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

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1 Introduction This summary provides an overview of TCRP Research Report 202: Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination. A companion document, “State-by-State Profiles for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination,” presents a non-emergency medical transportation (NEMT) profile for each of the 50 states and the District of Columbia. Medicaid is a joint federal and state program that provides health coverage for millions of individuals and families with limited incomes and resources. The Medicaid program provides critical health insurance for millions of people who might not otherwise be able to afford it. The assurance of transportation to necessary medical care is an important feature that sets Medicaid apart from traditional health insurance. Medicaid NEMT is an important benefit for Medicaid beneficiaries who need to get to and from medical services and have no other means of transportation. The purpose of this handbook is to provide information to better understand what influences state Medicaid agencies to establish separate 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 Medicaid managed care. The handbook provides background information about NEMT and describes the different models available to states for providing NEMT for Medicaid beneficiaries. The handbook also discusses why human services transportation and public transportation providers encourage coordination of NEMT with other transportation services. Stakeholders for NEMT, human services transportation, and public transportation have common desired outcomes for providing NEMT services. The desired outcomes are to: • Improve health for Medicaid beneficiaries who need help with transportation, • Provide better quality of service for NEMT customers, and • Maximize transportation services within available resources. This handbook identifies opportunities and suggests strategies to coordinate these transportation programs to contribute to the common desired outcomes. The handbook is organized into seven main chapters, as discussed in this summary. Chapter 1: Introduction introduces readers to the handbook and describes the study S U M M A R Y Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination

2 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination research objectives, audiences, and research process, as well as the purpose and organization of the handbook. Medicaid Chapter 2: Medicaid provides background on the Medicaid program to understand the context for NEMT. The chapter discusses the requirement for state Medicaid programs to assure NEMT for Medicaid beneficiaries who need transportation to get to and from medical services, how recent federal legislation has increased Medicaid enrollment, and why states are seeking to reduce the costs of providing NEMT. Key findings of this research include the following: • Medicaid serves the most vulnerable. The beneficiaries of Medicaid include the nation’s most vulnerable populations: infants and children in low-income families, individuals and families with low incomes or limited resources, individuals of all ages with disabilities, and very low-income seniors. Often, these groups lack the resources to afford a reliable means of getting to medical appointments, have limited options and long travel times, and may have frequent appointments for certain medical conditions. In addition to access to health care services, Medicaid beneficiaries also experience mobility challenges in other important areas of life, such as accessing jobs and shopping for necessities. These mobility challenges can also affect health outcomes. • States are required to assure NEMT for Medicaid services. State Medicaid programs are required to assure NEMT for Medicaid beneficiaries who need to get to and from medical services and have no other means of transportation. Without NEMT, the individuals who most need medical care might not be able to access critical services. • NEMT is different in every state. Each state administers its own Medicaid program, consistent with federal regulations and guidelines. This means that there are significant state-to-state variations in how NEMT is provided. • Medicaid expenses are increasing. The Patient Protection and Affordable Care Act (ACA) of 2010 extended Medicaid eligibility to individuals under 65 years of age with an income below 133 percent of the federal poverty level. In addition, ACA gave states the option to provide coverage to individuals that have an income between 133 percent and 200 percent of the federal poverty level. Nearly 17.2 million additional individuals were enrolled in Medicaid in December 2016 compared to 2013, prior to ACA. ACA has amplified the concerns of states about controlling the cost of Medicaid services. • States seek to reduce NEMT costs. Although NEMT is estimated to be less than 1 percent of the federal and state investment in the Medicaid program, states are looking for ways to reduce the cost of NEMT. NEMT for Medicaid Chapter 3: Non-Emergency Medical Transportation for Medicaid discusses the require- ment to assure NEMT for those who need transportation to get to and from medical services, the ability for each state to determine how to deliver NEMT, and how major legislation affects NEMT trends to brokerages and managed care. Important topics in this chapter include the following: • States are creating NEMT brokerages. In recent years, numerous state Medicaid pro- grams have separated NEMT from locally or regionally coordinated transportation sys- tems by creating a statewide or regional NEMT brokerage. This trend was accelerated by the Deficit Reduction Act (DRA) of 2005, which provided an option to establish an NEMT brokerage without the administrative burden of applying for a waiver every few State Medicaid programs are required to provide NEMT for Medicaid beneficiaries who need to get to and from medical services and have no other means of transportation.

Summary 3 years. The DRA included an incentive to establish an NEMT brokerage: the ability for a state Medicaid agency to receive a higher federal matching rate for NEMT as a medical service expense. States pursue the broker model for cost savings, fraud deterrence, and administrative efficiency. • The Medicaid program is moving to managed care. Passage of the ACA is encourag- ing a shift in the Medicaid program from traditional, state-administered fee-for-service medicine to a coordinated or accountable care model that rewards medical providers for keeping people healthy and out of costly emergency facilities. Increasingly, states are moving to assign managed care organizations with the responsibility to provide NEMT. • The trends for NEMT brokers and managed care with carved-in NEMT may lead to less transportation coordination. Professionals responsible for transportation coordination and mobility management say the changes to create NEMT brokerages and move to managed care are leading to less coordination of transportation resources. The trends also create challenges for Medicaid beneficiaries, who may be required to arrange travel with multiple transportation providers, depending on the purpose of each trip. Chapter 3 also identifies the different models available to state Medicaid agencies for providing NEMT and discusses the trend to create statewide or regional brokerages. This research identified the following principal NEMT models in use in the 50 states and the District of Columbia: • In-house management. The in-house management model is one in which a state Medicaid agency administers NEMT for beneficiaries at a state, regional, or county level. States using the in-house management model usually contract NEMT to transportation providers on a fee-for-service basis. • Brokers. Some state Medicaid agencies contract with brokers to provide NEMT service. Brokers qualify and authorize beneficiaries for transportation and then contract with transportation providers to perform NEMT services. Broker types include: – Statewide broker. Under a statewide broker NEMT model, the broker manages services statewide, centralizing call centers, eligibility determination, and trip authorization. Statewide brokers are typically for-profit, national brokers. – Regional broker. A regional broker is responsible for eligibility determination and trip authorization at a regional level. A broker may operate in one region or several regions, as the state Medicaid agency may specify. Regional brokers may be for-profit or not-for- profit. Not-for-profit brokers may be human services agencies, public transit agencies, other governmental entities, or nonprofit organizations. • Managed care organization (MCO). Managed care is an organized health care deliv- ery system designed to manage health care cost, use, and quality. Through contracted arrangements with state Medicaid agencies, MCOs seek to improve health care for a pop- ulation of Medicaid beneficiaries, often with chronic and complex conditions, while also managing the cost of that care. MCOs may integrate NEMT in the health care system. This strategy is referred to as carved-in NEMT. • Mixed NEMT models. Some state Medicaid agencies use more than one model to provide NEMT. In-house management, MCOs, and statewide or regional brokers often coexist in a state to provide NEMT services. Coordination of Public Transportation with Human Services Transportation Federal transportation policy encourages public transit agencies that receive federal funds to coordinate public transportation with human services transportation, which includes NEMT. Chapter 4: Coordination of Public Transportation with Human Services Brokers qualify and authorize beneficiaries for transportation and then contract with transportation providers to perform NEMT services.

4 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination Transportation provides the context to understand why human services transportation providers and public transit agencies want to coordinate NEMT with other transportation services. Human Services Transportation Human services transportation refers to a range of transportation services designed to meet the needs of individuals who have difficulties providing their own transportation due to age, disability, or income, sometimes referred to as transportation-disadvantaged popu- lations. Medicaid NEMT is an example of human services transportation to provide access to authorized medical services for Medicaid beneficiaries with low incomes. Key findings include the following: • Human services transportation is complex and not consistently coordinated. Spend- ing for human services transportation is typically funded from federal programs, state and local funds, and private sources of revenue. With so many organizations involved, human services transportation has become a complex and often fragmented system. The large number and diversity of human services transportation programs can lead to underutilization of resources, inconsistent standards, greater administrative costs due to fragmented or duplicative services, and customer inconvenience. Services can overlap in some areas and be entirely absent in others. • Human services transportation refers to a range of transportation services designed to meet the needs of individuals who have difficulties providing their own transportation due to age, disability, or income. • Advocates for the transportation disadvantaged encourage transportation coordi- nation. To address the problems of the complexity of human services transportation, governmental entities, human services organizations, and transportation providers have advocated improved coordination among human services transportation services, including Medicaid NEMT. Public Transportation The purpose of providing public transportation is to offer the general public better access to economic and community activities such as employment, education and training, medical appointments and health services, social services, and shopping. In this handbook, public transportation refers to the transportation programs and services that are eligible for federal funding from FTA. Key findings include the following: • The types of public transportation are fixed route, flexible route, or demand response. Fixed-route transit operates on a schedule with vehicles passing on a regular frequency. Fixed-route bus and rail services generally have the capacity to include additional pas- sengers at a low or no marginal cost per additional passenger. In a variation on fixed routes, flexible-route buses operate along a fixed route, but the buses may deviate from the route to go to a specific location. Demand-response public transportation responds to individual passenger requests for service between a specific origin and destination. Each additional demand-response passenger or flexible-route deviation increases operations costs. Shared rides (i.e., two or more passengers transported in the same vehicle trip) can help to improve demand-response cost-effectiveness (cost per passenger). • Public transportation providers that operate fixed-route services must provide complementary paratransit in accordance with the Americans with Disabilities Act The purpose of providing public transportation is to offer the general public better access to economic and community activities such as employment, education and training, medical appointments and health services, social services, and shopping.

Summary 5 (ADA). Complementary paratransit or ADA paratransit is a form of demand-response public transportation for individuals with disabilities. ADA regulations require public transit agencies that provide local fixed-route transit services (bus or rail) to operate complementary paratransit for individuals who cannot use the local fixed-route service because of a disability. ADA and FTA regulations do not permit a public transit agency to deny a trip request from an ADA-eligible traveler due to capacity constraints. • Fixed-route public transportation offers lower-cost transportation. If appropriate for the individual, Medicaid beneficiaries can travel to and from medical appointments on fixed-route public transportation for the fare. This is usually the lowest-cost trans- portation available. • Public transportation providers can contract to provide demand-response NEMT. Public transit agencies are interested in providing demand-response NEMT to complement other public transportation services for low-income passengers and to earn revenues that can provide local match for federal transit grants. • Federal transportation policy calls for coordination. The federal transportation policy for coordinating transportation has been included in provisions of every fed- eral transportation authorization bill since 2005. According to the federal legislation, public transit agencies are expected to coordinate public transportation with human services transportation. • The Coordinating Council on Access and Mobility represents federal agencies that fund transportation. Chaired by the secretary of transportation, the council is responsible for promoting federal interagency cooperation and developing appropriate mechanisms to minimize duplication of federal programs and services so that transportation-disadvantaged persons have access to more transportation services. Coordination Medicaid NEMT is the largest source of federal revenues for human services transporta- tion. Federal NEMT expenditures are about $3 billion per year, which is less than 1 percent of the federal investment in Medicaid but equal to about 25 percent of the annual federal transit appropriation. Public transit agencies often attempt to coordinate NEMT with public transportation. The purpose of coordination is to enhance customer access to the variety of transportation services available and to ensure the most efficient use of the resources available. Coordinat- ing NEMT with other human services transportation and public transportation offers the following advantages: • Expand access to transportation and improve mobility. The coordination of NEMT with public transportation and other human services transportation programs can better meet the needs of transportation-disadvantaged individuals for all trip purposes. • Leverage public transportation expertise and resources. Coordinating NEMT with the local public transportation provider can help to make full use of required compliance with federal and state regulations, increasing the safety and quality of service for NEMT. Federal cost principles enable public transit agencies to share the use of vehicles to provide NEMT. • Improve service efficiency. Coordinating transportation can improve the efficiency of transportation services by reducing unnecessary duplication of service and more efficiently using existing transportation resources for shared-ride transportation. • Benefit from lower-cost fixed-route public transportation. Where appropriate, indi- viduals can travel to medical appointments on fixed-route public transportation for the

6 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination cost of the fare charged to all riders. Public transit agencies benefit from NEMT riders on fixed routes to increase productivity and cost-effectiveness. Medicaid benefits from the lower cost for an NEMT trip. • Improve accessibility for individuals with disabilities. A public transit agency that operates local fixed-route transit must provide ADA paratransit service for people with disabilities. A state Medicaid agency or broker can work with a public transit agency to provide NEMT trips on ADA paratransit at a rate no more than the rate charged to other human services agencies for similar trips. The public transit agency benefits from recov- ering a part of the cost of an ADA paratransit trip, and Medicaid benefits from a lower cost for an NEMT trip for an individual with a disability. The Medicaid beneficiary with a disability benefits from improved accessibility and the convenience of scheduling service with one transportation provider. • Provide local match for FTA funding programs. Revenues earned by a transit agency that contracts to provide NEMT can be applied as local match for FTA funding programs. Models for Providing NEMT The purpose of Chapter 5: Models for Providing Non-Emergency Medical Trans- portation is to describe how seven case study states provide NEMT and the effects of the models on transportation coordination. Interviews with different stakeholders help to understand the complex issues surrounding NEMT and make possible contextual analysis of the information. The chapter documents the impacts of different NEMT models on access to Medicaid services, coordination with human services transportation, and coordination with public transportation. NEMT models and the corresponding case study states are as follows: 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 a statewide broker. Regional brokers: 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 organizations: 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 coordinated care organizations with carved-in NEMT. The state Medicaid agencies in Texas and Pennsylvania operate mixed NEMT models (two different models). Case study summaries for the seven states are included in the appendix of this handbook.

Summary 7 Common Desired Outcomes Although stakeholders have different perspectives about NEMT, they also share common desired outcomes for providing NEMT services, as shown in the following illustration. Chapter 6: Common Desired Outcomes identifies shared desired outcomes and sets a framework for collaboration to achieve better results. Strategies to Achieve Common Desired Outcomes Chapter 7: Strategies to Achieve Common Desired Outcomes identifies opportunities and suggests strategies to coordinate NEMT with human services transportation and public transportation. If stakeholders collaborate on the opportunities that apply best to specific circumstances, the strategies can help to achieve common desired outcomes. Strategies to Focus on Common Desired Outcomes The first three strategies can help stakeholders with different perspectives to focus on opportunities to achieve positive outcomes: 1. Align goals and objectives to achieve common desired outcomes. 2. Include NEMT stakeholders when preparing or updating a locally developed, coordi- nated human services transportation–public transportation plan. 3. Adopt common geographic boundaries for service areas. Strategies to Document Better Health Outcomes Access to medical services and general mobility are important to improve health out- comes and lower medical costs; however, more data are needed to accurately measure transportation-related benefits and actual reduced health costs. Three strategies will help to demonstrate how NEMT and transportation to other services and activities contribute to better health outcomes: 4. Measure the contribution of transportation to better health outcomes and reduced health care costs. 5. Coordinate NEMT with public transportation to meet the unique requirements of Medicaid beneficiaries, particularly in rural areas. 6. Demonstrate and evaluate the value of a ridesourcing program for NEMT medical appointments. Strategies to Contribute to a Better Quality of Service for NEMT Stakeholders agreed that providing dependable NEMT services that are safe and on time will improve access to medical services, contribute to improved health outcomes, and lead Stakeholders agreed that providing dependable NEMT services that are safe and on time will improve access to medical services, contribute to improved health outcomes, and lead to a better quality of life.

8 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination to a better quality of life. Two strategies will contribute to providing a better quality of service through coordinated transportation: 7. Use technology to enhance NEMT program administration and verify medical trips. 8. Identify the key data required and establish standard procedures for data collection and reporting of NEMT performance. Strategies to Maximize Transportation Services Delivered Within Available Resources Delivering efficient transportation can help to maximize transportation services delivered within the constraints of limited funding. Six strategies are identified to help to maximize transportation services delivered within available resources by coordinating NEMT with public transportation: 9. Use fixed-route transit for appropriate NEMT trips at the lowest cost. 10. Coordinate shared-ride, demand-response NEMT with other transportation programs to reduce costs per trip. 11. Implement a transparent cost allocation methodology to show how shared-ride public transportation can lower the cost for an NEMT trip. 12. Establish a procedure to set a rate for NEMT trips on ADA paratransit that is consistent with Medicaid guidelines. 13. Negotiate operations practices and reimbursement rates for transportation providers to recover the direct costs of delivering NEMT service. 14. Adopt procedures and timelines for invoicing and payment for NEMT.