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