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3 CHAPTER ONE INTRODUCTION BACKGROUND NON-EMERGENCY MEDICAL TRANSPORTATION Coordination of human service and public transportation has NEMT as part of Title XIX of the Social Security Act (Med- been a valuable tool for transit operators for almost 30 years. icaid) is the focus of this coordination synthesis. NEMT is Before the creation of rural public transit subsidies in the significant because of its size as the largest human service 1980s, many rural transportation programs saw the coordi- transportation program. The Community Transportation nation of multiple human service programs as the only way Association of America (CTAA) reported that NEMT, they could survive. The U.S. General Accounting Office nationwide, spends approximately $1.75 billion annually, recognized this in the first of its studies on the coordination which is far more than any other human service transportation of human service transportation (Hindrances . . . 1977). This program (Medicaid Transportation . . . 2001). It is funded by report concluded that the most significant hindrance to coordi- a combination of state and federal dollars. The program itself nation was confusion and misperception regarding restrictions is state run, with each state determining its approach to to coordination. NEMT. This explains why there are so many variations in ser- vice design among the states (and, within some states, each In the almost 30 years since that initial study, coordination county). The entitlement nature of the program requires that has been and continues to be important to the well being of there be no limits to legitimate service needs (as with ADA many rural transit agencies, whereas urban transit agencies paratransit). NEMT was initiated in the mid-1970s to ensure have typically eschewed coordination of paratransit as an that necessary transportation to the nearest appropriate med- unnecessary complication to the Americans with Disabilities ical facilities was available to Medicaid-eligible clients. The Act (ADA) service that is already difficult to operate (a view importance of Medicaid's NEMT program in any coordina- expressed by many of the ADA paratransit managers inter- tion effort cannot be stressed enough. viewed, including San Antonio, Texas; Baltimore, Maryland; Austin, Texas; and Philadelphia, Pennsylvania). However, two large urban agencies that have operated the two programs, PUBLIC TRANSPORTATION AND AMERICANS Portland, Oregon, and Broward County, Florida, have kept the WITH DISABILITIES ACT programs separate. Fixed-route service, however, is a service that some state and local Medicaid programs have used to dra- For purposes of this synthesis, public transportation is any matically reduce their per-trip costs. Fixed-route service can transit program funded by the FTA and/or state and local be a cost-effective tool to coordinate Non-Emergency Medical dollars specifically for the public. These programs exist in Transportation (NEMT) and urban public transit without dis- rural, small urban, and large urban areas--each having dif- rupting the public transit network. ferent funding match rates for federal funding. For example, large urban transit agencies do not receive federal operating There are many studies that promote the benefits of coordi- subsidies, relying instead on local and (sometimes) state nation from across the country. The economic benefits of coor- funding for all operating expenses, whereas small urban and dination have recently been quantified in TCRP Report 91: rural agencies are eligible for a 50% match for operating Economic Benefits of Coordinating Human Service Trans- funds. portation and Transit Services (Westat and Nelson/Nygaard Consulting Associates 2003). This report found that these ben- "Complementary" paratransit is a requirement of ADA-- efits included increased funding, improved productivity, and each transit system that operates fixed-route service must economies of scale. In addition, TCRP Report 70: The Guide- operate paratransit within three-quarters of a mile of the fixed book for Change and Innovation for Small Urban and Rural route. There are no restrictions on the use of this service other Transit Systems (KFH Group and AMMA 2000) noted that than an eligibility requirement. There is no specific funding rural transit managers recognize the need for funding from as for ADA paratransit; however, as with NEMT, there are many sources as possible, including human service trans- no limits to the level of service that eligible passengers can portation programs. These managers noted that coordination take. In large urban areas, these programs do not receive any can be a sound business practice. federal funds.