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

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.

2018 T R A N S I T C O O P E R A T I V E R E S E A R C H P R O G R A M TCRP RESEARCH REPORT 202 Research sponsored by the Federal Transit Administration in cooperation with the Transit Development Corporation Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination Linda Cherrington Suzie Edrington Texas a&M TransporTaTion insTiTuTe College Station, TX Jon Burkhardt skyCasTle enTerprises Potomac, MD David Raphael CoMMuniTy MobiliTy soluTions Portland, OR Patricia Weaver Collette kansas universiTy TransporTaTion researCh insTiTuTe Lawrence, KS i n a s s o c i a t i o n w i t h Stephen Borders Grand valley sTaTe universiTy Allendale, MI Ross Peterson Jeremy Dalton GridWorks Portland, OR Richard Garrity rls & assoCiaTes, inC. Dayton, OH Subject Areas Public Transportation • Passenger Transportation

TCRP RESEARCH REPORT 202 Project B-44 ISSN 2572-3782 ISBN 978-0-309-39065-1 © 2018 National Academy of Sciences. All rights reserved. COPYRIGHT INFORMATION Authors herein are responsible for the authenticity of their materials and for obtaining written permissions from publishers or persons who own the copyright to any previously published or copyrighted material used herein. Cooperative Research Programs (CRP) grants permission to reproduce material in this publication for classroom and not-for-profit purposes. Permission is given with the understanding that none of the material will be used to imply TRB, AASHTO, FAA, FHWA, FMCSA, FRA, FTA, Office of the Assistant Secretary for Research and Technology, PHMSA, or TDC endorsement of a particular product, method, or practice. It is expected that those reproducing the material in this document for educational and not-for-profit uses will give appropriate acknowledgment of the source of any reprinted or reproduced material. For other uses of the material, request permission from CRP. NOTICE The research report was reviewed by the technical panel and accepted for publication according to procedures established and overseen by the Transportation Research Board and approved by the National Academies of Sciences, Engineering, and Medicine. The opinions and conclusions expressed or implied in this report are those of the researchers who performed the research and are not necessarily those of the Transportation Research Board; the National Academies of Sciences, Engineering, and Medicine; or the program sponsors. The Transportation Research Board; the National Academies of Sciences, Engineering, and Medicine; and the sponsors of the Transit Cooperative Research Program do not endorse products or manufacturers. Trade or manufacturers’ names appear herein solely because they are considered essential to the object of the report. TRANSIT COOPERATIVE RESEARCH PROGRAM The nation’s growth and the need to meet mobility, environmental, and energy objectives place demands on public transit systems. Cur- rent systems, some of which are old and in need of upgrading, must expand service area, increase service frequency, and improve efficiency to serve these demands. Research is necessary to solve operating prob- lems, adapt appropriate new technologies from other industries, and introduce innovations into the transit industry. The Transit Coopera- tive Research Program (TCRP) serves as one of the principal means by which the transit industry can develop innovative near-term solutions to meet demands placed on it. The need for TCRP was originally identified in TRB Special Report 213—Research for Public Transit: New Directions, published in 1987 and based on a study sponsored by the Urban Mass Transportation Administration—now the Federal Transit Administration (FTA). A report by the American Public Transportation Association (APTA), Transportation 2000, also recognized the need for local, problem- solving research. TCRP, modeled after the successful National Coop- erative Highway Research Program (NCHRP), undertakes research and other technical activities in response to the needs of transit ser- vice providers. The scope of TCRP includes various transit research fields including planning, service configuration, equipment, facilities, operations, human resources, maintenance, policy, and administrative practices. TCRP was established under FTA sponsorship in July 1992. Proposed by the U.S. Department of Transportation, TCRP was authorized as part of the Intermodal Surface Transportation Efficiency Act of 1991 (ISTEA). On May 13, 1992, a memorandum agreement outlining TCRP operating procedures was executed by the three cooperating organi- zations: FTA; the National Academies of Sciences, Engineering, and Medicine, acting through the Transportation Research Board (TRB); and the Transit Development Corporation, Inc. (TDC), a nonprofit educational and research organization established by APTA. TDC is responsible for forming the independent governing board, designated as the TCRP Oversight and Project Selection (TOPS) Committee. Research problem statements for TCRP are solicited periodically but may be submitted to TRB by anyone at any time. It is the responsibility of the TOPS Committee to formulate the research program by identi- fying the highest priority projects. As part of the evaluation, the TOPS Committee defines funding levels and expected products. Once selected, each project is assigned to an expert panel appointed by TRB. The panels prepare project statements (requests for propos- als), select contractors, and provide technical guidance and counsel throughout the life of the project. The process for developing research problem statements and selecting research agencies has been used by TRB in managing cooperative research programs since 1962. As in other TRB activities, TCRP project panels serve voluntarily without compensation. Because research cannot have the desired effect if products fail to reach the intended audience, special emphasis is placed on disseminat- ing TCRP results to the intended users of the research: transit agen- cies, service providers, and suppliers. TRB provides a series of research reports, syntheses of transit practice, and other supporting material developed by TCRP research. APTA will arrange for workshops, train- ing aids, field visits, and other activities to ensure that results are imple- mented by urban and rural transit industry practitioners. TCRP provides a forum where transit agencies can cooperatively address common operational problems. TCRP results support and complement other ongoing transit research and training programs. Published research reports of the TRANSIT COOPERATIVE RESEARCH PROGRAM are available from Transportation Research Board Business Office 500 Fifth Street, NW Washington, DC 20001 and can be ordered through the Internet by going to http://www.national-academies.org and then searching for TRB Printed in the United States of America

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, non- governmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.national-academies.org. The Transportation Research Board is one of seven major programs of the National Academies of Sciences, Engineering, and Medicine. The mission of the Transportation Research Board is to increase the benefits that transportation contributes to society by providing leadership in transportation innovation and progress through research and information exchange, conducted within a setting that is objective, interdisciplinary, and multimodal. The Board’s varied committees, task forces, and panels annually engage about 7,000 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. Learn more about the Transportation Research Board at www.TRB.org.

C O O P E R A T I V E R E S E A R C H P R O G R A M S AUTHOR ACKNOWLEDGMENTS Shuman Tan and Jinuk Hwang of the Texas A&M Transportation Institute provided graphic assistance, Maarit Moran and Jitendra Jan also of the Texas A&M Transportation Institute contributed to the final revisions, and the communications staff at Austin Technology Incubator provided technical editing and handbook design. The researchers thank the project panel and the TCRP senior program officer for their thoughtful comments and suggestions throughout the project. The researchers also wish to acknowledge the many organizations and their staff members who took the time to participate in interviews during the case study research. CRP STAFF FOR TCRP RESEARCH REPORT 202 Christopher J. Hedges, Director, Cooperative Research Programs Lori L. Sundstrom, Deputy Director, Cooperative Research Programs Gwen Chisholm Smith, Manager, Transit Cooperative Research Program Dianne S. Schwager, Senior Program Officer Daniel J. Magnolia, Senior Program Assistant Eileen P. Delaney, Director of Publications Natalie Barnes, Associate Director of Publications Sreyashi Roy, Editor TCRP PROJECT B-44 PANEL Field of Service Configuration Gail Bauhs, TripSpark Medical, Cedar Rapids, IA (Chair) Lisa M. Bacot, Florida Public Transportation Association, Tallahassee, FL Robert J. Brink, Jr., Kerr Area Rural Transportation Authority, Henderson, NC Charles R. Carr, Mississippi DOT, Jackson, MS Steven R. Fittante, Total Transportation Corp., Phillipsburg, NJ Karen Hoesch, ACCESS Transportation Systems, Pittsburgh, PA Kenneth L. Hoggard, LogistiCare Solutions, LLC, Alexandria, VA Heather M. Hume, Massachusetts Bay Transportation Authority, Boston, MA Robert E. Knox, Virginia Department of Medical Assistance Services, Richmond, VA Sarah B. Lenz, Roseville, MN Peter McNichol, Vermont Department of Health Access, Williston, VT Paul A. Meury, Washington State Health Care Authority, Olympia, WA Rik Opstelten, FTA Liaison Billy Altom, Association of Programs for Rural Independent Living Liaison Kelly Buckland, The National Council on Independent Living Liaison Charles H. Dickson, Community Transportation Association of America Liaison Richard Weaver, APTA Liaison Stephen J. Andrle, TRB Liaison

TCRP Research Report 202 presents information for a broad range of transportation pro- viders, public agencies, and other relevant stakeholders to improve their understanding of what influences state Medicaid agencies to establish Non-Emergency Medical Transpor- tation (NEMT) brokerages and the resulting effects on NEMT customers, human services transportation, and public transportation. The handbook also addresses the trend for states to include NEMT as part of the Medicaid managed care. Federal transportation policy calls for coordination of public transportation with human services transportation to avoid duplicative and overlapping services and to achieve cost savings for all federally funded programs. The Medicaid program is the largest federal program for human services transportation, spending approximately $3 billion annually on Non-Emergency Medical Transportation (NEMT). The successful coordination of trans- portation services is affected by the extent to which resources for NEMT are coordinated with and complement public transportation and other human services transportation pro- grams. Because the Medicaid program is administered by states, which are able to set their own rules within federal regulations and guidelines set by the Centers for Medicare and Medicaid Services, coordination of NEMT with public transit and human services trans- portation is highly dependent on each state Medicaid agency’s policies and priorities. Over the past decade, many states have made significant progress coordinating NEMT with other federally funded transportation services, most often by allowing local or regional transportation providers to coordinate NEMT trips with numerous other trip types. This approach results in transportation resources and costs being shared across multiple programs and transportation providers. TCRP Research Report 202: Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination provides background information about NEMT and describes the different models available to states for provid- ing NEMT for Medicaid beneficiaries. The handbook also discusses why human services transportation and public transportation providers encourage coordination of NEMT with other transportation services. The research approach for this project included: • Review of literature, regulations, and prior research. To understand NEMT, the researchers studied applicable laws and regulations, and reviewed literature and previous studies on the topic. • State survey. To determine how states are providing NEMT and the changes that have occurred in recent years, the researchers conducted a survey of the Medicaid agencies in the 50 states and the District of Columbia. F O R E W O R D By Dianne S. Schwager Staff Officer Transportation Research Board

• Case studies. The research team first prepared mini case studies for 15 states using infor- mation from personal interviews, the previous literature review, and Internet research. From the 15 mini case studies, the research team then selected seven for full case studies representing a range of models for providing NEMT. NEMT, human services transportation, and public transportation have common desired outcomes: to improve health outcomes, to contribute to a better quality of service for customers, and to maximize transportation services delivered within available resources. This handbook identifies opportunities and suggests strategies to coordinate these trans- portation programs to contribute to the common desired outcomes. The audiences for this research include the following key stakeholders: • State-level officials, • Regional and local transportation providers including human services transportation providers and public transit agencies, • For-profit and not-for-profit NEMT brokers, • Human services program managers, • Mobility managers, and • Managed care organizations. Although not a primary audience for the handbook, customers of NEMT services (Medicaid beneficiaries) are directly affected by the different models for providing NEMT and represent an important stakeholder for this research. Each of these stakeholders has different perspectives that are important to consider. Understanding the differences in perspectives is fundamental to seeing opportunities to coordinate transportation programs and to achieve positive outcomes. Further serving the stakeholders, this report is supported by a companion document, “State-by-State Profiles for Examining the Effects of Non-Emergency Medical Transporta- tion Brokerages on Transportation Coordination,” available on the TRB website (www.trb.org) by searching for “TCRP Research Report 202.”

1 Summary 1 Introduction 2 Medicaid 2 NEMT for Medicaid 3 Coordination of Public Transportation with Human Services Transportation 6 Models for Providing NEMT 7 Common Desired Outcomes 7 Strategies to Achieve Common Desired Outcomes 9 Chapter 1 Introduction 9 Objectives 10 Audiences 10 Research Methodology 11 Purpose of This Handbook 12 Organization of This Handbook 13 Chapter 2 Medicaid 13 What Are the Medicare and Medicaid Programs? 15 What Do I Need to Understand About Medicaid? 18 What Is the Impact of the Affordable Care Act of 2010? 22 Summary 23 Chapter 3 Non-Emergency Medical Transportation for Medicaid 23 Why Is Transportation Important to Medicaid? 25 What Is the Deficit Reduction Act of 2005? 30 What Are the Models for Providing NEMT? 32 What Are the Current Trends in NEMT? 34 Summary 35 Chapter 4 Coordination of Public Transportation with Human Services Transportation 35 What Is Human Services Transportation? 37 What Is Public Transportation? 43 Why Coordinate NEMT with Public Transportation? 49 Summary 50 Chapter 5 Models for Providing Non-Emergency Medical Transportation 50 What Is the NEMT Model in Each Case Study State? 55 What Are the Effects of the NEMT Models? 59 Summary C O N T E N T S

60 Chapter 6 Common Desired Outcomes 60 What Are the Stakeholder Perspectives About NEMT? 61 What Are the Common Desired Outcomes for NEMT? 63 Summary 64 Chapter 7 Strategies to Achieve Common Desired Outcomes 64 What Strategies Focus on Common Desired Outcomes? 65 What Strategies Can Help to Document Better Health Outcomes? 65 What Strategies Contribute to a Better Quality of Service for NEMT? 66 What Strategies Maximize Transportation Services Delivered Within Available Resources? 67 Description of Strategies 81 Acronyms and Glossary 88 References A-1 Appendix State Case Study Summaries