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TRANSIT TCRP SYNTHESIS 65 COOPERATIVE RESEARCH PROGRAM Sponsored by the Federal Transit Administration Transit Agency Participation in Medicaid Transportation Programs A Synthesis of Transit Practice

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TCRP OVERSIGHT AND PROJECT TRANSPORTATION RESEARCH BOARD 2006 EXECUTIVE COMMITTEE SELECTION COMMITTEE (Membership as of June 2006) (as of June 2006) OFFICERS CHAIR DAVID A. LEE Chair: Michael D. Meyer, Professor, School of Civil and Environmental Engineering, Georgia Connecticut Transit Institute of Technology MEMBERS Vice Chair: Linda S. Watson, Executive Director, LYNX--Central Florida Regional ANN AUGUST Transportation Authority Santee Wateree Regional Transportation Executive Director: Robert E. Skinner, Jr., Transportation Research Board Authority LINDA J. BOHLINGER MEMBERS HNTB Corp. ROBERT I. BROWNSTEIN MICHAEL W. BEHRENS, Executive Director, Texas DOT PB Consult, Inc. ALLEN D. BIEHLER, Secretary, Pennsylvania DOT SANDRA K. BUSHUE FTA JOHN D. BOWE, Regional President, APL Americas, Oakland, CA PETER CANNITO LARRY L. BROWN, SR., Executive Director, Mississippi DOT Metropolitan Transportation Authority--Metro DEBORAH H. BUTLER, Vice President, Customer Service, Norfolk Southern Corporation and North Railroad Subsidiaries, Atlanta, GA GREGORY COOK Ann Arbor Transportation Authority ANNE P. CANBY, President, Surface Transportation Policy Project, Washington, DC NATHANIEL P. FORD DOUGLAS G. DUNCAN, President and CEO, FedEx Freight, Memphis, TN San Francisco MUNI NICHOLAS J. GARBER, Henry L. Kinnier Professor, Department of Civil Engineering, Univer- RONALD L. FREELAND sity of Virginia, Charlottesville Booz Allen Hamilton, Inc. ANGELA GITTENS, Vice President, Airport Business Services, HNTB Corporation, Miami, FL FRED M. GILLIAM Capital Metropolitan Transportation Authority GENEVIEVE GIULIANO, Professor and Senior Associate Dean of Research and Technology, KIM R. GREEN School of Policy, Planning, and Development, and Director, METRANS National Center GFI GENFARE for Metropolitan Transportation Research, USC, Los Angeles JILL A. HOUGH SUSAN HANSON, Landry University Prof. of Geography, Graduate School of Geography, North Dakota State University JOHN INGLISH Clark University Utah Transit Authority JAMES R. HERTWIG, President, CSX Intermodal, Jacksonville, FL JEANNE W. KRIEG GLORIA J. JEFF, General Manager, City of Los Angeles DOT Eastern Contra Costa Transit Authority ADIB K. KANAFANI, Cahill Professor of Civil Engineering, University of California, Berkeley CELIA G. KUPERSMITH HAROLD E. LINNENKOHL, Commissioner, Georgia DOT Golden Gate Bridge, Highway and Transportation District SUE McNEIL, Professor, Department of Civil and Environmental Engineering, University of Delaware CLARENCE W. MARSELLA DEBRA L. MILLER, Secretary, Kansas DOT Denver Regional Transportation District MICHAEL R. MORRIS, Director of Transportation, North Central Texas Council of Governments FAYE L. M. MOORE CAROL A. MURRAY, Commissioner, New Hampshire DOT Southeastern Pennsylvania Transportation Authority JOHN R. NJORD, Executive Director, Utah DOT MICHAEL H. MULHERN SANDRA ROSENBLOOM, Professor of Planning, University of Arizona, Tucson Massachusetts Bay Transportation Authority HENRY GERARD SCHWARTZ, JR., Senior Professor, Washington University Retirement Fund MICHAEL S. TOWNES, President and CEO, Hampton Roads Transit, Hampton, VA STEPHANIE L. PINSON C. MICHAEL WALTON, Ernest H. Cockrell Centennial Chair in Engineering, University of Gilbert Tweed Associates, Inc. ROBERT H. PRINCE, JR. Texas at Austin DMJM+Harris JEFFREY M. ROSENBERG EX OFFICIO MEMBERS Amalgamated Transit Union MICHAEL SCANLON THAD ALLEN (Adm., U.S. Coast Guard), Commandant, U.S. Coast Guard San Mateo County Transit District THOMAS J. BARRETT (Vice Adm., U.S. Coast Guard, ret.), Pipeline and Hazardous Materials BEVERLY SCOTT Safety Administrator, U.S.DOT Sacramento Regional Transit District MARION C. BLAKEY, Federal Aviation Administrator, U.S.DOT FRANK TOBEY First Transit JOSEPH H. BOARDMAN, Federal Railroad Administrator, U.S.DOT KATHRYN D. WATERS REBECCA M. BREWSTER, President and COO, American Transportation Research Institute, Dallas Area Rapid Transit Smyrna, GA FRANK WILSON GEORGE BUGLIARELLO, Chancellor, Polytechnic University of New York, and Foreign Secretary, Metropolitan Transit Authority of Harris County National Academy of Engineering EX OFFICIO MEMBERS SANDRA K. BUSHUE, Deputy Administrator, Federal Transit Administration, U.S.DOT WILLIAM W. MILLAR J. RICHARD CAPKA, Federal Highway Administrator, U.S.DOT APTA EDWARD R. HAMBERGER, President and CEO, Association of American Railroads ROBERT E. SKINNER, JR. TRB JOHN C. HORSLEY, Exec. Dir., American Association of State Highway and Transportation Officials JOHN C. HORSLEY DAVID H. HUGEL, Acting Administrator, Federal Motor Carrier Safety Administration, U.S.DOT AASHTO J. EDWARD JOHNSON, Director, Applied Science Directorate, National Aeronautics J. RICHARD CAPKA and Space Administration FHWA ASHOK G. KAVEESHWAR, Research and Innovative Technology Administrator, U.S.DOT TDC EXECUTIVE DIRECTOR WILLIAM W. MILLAR, President, American Public Transportation Association LOUIS SANDERS NICOLE R. NASON, National Highway Traffic Safety Administrator, U.S.DOT APTA JULIE A. NELSON, Acting Deputy Administrator, Maritime Administration, U.S.DOT SECRETARY JEFFREY N. SHANE, Under Secretary for Policy, U.S.DOT ROBERT J. REILLY CARL A. STROCK (Maj. Gen., U.S. Army), Chief of Engineers and Commanding General, TRB U.S. Army Corps of Engineers

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TRANSIT COOPERATIVE RESEARCH PROGRAM TCRP SYNTHESIS 65 Transit Agency Participation in Medicaid Transportation Programs A Synthesis of Transit Practice CONSULTANTS KENNETH I. HOSEN and ELISABETH FETTING KFH Group, Inc. Bethesda, Maryland S UBJECT A REAS Public Transit Research Sponsored by the Federal Transit Administration in Cooperation with the Transit Development Corporation TRANSPORTATION RESEARCH BOARD WASHINGTON, D.C. 2006 www.TRB.org

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TRANSIT COOPERATIVE RESEARCH PROGRAM TCRP SYNTHESIS 65 The nation's growth and the need to meet mobility, environ- Price $31.00 mental, and energy objectives place demands on public transit Project J-7, Topic SB-13 systems. Current systems, some of which are old and in need of ISSN 1073-4880 upgrading, must expand service area, increase service frequency, ISBN 0-309-09770-3 and improve efficiency to serve these demands. Research is nec- Library of Congress Control Number 2006905110 essary to solve operating problems, to adapt appropriate new technologies from other industries, and to introduce innovations 2006 Transportation Research Board into the transit industry. The Transit Cooperative Research Pro- gram (TCRP) serves as one of the principal means by which the transit industry can develop innovative near-term solutions to COPYRIGHT PERMISSION meet demands placed on it. Authors herein are responsible for the authenticity of their materials and for The need for TCRP was originally identified in TRB Special obtaining written permissions from publishers or persons who own the Report 213--Research for Public Transit: New Directions, pub- copyright to any previously published or copyrighted material used herein. lished in 1987 and based on a study sponsored by the Federal Cooperative Research Programs (CRP) grants permission to reproduce Transit Administration (FTA). A report by the American Public material in this publication for classroom and not-for-profit purposes. Transportation Association (APTA), Transportation 2000, also Permission is given with the understanding that none of the material will be recognized the need for local, problem-solving research. TCRP, used to imply TRB, AASHTO, FAA, FHWA, FMCSA, FTA, or Transit modeled after the longstanding and successful National Coopera- Development Corporation endorsement of a particular product, method, or tive Highway Research Program, undertakes research and other practice. It is expected that those reproducing the material in this document for educational and not-for-profit uses will give appropriate acknowledgment technical activities in response to the needs of transit service provid- of the source of any reprinted or reproduced material. For other uses of the ers. The scope of TCRP includes a variety of transit research material, request permission from CRP. fields including planning, service configuration, equipment, fa- cilities, operations, human resources, maintenance, policy, and ad- ministrative practices. NOTICE TCRP was established under FTA sponsorship in July 1992. Proposed by the U.S. Department of Transportation, TCRP was The project that is the subject of this report was a part of the Transit Coop- authorized as part of the Intermodal Surface Transportation Effi- erative Research Program conducted by the Transportation Research Board ciency Act of 1991 (ISTEA). On May 13, 1992, a memorandum with the approval of the Governing Board of the National Research Coun- cil. Such approval reflects the Governing Board's judgment that the project agreement outlining TCRP operating procedures was executed by concerned is appropriate with respect to both the purposes and resources of the three cooperating organizations: FTA, the National Academy of the National Research Council. Sciences, acting through the Transportation Research Board The members of the technical advisory panel selected to monitor this (TRB); and the Transit Development Corporation, Inc. (TDC), a project and to review this report were chosen for recognized scholarly com- nonprofit educational and research organization established by petence and with due consideration for the balance of disciplines appropri- APTA. TDC is responsible for forming the independent govern- ate to the project. The opinions and conclusions expressed or implied are ing board, designated as the TCRP Oversight and Project Selec- those of the research agency that performed the research, and while they tion (TOPS) Committee. have been accepted as appropriate by the technical panel, they are not nec- Research problem statements for TCRP are solicited periodi- essarily those of the Transportation Research Board, the Transit Develop- cally but may be submitted to TRB by anyone at any time. It is ment Corporation, the National Research Council, or the Federal Transit Administration of the U.S. Department of Transportation. the responsibility of the TOPS Committee to formulate the re- Each report is reviewed and accepted for publication by the technical search program by identifying the highest priority projects. As panel according to procedures established and monitored by the Transporta- part of the evaluation, the TOPS Committee defines funding tion Research Board Executive Committee and the Governing Board of the levels and expected products. National Research Council. Once selected, each project is assigned to an expert panel, ap- pointed by TRB. The panels prepare project statements (requests for proposals), select contractors, and provide technical guidance The Transportation Research Board of The National Academies, the and counsel throughout the life of the project. The process for Transit Development Corporation, the National Research Council, and the developing research problem statements and selecting research Federal Transit Administration (sponsor of the Transit Cooperative agencies has been used by TRB in managing cooperative re- Research Program) do not endorse products or manufacturers. Trade or search programs since 1962. As in other TRB activities, TCRP manufacturers' names appear herein solely because they are considered project panels serve voluntarily without compensation. essential to the clarity and completeness of the project reporting. Because research cannot have the desired impact if products fail to reach the intended audience, special emphasis is placed on disseminating TCRP results to the intended end users of the re- Published reports of the search: transit agencies, service providers, and suppliers. TRB TRANSIT COOPERATIVE RESEARCH PROGRAM provides a series of research reports, syntheses of transit practice, and other supporting material developed by TCRP research. are available from: APTA will arrange for workshops, training aids, field visits, and Transportation Research Board other activities to ensure that results are implemented by urban Business Office and rural transit industry practitioners. 500 Fifth Street, NW Washington, DC 20001 The TCRP provides a forum where transit agencies can coop- eratively address common operational problems. The TCRP results and can be ordered through the Internet at http://www.national-academies.org/trb/bookstore support and complement other ongoing transit research and train- ing programs. Printed in the United States of America

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished schol- ars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. On the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and techni- cal matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Acad- emy of Sciences, The National as a parallel Academy organization of Sciences of outstanding is a private, nonprofit,engineers. It is autonomous self-perpetuating society of in its administration distinguished schol- and in the selection ars engaged of its in scientific members, and sharing engineering with the research, National dedicated Academy to of Sciences the furtherance the responsibility of science for and technology advising the federal government. The National Academy of Engineering also sponsors engineering and to their use for the general welfare. On the authority of the charter granted to it by the Congress in programs aimed at meeting 1863, the Academy national needs, encourages has a mandate education that requires andthe it to advise research, federal and recognizes government on the superior scientific andachieve- techni- ments of engineers. cal matters. Dr. Dr. Ralph J.William CiceroneA.isWulf is president president of the National of the National AcademyAcademy of Engineering. of Sciences. The Institute Academy The National of Medicine was established of Engineering wasin 1970 by the established National in 1964, Academy under of Sciences the charter to secure of the National the Acad- services of eminent members of appropriate professions in the examination of policy matters pertaining emy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration to the and in health of the public. the selection The Institute of its members, acts sharing under with thethe responsibility National Academy given to the National of Sciences Academyfor the responsibility of Sciences the advising by federal its congressional government.charter to be an Academy The National adviser toof the federal government Engineering and,engineering also sponsors on its own initiative, programs to identify aimed issues national at meeting of medical care, needs, research, education encourages and education. Dr. Harvey and research, V. Fineberg and recognizes issuperior the president of the achieve- Institute of Medicine. ments of engineers. Dr. William A. Wulf is president of the National Academy of Engineering. The National The Institute Research of Medicine Council was organized was established by the in 1970 byNational Academy the National of Sciences Academy in 1916 of Sciences toto associate secure the the broadof services community of science eminent members ofand technology appropriate with the Academy's professions purposes of in the examination of furthering policy mattersknowledge and pertaining advising to the federal the health of the government. Functioning public. The Institute acts in accordance under with general the responsibility policies given determined to the National by the Acad- Academy of emy, the Council has become the principal operating agency of both the National Academy Sciences by its congressional charter to be an adviser to the federal government and, on its own initiative, of Sciences and the National to identify issues Academy of medical of care, Engineering research, inand providing services education. to the government, Dr. Harvey V. Fineberg the public, and is president the of the scientific Institute ofand engineering communities. The Council is administered jointly by both the Academies and Medicine. the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. William A. Wulf are chair and vice chair, The National respectively, Research of Council the National was organized Research Council. by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and The Transportation advising Research Board the federal government. is a division Functioning of the National in accordance Research with general Council, policies determinedwhich by serves the the Acad- National emy, the Academy Council hasof Sciences become and the the National principal Academy operating of Engineering. agency of both theThe Board'sAcademy National mission isof toSciences promote innovation and progress and the National Academy in transportation of Engineering through research. in providing In an to services objective and interdisciplinary the government, the public, and setting, the the Board facilitates the sharing of information on transportation practice and policy scientific and engineering communities. The Council is administered jointly by both the Academies and by researchers and practitioners; the Institute of stimulates Medicine. research Dr. RalphandJ.offers Ciceroneresearch and Dr. management William A.services Wulf are that promote chair and vice technical chair, excellence; respectively, provides expertResearch of the National advice on transportation policy and programs; and disseminates research Council. results broadly and encourages their implementation. The Board's varied activities annually engage more The Transportation than 5,000 engineers, Research scientists, Board is a and other division of the transportation National and researchers Research Council, practitioners fromwhich serves and the public the National Academy of Sciences and the National Academy of Engineering. The Board's mission private sectors and academia, all of whom contribute their expertise in the public interest. The program is is to promote innovation supported by and progress state in transportation transportation through departments, research. federal agencies Inincluding an objective and interdisciplinary the component administrationssetting, of the the Board facilitates the U.S. Department ofsharing of information Transportation, and on transportation other organizationspractice and and policy by individuals researchers interested in and the practitioners; development of stimulates research transportation. and offers research management services that promote technical www.TRB.org excellence; provides expert advice on transportation policy and programs; and disseminates research results broadly and encourages their implementation. The Board's varied activities annually engage more www.national-academies.org than 5,000 engineers, scientists, and other transportation researchers and practitioners from the public and private sectors and academia, all of whom contribute their expertise in the public interest. The program is supported by state transportation departments, federal agencies including the component administrations of the U.S. Department of Transportation, and other organizations and individuals interested in the development of transportation. www.TRB.org www.national-academies.org

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TCRP COMMITTEE FOR PROJECT J-7 COOPERATIVE RESEARCH PROGRAM STAFF ROBERT J. REILLY, Director, Cooperative Research Programs CHAIR CHRISTOPHER W. JENKS, Manager, TCRP FRANK T. MARTIN EILEEN P. DELANEY, Director of Publications PBS&J, Tallahassee, FL TCRP SYNTHESIS STAFF MEMBERS STEPHEN R. GODWIN, Director for Studies DEBRA W. ALEXANDER and Information Services Capital Area Transportation Authority, Lansing, MI JON WILLIAMS, Manager, Synthesis Studies DWIGHT FERRELL DONNA L. VLASAK, Senior Program Officer The Ferrell Group, Richardson, TX DON TIPPMAN, Editor MARK W. FURHMANN CHERYL KEITH, Senior Secretary Metro Transit, Minneapolis, MN ROBERT H. IRWIN TOPIC PANEL British Columbia Transit, Victoria, BC, Canada ANDREA V. BUSADA, Broward County Division of Mass Transit PAUL J. LARROUSSE DEBBIE COLLINS, North Carolina State University National Transit Institute, New Brunswick, NJ MAUREEN HENSLEY-QUINN, Community Transportation WADE LAWSON Association of America South Jersey Transportation Authority, Atlantic City, NJ REGINALD KNOWLTON, WHEELS, Inc. DAVID A. LEE CAREY ROESSEL, Access Transit Services, Inc. Connecticut Transit, Hartford, CT PAM WARD, Ottumwa Transit Authority DAVID PHELPS PARK WOODWORTH, King County Metro Transit Consultant, Moneta, VA DOUG BIRNIE, Federal Highway Administration (Liaison) HAYWARD M. SEYMORE, III BRYNA HELFER, Federal Highway Administration (Liaison) Laidlaw Transit Services, Inc., University Place, WA NIKKI BRATCHER-BOWMAN, U.S. Department of Health and PAM WARD Human Services (Liaison) Ottumwa Transit Authority, Ottumwa, IA JOEL R. WASHINGTON Washington Metropolitan Area Transit Authority, Washington, DC FTA LIAISON KAREN FACEN Federal Highway Administration TRB LIAISON PETER SHAW Transportation Research Board

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FOREWORD Transit administrators, engineers, and researchers often face problems for which in- By Staff formation already exists, either in documented form or as undocumented experience and Transportation practice. This information may be fragmented, scattered, and unevaluated. As a conse- Research Board quence, full knowledge of what has been learned about a problem may not be brought to bear on its solution. Costly research findings may go unused, valuable experience may be overlooked, and due consideration may not be given to recommended practices for solv- ing or alleviating the problem. There is information on nearly every subject of concern to the transit industry. Much of it derives from research or from the work of practitioners faced with problems in their day-to-day work. To provide a systematic means for assembling and evaluating such use- ful information and to make it available to the entire transit community, the Transit Co- operative Research Program Oversight and Project Selection (TOPS) Committee author- ized the Transportation Research Board to undertake a continuing study. This study, TCRP Project J-7, "Synthesis of Information Related to Transit Problems," searches out and synthesizes useful knowledge from all available sources and prepares concise, documented reports on specific topics. Reports from this endeavor constitute a TCRP re- port series, Synthesis of Transit Practice. This synthesis series reports on current knowledge and practice, in a compact format, without the detailed directions usually found in handbooks or design manuals. Each re- port in the series provides a compendium of the best knowledge available on those meas- ures found to be the most successful in resolving specific problems. PREFACE This synthesis documents and summarizes the tasks necessary for a public transit Non-Emergency Medical Transportation (NEMT) partnership to be successful. The purpose is to report on the real and perceived barriers to NEMT and public transit coordination and to describe case studies of Medicaid transportation program participation by transit agen- cies. This topic is of interest to transit agency staff at the local level. They might use this report to learn from and compare their experiences with the experiences of other agencies. Opportunities exist for public transit agencies to participate in the NEMT program as providers of service or as brokers. Findings in this report are based on a literature review; surveys of selected transit agen- cies, corresponding state department of transportation transit divisions, and state Medicaid agencies; analysis of documentation submitted; interviews; and site visits. Case study descriptions were prepared to reflect geographical diversity; urban, small urban, and rural agencies; and different service delivery models. The case studies are: Broward County, Florida; North Georgia Community Action Agency, Georgia; TriMet, Portland, Oregon; Texoma Area Paratransit System, Texas; and Chittenden County Transportation Authority, Vermont. Kenneth I. Hosen, KFH Group, Inc., Bethesda, Maryland, collected and synthesized the information and wrote the paper, under the guidance of a panel of experts in the subject area. The members of the Topic Panel are acknowledged on the preceding page. This syn- thesis is an immediately useful document that records the practices that were acceptable within the limitations of the knowledge available at the time of its preparation. As progress in research and practice continues, new knowledge will be added to that now at hand.

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CONTENTS 1 SUMMARY 3 CHAPTER ONE INTRODUCTION Background, 3 Non-Emergency Medical Transportation, 3 Public Transportation and Americans with Disabilities Act, 3 Purpose of Synthesis, 4 Synthesis Organization and Methodology, 4 Glossary, 4 6 CHAPTER TWO LITERATURE REVIEW Introduction, 6 Selected Publications, 6 Key Issues, 8 10 CHAPTER THREE SURVEY OF STATE MEDICAID AGENCIES, DEPARTMENTS OF TRANSPORTATION, AND TRANSIT AGENCIES Survey Methodology, 10 Survey Results, 10 Barriers and Challenges, 13 22 CHAPTER FOUR CASE STUDIES OF MEDICAID AND PUBLIC TRANSIT COORDINATION Emerging Coordination Themes, 22 Background, 22 Florida--Broward County Transit, 23 Georgia--North Georgia Community Action Agency, Jasper, 24 Oregon--TriMet, Portland, 25 Texas--Texoma Area Paratransit System, Sherman and Dennison, 26 Vermont--Chittenden County Transportation Authority, Burlington, 28 Summary--Case Studies, 29 31 CHAPTER FIVE CONCLUSIONS Success Factors, 31 Helpful Factors, 31 Challenges, 32 Suggestions for Further Research, 32 33 REFERENCES 34 BIBLIOGRAPHY

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35 APPENDIX A SURVEYS 48 APPENDIX B STATE DEPARTMENTS OF TRANSPORTATION, MEDICAID AGENCIES, AND TRANSIT SYSTEMS RESPONDING TO THE SURVEYS