Transit Agency Participation in Medicaid Transportation Programs (2006)

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

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

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

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