Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination (2018)

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50 [In Florida] MCOs are responsible for NEMT as a service of the managed care plan. This chapter describes case study research to document the effects of different models for providing NEMT on access to Medicaid services, on coordination with other human services transportation, and on coordination with public transportation. Case study research provided an opportunity to review different models for providing NEMT in seven states. Table 6 lists the seven case study states and the different NEMT models. The effects of different models for providing NEMT were confirmed through multiple inter- views with stakeholders in each state. In some states, the state Medicaid agency had changed the NEMT approach to a model using brokers or managed care. Case study research helped to identify influences for the decision to change the NEMT model and the impacts on access to Medicaid services and transportation coordination. What Is the NEMT Model in Each Case Study State? This section provides a brief description of NEMT in each of the seven case study states, and the following section summarizes the effects of each NEMT model on access to Medicaid services, on coordination with other human services transportation, and on coordination with public transportation. The appendix includes an in-depth case study summary for each state. Florida: Change to Managed Care Organizations with Carved-In NEMT Change from County-Based Coordinated Transportation Prior to 2014, the Florida Agency for Health Care Administration contracted with the state’s Commission for the Transportation Disadvantaged (CTD) to manage NEMT for all Medicaid beneficiaries across the state. CTD contracted with county-based community transportation coordinators (CTCs) to provide NEMT. The CTCs are responsible for providing human services transportation at the county level, and this arrangement made it possible for CTCs to coordinate NEMT with other transportation programs. Change to Managed Care with Carved-In NEMT The Florida Legislature established the Managed Medical Assistance program in 2011. The program was implemented in 2014. The state is divided into 11 managed care regions, and each region has two or more MCOs to provide the Medicaid beneficiary a choice. The MCOs are responsible for NEMT as a service of the managed care plan. Each MCO receives a capitated payment to provide medical care and NEMT. C H A P T E R 5 Models for Providing Non-Emergency Medical Transportation

Models for Providing Non-Emergency Medical Transportation 51 Each MCO Contracts with Private For-Profit Brokers Each MCO contracts with one of three for-profit brokers to provide NEMT under the managed care plan. The brokers contract with a variety of transportation providers including taxi companies, public transit agencies, human services transportation providers, and for-profit transportation companies. In some counties, the CTC that was once responsible for provid- ing NEMT now competes with other transportation providers for NEMT trips assigned by the broker. Community Transportation Coordinators Report Fewer Shared NEMT Trips Since Managed Care CTCs, particularly in rural areas, report a significant loss of revenues earned from providing NEMT. With fewer shared NEMT passenger trips, the cost per passenger for other transportation programs has increased. The loss of NEMT revenues has reduced the capacity of CTCs to provide other human services transportation. Massachusetts: Regional Brokers NEMT Is Part of a Coordinated Transportation Program In Massachusetts, the state Medicaid agency is MassHealth, a part of the Executive Office of Health and Human Services (EOHHS). MassHealth provides NEMT through a coordinated transportation program operated by EOHHS through the Human Service Transportation Office. In Massachusetts, NEMT is known as the Prescription for Transportation (PT-1). Human Service Transportation Office Oversees Coordinated Transportation In 2001, EOHHS established the Human Service Transportation Office to coordinate trans- portation for multiple health and human services agencies, including NEMT for MassHealth. Human services transportation oversees a system of coordinated transportation services for eligible EOHHS consumers to access medical, social, and day habilitation services across Massachusetts. Human services transportation also provides technical assistance and outreach programs called MassMobility in support of local mobility and transportation coordination efforts for transportation-disadvantaged Massachusetts residents. Brokers Are Regional Transit Authorities The human services transportation system was designed and implemented in partnership with the Massachusetts DOT. Massachusetts is divided into nine regions for human services State NEMT Models Florida • Managed care with carved-in NEMT Massachusetts • Regional brokers (regional transit authorities) New Jersey • Statewide broker (for profit) North Carolina • In-house management (county based) Oregon • Managed care with carved-in NEMT Pennsylvania • Regional broker (for profit) in Philadelphia County • In-house management all other counties Texas • Regional broker (for profit and not for profit) • In-house management (one region) Table 6. Case study states and NEMT models. [In Massachusetts] human services transportation contracts with six regional transit authorities to act as brokers for transportation services . . .

52 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination transportation coordinated transportation. Human services transportation contracts with six regional transit authorities to act as brokers for transportation services for EOHHS clients. Brokers Reduce State Administration The goal of coordinated brokerages is to reduce administrative burden at the state level. All brokers are required to adhere to performance standards defined by EOHHS. The Human Ser- vice Transportation Office confirms compliance with vehicle maintenance, driver qualifications, insurance compliance, and timely payment of vendors. Each Broker Subcontracts with Transportation Providers in the Region Transportation providers are primarily private for-profit and not-for-private companies. Five regional transit authorities, which do not act as brokers for human services transportation, serve as transportation providers. These brokers dispatch demand-response transportation based on the lowest cost among the transportation providers in each region. A feature of the NEMT model is the shared-cost-savings incentives built into broker contracts. New Jersey: Change to Statewide Broker Change from Community Transportation Provider in Each County The Division of Medical Assistance and Health Services (DMAHS) in the Department of Human Services is the state Medicaid agency responsible for NEMT in New Jersey. Prior to 2009, DMAHS contracted for NEMT primarily with county-based community transportation providers in each of the 21 counties in the state with a fee-for-service payment. These transpor- tation providers coordinated transportation by providing shared-ride services for NEMT riders and other general public or sponsored riders. Change to Statewide Broker with Capitated Payment In July 2009, DMAHS changed the NEMT service model to a statewide broker with capitated payment. The current statewide broker is a private company operating similar services nationally. The move to a statewide broker was influenced by multiple factors, including recent and projected cost increases. DMAHS needed greater cost control and was concerned about fraud in claims for providing NEMT trips. North Carolina: In-House Management In-House Management for NEMT Is County-Based The North Carolina DHHS is the state Medicaid agency. The Division of Medical Assistance in the North Carolina DHHS is responsible for overseeing NEMT. The Department of Social Services in each of the 100 counties is responsible for meeting NEMT obligations through community transportation. Public Transportation Is Part of Community Transportation Community transportation in North Carolina coordinates public transportation with human services transportation. Each of the 100 counties in North Carolina has a community trans- portation system. Generally, transportation services are provided at the county level, but in a few cases, a regional provider operates services for multiple counties. A few counties have gone further and combined the urban transportation services into a unified urban-rural service within a county. The move to a statewide broker [in New Jersey] was influenced by multiple factors, including recent and projected cost increases. Community trans- portation in North Carolina coordi- nates public trans- portation with human services transportation.

Models for Providing Non-Emergency Medical Transportation 53 County-Based Management for NEMT Using Community Transportation Each county DSS contracts with the local community transportation provider to provide NEMT on a fee-for-service basis. DSS is responsible for determining if a Medicaid beneficiary is eligible for NEMT, authorizing trip eligibility, and record keeping for post-trip verification. The community transportation system schedules and provides the authorized transportation. Medicaid Is Transitioning to Managed Care In September 2015, the North Carolina General Assembly enacted legislation to transition the state Medicaid plan from a fee for service for Medicaid services to managed care. The North Carolina DHHS submitted the proposed program design for Medicaid managed care to CMS in August 2017 and anticipates launching Medicaid managed care in 2019. The North Carolina DHHS proposes entering into contracts with companies that will offer managed care with carved-in NEMT. Oregon: Change to Managed Care Organizations with Carved-In NEMT Change from Coordinated Transportation Through Regional Community Brokers Prior to 2012, NEMT in Oregon was provided as coordinated transportation through regional community brokers. The first public agency community broker was the Tri-County Metro- politan Transportation District of Oregon (TriMet). TriMet worked in collaboration with the Oregon DOT and the Oregon Department of Human Services to coordinate ADA paratransit, NEMT, and other human services transportation programs. TriMet provided the call center and brokered transportation service to for-profit and not-for-profit transportation providers. After the TriMet example, Oregon DOT and the Oregon Department of Human Services cooperated in the expansion of the community broker model statewide, eventually establishing eight regional community brokers. In addition to TriMet, other transit agencies and councils of governments established community brokers. Each public agency established the broker as an independent business unit with a cost accounting system separate from the transit agency, consistent with Medicaid guidelines. Change to Managed Care with Carved-In NEMT The Oregon Health Authority began transforming the Oregon Health Plan to a managed care model in 2012. The Oregon Health Authority refers to managed care as coordinated care. The goals for the Oregon Health Plan under coordinated care are known as the Triple Aim: better health, better care, and lower costs. Coordinated care involves consolidation of health-supportive services under the umbrella of a coordinated care organization (CCO). Coordinated care is delivered through 16 CCOs operating in all counties around the state. In some counties, two or more CCOs have overlapping service areas. Each CCO Is Responsible for NEMT for Its Members Each CCO provides NEMT through transportation brokers. The type of broker (i.e., public agency, private company, or nonprofit agency) and the approach to NEMT within the Oregon Health Authority guidelines differ by CCOs. Statewide, 12 NEMT brokers provide service to 16 CCOs. Case study research helped the researchers to learn about the change in NEMT in Oregon. The case study focused on the change to NEMT under coordinated care in three areas: Lane County, southern Oregon (seven counties), and the Tri-County/Portland metropolitan area. The goals for the Oregon Health Plan under coordinated care are known as the Triple Aim: better health, better care, and lower costs.

54 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination Pennsylvania: In-House Management and Regional Broker County Coordinators for Transportation Services In Pennsylvania, NEMT is called the Medical Assistance Transportation Program (MATP). In 66 counties (other than Philadelphia County), the state Medicaid agency, the Department of Human Services, provides MATP funding through a combination of fee for service and block grants to the MATP coordinator in each county. The MATP coordinator is a part of the county government or, in a few counties, the public transportation authority. The MATP coordinator arranges transportation for eligible Medicaid beneficiaries to approved medical services using fixed-route public transportation, mileage reimbursement, or local transporta- tion providers for shared-ride transportation. Generally, each county has its own program, but some counties have pooled resources and formed multicounty organizations to serve their residents who are eligible for MATP. Shared-Ride Human Services Transportation Pennsylvania began shared-ride human services transportation in 1980. The purpose of human services transportation is to provide affordable, accessible, individualized transportation for people with limited mobility options. In 66 counties, NEMT is coordinated with human services transportation. Pennsylvania has not made substantial changes in NEMT in recent years, except to encourage the regional coordination of transportation services. Full-Risk Broker in Philadelphia County In the most densely populated county in the state, Philadelphia County, MATP is provided by a full-risk private broker with capitated payment. Case study research in Pennsylvania focused on three MATP examples: the private broker in Philadelphia County; ACCESS, the ADA paratransit provider for the Port Authority of Allegheny County (Pittsburgh); and the Central Pennsylvania Transportation Authority. Texas: Regional Brokers and In-House Management Change from In-House Management The Health and Human Services Commission (HHSC) is responsible for the Medical Transportation Program in Texas. Through the Medical Transportation Program, HHSC arranges NEMT services for Medicaid-eligible beneficiaries. Prior to 2012–2014, HHSC pro- vided demand-response NEMT through fee-for-service contracts with transportation providers in 24 transportation service areas. Fifteen transportation providers served the 24 transportation service areas. Of the 15 service providers, 10 were rural or urban public transit districts, three were for-profit transportation companies, and two were nonprofit human services transportation providers. Change to Regional Brokers HHSC changed NEMT from in-house management to regional brokers in 2012–2014. The purpose of the change was to improve transportation service delivery to NEMT clients, contain program cost, and reduce the incidence of fraud, waste, and abuse. In 2012, HHSC implemented full-risk brokers with capitated payment in two service delivery areas in Dallas/Fort Worth and Houston. Effective 2014, HHSC implemented managed transpor- tation organizations in 10 regions (originally 11 regions), changing from in-house management to a system of regional brokers with capitated payment. The broker in one region was terminated [In Pennsylvania] the MATP [NEMT] coordinator arranges transpor- tation for eligible Medicaid benefi- ciaries to approved medical services . . . [In Texas] the Health and Human Services Commission changed NEMT from in-house management to regional brokers in 2012–2014.

Models for Providing Non-Emergency Medical Transportation 55 for failure to maintain adequate financial records and client encounter data, and HHSC assumed responsibility for in-house management in that one region. Benefits of the Change to Regional Brokers From the perspective of the state Medicaid agency, the change to regional brokers lowered the capitated payment for NEMT after 2014 and reduced the potential for fraud, waste, and abuse. Contracts with brokers include performance standards and minimum require- ments for vehicle condition and driver qualifications. Concerns include broker performance; HHSC has terminated contracts with one public transit district and one private broker for performance. Challenges for Coordination of NEMT with Other Transportation Services In Texas, lead entities in 24 regions develop regionally coordinated transportation plans; however, most NEMT regional brokers are not actively involved in the efforts to coordinate transportation services. Rural transit districts reported data that show NEMT ridership and revenues have decreased 41 percent from 2014 to 2016 after the change to regional brokers. Fewer passengers and fewer shared rides led to higher cost per passenger trip for public trans- portation and NEMT, especially in rural areas. A loss of NEMT revenues also reduces this source of funds for a rural transit district to match federal transit grants. What Are the Effects of the NEMT Models? The purpose of this section is to document how different NEMT models affect access to Medicaid services, coordination with human services transportation, and coordination with public transportation. Table 7 identifies the NEMT models and corresponding case studies. In Texas, the state Medicaid agency terminated the contract with a regional broker in one region and now contracts with transportation providers in that region on a fee-for-service basis. Given this circumstance, Texas is not discussed as an example for in-house management in the next section. Table 7. Identification of NEMT models by case study states. NEMT Model Case Study States In-house management • North Carolina—community transportation with county-based in- house management. • Pennsylvania*—coordinated transportation with county-based in-house management (in all counties except Philadelphia County). • Texas*—in-house management in one region. Statewide broker • New Jersey—change from county-based community transportation with in-house management to statewide broker. Regional broker • Massachusetts—coordinated transportation with regional transit authorities as regional brokers. • Texas*—change from in-house management to regional brokers (multiple for-profit brokers and one not-for-profit human services broker). • Pennsylvania*—regional broker (for-profit) in Philadelphia County. Managed care organization • Florida—change from county-based coordinated transportation to MCOs with carved-in NEMT. • Oregon—change from coordinated transportation with public agencies as regional brokers to CCOs with carved-in NEMT. *States with mixed NEMT models.

56 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination In-House Management Case study states for in-house management are North Carolina and Pennsylvania. In both states, the NEMT model is in-house management for county-based, coordinated transportation, shown in Table 8. Statewide Broker The case study state for a statewide broker is New Jersey. Prior to 2009, the state Medicaid agency contracted for NEMT primarily with county-based community transportation providers in each of the 21 counties in the state with a fee-for-service payment. In July 2009, New Jersey changed the NEMT service model to a statewide broker with capitated payment. The current statewide broker is a private company operating similar services nationally. Table 9 identifies the effects of the change to a statewide broker. Effects North Carolina Pennsylvania Access to Medicaid services • Each county Department of Social Services may contract with the community transportation provider for NEMT service on a fee-for-service basis. • The state Medicaid agency solicited proposals from NEMT brokers in 2012, but the existing model for coordinated transportation was less expensive. • The state Medicaid agency has applied for approval from CMS to change the Medicaid program to managed care with carved-in NEMT, effective 2019. • The state Medicaid agency provides NEMT funding through a combination of fee-for-service and block grants to the NEMT coordinator in 66 of 67 counties (except Philadelphia County). • Coordinated transportation service delivers more NEMT trips for Medicaid services than any state with comparable population. • Pennsylvania reports the lowest cost per passenger trip for NEMT compared to other case study states. Coordination with human services transportation • Community transportation increases operating efficiencies for shared rides on demand- response transportation • Coordinating NEMT trips with community transportation achieves increased productivity of 5 percent. • NEMT clients can arrange transportation for multiple trip purposes with one call/ one click. • Human services transportation is unique in every county, and the complexities of the various programs may be difficult for local human services agencies and users to understand. • NEMT clients can arrange transportation for multiple trip purposes with one call/one click in most counties. Coordination with public transportation • Most community transportation systems that are public entities are the public transit agency in the counties served. • The matching funds earned by public transit agencies for NEMT are used as local share for federal transit grants. • NEMT’s coordination with public transportation reduces the cost per passenger trip. A fare on fixed-route public transit is the lowest-cost transportation for an NEMT trip. • Forty-one percent of NEMT trips statewide are on public transportation. NEMT expenses per trip statewide Estimated $28 per passenger trip (2014) Estimated $13 per passenger trip (2014) services. Table 8. Case study states for NEMT model: in-house management.

Models for Providing Non-Emergency Medical Transportation 57 Regional Brokers Case study states for regional brokers are Massachusetts and Texas. In Massachusetts, the regional brokers are regional transit authorities. A feature of the Massachusetts NEMT model is the shared-cost-savings incentives built into broker contracts. Brokers are rewarded for reducing trip expenses and improving efficiency, with the cost savings reinvested back into the brokerage. The shared-cost-savings incentive program was introduced in 2009. Texas changed the NEMT model from in-house management with fee for service to regional brokers with capitated payment in 2012 and 2014. The regional brokers are three for-profit private companies and one not-for-profit human services agency. The NEMT model in Philadelphia County, Pennsylvania, is also a regional broker. Philadelphia County is the most urbanized county in Pennsylvania and the only county where the NEMT model is a for-profit broker with capitated payment. In FY 2013, over 74 percent of all NEMT trips in Philadelphia County were on regional public transit. Philadelphia County is not identi- fied as a state case study in Table 10. Managed Care Organizations The case study states for managed care are Florida and Oregon. Both states implemented managed care with carved-in NEMT between 2012 and 2014. The state Medicaid agency in Florida changed from an NEMT model for county-based, coordinated transportation to MCOs responsible for NEMT. The state Medicaid agency in Oregon changed from public agencies as regional community brokers to CCOs responsible for NEMT. Table 11 lists the effects of the change to managed care. Effects New Jersey Access to Medicaid services • From the perspective of the state Medicaid agency, the statewide broker has enhanced cost control and reduced the risk of fraud. • The state Medicaid agency reports access to health care services has improved since the change to the statewide broker. • Some medical providers believe that improvements in reliable NEMT are still required. • New Jersey reports a higher cost per passenger trip for NEMT compared to other case study states. Coordination with human services transportation • There has been a decline in NEMT trips coordinated with other transportation services since the change to a statewide NEMT broker. Fewer NEMT trips are on county-based transportation services. • NEMT clients do not have the ability to arrange transportation for multiple trip purposes with one call/one click. Coordination with public transportation • The broker purchases tickets and monthly passes for NEMT clients who can use public transportation in urban areas. In urban areas, public transportation represents 23.5 percent of NEMT trips. • In rural areas, not every public transportation provider has a meaningful participation in the NEMT program. The statewide broker may not assign trips to the rural public transportation provider. In rural areas, public transportation represents about 2.4 percent of NEMT trips. • The loss of NEMT revenue reduces a source of local match for federal transit funds for public transportation in rural areas. NEMT expenses per trip statewide Estimated $34 per passenger trip (2014) Table 9. Case study state for NEMT model: statewide broker.

58 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination Effects Massachusetts Texas Access to Medicaid services • The use of regional transit authorities to broker coordinated human services transportation has produced positive results for the state Medicaid agency by containing costs per passenger trip and ensuring service quality. • Massachusetts reports a lower cost per passenger trip for NEMT compared to other case study states. • From the perspective of the state Medicaid agency, the change to regional brokers lowered the capitated payment for NEMT and reduced the potential for fraud, waste, and abuse with increased oversight. • Performance standards for NEMT (on-time performance, wait times and maximum travel times) may require transportation providers to operate single-passenger trips, reducing shared rides and increasing costs. Coordination with human services transportation • The state Medicaid agency sets consistent service standards and monitors service quality for all coordinated transportation services. • Coordination is promoted through well-regarded mobility managers. • NEMT clients can arrange transportation for multiple trip purposes with one call/one click. • Lead entities develop regionally coordinated transportation plans; however, most NEMT regional brokers are not actively involved. • NEMT clients do not have the ability to arrange transportation for multiple trip purposes with one call/one click. Coordination with public transportation • Regional transit authorities serve as the brokers for NEMT and coordinate transportation services. • Regional brokers are successful in serving an increased number of NEMT trips while also containing costs per passenger trip. • Rural transit districts reported NEMT ridership and revenues decreased after the change to regional brokers. • The loss of NEMT revenue reduces a source of local match for federal transit funds for public transportation in rural areas. • Brokers may not be using fixed- route transit to full advantage. NEMT expenses per trip statewide Reported $18 per passenger trip (2015) Estimated $28 per passenger trip (2014) Table 10. Case study states for NEMT model: regional brokers. Table 11. Case study states for NEMT model: MCOs. Effects Florida Oregon Access to Medicaid services • The change to managed care with carved-in NEMT has enabled private brokers to increase NEMT coverage across multiple regions in the state. • From the perspective of the state Medicaid agency, the change to managed care has curtailed the increase in the costs of Medicaid. • The CCOs have included NEMT into fully integrated care. • From the perspective of the state Medicaid agency, the change to coordinated care with carved-in NEMT helps the Triple Aim: better health, better care, and lower costs.

Models for Providing Non-Emergency Medical Transportation 59 Summary This chapter examines how the different NEMT models affect access to Medicaid services and coordination with human services transportation and public transportation. The different NEMT models are in-house management, statewide broker, regional brokers, and MCOs. Case study research provided the opportunity to learn what influences states to use different models for NEMT. Recently, several states have made strategic decisions to revise the approach to NEMT, implementing brokerages or moving toward managed care with carved-in NEMT. The case studies helped to explore the influences for those decisions. A summary for each of the seven case studies is provided in the appendix to this hand- book. In addition, a companion document, “State-by-State Profiles for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination,” pres- ents NEMT profiles for each of the 50 states and the District of Columbia. The next chapter discusses different stakeholder perspectives about NEMT. The chapter also presents a discussion of the nexus of desirable outcomes for NEMT, human services trans- portation, and public transportation. Table 11. (Continued). Effects Florida Oregon Coordination with human services transportation • The CTD reports a decline in coordination of NEMT trips with community transportation services since the change to managed care. • The CTCs report higher per- passenger trip costs with fewer NEMT shared rides. • NEMT clients can no longer arrange transportation for multiple trip purposes with one call/one click. • For those CCOs that continue to work with the regional community broker, coordination continues. • Transportation coordination is more difficult if the community broker is no longer the NEMT broker for all CCOs in a region. • In some regions, the regional community broker is no longer involved in NEMT in any way, limiting transportation coordination. Coordination with public transportation • The loss of NEMT revenue reduces a source of match for federal transit funds, particularly in rural counties. • The Jacksonville Transportation Authority documented the increase in trips on ADA paratransit during the Demonstration Pilot Program for Managed Care with carved-in NEMT. The public transportation authority did not recover the increased cost from the MCO or the MCO broker. • For those CCOs that continue to work with the regional community broker, public transportation may provide NEMT trips. • In regions where the community broker is no longer the NEMT broker for all CCOs in a region, public transportation may or may not serve a role in NEMT. • In the Tri-County/Portland area, TriMet was the regional community broker but is no longer involved in NEMT in any capacity. NEMT expenses per trip statewide Estimated $22 per passenger trip (2014) Estimated $26 per passenger trip (2013)