TxDOT has recently imple- mented a planning requirement for 24 designated areas cov- ering the entire state. All major agencies and stakeholders are involved. It is not clear how the results of these meet- ings will affect or influence Medicaid transportation (pro- cured outside the influence of this planning process) and the other programs. It should also be noted that without Medic- aid transportation, there is little left to coordinate because MTP contributes the vast majority of human service fund- ing and customers. Texoma Area Paratransit System Coordination Efforts to Date TAPS is a fully coordinated transit agency that, in addition to public transportation, contracts with TxDOT to operate Med- icaid transportation. The recent changes place a sub-broker between TAPS and TxDOT. TAPS also assists a number of senior centers and the TWC. Employment transportation is coordinated directly with employers and employee organiza- tions. TAPS also works with other small agencies to assist them in their transportation needs. TAPS has taken the initiative to coordinate NEMT with public transit for its entire 20-year existence. Management believes that “all coordination is local” in that all of the activ- ities necessary for coordination have been conducted at the local level. During those 20 years, TAPS was required to engage in a competitive procurement conducted by MTP and, at this time, has retained its contract. TAPS must work with two separate TxDOT MTP managers and two different TxDOT public transit coordinators. Now it must also work with an MTP sub-broker. Innovation to Enhance Coordination TAPS and one of its TxDOT MTP field managers have initi- ated a pilot program in four of the TAPS counties. TAPS sells bus passes for travel within each county. The MTP office in Dallas purchases discounted passes and distributes them to riders with demonstrated need. The customer then calls TAPS for their trip and is treated as any other customer. This elimi- nates the need for expensive invoicing and processing for both the operator and the MTP. It allows the transit provider to control the scheduling process, which also enhances their productivity. Record keeping is kept to a minimum as well. Lastly, it allows the MTP customers to gain a familiarity with the agency.

28 Activities That Affect Coordination TAPS management was clear in its statement that all coordi- nation is local. Management has worked hard to build a high level of trust. It credits considerable work at the local level for all of the coordination success TAPS has had over the years. Following are the factors that affect coordination in TAPS service area. • Local level success and trust—TAPS and other Texas rural operators have a long history of successful coor- dination at the local level. These coordination efforts are built on trust and the development of relationships between partnering entities. • Communication issues—Working with four different TxDOT field staff for two programs makes for commu- nication issues. Perceptions and priorities are not always compatible between these programs and with TAPS. • Unclear decision-making authority—In addition to the previous concern, it is not yet clear how the new plan- ning process will be used to determine the level of coor- dination. There does not appear to be a link between the planning process and the NEMT procurement. • State and federal government—TAPS management believes that the state and federal governments have no effect on TAPS coordination efforts. However, neither does government pose a barrier, with the possible exception of MTP. • Sound business practice—TAPS will consider any coordination opportunity where they will not lose money. The objective is to provide more service. • Flexible Medicaid funds—In rural areas, TAPS can use a portion of its MTP funds as part of its local match, giv- ing a financial incentive to coordination in rural areas. • Service standards—The previous procurement (when MTP was at the Department of Health) called for a lower level of safety and operating standards than rural operators provide. This made it difficult for transit agencies to compete with providers that offer the least stringent standards. This situation was improved in the latest procurement. VERMONT—CHITTENDEN COUNTY TRANSPORTATION AUTHORITY, BURLINGTON The focus of this case study is on Burlington’s transit agency, the Chittenden County Transportation Authority (CCTA), which has a service area population of 87,000. CCTA is a small urban agency that also operates the transit service in the state capital of Montpelier. CCTA has been designated the broker for its Burlington service area and uses a variety of methods to meet the needs of Medicaid customers in a cost- effective manner. The agency provides more than 1.6 million fixed-route trips and 29,000 paratransit trips annually. Of this total, 172,000 were NEMT trips, with 75% of these on fixed routes. Vermont, a predominantly rural state, has a unique approach to the coordination of Medicaid and public trans- portation. The state contracts with the Vermont Public Transit Association (VPTA) to administer and manage the NEMT program. VPTA, which is made up of the public transit oper- ators, then contracts with those public transit operators who coordinate the service with their public transit. Relationship Between Stakeholders There is a very high level of trust between VPTA, the oper- ators, and the state Medicaid agency. These agencies have been working together for 19 years. This trust has fostered a cooperative relationship that has enabled a high level of coordination. State Level Service Delivery Model The service delivery model places VPTA as the administrator of all Medicaid transportation in the state. VPTA contracts directly with nine public transit and paratransit agencies in the state. The operators serve as brokers, placing Medicaid cus- tomers on either fixed-route or paratransit and utilizing a strong network of volunteers. The volunteer programs, requir- ing significant effort to maintain, have a long tradition of assistance in this state, where fewer resources are available than typically found in large states and cities. This service delivery approach is fully coordinated and, as seen in other regional and local models, very flexible in meet- ing local needs. For example, the urban areas of Burlington and Rutland rely on fixed-route service, whereas rural Addison County relies just as heavily on an extensive volunteer network. State Level Coordination Efforts to Date VPTA’s operation of the program began in 1986 when the state’s Agency of Human Services contracted with VPTA to manage the NEMT program. VPTA serves as the program manager and is the single point of contact and accountability for the medical transportation programs of nine regional Medicaid brokers in the state. The objective of the VPTA Medicaid/Reach Up Transportation Program is to provide the most cost-effective, appropriate transportation based on individual needs, medical circumstances, and available com- munity resources. A corps of volunteer and professional drivers transport several hundred thousand rides to medical services, employment, and training centers each year. The VPTA brokerage system is the major provider of NEMT for Vermont’s Medicaid-eligible citizens. Broker organizations include public transit agencies and paratransit providers. Involvement in the Medicaid transportation pro- gram requires brokers to be subject to service approval, claims processing, and utilization review. During FY 2004,

29 VPTA members used fixed-route buses (36%), a network of hundreds of volunteers (27%), taxis (20%), and vans (8%), to provide 490,383 Medicaid/Reach Up trips statewide. VPTA and the Agency of Human Services have coordi- nated for 19 years, and there is a very high level of trust between the organizations. VPTA also works closely with the Agency of Transportation (AOT). VPTA management reports state that NEMT was the impetus for initiating pub- lic transit in rural areas of the state and was the framework for transit services, with transit service areas coinciding with Medicaid catchment areas. One concern that could affect coordination across the state is that the AOT believes that the Medicaid/Reach Up program should pay for depreciation of AOT-sponsored vehicles. This issue is currently under discussion and likely to be resolved by the state. CCTA Coordination Efforts CCTA is a small urban transit operator serving the greater Burlington area. In addition, CCTA operates and manages Green Mountain Transit, a rural transit agency in the state capital of Montpelier. CCTA was designated the broker for its service areas. As broker, CCTA’s first priority is to place as many Medicaid customers on fixed-route service as possi- ble. Currently, more than 80% of the Medicaid trips in the county that use Medicaid/Reach Up are on fixed routes and use bus passes. Demand-response trips are provided by taxi and coordinated through the nonprofit agency that contracts for ADA service. Activities That Affect Coordination • The Medicaid agency trust level—There is a high level of trust between the state Agency for Human Services and VPTA, built over years of cooperation. Their trust level extends to the operators. • Coordination of state agencies—Each of the agencies and the brokerage work well together and discuss issues on a regular basis in a variety of forums. • Using the operators as brokers—This decision was critical to the coordination effort and is an excellent example of the state facilitating coordination. • High utilization of fixed-route service—Vermont has a high level of fixed-route use (36% for 11% of the cost). Considering that Vermont is a very rural state makes it even more impressive. According to VPTA, the cost for a fixed-route trip is less than 20% of the average cost for the other modes. • Adequate funding for NEMT—Each of the brokers is reimbursed for the trip provided (volunteer or transit), as well as for expenses related to administration and trip intake. The costs of trip intake are almost as much as the trip itself and are related to: – trip and eligibility verification and assignment of most appropriate mode, and – recruitment, training, administration payment, verifi- cation, and programs designed to retain volunteers. • Level playing field—VPTA determines the service stan- dards that all brokers must comply with. The playing field is level. SUMMARY—CASE STUDIES NEMT is essentially a state designed and managed program; therefore, there are a variety of effective approaches to coor- dination and service delivery. The five case studies repre- sented in this synthesis illustrate the flexibility states have in designing a NEMT program. The case studies indicated that there are a number of lessons to be learned and that there are a variety of factors and actions that can determine coordination potential at the transit agency level. The most important are discussed here. • Lesson 1: Coordination of fixed-route service is encour- aged by most states—Florida, an early practitioner of fixed-route bus passes, has seen considerable cost sav- ings using this approach. Vermont and Oregon are also practitioners of the use of fixed-route service. Georgia’s private brokers see financial gain through the use of fixed-route service and presumably the state Medicaid agency benefits from this approach. However, although in the 1980s and early 1990s Texas relied heavily on fixed-route service, its use has been reduced since that time. With some exceptions, most states have seen sig- nificant financial savings through the use of fixed-route service. • Lesson 2: Cost transferring onto paratransit is prob- lematic—Paratransit, the mode used by many clients, operates differently from fixed-route service. Where the use of fixed-route service can benefit all riders, paratransit typically requires fully allocated costs to be successful. • Lesson 3: Service model—The service model used will, in part, determine the level and ability of the transit agen- cies to coordinate. The service model used by Vermont is built on trust at the local level and through state initia- tive with the transit association; this has introduced a model of service delivery that is the epitome of coordi- nation. Oregon also has a strong coordination model. In each of these cases, the transit agencies serve as brokers or operators of service. Florida’s model also fosters coor- dination between transit agencies. NEMT has seen some transit agencies withdraw or consider withdrawing from the NEMT program owing to funding cuts. In the past, Texas was a highly coordinated state through the strength of its transit agencies. The recently introduced RFP is a coordination neutral approach and several systems lost

30 their contracts. Low price and other factors will deter- mine the selection process. Finally, Georgia has a model that makes coordination difficult to achieve through its large regional brokers. The approach used by each state will help determine coor- dination potential; however, coordination can still occur even with a model that does not necessarily encourage coordination. The local transit agency will also, in large part, determine if coordination will be used. • Lesson 4: Building on trust—As in any business rela- tionship, coordination is built on trust. In Vermont and Oregon the trust level is high at all levels of manage- ment. The other case studies indicated significant trust at the local level where coordination was successful.

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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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