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4 PURPOSE OF SYNTHESIS and levels of responsibility. Some brokerages are statewide (either for profit or state operated); others are Opportunities exist for public transit agencies in both urban regional or "community based" (including many tran- and rural areas to participate either as providers or brokers in sit agencies). Medicaid transportation programs. Although rural areas have Capitated model--Capitation is used to describe a bro- historically taken advantage of coordination opportunities, kerage where the broker is given a set amount of fund- many transit and Medicaid agencies do not coordinate in the ing per Medicaid recipient for the designated service provision of NEMT because of real or perceived barriers. This area. The broker then must provide all appropriate synthesis examines how a public transitNEMT partnership transportation for the set rate. can be successful and under what types of circumstances. Coordination--When two or more organizations work together to their mutual benefit to gain economies of The purpose of this synthesis is to report on the real and scale, eliminate duplication, expand service, and/or perceived barriers to NEMT and public transit coordination improve the quality of service. According to the and develop case studies of Medicaid transportation program United We Ride initiative (described later), coordi- participation by transit agencies. The synthesis also looked nation makes the most efficient use of limited trans- at the positive aspects of coordination; that is, what are the portation resources by avoiding duplication caused essential ingredients to successful coordination. by overlapping individual program efforts and encouraging the use and sharing of existing commu- Much of the effort focuses on coordination of actual services nity resources. There are many levels of coordina- at the transit system level, rather than on coordination among tion, from simple sharing of training resources all the state agencies. The synthesis reviewed decision-making and way to full consolidation. operational frameworks for creating a contractual relationship Cost transferring--The term "client shedding" has been between the Medicaid program and the public transit agency as in use in the transit industry for a number of years. That a direct provider, broker, or subcontractor. It is intended that term, however, has negative connotations and is not as this document be used by transit agencies to initiate further accurate in describing the essence of the issue, which dialogue regarding this important issue. is the transferring of financial responsibility for a group or class of human service agency clients. For this report, the term "cost transferring" will refer to the SYNTHESIS ORGANIZATION AND METHODOLOGY transferring of funding for NEMT clients from state and federal NEMT funds to local transit dollars. The Following this introductory chapter, the synthesis reviews transferring of responsibility for funding NEMT to the relevant literature in the field (chapter two). Chapter three local transit agencies instead of NEMT is a core issue presents the results of the survey of selected transit agencies, in coordination. state DOTs, and Medicaid agencies to report on the current Fixed-route service and ADA complementary paratran- state of the practice. Based on the survey results, the litera- sit--These are the two predominant modes of transit ture review, and the researchers knowledge of NEMT pro- used by NEMT and public transit. Fixed-route service grams, case studies were developed to profile innovative and is typically found in most cities and employs buses successful practices, as well as lessons learned and gaps in following a designated route according to a timetable. information (chapter four). The final chapter (chapter five) Passengers come to the bus stop to wait for the bus. includes conclusions and suggestions for further study. Virtually all fixed-route buses are wheelchair accessi- ble. ADA paratransit, which is much more expensive on a per-trip basis, provides service from a customer's GLOSSARY origin to their destination. ADA complementary paratransit (curb-to-curb or door-to- There are a number of terms used extensively throughout the door)--This is required in all transit service areas that literature that have also gained popular usage in the industry. have fixed-route service (within three-quarters of a mile These terms, however, have a variety of meanings and are of the fixed route). ADA paratransit is available for per- clarified here for purposes of this synthesis. The following is sons who cannot ride fixed-route service. Passengers a glossary of some of the basic terms used throughout this must undergo a certification process to determine if report. Please see the CTAA's Medical Transportation they are eligible for fixed-route, paratransit, or a com- Toolkit and Best Practices (2005) for a more comprehensive bination of services. glossary of NEMT terms. Freedom of Choice Waiver--NEMT is treated as a med- ical program if the state chooses to use the medical Brokerage--Any entity that takes trip requests and dis- matching rate, which is usually higher than the admin- tributes the trips to more than one service provider. istrative rate of 50%. States can allow Medicaid Brokerages come in all sizes, with different functions clients to use any registered provider of transportation

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5 or request a Section 1915 (b)(4) waiver allowing the National Leadership Forum--a coordination confer- state to limit access to fewer providers. Some states ence, (4) state coordination grants to address coordi- have applied for and received waivers, others use nation gaps, and (5) a technical assistance program. administrative funds, whereas still others allow for some level of freedom of choice. It should be noted that coordination is not the goal of tran- United We Ride initiative--This is a coordination initia- sit agencies, but is a tool that can be used to achieve the tive of the Federal Coordination Council on Access true goals of providing more rides of greater quality, cost- and Mobility, started in December 2003. There are five effectiveness, and safety. Furthermore, coordination is not components of the United We Ride initiative: (1) The always the best solution to meeting these goals. Therefore, Framework for Action--a tool that can be used to although coordination is discussed in the various states and assess state and community coordination efforts, (2) transit agencies, nothing in this discussion is implied to sug- state leadership awards that recognize states that have gest (one way or another) the quality and/or effectiveness of made significant progress in coordination, (3) The the states and transit agencies reviewed.