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

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A-1 This appendix provides seven state case study summaries. The purpose of the case study research was to document the effects of different models for providing non-emergency medical transportation (NEMT) on access to Medicaid services, on coordination with other human services transportation, and on public transportation. Table A-1 documents the case study states and the NEMT models. The case studies provided the opportunity to: • Collect firsthand information about how NEMT is provided, • Research the opportunities and challenges faced in each of the states by different stakeholders, and • Examine the experiences regarding coordination of NEMT with human services transportation and public transportation. The researchers interviewed stakeholders with many different perspectives: state Medicaid agencies, state departments of transportation, managed care organizations (MCOs), customer advocacy groups, public transit agencies, human services program managers, nonprofit NEMT brokers, and for-profit NEMT brokers. Interviews with different stakeholders help to understand the complex issues surrounding NEMT and make possible contextual analysis of the information. In a number of cases, the research team found data to be limited and often out of date. The effects of different models for providing NEMT were confirmed through multiple interviews with stakeholders in each state. In some states, case study research provided material to understand how state Medicaid agencies A P P E N D I X State Case Study Summaries State NEMT Models Page Florida • Managed care organizations with carved-in NEMT A-2 Massachusetts • Regional brokers (regional transit authorities) A-7 New Jersey • Statewide broker (for profit) A-15 North Carolina • In-house management (county-based) A-21 Oregon • Managed care organizations with carved-in NEMT A-30 Pennsylvania • In-house management in all counties but Philadelphia County • Regional broker (for profit) in Philadelphia County A-43 Texas • Regional brokers (for profit and not for profit) • In-house management (one region) A-52 Summary • What Are the Effects of the Different Models for Providing NEMT? • Effects on Access to Medicaid Services • Effects on Coordination with Human Services Transportation • Effects on Coordination with Public Transportation A-62 Table A-1. Case study states and NEMT models.

A-2 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination Key Data Source Demographic Features • State Population (2015) U.S. Census 2015 5-Year Estimate • Urban Population (2010) U.S. Census 2010 • Rural Population (2010) U.S. Census 2010 • Population at or below poverty line (2015) U.S. Census 2015 5-Year Estimate NEMT Oversight TCRP B-44 research Medicaid & NEMT Enrollment Data • Medicaid & Children’s Health Insurance Program (CHIP) Enrollment (December 2013) Centers for Medicare & Medicaid Services (CMS), July–September 2013 • Medicaid & CHIP Enrollment (December 2016) CMS, December 2016 • Percent Increase 2013–2016 CMS calculated • Medicaid Enrollees that Used NEMT (2013) TCRP B-44 2014 National NEMT Survey NEMT Model TCRP B-44 research Operating Authority TCRP B-44 research Medicaid Match Kaiser Family Foundation Expanded Medicaid under Affordable Care Act CMS Medicaid Enrollees in a Managed Care Program Kaiser Family Foundation NEMT Expenses & Activity Data • Annual Medicaid Expenses (2015) Kaiser Family Foundation • Estimate Annual NEMT Expenses TCRP B-44 2014 National NEMT Survey • NEMT as % of Medicaid Expenses TCRP B-44 calculated • Estimate Annual NEMT Passenger Trips TCRP B-44 2014 National NEMT Survey • % of NEMT Trips on Public Transit TCRP B-44 2014 National NEMT Survey • NEMT Expenses per Trip Statewide TCRP B-44 calculated Table A-2. Sources of key data for case study states. revised the approach to NEMT and the influences for those decisions. References are listed after each state case study. The sources for key data for each case study state are listed in Table A-2. Florida: Change to Managed Care Organizations with Carved-In NEMT Key Data Key Data Demographic Features • State Population (2015) 19,645,772 • Urban Population (2010) 87% • Rural Population (2010) 13% • Population at or below poverty line (2015) 16% NEMT Oversight Agency for Health Care Administration Medicaid & NEMT Enrollment Data • Medicaid & CHIP Enrollment (December 2013) 3,104,996 • Medicaid & CHIP Enrollment (December 2016) 4,337,514 • Percent Increase 2013–2016 40% • Medicaid Enrollees that Used NEMT (2013) 2.5% NEMT Model Managed Care Organization Operating Authority Section 1115 Demonstration Waiver Medicaid Match Medical Service (61%) Expanded Medicaid under Affordable Care Act No Medicaid Enrollees in a Managed Care Program 79% • NEMT under Managed Care Managed Care with carved-in NEMT NEMT Expenses & Activity Data • Annual Medicaid Expenses (2015) $21,476,052,754 • Estimate Annual NEMT Expenses (2014) $ 61,000,000 • NEMT as % of Medicaid Expenses <1% • Estimate Annual NEMT Passenger Trips (2014) 2,815,811 • % of NEMT Trips on Public Transit (2014) 2.5% • NEMT Expenses per Trip Statewide (2014) Est. $22

State Case Study Summaries A-3 NEMT Description Change from county-based coordinated transportation. Prior to 2014, the Florida Agency for Health Care Administration (AHCA) contracted with the state’s Commission for the Transportation Disadvantaged (CTD) to manage NEMT for 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. The Florida Legislature established the Managed Medical Assis- tance (MMA) program in 2011. The first phase of the MMA program was implemented on May 1, 2014, and the final phase of the program was implemented on August 1, 2014. The managed care model is approved under a Section 1115 Demonstration Waiver. The state is divided into 11 managed care regions, and each region has two or more MCOs to provide the Medicaid beneficiary a choice. NEMT is carved in the managed care plans (the MCO is responsible for NEMT as part of the managed care plan). AHCA pays each MCO a capitated payment to provide medical care and NEMT for the Medicaid members on the plan. Each MCO contracts with one of three for-profit private brokers to provide NEMT under the managed care plans. The brokers each 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 to provide NEMT now competes with other transportation providers for NEMT trips assigned by the broker. Not every CTC chooses to provide NEMT. AHCA assigns the Medicaid beneficiaries who are not participating in managed care to one of the brokers in the applicable region for NEMT service. Coordinated Transportation in Florida The Transportation Disadvantaged Program in Florida is a coordinated statewide effort that groups riders together for a shared-ride service. The goal of this coordination is to ensure the cost-effective provision of transportation for the transportation disadvantaged by qualified transportation providers. Transportation disadvantaged in the state of Florida are defined as those individuals who because of age, disability, or low income, do not have access to conventional transportation options. Commission for the Transportation Disadvantaged In 1979, the Florida Legislature enacted Chapter 427 of the Florida Statutes, establishing the Coordinating Council of the Transportation Disadvantaged under the authority of the Florida Department of Transportation (FDOT). The coordinating council was created to consolidate overlapping transportation assistance programs that existed throughout the state. Over the next 10 years, the coordinating council established or designated a CTC in each county in the state. The Florida Legislature replaced the coordinating council with CTD in 1989. CTD’s mission is to ensure the coordination of transportation services that enhance access to employment, health care, education, and other life-sustaining activities for older adults, persons with disabilities, people with low incomes, and at-risk children who are dependent upon others for transportation. Community Transportation Coordinators The duties of CTD include approving a community transportation coordinator in each county in the state and contracting with CTCs to provide coordinated transportation services.

A-4 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination The CTC in each of 67 Florida counties provides transportation services for those who are eligible for the Transportation Disadvantaged Program and have no other access to transportation. Transportation Disadvantaged Trust Fund The Florida Legislature established the Transportation Disadvantaged (TD) Trust Fund in 1989. CTD administers the TD Trust Fund. The purpose of the TD Trust Fund is to help CTD achieve the purposes of the Transportation Disadvantaged Program. The TD Trust Fund comes from revenues collected from the statewide vehicle registration fee. For each registration or renewal, $1.50 is designated for the TD Trust Fund. Additional voluntary contributions can be indicated on the vehicle registration form. CTD Responsibility for NEMT In 2003, the University of Florida Bureau of Economic and Business Research produced an independent assessment of Florida’s NEMT program and found coordinating NEMT with the Transportation Disadvantaged Program would be cost effective. AHCA relied upon this assess- ment to support a 1915(b) Freedom of Choice waiver, allowing AHCA to set up a master agree- ment with CTD to manage NEMT, effective 2004. Since CTCs are responsible for providing human services transportation at the county level, the AHCA agreement with CTD allowed CTCs to coordinate NEMT with other human service transportation services, such as the state Transportation Disadvantaged Program. In some counties, the CTC is the public transit agency and coordinated services include public transportation. A study by Florida State University in 2008 identified the return on investment to the state of Florida for transportation disadvantaged programs. The primary purpose of medical trips is to provide access to preventive medical care for the transportation disadvantaged citizens who have no other way of receiving these services. The study found if 1 percent of the medical trips funded result in the avoidance of a hospital stay, the payback to the state would be 1108 percent, or about $11.08 for each dollar the state invests in the program. The state also benefits from healthier citizens and a reduction in the need to invest in medical care for transportation disadvantaged citizens. In 2008, when AHCA renewed the contract with CTD to manage NEMT, the new agreement required expanded reporting requirements. Each CTC was required to document additional encounter data for NEMT passenger trips. By the time the renewed contract was executed, several CTCs—mostly representing large urban areas—discontinued providing NEMT due to the increased administrative burden without financial compensation. In response, AHCA and CTD established the subcontracted transportation provider designation to allow CTD to subcontract with providers other than CTCs to provide NEMT. In 2014, the CTC in 55 of the 67 counties coordinated NEMT with human services transportation and public transportation. The remaining 12 counties provided NEMT as a separate service. AHCA conducted the Medical Reform Demonstration Pilot Program for Managed Care in Broward (Fort Lauderdale) and Duval (Jacksonville) Counties starting in 2006, and then expanded to include Duval’s neighboring counties. Under the demonstration pilot, a subset of Medicaid beneficiaries in each county was provided with a managed care health plan through an MCO, covering all Medicaid benefits including NEMT. An evaluation of the demonstration pilot by AHCA in 2011 concluded the demonstration pilot was successful in improving access to care, customer satisfaction, and cost effectiveness for medical care. The evaluation did not address NEMT. The Florida Legislature approved the MMA program in 2011. AHCA implemented managed care between May 1 and August 1, 2014. The responsibility for NEMT changed from CTD to the MCOs.

State Case Study Summaries A-5 Medicaid beneficiaries who were not participating in managed care as of May 2014 continued to receive NEMT through Florida’s CTD. In February 2015, CTD transitioned NEMT recipients to one of the brokers, concluding CTD involvement in NEMT. Effects of NEMT Change to Managed Care In the case study research, assessments of the effects of the change to managed care with carved-in NEMT were obtained from interviews with a variety of key stakeholders, including the state Medicaid agency, the state department of transportation, MCOs, the county-based transportation providers, and the NEMT brokers. Access to Medicaid Services AHCA reports that managed health care has successfully curtailed the costs of the Medicaid program in Florida. In the 2011 evaluation of the demonstration pilot for AHCA, the University of Florida, Department of Health Services Research, Management, and Policy concluded the demonstration pilot was successful in improving access to care, customer satisfaction, and cost effectiveness for medical care. The evaluation did not address NEMT specifically. The shift of NEMT to managed care has enabled private brokers to increase NEMT coverage across multiple MMA regions in the state. Coordination with Human Services Transportation Under the previous AHCA contract with CTD to provide NEMT, the CTCs in each county were able to coordinate NEMT rides with the Transportation Disadvantaged Program. While the CTCs in more urbanized counties may have discontinued providing NEMT between 2008 and 2014 due to the increased administrative effort required, the CTCs in rural counties continued to coordinate NEMT with other human services transportation programs. Now the rural CTCs compete with other transportation providers to provide NEMT for the brokers that serve the MCOs. Brokers do not always contract with the CTC in each county. Some rural CTCs report a significant loss of revenues earned from providing NEMT. With fewer shared NEMT passenger trips, the cost per passenger trip for other transportation programs has increased. The loss of NEMT revenues has reduced the capacity of CTCs to provide other human services transportation. The CTCs in rural counties report there are not consistent operating standards for different NEMT brokers and MCOs, for the CTD Transportation Disadvantaged Program, and for the FDOT rural public transportation program. Coordination with Public Transportation Many CTC are public transit agencies. The CTCs in more urbanized counties discontinued providing NEMT in 2008 when the AHCA contract with CTD required an increased admin- istrative effort to document NEMT encounters. In 2013, AHCA estimated 9.2 percent of NEMT trips were on public transportation. Other public transit agencies, especially in rural counties, continued to provide NEMT and coordinate with public transportation services. Under MMA, the rural CTCs compete with other transportation providers to provide NEMT to the private broker for each MCO. A loss of NEMT revenues for rural counties reduces a source of match for federal transit funds. The Jacksonville Transportation Authority (JTA) provides paratransit service for individuals with disabilities as required by the Americans with Disabilities Act (ADA). JTA reported a trend for an increased number of ADA paratransit trips when MMA went into effect during the

A-6 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination demonstration pilot program for managed care in 2006. Other than the fare for ADA paratransit, JTA received no reimbursement or shared costs from the broker or the MCO. JTA was the CTC in Duval County and chose not to provide demand responsive NEMT when AHCA transitioned to managed care in 2014. However, public transit agencies in urbanized areas in Florida (including JTA) with fixed-route modes (bus, rail) can accom- modate NEMT trips at no increase in cost because seats are available to additional passengers on scheduled service. A fare on fixed-route transit is the lowest-cost transportation for an NEMT trip. Summary of the Florida Case Study The Florida AHCA changed NEMT from a contract with CTD to an MMA program with carved-in NEMT in 2014. The majority of Medicaid beneficiaries in Florida are participating in a managed care health plan. Each MCO contracts with one of three for-profit private brokers to provide NEMT under the MMA program. Following is a summary of effects: • Access to Medicare services: – According to AHCA, the MMA program has curtailed the increase in the costs of the Medicaid program. – An evaluation of the Medical Reform Demonstration Pilot Program for Managed Care in 2011 concluded the pilot was successful in improving access to care, customer satisfaction, and cost effectiveness for medical care. The evaluation did not address NEMT specifically. – The shift of NEMT to managed care has enabled private brokers to increase NEMT coverage across multiple MMA regions in the state. • Coordination with human services transportation: – The three for-profit, private NEMT brokers each contract with a variety of transportation providers including human services transportation providers, taxicabs, public transit, and the community transportation coordinator in some counties. – According to CTD, the number of NEMT trips coordinated with other transportation services declined after the change to managed care. Fewer CTC are providing NEMT trips, and the CTCs that contract to a private broker may provide less NEMT service. – Some rural CTCs report a significant loss of revenues earned from providing NEMT. With fewer shared NEMT passenger trips, the cost per passenger trip for other transportation programs has increased. The loss of NEMT revenues has reduced the capacity of some CTCs to provide other human services transportation. – NEMT clients can no longer arrange transportation for multiple trip purposes with one call, one click. – The CTCs in rural counties report there are not consistent operating standards for different NEMT brokers, different MCOs, and different funding programs. For example, different rules may apply for licensing vehicles, credentialing drivers, and documenting NEMT encounters. • Coordination with public transportation: – The loss of NEMT revenues by public transit agencies particularly in rural counties reduces a source of match for federal transit funds. – JTA documented the trend for an increased number of ADA paratransit trips during the Medical Reform Demonstration Pilot Program for Managed Care in 2006. ADA para- transit trips are more expensive for the public transit agency to deliver, and JTA received no reimbursement or shared costs from the broker or the MCO, other than the fare for ADA paratransit.

State Case Study Summaries A-7 References for the Florida Case Study Commission for the Transportation Disadvantaged. An Introduction to Florida’s Coordinated Transportation System. PowerPoint presentation, April 8, 2016. Cronin, J., Hagerich, J., Horton, J., and Hotaling, J. Florida Transportation Disadvantaged Services: Return on Investment Study. The Marketing Institute—Florida State University College of Business, Tallahassee, Florida, March 2008. www.fdot.gov/ctd/docs/aboutusdocs/roi_final_report_0308.pdf. Accessed December 12, 2017. Dewey, J. F., Dai, C., Lotfinia, B., and Krishnaprasad, B. Independent Assessment: Florida Non-Emergency Medicaid Transportation Waiver. University of Florida Bureau of Economic and Business Research, October 2003. http://www.fdot.gov/ctd/docs/AboutUsDocs/IndependentAssessmentOctober2003.pdf. Accessed Decem- ber 15, 2017. Duncan, R. P., Hall, A. G., Harman, J. S., McKay, N. L., Lemak, C. H., Landry, A. Y., and Robst, J. Evaluating Florida’s Medicaid Reform Demonstration Pilot: 2006–2011 Summary Report. University of Florida, Depart- ment of Health Services Research, Management, and Policy. 2011. Florida Agency for Health Care Administration. Implementation Plan: Florida’s Managed Medical Assistance Program. October 30, 2013. http://www.fdot.gov/ctd/docs/MeetingPackages/2013Meetings/Implementation %20Plan%20-%20Managed%20Medical%20Assistance%20Program%2010-2013.pdf. Accessed December 11, 2017. Gentry, C. “Medicaid ‘Reform’ Pays Off: Study.” Health New Florida. February 6, 2014. http://health.wusf.usf.edu/ post/medicaid-reform-pays-study#stream/0. Accessed December 8, 2017. Harman, J. S., Hall, A. G., Lemak, C. H., and Duncan, R. P. “Do Provider Service Networks Result in Lower Expenditures Compared with HMOs or Primary Care Case Management in Florida’s Medicaid Program?” Health Services Research, 49(3), 858–877. November 18, 2013. http://doi.org/10.1111/1475-6773.12129. Accessed December 17, 2017. Pease, J. “Florida’s Medicaid reform pilot is saving money, UF study finds.” University of Florida News. January 2014. http://news.ufl.edu/archive/2014/01/floridas-medicaid-reform-pilot-is-saving-money-uf- study-finds-1.html. Accessed December 8, 2017. Massachusetts: Regional Brokers (Regional Transit Authorities) Key Data Key Data Demographic Features • State Population (2015) 6,705,586 • Urban Population (2010) 90% • Rural Population (2010) 10% • Population at or below poverty line (2015) 11% NEMT Oversight MassHealth provides oversight for NEMT. Medicaid & NEMT Enrollment Data • Medicaid & CHIP Enrollment (December 2013) 1,296,359 • Medicaid & CHIP Enrollment (December 2016) 1,661,951 • Percent Increase 2013–2016 28% • Medicaid Enrollees that Used NEMT (2013) N/A NEMT Model Coordinated Transportation with Regional Transit Authorities as Regional Brokers Operating Authority Section 1115 Demonstration Waiver Medicaid Match Administrative Service (50%) Expanded Medicaid under Affordable Care Act Yes Medicaid Enrollees in a Managed Care Program 51.5% • NEMT under Managed Care NEMT carved out of Managed Care NEMT Expenses & Activity Data • Annual Medicaid Expenses (2015) $15,564,425,180 • Estimate Annual NEMT Expenses (2015*) $63,430,832 • NEMT as % of Medicaid Expenses <0.5% • Estimate Annual NEMT Passenger Trips (2015)* 3,522,212 • % of NEMT Trips on Public Transit (2015) N/A • NEMT Expenses per Trip Statewide (2015)* $18.01 * Human Service Transportation Office Annual Report 2015. Reported expenses and passenger trips for PT-1 (NEMT, Medicaid, MassHealth). Expenses do not include NEMT for individuals residing in rehabilitation and nursing facilities or personal mileage reimbursement.

A-8 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination NEMT Description NEMT as 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. EOHHS comprises 15 agencies that collectively deliver and administer most of the Common- wealth’s health and human services. EOHHS agencies provide services that include Medicaid, nutrition assistance, mental health, public health, and transitional assistance for low-income individuals and families. MassHealth is one of the 15 agencies in EOHHS. Role of the Human Service Transportation Office. In 2001, EOHHS established the Human Service Transportation Office to coordinate transportation 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. Coordinated Human Services Transportation in Massachusetts The Human Service Transportation Office is responsible for the coordination of transportation for consumers for seven human services programs within six EOHHS agencies: • MassHealth NEMT: NEMT for Medicaid beneficiaries who need transportation for authorized medical services. In Massachusetts, NEMT is known as the Prescription for Transportation, or PT-1. MassHealth transportation for people residing in institutions (rehabilitation and nursing facilities) is not part of the human services transportation coordinated transportation program. The Human Service Transportation Office oversees fee-for-service (FFS) transportation for MassHealth members who live in rehabilitation and nursing facilities. • MassHealth Day Habilitation (DayHab): Transportation to Medicaid-funded day habili- tation programs. • MassHealth and Department of Public Health Early Intervention Program: Transportation to and from early intervention programs for children (birth to three years) and families. • Department of Developmental Services: Transportation for adults enrolled in employment workshops and residential support programs. • Massachusetts Rehabilitation Commission: Transportation for individuals with disabilities to vocational rehabilitation services, community services, and other Massachusetts Rehabilita- tion Commission-authorized locations or programs. • Massachusetts Commission for the Blind: Transportation for individuals who are blind to social and rehabilitative programs and services and other Massachusetts Commission for the blind-authorized locations or programs. • Department of Mental Health: Transportation to Department of Mental Health-authorized locations for consumers of Department of Mental Health Clubhouse services. Clubhouse services provide employment and education support services, housing support services, and other support services to help individuals live a productive and stable life in the community. Participating agencies maintain full control and responsibility for determining consumer eligibility, determining facilities or locations to which consumers will be transported, determin- ing service areas for consumers (distances that consumers may be transported), and ensuring

State Case Study Summaries A-9 adequate funding of approved transportation services, as well as reimbursing the brokers for consumer trip costs. For example, MassHealth provides oversight for NEMT services, includ- ing determining eligibility for Medicaid beneficiaries and providing funding for authorized transportation to medical services. Human Services Transportation Brokerage Model in Massachusetts The human services transportation system was designed and implemented in partnership with the Massachusetts Department of Transportation (MassDOT). The Commonwealth is divided into nine regions for human services transportation service that include all cities and towns. Human services transportation contracts with six regional transit authorities (RTAs) to act as brokers to provide transportation services for EOHHS consumers. The six RTAs are: • Berkshire Regional Transit Authority, • Cape Ann Transit Authority, • Cape Cod Regional Transit Authority, • Franklin Regional Transit Authority, • Greater Attleboro/Taunton Regional Authority, and • Montachusett Area Regional Transit (is the broker for four regions). Human services transportation procured the original brokers for the first contract period 2001–2007 using a request for proposals. The second contract period was 2007–2015 (including contract extensions). The Human Service Transportation Office planned to transition from six regional brokers to one statewide broker and issued a request for proposals in 2013; however, the plan was sub- sequently postponed. The Human Service Transportation Office renewed contracts with the six existing regional brokers for the continuation of services through June 30, 2020. Broker Responsibilities The goal of the coordinated brokerages is to reduce administrative burden at the state level and to establish common service standards. The primary responsibilities of brokers include: • Arranging consumer trips and contracting for services with local providers, • Monitoring and ensuring service quality through on-site inspections, consumer surveys, etc., • Developing routing and other strategies to increase system efficiency, shared rides, and cost effectiveness, and • Tracking and reporting system usage and costs and monitoring performance benchmarks. All human services transportation brokers are required to adhere to performance standards. The human services transportation compliance officer conducts an annual review of each broker. The Human Service Transportation Office confirms compliance with vehicle maintenance, driver qualifications, insurance compliance, timely payment of vendors, and other areas for broker performance. At the time of the on-site review, randomly selected claims are selected for review and matched to claims documentation. Types of Human Services Transportation Service Brokers provide human services transportation to eligible consumers, as determined by the funding agency, via two types of service: • Demand response: Generally, transportation is authorized by the funding agency and consumers call to schedule their trips as needed with varying destinations, frequency, and times. This type of service is typically used for medical appointments. MassHealth PT-1 is a demand-response transportation service.

A-10 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination • Program-based: Transportation is authorized by the funding agency for a specific destination, frequency, and time, usually operating on a regularly scheduled basis. This type of transporta- tion is used for daily travel to rehabilitation or developmental programs. Transportation Providers Each human services transportation broker subcontracts with qualified transportation providers, primarily private for-profit and not-for-profit companies. Five (non-broker) RTAs serve as transportation providers, usually for demand-response service. Collectively the six RTAs subcontracted with 473 different transportation providers in the Commonwealth in fiscal year (FY) 2015. Brokers dispatch rides for demand-response transportation based on the lowest cost among the transportation provider’s subcontracts in each region. 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. The incentives must be invested into the brokerage service to upgrade software, buy new computers, hire additional staff, etc. Effects of NEMT as Coordinated Human Services Transportation with Regional Brokers The case study research for Massachusetts focuses on the outcomes for coordinated human services transportation through regional brokers that are public transit authorities. The case study included site visits to brokers in four regions: western Massachusetts (Berkshire Regional Transit Authority), northeastern Massachusetts (Cape Ann Transit Authority), southeastern Massachusetts (Greater Attleboro/Taunton Regional Authority), and Cape Cod (Cape Cod Regional Transit Authority). In the case study research, assessments of the effects of regional brokers and coordinated trans- portation are obtained from interviews with a variety of key stakeholders. Interviews included EOHHS and the Human Service Transportation Office, the statewide mobility manager for MassDOT, a representative for member services with MassHealth, the four regional brokers, the paratransit manager for the Massachusetts Bay Transportation Authority (Boston), and the director of community services for Mystic Valley Elder Services, an advocacy group for seniors and people with disabilities. Access to Medicaid Services The use of RTAs to broker coordinated human service transportation in Massachusetts has produced positive results for the Medicaid NEMT program by meeting an increasing demand for consumer trips, containing costs per trip, and ensuring service quality. Cost Effectiveness. A goal of the coordinated regional brokerages is to reduce administra- tive burden at the state level and to increase cost effectiveness. Table A-3 provides the follow- ing performance statistics for human services transportation (all brokerage programs) and MassHealth PT-1 (NEMT) for FY 2009 through FY 2015 for actual year of expenditure. The data in Table A-3 show the following data for MassHealth PT-1 service: • MassHealth PT-1 beneficiaries represented 67 percent of human services transportation consumers in FY 2015, and PT-1 trips were 45 percent of human services transportation trips. MassHealth PT-1 cost was 36 percent of human services transportation total operating costs.

State Case Study Summaries A-11 • Demand for MassHealth PT-1 increased 66 percent from 2.1 million trips in FY 2009 to 3.5 million trips in FY 2015. Cost for MassHealth PT-1 increased 71 percent from $37.1 mil- lion in FY 2009 to $63.4 million in FY 2015. • The cost per trip for PT-1 increased 2.9 percent over six years, or an average 0.4 percent per year. • In FY 2015, the PT-1 cost per trip was $18.01 as compared to the average total cost per trip for all human services transportation brokerage programs of $23.39. Broker management costs are established by contract with human services transportation and are reimbursed to the broker via a monthly recurring payment. Human services transportation held the total management fee to all brokers constant from FY 2009 through FY 2014. As the number of trips provided increased, the management cost per trip declined from $1.21 per trip Performance Statistics FY2009 FY2010 FY2011 FY2012 FY2013 FY2014 FY2015 2009– 2015 % Change 2009–2015 Avg Annual % Change Human Services Transportation (All Brokerage Transportation Programs) 36 MassHealth PT-1 (NEMT) Program 73% 23% 70% 49% 31% 16% -17% 14% 71% 66% 2.9% 2.7% 12.1% 3.8% 11.6% 8.2% 5.2% 2.6% -2.9% 2.3% 11.9% 11.1% 0.5% 0.4% HST Operating Cost Broker Management Cost* Total HST Cost Total HST Trips HST Consumers Served HST Operating Cost/Trip Management Cost/Trip Total HST Cost/Trip Management Cost/Trip As % HST Operating Cost MassHealth PT-1 Cost % of Total HST Cost MassHealth PT-1 Trips % of Total HST Trips PT-1 Cost per Trip MassHealth PT-1 Consumers Served % of HST Consumers Served $100,676,449 $6,318,647 $106,995,096 5,208,858 37,760 $19.33 $1.21 $20.54 6.3% $37,067,469 41% 2,116,882 43% $17.51 32,369 86% $104,952,047 $6,318,647 $111,270,694 5,548,178 ,387 $18.92 $1.14 $20.06 6.0% $34,107,570 31% 2,187,149 39% $15.59 24,638 68% $110,724,486 $6,318,647 $117,043,133 5,840,471 34,903 $18.96 $1.08 $20.04 5.7% $33,989,773 29% 2,303,978 39% $14.75 22,317 64% $122,499,523 $6,318,647 $128,818,170 6,296,376 36,134 $19.46 $1.00 $20.46 5.1% $38,048,781 30% 2,507,684 40% $15.17 22,781 63% $132,163,781 $6,318,647 $138,482,428 6,633,726 38,790 $19.92 $0.95 $20.87 4.8% $42,116,044 32% 2,717,257 41% $15.50 24,644 64% $51,952,015 $150,240,859 $6,318,647 $156,559,506 7,240,234 44,718 $20.75 $0.87 $21.62 4.2% 35% 3,100,327 43% $16.76 29,376 66% $173,814,030 $7,761,631 $181,575,661 7,762,221 49,477 $22.39 $1.00 $23.39 4.5% $63,430,832 36% 3,522,212 45% $18.01 33,230 67% Source: Human Service Transportation Office Annual Reports 2009 through 2015. Note: HST = human services transportation. *HST held the management fee to the brokers flat from FY2009 through FY2014. As the number of trips provided increased, the management cost per trip declined. New HST contracts signed in FY2015 with the regional brokers increased the management fee 23 percent. Table A-3. Massachusetts human services transportation and MassHealth PT-1 (NEMT) performance FY 2009–FY 2015.

A-12 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination in FY 2009 to $0.87 per trip in FY 2014. Human services transportation increased the broker management fee to $1.00 per trip (23 percent) in FY 2015. Quality of Service. Another goal for the coordinated transportation program is an assur- ance of service quality. The Human Service Transportation Office monitors service quality for coordinated transportation services, including PT-1, through on-site inspections, consumer surveys, and monitoring monthly performance reports. The human services transportation brokerage system consistently achieves a rating of 99 percent or better on contract performance standards. For example, human services trans- portation contract standards specify no more than three vehicle accidents per 10,000 consumer trips. In FY 2014, human services transportation performance was less than one accident per 25,000 consumer trips. The human services transportation system achieves greater than 99 percent on-time trips and complaint-free trips (based on consumer complaints received and on-site inspections performed). As part of ensuring service quality, the brokers are required to perform on-site service inspec- tions at consumer destination facilities (clinics, doctor offices, program sites, etc.). In FY 2014, brokers reported completing 6,250 inspections. In FY 2014, the brokers conducted 22,345 con- sumer surveys (phone and written surveys), representing 50 percent of the total 44,718 consumers transported that year. The positive response rate was 93 percent. Challenges. Human services transportation and the brokers report a number of challenges: • Affordable technology. The most consistently cited challenge for both the Human Service Transportation Office and brokers is consistent, affordable technology. Brokers use different scheduling software. • Limited brokerage management fee. A second challenge mentioned by the brokers was main- taining services within the brokerage management fee. Even though the fee was increased in FY 2015, the brokers interviewed during the case study stated a need to continue to work on rate adjustments and the mechanism by which incentives are provided. • Regional versus Statewide Broker. A third challenge was the discussion of a change to a single statewide broker. Brokers would like to explore if the centralized approach (statewide broker) would provide advantages over the current decentralized regional broker approach. • Program expansion. Finally, human services transportation is interested in continuing to add state programs to the brokerage, specifically the MassHealth NEMT for people residing in institutions. Coordination with Human Services Transportation The Human Service Transportation Office is responsible for coordination of transporta- tion for consumers for seven human services programs within six EOHHS agencies, including MassHealth PT-1 (NEMT). Human services transportation also provides technical assistance and outreach programs in support of local mobility and transportation coordination efforts for transportation-disadvantaged Massachusetts residents. Statewide and regional coordinating councils (RCCs) help to provide community input and to improve coordination. MassMobility. MassMobility is an initiative to increase mobility for seniors, people with disabilities, veterans, and others who lack transportation access in Massachusetts. MassMobility is housed at the Human Service Transportation Office and is funded by a federal grant through MassDOT. The Human Service Transportation Office helps to build the capacity of the Massachusetts community transportation network by appointing mobility managers to raise the awareness of existing services, fostering collaboration among programs, and sharing best practices.

State Case Study Summaries A-13 Statewide and Regional Coordinating Councils. Executive Order 530 (EO530) in April 2011 established a Commission for the Reform of Community, Social Service and Paratransit Transportation Services in the Commonwealth of Massachusetts (Commission). The Com- mission was given the responsibility for conducting a review of all state and federally funded community transportation services and making recommendations for reform, restructuring, and cost-savings initiatives. The report from the Commission was delivered in 2012 with over 60 recommendations, including a recommendation to establish a Statewide Coordinating Council on Community Transportation. In order to ensure that the work started by the Commission continued, MassDOT and EOHHS executed a Memorandum of Understanding in March 2013 to establish the Statewide Coordinating Council on Community Transportation. In partnership with MassDOT, the Human Service Transportation Office helped launch RCCs. There are currently 16 RCCs with diverse membership. RCC members differ from region to region but may include transit authorities and service providers; planning agencies; trans- portation management associations; the statewide demand management program (MassRIDES); and state community agencies that serve seniors, people with disabilities, and veterans. RCCs help to implement recommendations from the Executive Order 530 final report. Coordination with Public Transportation NEMT trips are not integrated with public transportation services in Massachusetts, although some human services transportation demand-response trips are provided by an RTA if the service meets the lowest cost service requirement. The EO530 final report recommended improved trip coordination by promoting shared rides by non-ADA human services transportation and ADA paratransit, where appropriate. The report also recommended establishing a working group to develop a mechanism to apply for Medicaid funding for NEMT services provided by MassDOT (specifically on Massachusetts Bay Transportation Authority fixed routes and ADA paratransit) to Medicaid-eligible beneficiaries. (At the time of the case study, this mechanism had not yet been implemented.) Summary of the Massachusetts Case Study In Massachusetts, the state Medicaid agency, MassHealth, provides NEMT through a coordi- nated transportation program operated by EOHHS through the Human Service Transportation Office. NEMT is known in Massachusetts as the Prescription for Transportation, or PT-1. The Human Service Transportation Office contracts with six RTAs to serve as brokers to provide transportation services in nine regions. Each human services transportation broker sub- contracts with qualified transportation providers to deliver transportation to the consumers. The transportation providers are primarily private for-profit and not-for-profit companies in each respective region. Following is a summary of effects: • Access to Medicare services: – Demand for MassHealth PT-1 increased 66 percent from 2.1 million trips in FY 2009 to 3.5 million trips in FY 2015. Cost for MassHealth PT-1 increased 71 percent from $37.1 million in FY 2009 to $63.4 million in FY 2015. – The cost per trip for PT-1 increased 2.9 percent over six years, or an average 0.5 percent per year. – In FY 2015, the PT-1 cost per trip was $18.01 as compared to the average total cost per trip for all human services transportation brokerage programs of $23.39. Of the

A-14 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination seven case studies, Massachusetts reported the second lowest average cost per NEMT passenger trip. • Coordination with human services transportation: – The Human Service Transportation Office sets consistent service standards and monitors service quality for coordinated transportation services. The human services transportation system achieves greater than 99 percent completed on-time trips and complaint-free trips. In FY 2014, human services transportation performance was less than one accident per 25,000 consumer trips. – In FY 2014, the brokers conducted 22,345 consumer surveys (phone and written surveys), representing 50 percent of the total 44,718 consumers transported that year. The positive response rate was 93 percent. – Good coordination is promoted through well-regarded mobility managers. – PT-1 clients can arrange transportation for multiple trip purposes with one call, one click. • Coordination with public transportation: – The use of RTAs to broker coordinated human services transportation in Massachusetts has produced positive results for the MassHealth PT-1 program by containing costs per trip and ensuring service quality. – Continuing challenges include: � The ability of all brokers to buy and maintain state of the industry software, � The adequacy of the brokerage management fee to sustain services, and � The need to add programs to the coordinated human services transportation. References for the Massachusetts Case Study Bhatnagar, H., and Fisher, B. “Implementing a Broad Set of Coordinated Options: MART’s Solution to Brokered Human Service Transportation.” Community Transportation Digital: The Infrastructure of Coordination. Winter: 29–31, 2011. http://web1.ctaa.org/webmodules/webarticles/articlefiles/DigitalCT_Winter_11_ Implementing_Coordinated_Options.pdf. Accessed December 11, 2017. Commonwealth of Massachusetts Division of Medical Assistance. “Transportation Manual.” Provider Manual Series, September 1, 2017. http://www.mass.gov/eohhs/docs/masshealth/regs-provider/regs-transportation.pdf. Accessed December 11, 2017. Community, Social Service, and Paratransit Transportation Commission. Executive Order 530 Final Report. Commonwealth of Massachusetts, July 19, 2012. http://www.mass.gov/eohhs/docs/hst/eo530-report.pdf. Accessed December 11, 2017. Hewitt, J. K., and Lambert, M. J. 2014 Annual Report, Statewide Coordinating Council on Community Transpor- tation. MassDOT and Massachusetts Executive Office of Health and Human Services, October 24, 2014. https://www.massdot.state.ma.us/Portals/12/docs/SCCCT/AnnualReport102414.pdf. Accessed July 15, 2015. Human Service Transportation Office, Executive Office of Health and Human Services. Transportation Provider Performance Standards. Commonwealth of Massachusetts, July 1, 2014. http://www.mass.gov/eohhs/docs/ hst/provider-performance-standards.pdf. Accessed July 15, 2015. Human Service Transportation Office, Executive Office of Health and Human Services. FY2008 Annual Report. Commonwealth of Massachusetts, 2009. http://www.mass.gov/eohhs/docs/hst/hst-annualreport-fy08.pdf. Accessed July 15, 2015. Human Service Transportation Office, Executive Office of Health and Human Services. FY2009 Annual Report. Commonwealth of Massachusetts, 2010. http://www.mass.gov/eohhs/docs/hst/hst-annualreport-fy09.pdf. Accessed July 15, 2015. Human Service Transportation Office, Executive Office of Health and Human Services. FY2010 Annual Report. Commonwealth of Massachusetts, 2011. http://www.mass.gov/eohhs/docs/hst/hst-annual-report-fy10.pdf. Accessed July 15, 2015. Human Service Transportation Office, Executive Office of Health and Human Services. FY2011 Annual Report. Commonwealth of Massachusetts, 2012. http://www.mass.gov/eohhs/docs/hst/hst-annual-report-fy11.pdf. Accessed July 15, 2015. Human Service Transportation Office, Executive Office of Health and Human Services. FY2012 Annual Report. Commonwealth of Massachusetts, 2013. http://www.mass.gov/eohhs/docs/hst/hst-annual-report-fy12.pdf. Accessed July 15, 2015.

State Case Study Summaries A-15 Human Service Transportation Office, Executive Office of Health and Human Services. FY2013 Annual Report. Commonwealth of Massachusetts, 2014. http://www.mass.gov/eohhs/docs/hst/hst-annual-report-fy13.pdf. Accessed July 15, 2015. Human Service Transportation Office, Executive Office of Health and Human Services. FY2014 Annual Report. Commonwealth of Massachusetts, 2015. http://www.mass.gov/eohhs/docs/hst/hst-annual-report-fy14.pdf. Accessed July 15, 2015. Human Service Transportation Office, Executive Office of Health and Human Services. FY2015 Annual Report. Commonwealth of Massachusetts, 2016. http://www.mass.gov/eohhs/docs/hst/hst-annual-report-fy15.pdf. Accessed July 15, 2015. Seifert, R. W., Grenier, M., and Sullivan, J. C. The MassHealth Waiver Extension for State Fiscal Years 2015–2019: Foundation for Coverage, Engine for Innovation. Center for Health Law and Economics, University of Massachusetts Medical School, Boston, Massachusetts, February 2015. http://bluecrossfoundation.org/ sites/default/files/download/publication/MassHealth_Waiver_report_FINAL.pdf. Accessed December 11, 2017. Massachusetts Department of Transportation, Rail & Transit Division. Statewide Coordinating Council on Community Transportation Operating Principles. September 23, 2013. https://www.massdot.state.ma.us/ Portals/12/docs/SCCCT/operatingPrinciples092313.pdf. Accessed December 11, 2017. Executive Order No. 530—Establishing a Commission for the Reform of Community, Social Service and Para- transit Transportation Services in the Commonwealth. Commonwealth of Massachusetts, April 6, 2011. http://www.mass.gov/courts/docs/lawlib/eo500-599/eo530.pdf. Accessed July 15, 2015. New Jersey: Change to Statewide Broker (For Profit) Key Data Key Data Demographic Features • State Population (2015) 8,904,413 • Urban Population (2010) 92% • Rural Population (2010) 8% • Population at or below poverty line (2015) 11% NEMT Oversight Department of Human Services, Division of Medical Assistance and Health Services Medicaid & NEMT Enrollment Data • Medicaid & CHIP Enrollment (December 2013) 1,283,851 • Medicaid & CHIP Enrollment (December 2016) 1,761,395 • Percent Increase 2013–2016 37% • Medicaid Enrollees that Used NEMT (2013) 4% NEMT Model Statewide Broker Operating Authority 1902(a)(70) State Plan Amendment Medicaid Match Medical Service (50%) Expanded Medicaid under Affordable Care Act Yes Medicaid Enrollees in a Managed Care Program 93% • NEMT under Managed Care NEMT carved out of Managed Care NEMT Expenses & Activity Data • Annual Medicaid Expenses (2015) $14,234,989,570 • Estimate Annual NEMT Expenses (2014) $165,000,000 • NEMT as % of Medicaid Expenses 1.2% • Estimate Annual NEMT Passenger Trips (2014) 4,800,000 • % of NEMT Trips on Public Transit (2014) 22.8% • NEMT Expenses per Trip Statewide (2014) Est. $34 NEMT Description Move to statewide broker with capitated payment. The Department of Human Services, Division of Medical Assistance and Health Services (DMAHS) is the state Medicaid agency in New Jersey responsible for NEMT. Prior to 2009, DMAHS contracted for NEMT primarily with county-based community transportation providers in each of the 21 counties in the state with an FFS payment. In July 2009, DMAHS changed the NEMT service model to a statewide

A-16 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination 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 the agency was concerned about fraud in claims for providing NEMT trips. Statewide broker responsibilities. The statewide broker’s responsibilities include: • Maintain a provider network, • Determine the appropriate mode of transportation for each beneficiary, • Dispatch appropriate vehicles to transport beneficiaries, and • Develop a quality assurance program to ensure access to appropriate transportation for NEMT clients based on medical necessity. The broker then (a) arranges NEMT trips by contracting with private and community trans- portation providers at the county level, (b) arranges NEMT trips on public transportation, or (c) provides mileage reimbursement for personal travel, as appropriate. The majority of NEMT trips are in urban areas. Table A-4 shows the percent of trips by transportation category for urban and rural areas. As part of the responsibility to maintain a provider network, the statewide broker arranges for transportation on a county-by-county basis. The broker purchases transportation from private and community transportation providers. Rates and other contractual terms and conditions may vary county to county and sometimes from provider to provider within a county. These variations are based on the geographic coverage area, the various types of transport provided, the hours of operation, and other factors. Procedure for fulfilling transportation requests. Medicaid beneficiaries place requests for transportation with the broker by telephone or online. Requests must be placed before 2:00 p.m. two business days before the trip. Same-day scheduling is available for specific situ- ations, such as a release from the hospital. The broker assigns trip requests to transportation providers the evening before the trip; providers have the option of not serving trip requests. Effects of the Patient Protection and Affordable Care Act (ACA). The increase in Medicaid enrollment for ACA also increased the demand for NEMT service. DMAHS reported NEMT call volume increased about 29 percent from November 2013 to May 2015 (during the same period, Medicaid enrollment increased about 35.2 percent). The broker has a large staff of trip schedulers; if the schedulers in New Jersey are busy with other customers, the call is routed to the statewide broker’s schedulers in other states. Transportation Category Urban Rural Urban/Rural Unknown Statewide NEMT demand response 74.6% 90.9% 73.5% 75.2% Public transportation 23.5% 2.4% 24.6% 22.8% Mileage reimbursement 1.9% 6.7% 1.9% 2.0% Total 100.0% 100.0% 100.0% 100.0% Percent of statewide total 95.3% 3.3% 1.4% 100.0% Source: Island Peer Review Organization, Inc., 2014. Table A-4. New Jersey NEMT trips.

State Case Study Summaries A-17 Public Transportation and Community Transportation in New Jersey The New Jersey Transit Corporation (NJ TRANSIT) is a public transportation corporation providing service throughout the state of New Jersey and connecting to New York City and Philadelphia. NJ TRANSIT operates an extensive statewide transit network comprised of fixed-route bus, light rail, commuter rail, vanpool, and complementary paratransit service known as Access Link. NJ TRANSIT is the nation’s third largest transit system in terms of ridership. Community transportation services are available in each of New Jersey’s 21 counties. Com- munity transportation providers operate demand-response and flexible transportation services to provide access to employment, essential shopping, and medical services. Services may also connect public transportation riders to NJ TRANSIT bus stops and commuter rail or light rail stations. Some community transportation services are public transportation, open to the general public. Others are human services transportation providers with eligibility requirements restricting service to senior citizens, people with disabilities, or social services clients. Many of the com- munity transportation services are funded by NJ TRANSIT with grants from the Federal Transit Administration (FTA) and with funds from New Jersey’s Casino Revenue fund under the Senior Citizens and Disabled Residents Transportation Assistance Program. Community transporta- tion providers also generate revenue from service contracts with a state, local, or private human services agencies or organizations, such as Medicaid to provide NEMT. Prior to 2009, DMAHS contracted with county DHS or welfare boards that then contracted with taxi/livery providers or county community transportation system providers to operate NEMT. These transportation providers coordinated transportation by providing shared-ride services for NEMT riders and other general public or sponsored riders. Since the change to a statewide NEMT broker, the broker contracts with community transportation providers in six of the state’s 21 counties. Coordinated transportation services are also made possible by the Casino Revenue fund. These revenues fund local specialized transportation services for the transportation disadvantaged. The Casino Revenue fund has declined in recent years, reflecting the trend in the casino business economy. Casino revenues for local transportation services in 2015 were about 50 percent of the revenues in 2010, causing serious financial hardship for several community transportation providers. Counties cut back on trips previously provided—trips for medical appointments, grocery shopping, employment, and/or out-of-county destinations—due to the reduction in funds. Effects of NEMT Change to Statewide Broker In the case study research, assessments of the effects of the change to a statewide broker were obtained from interviews with a variety of key stakeholders, including the state Medicaid agency, the statewide broker, the state department of transportation, the local county community transportation providers, and Medicaid beneficiaries who use NEMT and their advocates. An independent evaluation prepared by IPRO in 2014 was also referenced. Access to Medicaid Services From the perspective of the New Jersey state Medicaid agency (DMAHS), the NEMT change from in-house management to a statewide broker is positive. Administrative responsibility for the NEMT program has been shifted from DMAHS to the broker, and the role of DMAHS is now oversight for the NEMT program. DMAHS reported saving $30 million when the state changed to a broker.

A-18 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination Positive Results of the Change to a Statewide Broker. According to DMAHS, the following improvements have occurred since the change to a statewide broker: • Improved cost control. The contract with the statewide broker has enhanced cost control. • Reduced risk of fraud. The broker is responsible for ensuring eligible riders and trips. • Improved access. DMAHS reports that access to health care services has improved. The broker operates around the clock and on weekends. • Increased data. DMAHS is receiving more data about NEMT services under requirements of the contract with the broker. • Increased number of NEMT providers. • Improved vehicles used for NEMT trips. The broker is responsible for ensuring that trans- portation providers use vehicles that meet a higher standard for safety. • Increased insurance coverage for NEMT services. • Improved scheduling for NEMT trips. With the broker’s centralized reservation system, one- call access is now available for scheduling NEMT trips. DMAHS requires the statewide broker to report data in a monthly Transportation Broker Report. This report is a tool for DMAHS to monitor the NEMT program. The types of data reported are: • Provider network showing numbers of providers and numbers of vehicles, • Monitoring and inspections, • Eligible NEMT population, • Call center operations, • Trips including late trips, trips per capita, and provider no-shows, • Denials of service, • Complaints (type, percentage per trip, types during last two months), and • Customer satisfaction. Using such data, DMAHS can monitor and oversee NEMT services provided by the broker and the transportation providers. Challenges of the Change to a Statewide Broker. Not all stakeholders report positive reactions to the change to a statewide broker and different transportation service providers. Some Medicaid beneficiaries and advocates reported a reduction in transportation services with the change to a broker. At least some of these reports are due to the broker’s implementa- tion of DMAHS processes to verify eligible beneficiaries, to approve trips for medical services, and to assign the appropriate mode of transportation based on medical necessity. DMAHS also implemented a restriction on NEMT trip distance to 20 miles from the origin. The broker must provide a Closest Provider Certification for transportation over 20 miles. DMAHS will waive the 20-mile restriction if medical providers are not available or if the patient has been seeing the same medical provider for many years. Some riders of the NEMT services and their advocates are vocal about their problems with broker operations. These problems include the following: • Lack of adherence to scheduled times. Not picking up passengers on time or dropping them off at scheduled times and not picking up passengers for return trips. According to an independent survey, 34 percent of all trips were not picked up on time, and 42 percent of all trips were not dropped off on time. On-time performance was lower in rural areas than urban areas. • Travel times. Trip times have increased for passengers. • No service provided. No driver shows up to provide the trip requested.

State Case Study Summaries A-19 • Drivers are not familiar with the service area. Drivers do not know local routes or destinations, leading to late pickups and drop-offs or excessive travel times. Local medical service providers reported a number of similar concerns with transportation services provided through the brokerage program, although it could not be determined if these concerns were greater than, the same as, or less than transportation issues that existed before the brokerage was implemented. The number of NEMT clients being picked up and dropped off late was a particular concern that reportedly jeopardized medical appointments and caused the patients anxiety. While at least some these issues are serious, independent survey data gathered by IPRO indicate that a majority of Medicaid NEMT riders are satisfied with transportation services. Of the 84 percent of IPRO survey respondents who called the broker to schedule their transpor- tation, 86 percent rated their interactions with the broker as very good or good, while 14 percent rated their interactions poor or very poor. Coordination with Human Services Transportation There has been a decline in the degree to which other transportation services are coordinated with NEMT trips because of the change to a statewide broker in New Jersey. The broker acknowl- edges that county-based community transportation services are providing fewer NEMT trips than before because more trips are being provided by private providers. The county-sponsored community transportation services are often limited to weekdays and regular business hours, unlike other transportation providers who may be available 24 hours. The broker also seeks the lowest-cost transportation provider that can meet requirements for quality of service. The loss of revenues from the Casino Revenue fund since 2010 has also had a negative effect on the coordination of human services transportation. The effects of NEMT on coordination with other human services transportation are on a county-by-county basis. In counties where the broker continues to contract for NEMT services with the community transportation provider, coordination opportunities may have improved when shared rides are possible. This particularly occurs in urban counties where shared rides are more feasible. In other counties, where the broker does not continue to contract for NEMT services with the community transportation broker, many community transportation providers have seen decreases in revenues received (from NEMT and from the casino fund), leading to decreases in service hours, geographic coverage, and the number of riders served. There has been a decline in shared rides for the county-sponsored transportation services, and this has increased the average cost per trip. For Medicaid beneficiaries across the state, there may be one-call access to schedule NEMT services, but the same individuals have lost a one-call service to schedule trips for other purposes using a coordinated service. Now one call (or one click) is required to schedule NEMT trips, and another call is required to schedule any other trip with a county-based community transportation provider. Coordination with Public Transportation The change to a statewide broker for NEMT in New Jersey has affected coordination with public transportation in four ways, as discussed below. NEMT Trips on Fixed-Route Public Transportation. Because of the extensive NJ TRANSIT public transit system, many Medicaid beneficiaries in New Jersey can use public transpor- tation to travel to medical appointments. In urban areas, public transportation represents

A-20 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination 23.5 percent of NEMT trips. In some counties, the broker has successfully negotiated the purchase of bulk tickets and passes at fare rates for NJ TRANSIT fixed-route bus, light rail, and commuter rail services. The broker purchases tickets and monthly passes (when the purchase will meet the Medicaid guidance on eligibility of monthly passes as an NEMT expense) for NEMT clients who can use public transportation. Negotiated Rates for Demand-Response NEMT. The general practice of New Jersey’s broker is to negotiate specific rates for transportation with each individual public transportation provider for demand-response NEMT trips. Negotiated rates are usually flat rates per trip or mileage-based rates (with a specified amount for picking up the rider). Several public trans- portation providers are satisfied with the rates they have been offered by the broker; others are not. Some providers feel flat rates do not recognize all variable trip costs. Not Every County Public Transportation Provider Participates in NEMT. An important caveat is that the broker has not negotiated trip reimbursement rate that is acceptable to the public transportation provider in every county and therefore has not negotiated a contract for the public transportation provider to participate in NEMT. From the perspective of public transportation providers, the challenge is gaining the opportunity for meaningful participation in the state’s Medicaid NEMT program. When contracts are successfully negotiated, there is no assurance the broker will use the public transportation provider. The broker may elect to use other transportation providers for any or all NEMT trips rather than a public transporta- tion provider. Reduced Revenues for Local Match for FTA Grants. County public transportation pro- viders can use NEMT revenues as local match for FTA grants. The loss of NEMT revenues may reduce the source of match for federal transit grants. The loss of revenues from the Casino Revenue fund compounds the problem of insufficient local funds. Summary of the New Jersey Case Study New Jersey’s DMAHS changed NEMT from in-house management to a statewide broker in 2009. Following is a summary of effects: • Access to Medicare services: – From the perspective of DMAHS, the statewide broker has enhanced cost control and reduced the risk of fraud. DMAHS reports access to health care services has improved. Some medical providers believe that improvements in reliable NEMT are still required. – While there are service quality issues that the broker must address, an independent survey indicated that a majority of Medicaid NEMT riders are satisfied with transportation services. • Coordination with human services transportation: – There has been a decline in the degree to which NEMT trips are coordinated with other transportation services after the change to a statewide broker. – County-based community transportation services are providing fewer trips than before because more trips are being provided by private providers. – NEMT clients can no longer schedule transportation for multiple trip purposes with one call, one click. • Coordination with public transportation: – Because of the extensive NJ TRANSIT public transit system, many Medicaid beneficiaries in New Jersey can use public transportation to travel to medical appointments. In urban areas, public transportation represents 23.5 percent of NEMT trips. The broker purchases tickets and monthly passes for Medicaid beneficiaries who can use fixed-route public trans- portation. In rural areas, public transportation represents 2.4 percent of NEMT trips.

State Case Study Summaries A-21 – The broker has negotiated per trip reimbursement rates with some public transportation providers for demand-response NEMT. Several public transportation providers are satisfied with the rates; others say the rates do not cover the cost to provide the service. – Community transportation providers in less than one-third of New Jersey’s counties have meaningful participation in the state’s Medicaid NEMT program. When contracts are successfully negotiated, there is no assurance the broker will use the community provider. – The loss of NEMT revenues may reduce the source of local match for FTA grants. Public transportation providers may need to identify another source of local match to fully access FTA funds and sustain the current level of service or planned capital investments. References for the New Jersey Case Study Centers for Medicare & Medicaid Services. Medicaid & CHIP in New Jersey. no date. https://www.medicaid.gov/ medicaid/by-state/stateprofile.html?state=new-jersey. Accessed December 11, 2017. Chakravarty, S. Overview of the Comprehensive Medicaid Waiver Evaluation Strategy. Presentation at Medical Assistance Advisory Council Meeting, April 13, 2015. http://www.nj.gov/humanservices/dmahs/boards/ maac/MAAC_Meeting_Presentations_4_13_15.pdf. Accessed December 11, 2017. Improving Healthcare for the Common Good (IPRO). Transportation Utilization, Trip Analyses, and Member and Facility Satisfaction, New Jersey Medicaid LogistiCare Study. New Jersey Department of Human Services, Division of Medical Assistance and Health Services, August 2014. Mulford, K. “Patients: Medical rides are unreliable in South Jersey.” Courier-Post Online. January 12, 2015. http://www.courierpostonline.com/story/news/local/south-jersey/2015/01/11/breakdown-system/21615737/. Accessed December 11, 2017. New Jersey Division of Medical Assistance & Health Services, State of New Jersey Department of Health Services. Transportation Broker Report. Internal reporting document, May 2015. North Carolina: In-House Management (County Based) with Community Transportation Key Data Key Data Demographic Features • State Population (2015) 9,845,333 • Urban Population (2010) 55% • Rural Population (2010) 45% • Population at or below poverty line (2015) 16% NEMT Oversight Department of Health and Human Services, Division of Medical Assistance Medicaid & NEMT Enrollment Data • Medicaid & CHIP Enrollment (December 2013) 1,595,952 • Medicaid & CHIP Enrollment (December 2016) 2,025,016 • Percent Increase 2013–2016 27% • Medicaid Enrollees that Used NEMT (2013) 6% NEMT Model Community Transportation with County-Based In-House Management Operating Authority NEMT Assurance under the State Medicaid Plan Medicaid Match Administrative Service (50%) Expanded Medicaid under Affordable Care Act No Medicaid Enrollees in a Managed Care Program None Submitted Section 1115 Demonstration application to change to managed care (submitted August 2017) NEMT Expenses & Activity Data • Annual Medicaid Expenses (2015) $13,483,308,436 • Estimate Annual NEMT Expenses (2015) $53,900,000 • NEMT as % of Medicaid Expenses 0.4% • Estimate Annual NEMT Passenger Trips (2014) 1,916,857 • % of NEMT Trips on Public Transit (2014) N/A • NEMT Expenses per Trip Statewide (2014) Est $28

A-22 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination NEMT Description NEMT is part of community transportation. The North Carolina Department of Health and Human Services (NCDHHS) is the state Medicaid agency. The NCDHHS Division of Medical Assistance is responsible for overseeing NEMT. The Department of Social Services (DSS) in each of 100 counties acts as the transportation coordinating agent for NCDHHS, responsible for meeting NEMT obligations. NCDHHS issues administrative procedures related to NEMT and contracts for compliance reviews of the 100 county DSS agents for use of Medicaid transportation funds. Types of services. Each county DSS may arrange NEMT through different types of services: • Community transportation (demand-response service) based on FFS, • Purchase of fixed-route public transit tickets or tokens, • Payments made to private, for-profit transportation companies (for example, taxis), • Payments (mileage reimbursements) made to eligible individuals who travel in private automobiles, • Payments (mileage reimbursements) made to family or friends who provide transportation on behalf of the Medicaid beneficiary, and • Payments (mileage reimbursements) made to volunteers. The largest of these NEMT services is community transportation, estimated as 74 percent of NEMT services based on 2014 data. County-based decisions. Each county DSS may contract with the local community trans- portation provider to provide NEMT on an FFS basis. The DSS is responsible for determining if a Medicaid beneficiary is eligible for NEMT, authorizing trip eligibility, and recordkeeping for post-trip and verification. The community transportation system schedules and provides the authorized transportation. In FY 2014, the North Carolina Department of Transportation (NCDOT) Public Transportation Division reported the community transportation systems in the state carried 6.6 million passenger trips, and 21 percent of these trips (about 1.4 million pas- senger trips) were for NEMT. Public transportation is also part of community transportation. Public transportation in North Carolina is provided under a community transportation model that coordinates public transportation with human services transportation. Each of the 100 counties in North Carolina has a community transportation 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 community transportation systems and the role in providing NEMT are described in more detail in the next section. Community Transportation in North Carolina The community transportation systems in North Carolina have evolved over four decades. A brief history of the coordination of human services and public transportation is summarized below, with specific explanation of NEMT as part of community transportation. Early Days of Coordination The origin of coordination of public transportation with human services transportation in North Carolina began in the 1970s.

State Case Study Summaries A-23 • Early collaboration. Coordinated transportation services date back to 1975 and the earliest days of federal funding for transportation for seniors and people with disabilities, now the FTA Section 5310 program. This program provided federal capital assistance to nonprofit organizations to provide transportation services where existing services were insufficient, unavailable, or inappropriate. NCDOT Public Transportation Division was the administra- tive agency for the program. NCDOT coordinated with NCDHHS to identify appropriate projects to fund. This early collaboration set the stage for decades of interagency transportation coordination efforts at the state level. • County-based initiatives to support better coordination. In 1976, Governor James Hunt asked NCDOT and NCDHHS to work together to expand transportation for persons 60 years of age and older, especially in rural areas. The two departments cooperated to con- duct a yearlong study of mobility options for older adults and identify sources of funding. The governor also named a Blue Ribbon Commission on Rural Transportation. The Blue Ribbon Commission recommended strategies that encouraged county-based initiatives to support better coordination of human services transportation and public transportation. One strategy was to require a locally developed plan to reflect the coordination of transporta- tion services in a community. • Executive Order 29 mandates coordination. Signed by Governor Hunt in 1978, Executive Order 29 mandated the coordination of human services transportation for all agencies that used federal and state funding programs to support transportation. Executive Order 29 required that existing transportation resources be coordinated before additional resources would be funded. • Rural public transportation consistent with locally developed plan. The Federal Public Transportation Act of 1978 (Pub L. 95–599) created the Section 18 program, now known as Section 5311, to fund public transportation in rural areas. Effective in 1979, NCDOT required applications for rural public transportation funds to be consistent with the locally developed plan. • NEMT part of coordinated transportation program. A court decision (Blue v. Craig) required NCDHHS to amend the Medicaid state plan to include transportation services to and from authorized medical services. NCDHHS recognized the coordinated local transportation services would enable NCDHHS to fulfill its NEMT obligations under the terms of the court order. NCDHHS became a key advocate for coordinated transportation. Transition to Community Transportation The approach to coordinated transportation underwent modifications and refinement over the years, but combined human services transportation and public transportation remained the heart of the program. • Public Transportation Advisory Council. Executive Order 29 established two committees to address public transportation issues in North Carolina. One was the Public Transpor- tation Advisory Council, which served as a policy making body for public transportation issues, advising the governor and North Carolina Board of Transportation on matters related to public transportation. The second was the Interagency Transportation Review Committee, a technical committee with the job of reviewing all transportation funding applications. • Human Service Transportation Council (HSTC). At the state level, community transporta- tion was facilitated by an interagency organization, originally the Interagency Transportation Review Committee, and beginning in 1991, the HSTC. • Community Transportation Services Plan (CTSP). Included in the approach to coordi- nated transportation was the requirement for each county to prepare a five-year CTSP and

A-24 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination to establish a Transportation Advisory Board (TAB) to guide the community transportation program and recommend the CTSP. • TABs. Membership on the TAB varies from county to county, but TABs generally include representatives of transportation providers, human services agencies, transit users, and county government. TABs function as advisory boards; governance authority continues to rest with the county elected officials in most locations. In recent years, the coordinated program is supported at the local level. Executive Order 29 was not renewed in 2008. As a result, the HSTC has not met since that time. The county-level TABs continue providing ongoing coordination at the local level. Types of Community Transportation Systems Public transportation in North Carolina is provided by a series of urban fixed-route transit agencies in the state’s urbanized areas. Complementing the urban fixed-route systems, community transportation is available in all 100 counties in the state. There are five different types of community transportation systems, as follows: • Community—these are single-county, coordinated community transportation systems. This is the typical organization type (since most human services organizations were established at the county level), with 65 of the 81 systems representing this type. • Regional Community—these systems represent groups of counties that have opted to run programs on a regional or multicounty basis. • Consolidated Urban Community—these systems include city-operated transit systems in an urbanized area coordinating with the surrounding county or multiple counties to provide coordinated services. • Consolidated Small City Community—this program is similar to the urban community systems described above, but the small city has not yet achieved urbanized area status. • Human Services—these systems coordinate human services transportation within their county but do not provide general public service. The majority of the community transportation systems operate demand-response services that coordinate human services transportation and public transportation. Table A-5 identifies the number of systems and number of counties by type of community transportation system in North Carolina. Rural public transportation is provided in 98 out of the state’s 100 counties; two counties have elected to coordinate only human services transportation. Both public agencies and not-for-profit organizations serve as the agency for coordinated transportation at the local level. Almost 80 percent of the organizations are classified as a public entity as shown in Table A-6. Most public entities are the public transit agency in the counties served. Community Transportation System Type No.Systems No. Counties Served Community 65 65 Regional Community 7 22 Consolidated Urban Community 6 10 Consolidated Small City Community 1 1 Human Services 2 2 Total 81 100 Source: NCDOT, 2015. Table A-5. North Carolina community transportation systems.

State Case Study Summaries A-25 Estimating the Costs of NEMT NCDHHS documented total NEMT expenditures 2007 through 2012 in a report to the North Carolina General Assembly in October 2012. The expenses and annual NEMT recipients are summarized in Table A-7. NCDHHS reported total expenditures for NEMT, but not a breakdown by type of provider. Community transportation is one provider. Other types of provider include mileage reimburse- ment to eligible individuals, payments to family and friends who provide transportation on behalf of the Medicaid beneficiaries; payments to private, for-profit transportation companies; payments to volunteers; and payment for tickets or tokens for fixed-route public transit. North Carolina community transportation systems are not required to report revenue sources by individual categories; thus, there is no definitive quantification of NEMT payments to community transportation systems for the reporting years 2007–2012. NCDOT collects information on ridership but does not collect the corresponding FFS charges assessed to Medicaid for these services. NCDHHS has not historically collected data to calculate cost per passenger trip. Efforts to document per passenger trip costs can be a challenge. For example, any community transporta- tion system that provides shared rides (the transport of two or more sponsored passenger groups on the same vehicle trip) generates additional complexities to document the time and distance for individual trips to calculate the cost per passenger trip. NCDHHS began to collect the data for NEMT passenger trips after 2012. NCDOT Cost Allocation and Funding In 2000, NCDOT created a standardized cost allocation methodology for use by all commu- nity transportation systems. By introducing this spreadsheet tool, all providers had a common methodology to price service provided under contract for NEMT, as well as to all other human services agencies. Type of Organization No. Systems No. Counties Served Public Entities 64 79 17 21 Total 81 100 Source: NCDOT, 2015. Not-for-Profit Organizations Table A-6. North Carolina organizational status of community transportation systems. Fiscal Year Annual NEMT Recipients* Total NEMT Expenditures 2007 72,787 $38,223,180 2008 74,639 $39,983,557 2009 80,153 $46,082,200 2010 85,147 $51,907,228 2011 87,926 $52,841,556 2012 91,928 $54,090,353 *NCDHHS estimated Medicaid beneficiaries who require NEMT at 6 percent of the total eligible population. Source: NCDHHS, October 2012. Table A-7. North Carolina estimated NEMT expenditures.

A-26 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination Cost Allocation Methodology. The methodology was a variation on the fully allocated cost analysis, prepared for the U.S. Department of Transportation, Urban Mass Transportation Admin- istration, by Price Waterhouse in 1987. Designed for fixed-route use, the model was modified for demand-response operations in Comprehensive Financial Management Guidelines for Rural and Small Urban Public Transportation Providers, prepared for the Multi-State Technical Assistance Program, American Association of State Highway and Transportation Officials in 1992. NCDOT presented the methodology to the HSTC. The members of the HSTC concurred the cost allocation methodology was a reasonable method for pricing services under contract. The same methodology is applied to all contract users, including NEMT services. NCDOT Policy to Fund Administrative Costs and Vehicles. Typically, only the variable operating costs are used to calculate contract rates using the NCDOT cost allocation model. Variable operating costs exclude fixed administrative costs. To promote the policy goal of coordi- nation and efficiency of service delivery to transportation-disadvantaged populations, NCDOT pays 90 percent (80 percent federal funds and 10 percent state funds) of the administrative expenses for coordinated transportation systems that serve the public in rural areas. Community transportation systems deliver NEMT using vehicles that are owned by the respective systems. Almost all vehicles for public transportation have been purchased using federal transit funding sources. FTA will provide federal funds equal to 80 percent of cost, and NCDOT has a policy to provide state funds (at a minimum) equal to 10 percent of total cost. These vehicles must be used in public or shared-ride transportation service. Vehicles cannot be acquired specifically to transport the clients of any single human services program. While com- munity transportation systems may include the value of vehicle depreciation on the non-federal share in contract rates, most agencies do not do so. When DSS contracts with a community transportation system to provide NEMT, DSS benefits from lower contract rates due to the NCDOT policy to fund 90 percent of administrative costs and the shared use of transit vehicles. Effects of NEMT as Community Transportation The case study research for North Carolina documents the delivery of NEMT as part of the coordinated human services–public transportation service model known as the community transportation program. The resource material for the case study was research prepared originally in 2012 and updated in 2015 by a research team member familiar with North Carolina. Access to Medicaid Services Most, but not all, community transportation systems in North Carolina operate NEMT by contract. Each county DSS may coordinate with the local community transportation provider to provide NEMT on an FFS basis. Seventy-five of the 81 community transportation systems provide demand-response NEMT service. In 2014, the level of NEMT ridership on each of the 75 community transportation systems varied from less than 1 percent to 87 percent of total ridership, with a statewide average 21 percent. The county DSS may provide tickets or tokens for fixed-route transit if provided by the community transportation system. Each county DSS may also arrange and pay for NEMT through other types of services such as private-for-hire (taxis), volunteer drivers, and mileage reimbursement for the Medicaid beneficiary or a family member. In FY 2014, NCDHHS reported 1.9 million NEMT trips, approx- imately 1.4 million on community transportation systems. In 2012, the North Carolina General Assembly mandated NCDHHS study NEMT and then issue a request for proposals to secure the services of an NEMT broker. NCDHHS issued a report

State Case Study Summaries A-27 titled Non-Emergency Medical Transportation Services Management Report to the Joint Legisla- tive Oversight Committee on Health and Human Services and the Joint Legislative Oversight Committee on Transportation in October 2012. NCDHHS solicited proposals from NEMT brokers in the fall 2012. In August 2013, the proposals were rejected on the basis that the existing service model was less expensive. Benefits. In the report to the joint legislative committees, NCDHHS identified the following benefits of the community transportation systems: • Safe and reliable mobility. The coordinated model of public and human services transporta- tion has served millions, providing the safe and reliable mobility of North Carolinian citizens for 35 years. • Efficiency and quality of service. Community transportation results in overall efficiency and quality of service, and mobility for seniors and the disabled population. • Shared trips reduce costs per trip. NEMT is able to take advantage of the benefit of shared trips to reduce overall fully allocated costs per passenger trip. • Long-term investment. NCDHHS and NCDOT, with other local and state human services agencies, have a long-term investment of dollars, training, resources, and coordination with human services entities. • Higher standards. Transportation providers that receive state and/or federal funds are held to higher standards. Greater oversight by both the state and federal government in adhering to required policies, reporting, procedures, training, and guidance make public transportation service safer. • Individual flexibility for multiple transportation services. Many users have transporta- tion services funded by multiple agencies such as an individual that may be an NEMT recipient, receive transportation services from Senior Services as well as transportation services funded by the Home and Community Care Block Grant program. The community transportation system makes it possible for that individual to use one system for almost all transportation needs. Challenges. All NEMT services must meet the guidelines of CMS and the state Medicaid plan in order to be eligible for federal Medicaid funds. The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services conducted an audit of the North Carolina NEMT program by reviewing 2013 and 2014 records. The objective of the audit was to determine whether NCDHHS claimed federal reimbursement for NEMT services in accordance with federal and state requirements. OIG issued findings in November 2016. Not all deficiencies were based on community transportation systems. Some deficiencies occurred because some DSSs did not provide effective oversight of mileage reimbursement, volunteer drivers, and other types of services such as private-for-hire. The OIG findings are summarized as follows: • NCDHHS claimed federal Medicaid reimbursement for some NEMT services that did not comply with federal or state requirements. – Transportation services were not necessary, reasonable, or cost effective. For example, some DSS reimbursed transportation providers for mileage incurred before pick-up, after drop-off, or between stops when there was no NEMT client on the vehicle. – Some DSSs did not ensure transportation providers met all requirements. For example, some counties did not verify transportation providers maintained minimum vehicle liability insurance.

A-28 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination – Some DSSs lacked required supporting documentation to support the services claimed or to verify that the NEMT service provider transported the beneficiary to a location where the individual received a Medicaid-covered service. • DSSs did not meet safety and risk management policy requirements by ensuring that trans- portation contracts contained guarantees that all contractors would meet safety, liability, and other program requirements. • NCDHHS program design and oversight was inadequate. • NCDHHS also claimed NEMT administrative expenses at the higher North Carolina federal medical assistance percentage instead of the 50 percent administrative rate. In comments on the draft OIG report, NCDHHS generally disagreed with the OIG findings and recommendations but agreed the report identified some areas for improvement. Future: Managed Care. In September 2015, the General Assembly enacted Session Law 2015-245, directing the transition of Medicaid from an FFS structure to a managed care structure. CMS must approve the proposed changes in the North Carolina state Medicaid plan. NCDHHS submitted the proposed program design for Medicaid managed care to CMS in August 2017. The managed care contracts would begin 18 months after federal approval. NCDHHS anticipates launching Medicaid managed care in 2019. The NCDHHS goal is to improve the health of North Carolinians through an innovative, whole-person-centered, and well-coordinated system of care, which addresses both medical and non-medical drivers of health. The state proposes to enter into contracts with companies that will offer managed care with NEMT carved in. Coordination with Human Services Transportation Community transportation systems contract with other human services agencies in addition to NEMT. A best practice in program management is to create a diversified funding base; North Carolina’s community transportation systems reflect this principle. Other contract sources for human services transportation in 2014 included the following (the number after the agency reflects the number of community transportation systems out of 81 that contract to provide this service): • Senior services (70) • Health department (56) • Vocational workshop (49) • Vocational rehabilitation (37) • Nursing home (34) • DSS—Work First (32) • DSS—Other (28) • Mental health (23) • Local employer (21) • Parks & Recreation (10) • Head Start (8) • United Way (3) Based upon a 2012 study by Carolina Burnier with Noblis, Inc, community transportation systems in North Carolina achieve increased productivity estimated at 5 percent (expressed in terms of passengers per hour and passengers per mile) by coordinating NEMT clients with rural public transit passengers and other human services agency riders. Coordination with Public Transportation Most community transportation systems that are public entities are the public transit agency in the counties served. The North Carolina Public Transportation Association concluded that

State Case Study Summaries A-29 NEMT contributed the following benefits to the community transportation system: (a) increased operating efficiencies for shared-ride demand-response transportation services, and (b) provided matching funds that could be used for FTA grants. The North Carolina Public Transportation Association estimated the matching funds for Medicaid contract revenue are $36.9 million annually. Summary of the North Carolina Case Study NEMT in North Carolina is provided under a community transportation model that coordi- nates general public transportation with human services transportation. Each of the 100 counties in North Carolina has a community transportation system. Each county DSS may also arrange and pay for NEMT through other types of transportation such as private-for-hire (taxis), volunteer drivers, and mileage reimbursement for the Medicaid beneficiary or a family member. Following is a summary of effects: • Access to Medicaid services: – In North Carolina, each county DSS may contract with the community transportation provider for NEMT service on an FFS basis. – The state Medicaid agency solicited proposals from NEMT brokers in 2012 but the exist- ing model for coordinated transportation was less expensive than the proposals from brokers. • Coordination with human services transportation: – Community transportation increases operating efficiencies for shared rides on demand- response transportation services. Coordinating NEMT trips with community transportation achieves increased productivity estimated at 5 percent. – NEMT clients can arrange transportation for multiple trip purposes with one call, one click. • Coordination with public transportation: – Most community transportation systems are the public transit agency in the counties served. – Public transit agencies use funds earned for NEMT as local share for federal transit grants. In September 2015, the North Carolina General Assembly enacted legislation to transition the state Medicaid plan from an FFS for Medicaid services to managed care. NCDHHS submitted the proposed program design for Medicaid managed care to CMS in August 2017. NCDHHS anticipates launching Medicaid managed care in 2019. NCDHHS proposes to enter into con- tracts with companies that will offer managed care with carved in NEMT. References for the North Carolina Case Study Bonner, L. “NC legislature approves Medicaid privatization.” The Raleigh News & Observer. September 23, 2015. http://www.newsobserver.com/news/politics-government/state-politics/article36223626.html. Accessed December 12, 2017. Burkhardt, J., Hamby, B., MacDorman, L. C., McCollom, B. and Schreur, G. A. Comprehensive Financial Man- agement Guidelines for Rural and Small Urban Public Transportation Providers. AASHTO—Multi-State Technical Assistance Program, September 21, 1992. http://www.fdot.gov/ctd/docs/DoingBusinessDocs/ MTAP19920921.pdf. Accessed December 12, 2017. Burnier, C., Jacobi, A., Torng, G., Gross, Y., and Noblis, Inc. “Uncover the Impacts of Coordinating Human Service Transportation—One Study, Two Locations, and Three What-If Coordination Scenarios.” Pre- sented at the 93rd Annual Meeting of the Transportation Research Board, Washington, D.C., January 2014. North Carolina Department of Health and Human Services. North Carolina Improperly Claimed Federal Reimburse- ment for Some Medicaid Nonemergency Transportation Services, Report A-04-15-04037. November 2016. https://oig.hhs.gov/oas/reports/region4/41504037.pdf. Accessed December 11, 2017.

A-30 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination Garrity, R. An Overview of North Carolina’s Community Transportation System: An Examination of the Effectiveness of the Organizational Model in Today’s NEMT Brokerage Environment. NCDOT, RLS & Asso- ciates, Inc. May 2015. https://www.nctransit.org/wp-content/uploads/2015/10/An-Overview-of-North- Carolinas-Community-Transportation-System-Full-Report.pdf. Accessed December 12, 2017. North Carolina Department of Health and Human Services. Non-Emergency Medical Transportation Services Management Report. Joint Legislative Oversight Committee on Health and Human Services and Joint Legisla- tive Oversight Committee on Transportation, October 15, 2012. North Carolina Department of Health and Human Services. North Carolina’s Proposed Program Design for Medicaid Managed Care. August 2017. https://files.nc.gov/ncdhhs/documents/files/MedicaidManagedCare_ ProposedProgramDesign_REVFINAL_20170808.pdf. Accessed December 11, 2017. North Carolina Division of Social Services, North Carolina Department of Health and Human Services. North Carolina State Plan under Title XIX of the Social Security Act Medical Assistance Program. May 22, 1980. Revised March 1987. https://files.nc.gov/ncdma/documents/files/NC_State_Plan_For_Medical_Assistance_ Programs_1_0.pdf. Accessed December 12, 2017. United States General Accounting Office. Hindrances to Coordinating Transportation of People Participating in Federally Funded Grant Programs: Volume I, GAO/RCED-77-119. October 17, 1977. http://www.gao.gov/ assets/130/120385.pdf. Accessed December 12, 2017. Oregon: Change to Managed Care Organizations with Carved-In NEMT Key Data Key Data Demographic Features • State Population (2015) 3,939,233 • Urban Population (2010) 62% • Rural Population (2010) 38% • Population at or below poverty line (2015) 15% NEMT Oversight Oregon Health Authority Medicaid & NEMT Enrollment Data • Medicaid & CHIP Enrollment (December 2013) 626,356 • Medicaid & CHIP Enrollment (December 2016) 966,178 • Percent Increase 2013–2016 54.3% • Medicaid Enrollees that Used NEMT (2013) N/A NEMT Model Managed Care (Coordinated Care Organizations) Operating Authority Section 1115 Demonstration Waiver Medicaid Match Medical service (64.5%) Expanded Medicaid under Affordable Care Act Yes Medicaid Enrollees in a Managed Care Program 93% • NEMT under Managed Care Managed Care with carved-in NEMT NEMT Expenses & Activity Data • Annual Medicaid Expenses (2015) $8,066,724,366 • Estimate Annual NEMT Expenses (2013) $40,500,000 • Estimate Annual NEMT Passenger Trips (2013) 1,557,228 • % of NEMT Trips on Public Transit (2013) 22% • NEMT Expenses per Trip Statewide (2013) $26 NEMT Description The Oregon Health Authority (OHA) is the state Medicaid agency. Previously, the Medicaid program was the responsibility of the Oregon Department of Human Services (ODHS). In 2011, the Oregon Legislature transferred many of the health-related functions to the newly created OHA. The Oregon Health Plan (OHP) is the state Medicaid program. NEMT as part of coordinated care. Oregon began transforming the OHP to a coordi- nated care model in 2012, operated by 16 regional, community-based MCOs. Coordinated care

State Case Study Summaries A-31 involves consolidation of health-supportive services under the umbrella of a coordinated care organization (CCO). Between 2012 and January 1, 2014, OHA certified 16 CCOs to provide coordinated care in all counties around the state. In some counties, two or more CCOs have over- lapping service areas. Each CCO is responsible for NEMT for its members. OHA is responsible for NEMT for OHP members that are not enrolled in a CCO. Each CCO and OHA operates NEMT through trans- portation brokers. The type of broker (i.e., public agency, private company, nonprofit agency) and the approach to NEMT within OHA guidelines differ by CCO. Effect of ACA. In 2014, Oregon expanded Medicaid as allowed under the federal ACA. Medicaid enrollment in OHP increased 54.3 percent from 626,400 in September 2013 pre-ACA to 966,200 in December 2016 post-ACA. Almost 90 percent of the eligible Medicaid population is enrolled in a CCO. Many not enrolled in a CCO have exemptions such as dual enrollment in Medicare or other third-party coverage. Since Medicaid expansion took effect, Oregon’s uninsured rate dropped from 17 percent to 5 percent. After ACA, 95 percent of Oregonians have health coverage. The case study for Oregon focuses on NEMT in three areas: Tri-County/Portland metro- politan area, southern Oregon (seven counties), and Lane County. Before the case study discussion, the following two sections describe coordinated care in Oregon and the history of NEMT brokers in Oregon. Coordinated Care in Oregon The vision of the coordinated care model is to make CCOs accountable for attending to the global health needs of OHP members. The goals for OHP under the coordinated care model are known as the Triple Aim: • Better Health—increase access to health care for low-income Oregonians, • Better Care—improve the health of Oregonians by improving quality of care and access to preventive services, and • Lower Costs—contain the cost of health care. How Coordinated Care Organizations Work A CCO is a network of all types of health care providers (physical health care, substance abuse and mental health care, and dental care providers) who have agreed to work together in their local communities to serve people who receive health care coverage under the OHP. CCOs are focused on prevention and helping people manage chronic conditions, like diabetes. This is expected to help reduce unnecessary emergency room visits and give people support to be healthy. The state government has identified four key features of CCOs. They must (a) be locally gov- erned to address community needs; (b) operate all services within a global budget with a fixed rate of growth; (c) be accountable for health outcomes of the population they serve; and (d) be governed by a partnership of health care providers, community members, and stakeholders in the health systems that have financial responsibility and risk. How Coordinated Care Is Different Before CCOs, the Medicaid health care program separated physical, behavioral, and other types of care. According to OHA, that made things more difficult for patients and providers and more expensive for the state. CCOs have the flexibility to support new models of care that are intended to be team-focused. CCOs are able to better coordinate services and focus on prevention, chronic illness management,

A-32 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination and person-centered care. CCOs have flexibility within their budgets to provide services with the goal of meeting the Triple Aim of better health, better care, and lower costs for the population they serve. OHA provides each CCO one budget (global budget) that grows at a fixed rate to provide mental, physical, dental care, and related services, such as NEMT. CCOs are accountable for health outcomes of the population they serve within the global budget. OHA pays each CCO a monthly capitation payment to manage and deliver health care for the CCO’s members. By November 2015, OHA included NEMT in the global budget of each of the 16 CCOs. NEMT Brokers in Oregon In the 1990s, Oregon introduced the use of public agencies as regional community brokers to provide NEMT. The concept was borrowed from Washington State, where regional NEMT brokers were nonprofit agencies rather than public agencies. The first public agency NEMT broker in Oregon was developed by the Tri-County Metropolitan Transportation District of Oregon (TriMet) for the three-counties that comprise the Portland metropolitan area (Clackamas, Multnomah, and Washington Counties). TriMet is the RTA that provides bus, light rail, com- muter rail, and ADA paratransit services in the Portland region. Early Collaboration. TriMet and ODHS began collaboration in 1994 to coordinate ADA paratransit and Medicaid NEMT services. In the beginning, TriMet ran parallel service, separat- ing ADA paratransit and NEMT trips. Based on the initial demonstration, TriMet and ODHS concluded that coordination of the two programs for shared rides was possible and would result in cost savings. The Oregon Department of Transportation (ODOT) joined the collaboration to support using the expertise of transit to provide NEMT at a lower cost. ODOT provided funds for non-medical trips by Medicaid beneficiaries who were also eligible for other transportation programs. For the next 20 years, TriMet worked in collaboration with ODHS and ODOT to coordinate ADA paratransit, NEMT, and other human services transportation programs. TriMet provided the call center and brokered transportation service to over 45 for-profit and not-for-profit trans- portation providers. Regional Community Brokers. After the TriMet pilot project, ODOT and ODHS cooper- ated in the expansion of the broker model statewide beginning in 2001, eventually establishing eight regional community brokers. In addition to TriMet, other agencies that established com- munity brokers were public transit agencies and councils of governments. Each public agency established the broker as an independent business unit with a cost accounting system separate from the transit agency. Table A-8 lists the regional community brokers and the corresponding public agency sponsor. ODHS negotiated intergovernmental agreements for NEMT with the regional community brokers, providing consistency across contracts and standardizing NEMT policies and proce- dures statewide. ODOT provided funds for TriMet to develop the Oregon Brokerage Scheduling System, software for NEMT that was unique to Oregon. Five other regional community brokers adopted the software by 2008. TriMet also developed travel training and a volunteer driver pro- gram in cooperation with Ride Connection, a private nonprofit organization in Portland that advocates for transportation for vulnerable populations (older adults, people with disabilities, low income). The regional community brokers contracted with private and nonprofit transportation pro- viders to deliver NEMT trips. The brokers scheduled shared rides with other human services and public transportation riders to improve cost effectiveness.

State Case Study Summaries A-33 CCO Brokers. Statewide, 12 CCO NEMT brokers were active as of November 2015, as listed in Table A-9. Seven of eight regional community brokers continue to serve as the broker for one or more CCOs. TriMet no longer serves as an NEMT broker in any capacity. Case Study Examples for Oregon This case study for Oregon addresses how NEMT is provided under the coordinated care model for Medicaid in three areas: Tri-County/Portland metropolitan area, southern Oregon, and Lane County. The CCOs implemented NEMT through a different arrangement in each area. Regional Community Broker Public Agency Sponsor Cascade East Ride Center Central Oregon Intergovernmental Council Mid-Columbia Medical Transportation Mid-Columbia Council of Governments NW Ride Center Sunset Empire Transportation District Ride Line Cascades West Council of Governments RideSource Lane Transit District TransLink Rogue Valley Transportation District TriMet Medical Transportation Program TriMet TripLink Salem-Keizer Transit Source: ODHS, 2011. Table A-8. Oregon regional community brokers by public agency sponsor, 2011. CCO NEMT Broker CCO Bay Cities Ambulance For Umpqua Health Alliance members only Cascade East Ride Center* Central Oregon Intergovernmental Council PacificSource Community Solutions CCO, Central Oregon Region Cascades West Ride Line* Cascades West Council of Governments Intercommunity Health Network CCO ReadyRide For AllCare Health Plan members only Ride To Care Access2Care, American Medical Response For Health Share of Oregon and FamilyCare, Inc. members only RideCare* (formerly NW Ride Center) Sunset Empire Transportation District Columbia Pacific CCO RideSource* Lane Transit District Trillium Community Health Plan TransLink* Rogue Valley Transportation District Cascade Health Alliance Jackson Care Connect Primary Health Care of Josephine County, LLC Western Oregon Advanced Health, LLC For OHP FFS members in Lake County Transportation Network* (formerly Mid-Columbia Medical Transportation) Mid-Columbia Council of Governments Eastern Oregon CCO PacificSource Community Solutions CCO, Columbia Gorge Region Tri-County MedLink First Transit, Inc. For OHP FFS members only in Clackamas, Multnomah, Washington, and Yamhill Counties TripLink* Salem-Keizer Transit Willamette Valley Community Health, LLC WellRide First Transit, Inc. For Yamhill CCO members only *Public agency brokers provide NEMT for OHP FFS members in the counties served unless otherwise noted (Lake County). Source: OHA, 2015. Table A-9. Oregon CCO NEMT brokers by CCO, 2015.

A-34 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination The case study information is based on interviews with stakeholders from OHA, ODOT, CCOs, NEMT brokers, transportation providers, public transit agencies, and customer advo- cates. The purpose of the interviews was to hear different perspectives and learn from diverse experiences. Tri-County/Portland Metropolitan Area The Tri-County/Portland metropolitan area includes Clackamas, Multnomah, and Washington Counties. Portland, the largest city in Oregon, is located in the tri-county area. The estimated 2015 population of the area was 1.7 million, about 44 percent of the state’s population. Approxi- mately 360,000 individuals (21 percent of the tri-county population) are enrolled in the OHP. With the implementation of coordinated care, OHA certified two CCO for the tri-county area. The two CCOs are Health Share of Oregon (Health Share) and FamilyCare, Inc. Regional Community Broker—TriMet. Prior to the transformation of the Oregon health care system to the coordinated care model, ODHS contracted with TriMet to serve as the broker for NEMT trips. TriMet subcontracted demand-response NEMT trips to private for-profit and not-for-profit transportation providers in the tri-county area. ODHS paid for NEMT on an FFS basis. CCO NEMT Broker—Ride To Care. In 2014, Health Share and FamilyCare issued a joint request for proposals to provide NEMT broker services in the tri-county area. The CCOs received proposals from TriMet and Access2Care (at a minimum). Health Share stated the criteria for evaluating proposals included the following: • Ability to serve a medically and culturally diverse community within a large and varied geographical area covering more than 3,000 square miles, • Understanding and knowledge of Medicaid rules, procedures, and policies, • Assuring that the transportation mode is appropriate and relevant to member needs, • Responsive and works collaboratively to ensure provider concerns are addressed, and • Available to supply members with efficient and safe transport, as needed. Health Share and FamilyCare selected Access2Care, a division of American Medical Response to serve as the NEMT broker. American Medical Response is a national transportation manage- ment company, and Access2Care operates similar brokerages in other states. Health Share and FamilyCare each has a separate contract and different financial arrangements with Access2Care. Health Share and FamilyCare branded the NEMT program as Ride To Care. Ride To Care is responsible for arranging transportation to meet the CCO member’s needs. Ride To Care does not operate its own vehicles but instead subcontracts demand-response pas- senger trips to local transportation providers. The type of transportation is based on the medical condition of the CCO member at the time of the appointment. According to the Ride To Care website, “Most often, this means bus tickets/passes” (see https://www.ridetocare.healthcare/ members-riders). The broker also schedules NEMT trips by car, taxi, van, wheelchair van, or stretcher van. Ride To Care can pay gas expenses to a friend or family member who provides a ride to the CCO member. Ride To Care also works with volunteers who give rides to health care appointments. The transition to Ride To Care in January 2015 ended TriMet’s 20-year service as the NEMT broker for the tri-county area. The termination of TriMet’s role as the regional community broker impacted coordination of NEMT trips on shared rides with public transportation and resulted in fragmentation of other human services transportation programs such as Medicaid- funded non-medical rides for individuals enrolled in long-term care services. TriMet also no

State Case Study Summaries A-35 longer provided technical support for the Oregon Brokerage Scheduling System used by other brokers in Oregon. Following the transition of NEMT services to CCOs, OHA contracted with a private com- pany, First Transit, Inc., to provide broker services for the small percent of Medicaid enrollees in the OHP FFS program in Clackamas, Multnomah, Washington, and Yamhill Counties. Southern Oregon The southern Oregon area encompasses seven counties: Coos, Curry, Douglas, Jackson, Josephine, Klamath, and Lake Counties. The 2015 population is estimated as 558,000 for the seven counties. There are two urbanized areas: Medford in Jackson County and Grants Pass in Josephine County. The OHP enrollment for the seven counties is estimated as 185,600, or 33 percent of the population. Regional Community Broker—TransLink. From 2001 through 2014, the regional com- munity broker in southern Oregon was TransLink, a service of the Rogue Valley Transportation District (RVTD). RVTD is the public transportation provider for the Rogue Valley, serving the cities of Medford, Ashland, Central Point, Talent, Phoenix, White City, and Jacksonville in Jackson County. Working with ODOT and ODHS, RVTD created TransLink as the regional community broker in southern Oregon in 2001. Prior to the change in the OHP to the coordinated care model, ODHS contracted with TransLink to serve as the broker for NEMT trips in the seven-county region. TransLink provided over 400,000 NEMT trips in the year October 1, 2013, through September 30, 2014, before the transition to CCO NEMT in southern Oregon. TransLink reported that about 14 percent of NEMT trips were provided on public transportation fixed routes. TransLink subcontracted demand-response NEMT trips to RVTD and about 38 subcontractors. CCO NEMT Brokers in Southern Oregon. Since transformation of the OHP to the coor- dinated care model, eight CCOs serve OHP enrollees in the seven counties in southern Oregon. Some of the CCOs have overlapping service areas in the same county. The eight CCOs contract with five different NEMT brokers. Table A-10 identifies the CCOs and CCO NEMT brokers by county. County CCO CCO NEMT Broker Coos Western Oregon Advanced Health TransLink Curry Western Oregon Advanced Health AllCare Health Plan TransLink ReadyRide Douglas Umpqua Health Alliance AllCare Health Plan (two zip codes) Bay Cities Ambulance ReadyRide Jackson Jackson CareConnect AllCare Health Plan Primary Health of Josephine County TransLink ReadyRide TransLink Josephine Primary Health of Josephine County AllCare Health Plan TransLink ReadyRide Klamath Cascade Health Alliance PacificSource Community Solutions CCO, Central Oregon Region (specific zip codes) TransLink Cascade East Ride Center Lake Eastern Oregon CCO Transportation Network All Counties OHP FFS members TransLink Source: OHA, 2015. Table A-10. Southern Oregon CCOs and CCO NEMT brokers by county, 2015.

A-36 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination Lane County The population of Lane County, Oregon, is estimated as 362,900 in 2015. Eugene is the urban- ized area in Lane County with a population about 260,000. The OHP enrollment for Lane County is estimated as 103,800 or 28.6 percent of the population. The CCO in Lane County is Trillium Community Health Plan. Trillium is a wholly owned subsidiary of Centene Corporation, a multinational health care enterprise. Regional Community Broker—RideSource. Lane Transit District (LTD) is the public transit agency that provides bus, bus rapid transit, and ADA paratransit service in the Eugene urbanized area and provides limited service to the rural areas of Lane County. Working with ODOT and ODHS, LTD created the RideSource call center. LTD operated the call center to broker Medicaid, ADA paratransit, and other human services demand-response transportation. RideSource was one of the eight regional community brokers in Oregon. RideSource offered a comprehensive approach to coordinating local transportation services: • Coordination and cost sharing with public transportation and other human services trans- portation programs, • Transportation needs assessment to determine the right kind of transportation service through a personal in-the-home interview by trained transportation coordinators from Senior and Disabled Services and Alternative Work Concepts, • Interagency collaboration with ODHS case managers, and • Sophisticated applications for technology and software. RideSource operates the one-call center for different transportation programs and sub- contracts demand-response transportation to local public and private providers. RideSource brokered NEMT for individuals eligible under the OHP from 2008 through June 2013. CCO NEMT Broker—RideSource. When LTD published the 2013 Update for the Lane Coordinated Public Transit Human Services Transportation Plan, the transit district did not know if RideSource would continue as the broker for NEMT transportation when the local CCO took over by July 1, 2013. In the updated plan, LTD explained if the RideSource call center did not continue, the five-year effort to coordinate transportation services for people who are eligible for and use multiple transportation programs would be lost. Trillium did select RideSource as the NEMT transportation broker. After a challenging transition period, LTD reports a good relationship with the CCO. Trillium and RideSource worked through the transition by learning each other’s business. LTD worked to understand the Triple Aim objectives, and Trillium worked to understand the challenges of providing NEMT. LTD collaborated with Trillium to develop a compliance plan and a cost allocation model for Medicaid NEMT services. LTD says the key is that the CCO and transportation broker both want the same thing—good customer care. In the CCO model, RideSource works with caseworkers and mental health workers to assure continuity of care. The goal is prevention of unnecessary emergency room visits. LTD provides both medical and non-medical transportation to improve physical and mental health. Table A-11 provides data for NEMT, ADA paratransit, and other human services transporta- tion trips from July 2011 through June 2015 and compares trips prior to CCOs and Medicaid expansion (July 2011 through June 2012) to post-CCO and Medicaid expansion (July 2014 through June 2015). Table A-12 shows that RideSource has increased the assignment of passenger trips to fixed-route and contracted services to serve the expanded NEMT and other human services transportation

State Case Study Summaries A-37 demand. RideSource also now provides mileage reimbursement to CCO members. Table A-12 compares trips prior to CCOs and Medicaid expansion (July 2011 through June 2012) to post- CCO and Medicaid expansion (July 2014 through June 2015). Effects of NEMT Change to Managed Care In the case study research, assessments of NEMT as a service of coordinated care were obtained from interviews with a variety of key stakeholders in Oregon, including representatives from OHA, ODOT, CCOs, NEMT brokers, transportation providers, public transit agencies, and customer advocates. The federally required annual external quality review of managed care for 2016 is also referenced. Access to Medicaid Services Oregon implemented CCOs following CMS approval on July 5, 2012, of the transformation of the health plan in a Section 1115 Medicaid Demonstration waiver. The waiver was renewed on January 12, 2017, and is currently approved through June 30, 2022. Currently, 16 CCOs manage physical, behavioral, and dental health services for OHP members across the state. Key Elements of Oregon’s Health System Transformation. CCOs are held accountable for outcomes that result in better health and more sustainable costs. To provide status updates on the state’s progress toward the Triple Aim, OHA publishes regular reports showing quality and Community Broker CCO NEMT Broker % Change July 2011 July 2012 July 2013 July 2014 2011–12 Program June 2012 June 2013 June 2014 June 2015 to 2014–15 NEMT 147,936 158,778 201,044 306,424 107% • OHP FFS 147,936 158,778 5,937 9,550 • Trillium CCO — — 195,107 296,874 ADA Paratransit 86,916 81,313 77,351 78,839 -9% Other—Human Service 59,493 73,540 85,683 97,346 64% Total Passenger Trips 294,345 313,631 364,078 482,609 64% Source: LTD, 2015. Table A-11. Oregon RideSource passenger trips by program, 2011–2012 to 2014–2015. Community Broker CCO NEMT Broker % Change July 2011 July 2012 July 2013 July 2014 2011–12 Provider June 2012 June 2013 June 2014 June 2015 to 2014–15 LTD Demand Response 145,811 150,521 152,043 159,088 9% LTD Fixed Route 32,396 34,195 29,315 70,457 117% Contracted Providers 116,138 128,915 155,536 208,839 80% Mileage Reimbursement — — 27,184 44,225 100% Total Passenger Trips 294,345 313,631 364,078 482,609 64% Source: LTD, 2015. Table A-12. Oregon RideSource passenger trips by provider, 2011–2012 to 2014–2015.

A-38 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination access data, financial data, and progress toward reaching benchmarks. Key elements of Oregon’s health system transformation include: • Using best practices to manage and coordinate care. The model is built on the use of evidence-based best practices to manage and coordinate care. This is expected to produce better care and improved outcomes, including a positive patient experience and lower costs. • Shared responsibility for health. Providers and consumers share responsibility and decision making for care, while coming to joint agreements on how the individual wants to improve or maintain positive health behaviors. • Transparency in price and quality. Information about the price of services is publicly avail- able. Information on plan performance including quality, patient experience, and access to medical services is publicly posted. • Measuring performance. Measuring performance consistently across health systems improves accountability. Oregon’s CCOs are held accountable for 33 quality metrics, which are pub- licly available and updated regularly. These metrics do not include specifics about NEMT performance. • Paying for outcomes and health. Oregon’s CCOs receive incentive payments for the quality of care they provide. Of the 33 quality and access metrics, CCOs receive incentive payments for making targeted improvements or meeting benchmarks on 17 of these metrics. • A sustainable rate of growth. The target for sustainable costs is an annual health care cost growth rate not to exceed 3.4 percent. Each of these elements individually and collectively is expected to produce better health outcomes for Oregonians at sustainable costs. CCOs have flexibility under the global budget to include transportation as a means to improv- ing health outcomes. CCOs have exercised this flexibility by implementing the following: • Hired nontraditional staffing to monitor and identify issues that lead to poor health including finding stable housing and reliable transportation; • Funded nontraditional medical trips to the gym, grocery store, and other activities to prevent illness rather than treat illness; and • Implemented pilot transportation programs such as same-day/extended service and smart- phone applications to improve customer service. External Quality Review. Federal law requires states to conduct an annual external quality review of Medicaid services delivered through managed care. OHA contracts with HealthInsight Oregon to perform the annual external quality review in Oregon. The review for 2016 identified strengths and areas for improvement. Overall Strengths. The external quality review found that CCOs have been able to expand their delivery networks in response to Medicaid expansion by increasing practitioner caseloads and/or adding new clinics and providers. The CCOs have established robust care management processes. CCOs have made progress in integrating physical and behavioral health care, particu- larly through co-location strategies. Most CCOs have begun monitoring their subcontractors for compliance with managed care requirements. Areas for Improvement for NEMT. The external quality review for 2016 identified specific areas for improvement that involve NEMT: • Service integration. Overall, the CCOs have made progress in transitioning to fully integrated care delivery systems, having added NEMT services to the benefits plans during 2014–2015. However, for the majority of CCOs, member grievances in 2016 indicated significant con- cerns related to NEMT services. Members reported transportation providers not providing

State Case Study Summaries A-39 rides, arriving late for pick-up leading to late or missed appointments, and lack of communi- cation, creating barriers to receiving care. • Timeliness. Most CCOs have reduced avoidable emergency room visits, but most CCOs do not monitor the timeliness of NEMT services. • Credentialing. Many CCOs address credentialing of licensed or certified professionals but did not address other types of employees, such as NEMT drivers. Most CCOs lacked poli- cies and procedures that adequately addressed the credentialing of contracted transportation providers. • Information systems integration. Overall, the CCOs have made significant progress inte- grating required services and associated claims/encounter data into the information systems. Some CCOs have integrated NEMT service data and health services encounter data, while other CCOs continue to work toward that goal. The external quality review found specific NEMT brokers had not submitted required encounter data, or the CCO had not verified the encounters. OHA and the CCOs have not developed a statewide performance measurement system specifically for NEMT. OHA performance reports do not include NEMT metrics. Coordination with Human Services Transportation For those CCOs that continued to work with the regional community broker, the support for coordination with human services transportation continues. Transportation coordination for multiple programs is more difficult if the regional community broker is no longer the NEMT broker for all CCOs in a region, or is no longer involved as an NEMT broker. Lane County. In Lane County, the CCO elected to continue contracting with the established regional community broker (RideSource) that is a service of the public transit agency, LTD. Therefore, interruption in the coordinated transportation system was minimal. The benefits of the transit agency continuing as the NEMT broker include allowing customers to continue to have a one-call system for scheduling all types of trips, including NEMT. Customers can trip chain (i.e., take connected trips for multiple purposes). An advantage of a transit agency serving as a broker is the ability to pool funds from a variety of sources to serve diverse customer trip needs, to leverage federal transit grants, and to coordinate transportation services in shared rides for improved cost effectiveness. Total passenger trips brokered by RideSource increased 64 percent after implementation of CCOs and Medicaid expansion (see Table A-11). Passenger trips funded by human services pro- grams increased 64 percent. NEMT passenger trips increased 107 percent, and ADA paratransit trips decreased 9 percent. Southern Oregon. In southern Oregon, the multiple CCOs and introduction of new trans- portation brokers can be confusing to the customer. The CCOs and transportation providers in southern Oregon reported challenges during the transition period and continue to work through transportation issues. Because not all CCOs continued with the established regional community broker (TransLink), there is not a central one-call provider throughout the region. Because some CCOs serve only specific areas, Medicaid beneficiaries may find it difficult to identify what NEMT broker to contact because of overlaps in service area. If the health care trip is not handled by the community broker, then the Medicaid customer does not have the opportunity to schedule non-medical-related trips at the same time. The benefit of the coordinated care model is the flexibility of some CCOs to fund trans- portation services such as same-day/late night service, extended call center hours, and soft- ware enhancements to electronically bill and collect encounter data while protecting personal

A-40 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination information under privacy provisions of the Health Insurance Portability and Accountability Act. CCO relationships with medical providers have also helped to schedule more efficiently medical trips to dialysis centers and substance abuse treatment clinics. Tri-County/Portland Metropolitan Area. In the Tri-County/Portland metropolitan area, TriMet had served as the regional community broker for 20 years. With the transition to the CCO model and a new NEMT broker, TriMet is no longer the regional community broker. From the perspective of OHA, the move to coordinated care has been successful in meeting CCO performance incentives and in providing trips to health care appointments. From a transporta- tion coordination perspective, the benefit of TriMet as the broker for coordinated transportation services and non-Medicaid funding is lost. Coordination with Public Transportation Similar to human services transportation, the effects of the change to CCO responsibility for NEMT on public transportation depend on the type of broker the CCO chooses. Lane County. In Lane County, RideSource is a service of the public transit agency, LTD. As the NEMT broker, RideSource assigns appropriate trips to LTD demand response, LTD fixed route, subcontract transportation provider, or provided mileage reimbursement. Total passenger trips brokered by RideSource increased 64 percent after implementation of CCOs and Medicaid expansion (see Table A-12). Passenger trips on LTD fixed route increased 117 percent, and passenger trips assigned to LTD demand response increased 9 percent. The trips subcontracted to transportation providers increased 80 percent. RideSource also began providing mileage reimbursement for personal transportation. Southern Oregon. Since transformation of the OHP to the coordinated care model, eight CCOs serve OHP enrollees in the seven counties in southern Oregon. The eight CCOs contract with five different NEMT brokers. The effect on public transportation depends on the broker. TransLink continues as the NEMT broker for four CCO (Primary Health of Josephine County, Jackson CareConnect, Cascade Health Alliance, and Western Oregon Advanced Health). TransLink is a service of RVTD, the public transit agency for the Rogue Valley. RVTD staff stated that there has been little impact on ADA paratransit in terms of passenger trips provided since the change to the CCO model. The percent of Medicaid trips provided on fixed route is about the same—14 percent pre-CCO to 13 percent post-CCO. Now that TransLink no longer serves as the community broker for the seven-county region, there has been an esti- mated 21 percent decrease in NEMT trips and a 7 percent decrease in cost. Cost did not decrease at the same rate as trips because TransLink is no longer providing the lower cost, shorter distance trips in Josephine and Jackson Counties. Other public or private brokers may subcontract NEMT service to a public transit agency. For example, ReadyRide subcontracts NEMT trips on Josephine Community Transit, the local public transit provider in Josephine County. Additional data are not available to evaluate the impact of the change on public transporta- tion. OHA issues performance reports for 33 quality metrics, which are publicly available and updated regularly. These metrics do not include information about NEMT performance to evaluate the effects of the change to CCO responsibility for NEMT on public transportation. Tri-County/Portland Metropolitan Area. The biggest impact of the transformation of Medicaid to the coordinated care model on public transportation is in the tri-county area that

State Case Study Summaries A-41 includes Portland. TriMet worked in collaboration with ODHS and ODOT to coordinate public transit ADA paratransit and NEMT beginning in 1994. The transition to the Ride To Care broker in January 2015 ended TriMet’s 20-year service as the NEMT broker for the tri-county area. The termination of TriMet’s role as the regional com- munity broker impacted coordination of NEMT trips on shared rides with public transportation. TriMet’s representative stated that TriMet has not experienced noticeable impacts to ADA paratransit (LIFT) ridership or applications that could be traced to client shifting by the current NEMT broker. TriMet’s weekday LIFT ADA ridership growth of 1.6 percent (for the fiscal year following the transition) is in line with the agency’s projections and does not appear to have been affected by the move of NEMT services to a different broker. The one operational impact TriMet has noticed after the transition of NEMT to Ride To Care is reduced accessible taxi availability. TriMet contracts with a local taxi company to provide taxi back-up to supplement the LIFT trips. After the new NEMT broker began in January 2015, TriMet noticed more competition for accessible vans available from the taxi company. Ride To Care purchases some LIFT rides, but the majority of purchases are for fixed-route passes and tickets. In December 2015/January 2016, Ride To Care purchased approximately 5,000 passes and 800 tickets. Summary of the Oregon Case Study Oregon has transformed the OHP to a coordinated care model. The goals for the OHP under the coordinated care model 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 CCO. Coordinated care is now delivered through 16 CCOs operating in all counties around the state. Each CCO is responsible for NEMT for its members. Statewide, 12 CCO NEMT brokers provide the service to the 16 CCOs. The case study focused on the change to NEMT under the coordinated care model in three areas: Tri-County/Portland metropolitan area, southern Oregon (seven counties), and Lane County. Following is a summary of effects: • Access to Medicaid services: – Overall, the CCOs have made progress in transitioning to fully integrated care delivery systems, having added NEMT services to the benefits plans during 2014–2015. Most CCOs have reduced avoidable emergency room visits. – Some CCOs have integrated NEMT service data and health services encounter data into the information systems, while other CCOs continue to work toward that goal. – OHA and the CCOs have not developed a statewide performance measurement system specifically for NEMT. OHA performance reports do not include NEMT metrics. Without these data, OHA cannot assess the contributions of NEMT to the Triple Aim. • Coordination with human services transportation: – For those CCOs that continued work with the regional community broker, coordination with human services transportation continues. Transportation coordination for multiple programs is more difficult if the regional community broker is no longer the NEMT broker for all CCOs in a region. � In Lane County, the CCO elected to continue contracting with the established regional community broker (RideSource) that is a service of the public transit agency, LTD. Therefore, interruption in the coordinated transportation system was minimal.

A-42 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination � In southern Oregon, the multiple CCOs and introduction of new NEMT brokers create challenges for coordination. Because not all CCOs elected to continue with the established regional community broker (TransLink), there is not a central one-call provider through- out the region. If the reservation for a health care trip is not handled by TransLink, then the Medicaid customer does not have the opportunity to schedule non-NEMT related trips at the same time. � In the Tri-County/Portland metropolitan area, TriMet is no longer the regional com- munity broker with the transition to the CCO model and a new NEMT broker. From the perspective of OHA, the move to coordinated care has been successful in meeting CCO performance incentives and in providing trips to health care appointments. From a transportation coordination perspective, the change limited coordination of trans- portation programs. • Coordination with public transportation: – Similar to human services transportation, the effects of the change to CCO responsibility for NEMT on public transportation depend on the type of broker the CCO chooses. � RideSource. As the NEMT broker in Lane County, RideSource assigns appropriate trips to LTD fixed route or demand response. Under the CCO model, passenger trips assigned to LTD fixed route increased 117 percent. � TransLink. In southern Oregon, TransLink continues as the NEMT broker for four CCOs. TransLink is a service of RVTD, the public transit agency for the Rogue Valley. RVTD staff stated that there has been little impact on public transportation since the change to the CCO model. � TriMet no longer serves as an NEMT broker in any capacity. The two CCOs in the tri- county area selected a private NEMT broker, Ride To Care. TriMet’s representative stated that TriMet has not experienced noticeable impacts to ADA paratransit ridership or applications that could be traced to client shifting by the current NEMT broker. Ride To Care purchases a few LIFT rides, but the majority of purchases are for fixed-route passes and tickets. References for the Oregon Case Study Community Transportation Association of America. “Oregon Transit Trail.” Community Transportation Digital. Summer, 2015. http://web1.ctaa.org/webmodules/webarticles/articlefiles/Summer15.pdf. Accessed April 1, 2017. Garrity, R., and McGehee, K. TCRP Research Results Digest 109: Impact of the Affordable Care Act on Non-Emergency Medical Transportation (NEMT): Assessment for Transit Agencies. 2014. http://www.trb.org/Publications/ Blurbs/171539.aspx. Accessed April 1, 2017. Health Share of Oregon. “Press Release.” June 2015. http://www.healthshareoregon.org/press-releases/health- share-of-oregon-meets-100-of-oregon-health-authority-2014-incentive-measures-for-coordinated-. Accessed December 17, 2017. Hogue, K. “Medicaid Non-emergency Transportation Stumbles During 2015 Transition.” The Lund Report. October 2015. https://www.thelundreport.org/content/medicaid-non-emergency-transportation-stumbles- during-2015-transition. Accessed December 12, 2017. Oregon Health Authority. Oregon Health Policy Board. Oregon Health Policy Board Coordinated Care Organizations, September 2015. http://www.oregon.gov/oha/ohpb/pages/health-reform/ccos.aspx. Accessed April 1, 2017. Oregon Health Authority. Technical Specifications and Guidance for CCO Incentive Measures. September 14, 2005. http://www.oregon.gov/oha/analytics/Pages/CCO-Baseline-Data.aspx. Accessed April 1, 2017. Oregon Health Authority, Health Systems Division. Non-Emergent Transportation Brokerages for Oregon Health Plan members. November 1, 2015. http://www.oregon.gov/oha/HSD/OHP/Tools/Transportation%20Brokerage %20Map.pdf. Accessed December 11, 2017. Oregon Health Authority, Office of Health Analytics. Coordinated Care, Managed Care and Fee for Service Enroll ment. August 2015. http://www.oregon.gov/oha/healthplan/DataReportsDocs/September%202015 %20Coordinated%20Care%20Service%20Delivery%20by%20County.pdf. Accessed April 1, 2017.

State Case Study Summaries A-43 Owens, J., Marshall, N., Mayfield, D., Landsman, C., and Larson, C. Transportation-Human Services Coordina- tion Study. Association of Oregon Counties, ODOT, Public Transit Division, and Oregon Department of Human Services, 2013. http://www.oregon.gov/ODOT/RPTD/RPTD%20Document%20Library/AOC%20 Transportation-Human-Services-Coord-Study.pdf. Accessed December 12, 2017. Steranka, M., and Raphael, D. The Coordination Challenge: State Agency Transportation Coordination Project, State of Oregon. ODOT, Public Transit Division, 2000. https://digital.osl.state.or.us/islandora/object/ osl%3A8750/datastream/OBJ/view. Accessed December 12, 2017. Tang, D. X. Oregon Health Plan Medicaid Demonstration. Office of Health Analytics, Oregon Health Authority, 2014. http://library.state.or.us/repository/2011/201102011349262/Jul2014.pdf. Accessed April 1, 2017. Pennsylvania: In-House Management with Coordinated Transportation and Regional Broker (For Profit) in Philadelphia County Key Data Key Data Demographic Features • State Population (2015) 12,779,559 • Urban Population (2010) 71% • Rural Population (2010) 29% • Population at or below poverty line (2015) 13% NEMT Oversight Department of Human Services, formerly the Department of Public Welfare Medicaid & NEMT Enrollment Data • Medicaid & CHIP Enrollment (December 2013) 2,386,046 • Medicaid & CHIP Enrollment (December 2016) 2,918,260 • Percent Increase 2013–2016 22% • Medicaid Enrollees that Used NEMT (2013) 7% NEMT Model (1) Regional Broker in Philadelphia County, (2) County-Based In-House Management in remaining counties Operating Authority NEMT Assurance under the State Medicaid Plan 1902(a)(70) State Plan Amendment Medicaid Match Medicaid Service (52%) Expanded Medicaid under Affordable Care Act Yes Medicaid Enrollees in a Managed Care Program 70% • NEMT under Managed Care NEMT carved out of Managed Care NEMT Expenses & Activity Data • Annual Medicaid Expenses (2015) $23,394,254,112 • Estimate Annual NEMT Expenses (2014) $148,600,000 • NEMT as % of Medicaid Expenses <1% • Estimate Annual NEMT Passenger Trips (2014) 11,468,394 • % of NEMT Trips on Public Transit (2014) 41% • NEMT Expenses per Trip Statewide (2014) $13 NEMT Description In Pennsylvania, NEMT is called the Medical Assistance Transportation Program (MATP). MATP provides transportation to medical appointments for Medical Assistance (Medicaid) recipients. The state Medicaid agency, the Department of Human Services (PA-DHS), currently uses two approaches for delivery of MATP services: • Full-risk broker. In the most densely populated county in the state, Philadelphia County, MATP is provided by a full-risk private broker with capitated payments from PA-DHS. • Coordinator for transportation services. In the remaining 66 counties in the state, PA-DHS provides MATP funding through a combination of FFS and block grants to the county MATP coordinator in each county. The MATP coordinator is the county or, in a few cases, the pub- lic transportation authority. The county MATP coordinator then arranges transportation

A-44 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination for eligible Medicaid beneficiaries to approved medical services using fixed-route public transportation, mileage reimbursement, or local transportation providers for shared-ride transportation. Each county is reimbursed for costs either directly or indirectly related to MATP transporta- tion. 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. Responsibilities of the county MATP coordinators are: • Verifying individual eligibility for Medical Assistance and assessing transportation needs, including determination of the least expensive, most effective mode of transportation; • Informing and educating Medical Assistance recipients about MATP services; • Operating the MATP telephone line or call center; • Authorizing transportation services, scheduling, and dispatching MATP trips; • Recruiting, maintaining, and monitoring an adequate transportation provider network; • Managing the MATP to ensure cost-effective, appropriate transportation services; • Maximizing the cost effectiveness and quality of services through coordination with local programs and stakeholders; and • Ensuring quality of services through a complaint tracking system. The county of residence is responsible for providing the type of MATP transportation that is the least expensive while still meeting the individual’s needs. Counties currently use the following three modes to provide MATP transportation services: • Fixed-route public transportation. Where public transit is available, county MATP coordi- nators provide tokens, passes, scrip, or reimbursement to eligible Medicaid beneficiaries to cover the fare for public transit services. • Mileage reimbursement. Where appropriate, the county MATP may reimburse Medicaid beneficiaries who have access to private vehicles but not the means to pay for the cost of trans- portation. The reimbursement is at a specified rate per mile plus parking and tolls. • Demand responsive (paratransit). Where fixed-route public transit is not available or is not appropriate for the rider, counties provide shared-ride demand-response rides on vans, lift- equipped vans, and taxis. Pennsylvania has not made substantial changes in MATP service delivery in recent years, except to encourage regional coordination of services. The case study for Pennsylvania includes three MATP examples: the full-risk private broker in Philadelphia County (Philadelphia); the Allegheny County Department of Human Services (Allegheny County DHS) using the ADA paratransit provider (ACCESS) for the Port of Authority of Allegheny County (Pittsburgh); and the regional shared-ride coordinator in the south-central counties of York, Adams, Northumberland, and Cumberland. Before the case study examples, the following section describes human services transportation in Pennsylvania. Human Services Transportation in Pennsylvania 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 populations. Many federal, state, and local public agencies, nonprofit organizations, and private entities provide or fund transportation services that are specifically for people who face mobility challenges, including

State Case Study Summaries A-45 seniors, individuals with disabilities, and people with lower incomes who cannot afford private transportation. Often, these individuals live in rural communities with limited or no public transportation, further restricting options for mobility. The Pennsylvania Department of Transportation (PennDOT) Shared-Ride Program for Senior Citizens and Rural Transportation for Persons with Disabilities Program are examples of human services transportation for the public. PennDOT makes fare subsidies available for eligible indi- viduals, and many human services agencies purchase service from the coordinated system. The Commonwealth of Pennsylvania began funding shared-ride transportation in 1980. Shared-ride transportation is available in all 67 counties in Pennsylvania and is locally managed and operated. The PA-DHS MATP program is an example of a human services transportation program for Medicaid beneficiaries who do not have transportation to necessary medical services. Other human services transportation programs are the Department of Aging support for local Area Agencies on Aging to meet the transportation needs of senior citizens; PennDOT funds Welfare to Work transportation; and PA-DHS provides funding through county mental health offices to support shared-ride transportation for mental health and developmental disabilities programs. Human Services Transportation Coordination Study In 2007, the Pennsylvania General Assembly passed Act 44 directing PennDOT to evaluate human services transportation coordination. PennDOT included the Department of Public Welfare (later the Department of Human Services), the Department of Aging, and the Office of the Budget in the evaluation. The secretaries of the four agencies presented the Human Service Transportation Coordination Study: Summary Report to the governor and members of the General Assembly in July 2009. The study documented that human services transportation serves critical needs by providing access to medical care, jobs, and important social services. However, the study found that shared-ride human services transportation was threatened with escalating costs and increasing demands for more service. Findings: Human Service Transportation Coordination Study. The Human Service Trans- portation Coordination Study identified the following findings about human service transporta- tion in Pennsylvania: • Local human service transportation is unique in every county; • Each state agency independently communicates with local transportation providers, develops policies, manages services, and sets requirements for each program; • Human services programs and transportation service challenges require a high degree of skills in business management, transportation delivery, and transportation analysis for effective administration; • Transportation service should be easy to use; however, the unique attributes of each county’s human service transportation and the complexities of the various programs may make it dif- ficult for local human service agencies and consumers to understand; and • Regional service coordination offers the greatest opportunity for increased service quality and improved efficiencies with cost savings. Recommendations: Human Service Transportation Coordination Study. The state agencies involved in the Human Service Transportation Coordination Study identified four recommen- dations related to program management and service delivery: 1. Coordinated approach. The Commonwealth should move toward a coordinated approach to human service transportation management.

A-46 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination 2. Regional pilot. In partnership with local government, the Commonwealth should pilot a regional approach to human service management and service delivery. 3. Customer input. The Commonwealth and local government should conduct listening sessions with customers on the design of the coordinated program. 4. Program measurement. In partnership with local government, the Commonwealth should establish performance criteria, standards, and targets to measure efficiency, productivity, and effectiveness of human service transportation. Act 89 Transportation Funding On November 25, 2013, Act 89 was signed into law, providing $2.3 billion per year to support transportation infrastructure and services, including ports and waterways, freight and passen- ger rail, aviation, transit, and bicycle and pedestrian projects, as well as local roads and bridges, public transportation, and turnpike expansion projects. Act 89 authorizes PennDOT to develop and implement pilot projects to explore different service delivery and payment options for shared-ride human services transportation as recom- mended by the Human Service Transportation Coordination Study. Overall, Act 89 supports coordination of human services transportation, including MATP. Lottery Funding Applied to MATP Established in 1971, the Pennsylvania Lottery funds programs and services benefiting older Pennsylvanians. Lottery funds have long been used to support public transit for persons 65 years of age and older. Lottery funds pay for 85 percent of shared-ride trip fares and 100 percent of fixed-route bus fares for seniors. Registered senior citizens pay the remaining 15 percent of the general public fare for shared-ride transportation. The Commonwealth legislation was written such that lottery funds would be used after any other mutually eligible funding such as MATP funding for eligible medical trips. An audit by CMS prompted the Commonwealth to revise this practice in 2014. CMS stated that under federal statute and Medicaid regulations, Medicaid is the payer of last resort. Therefore, MATP should be charged only for trip costs that are not subsidized by other programs or covered under other available funding. If lottery funds are available for 85 percent of the shared-ride trip fare for an eligible Medicaid beneficiary who is also 65 years of age or older to travel to an approved medical service, then MATP should pay 15 percent of the cost of the trip. Effective July 1, 2014, MATP pays the approved percentage of the co-payment amount (15 percent) for Medicaid beneficiaries who are eligible to use the PennDOT Shared Ride Program for Senior Citizens to travel to an approved medical appointment. Pennsylvania lottery funds pay for the first 85 percent of the cost of the trip, or a maximum of $42.50 if the cost of the trip is over $50. Case Study Examples in Pennsylvania The case study for Pennsylvania focuses on three MATP examples: the full-risk private broker in Philadelphia County (Philadelphia); Allegheny County DHS contracting MATP to the ADA paratransit provider (ACCESS) for the Port of Authority of Allegheny County (Pittsburgh); and regional coordination in the south-central Pennsylvania counties of York, Adams, Northumberland, and Cumberland. Philadelphia County Philadelphia County is the most urbanized county in the state, and the one county where MATP is administered through a for-profit broker with capitated payment. The first broker in

State Case Study Summaries A-47 the county goes back to 1983 when Wheels, Inc., a nonprofit transportation provider, served as the MATP broker for Philadelphia County. At that time, Wheels was already coordinating paratransit services for the Southeastern Pennsylvania Transportation Authority, Philadelphia’s public transit agency. Wheels, Inc. was eventually replaced by a private broker. Philadelphia County is densely populated and fixed-route public transit (bus, trolleybus, streetcar, heavy rail, and commuter rail) is widely available. Today, while the number of MATP trips provided by the Philadelphia broker roughly equals the number provided in the rest of the state, the brokerage accounts for just over 30 percent of annual MATP expenditures, reflecting the cost effectiveness of fixed-route public transportation to transport Medicaid beneficiaries to required medical appointments. In FY 2013, over 74 percent of MATP trips in Philadelphia County were on public transit. Allegheny County The city of Pittsburgh is in Allegheny County, the second most populous county in Pennsylvania. The local Medical Assistance agency is the Allegheny County DHS. The para- transit provider for MATP trips in Allegheny County is ACCESS Transportation Systems (ACCESS), the ADA paratransit provider for the Port Authority of Allegheny County, the public transit agency for Pittsburgh and Allegheny County. ACCESS subcontracts to six different transportation providers throughout the county to provide MATP trips. As the shared-ride coordinator, ACCESS is able to coordinate MATP with human services transportation programs. Allegheny County DHS determines the most appropriate mode of travel for MATP riders. The agency partners with Traveler’s Aid, a United Way nonprofit, to distribute transit fare instruments and manage mileage reimbursement for MATP riders. In 2015, 57 percent of MATP trips were on fixed-route transit and just over 21 percent of MATP trips were made on demand- response paratransit vehicles. The remaining MATP trips were paid by mileage reimbursement. This combination of low utilization of paratransit and high utilization of fixed-route transit for MATP has helped Allegheny County maintain one of the lowest costs per passenger trip for MATP in the state ($9.73 per passenger trip in fiscal 2015). ACCESS uses a detailed cost allocation model to allocate costs equitably between sponsors. The cost allocation model helps sponsors to understand the costs of a trip and what factors influence that cost. ACCESS performs a quarterly analysis of a statistically valid sample of trips. The analysis includes factors that influence cost, such as average trip lengths, ride time and dead time, percent of wheelchair boardings, and percent of no-shows. The analysis of trips is then applied to the full costs of providing service, including labor and overhead, capital costs and materials, fuel, insurance, licensing, hiring costs, vehicle maintenance, and administrative costs. The cost allocation model used by ACCESS provides an explanation for the costs of services as well as transparency about the way money is spent. The cost allocation model calculates an average cost per passenger trip for the system, an average cost per passenger trip that is specific to a sponsor, and the marginal cost per passenger trip. ACCESS also uses the cost allocation model to demonstrate how sponsors can adopt operating policies that can lower cost. For example, operating policies that increase productivity (riders per hour) will lower the cost per passenger trip. Regional Coordination in Central Pennsylvania The 2009 Human Service Transportation Coordination Study recommended increased coordination of human services transportation, in part through the introduction of regional coordination pilots. In 2011, the governor’s Transportation Funding Advisory Commission (Commission) called for PennDOT to study the formation of regional transit agencies. The

A-48 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination counties in south-central Pennsylvania asked to examine the potential benefits of an integrated regional transportation authority providing both fixed-route and shared-ride services. Act 89 further supported the establishment of regional transit operations by providing incentives for local municipalities to pursue such regionalization. The call for increased regional coordination led to the merging of the transit authorities in York and Adams Counties to form the York Adams Transportation Authority (YATA) in 2011. The transit authority does business as rabbittransit. The regional authority continues to expand. • Soon after YATA was formed in 2011, nearby Northumberland County withdrew from involvement in human services transportation programs including MATP. PennDOT and PA-DHS contracted with YATA to be the shared-ride coordinator for MATP and other human services transportation programs in Northumberland County. • Cumberland County Commissioners appointed YATA as the shared-ride coordinator in July 2015. To strengthen mobility services in the region, Cumberland County joined YATA, which prompted a new name. YATA became the Central Pennsylvania Transportation Authority (CPTA) in December 2015. • In 2016, Columbia, Franklin, Union, Snyder, Montour, and Perry Counties appointed CPTA as the shared-ride coordinator. With a multicounty service area, CPTA is representative of a regional approach to human services transportation management and service delivery. With the coordinated approach, CPTA is better equipped to fulfill trips across county lines, and can provide additional mobil- ity services for the region. Cost efficiencies are realized by eliminating duplicative administrative costs for county- specific programs. The coordination of multiple operations has created a centralized call center and mobility planning office in York, which are fully coordinated to assist riders from the counties in the CPTA service area. This includes assessing appropriate modes for passengers, offering trip planning assistance, and general mobility case management. Effects of NEMT as Human Services Transportation In the case study research, assessments of NEMT as human services transportation were obtained from interviews with a variety of key stakeholders in Pennsylvania, including represen- tatives of PA-DHS, PennDOT, county-based transportation providers, and mobility managers. Efforts to meet with the NEMT broker in Philadelphia County were not successful. Access to Medicaid Services Customer served. The percentage of Medicaid enrollees in Pennsylvania who rely on MATP for transportation to medical services has grown significantly: • 1999—2.8 percent • 2003—4.3 percent • 2009—6.8 percent • 2013—7.2 percent PA-DHS reported 11.5 million MATP trips in 2013. This is more NEMT trips than any other state, indicating MATP is effectively providing access to Medicaid services. Funding. Effective July 1, 2014, MATP pays the approved percentage of the co-payment amount (15 percent) for Medicaid beneficiaries who are eligible to use the PennDOT Shared Ride Program for Senior Citizens to travel to an approved medical appointment. Pennsylvania lottery funds pay for the first 85 percent of the cost of the trip.

State Case Study Summaries A-49 Customer and health care provider satisfaction. The most recent documentation of customer satisfaction was reported by the Pennsylvania Department of Public Welfare (now PA-DHS) in 2010. The department conducted a survey of 5 percent of MATP users July 2008 through June 2009 in each of 66 of the 67 Pennsylvania counties. The department did not include Philadelphia County in the consumer survey. Shared-ride services were the most used mode of transportation among survey respondents (44 percent). According to the department’s report on the survey, overall results indicate that MATP was delivering high-quality services at that time, resulting in high levels of user satisfaction. Over 86 percent of users rated their overall MATP experience as excellent or good. In the case study research, discussions with health care providers and patient advocates revealed that these stakeholders want MATP to be held to higher standards of performance for on-time performance, wait times, maximum travel times, and missed trips. Transportation providers want to be able to work with health care providers on logistics, timing appointments when cost-effective shared-ride transportation can be made available. Yet many health care pro- viders and patient advocates feel that rides need to be provided when medical appointments are available; not scheduled to benefit transportation cost effectiveness. This is the important differ- ence of perspective for transportation as a complementary medical service rather than as a mode of access to a destination. Health care providers are interested in how transportation for medical services can make a significant difference in lowering the cost of health care rather than lowering the cost of transportation (that is a small percent of the total cost of health care). Coordination with Human Services Transportation Pennsylvania has made a considerable effort to coordinate human services transportation, in particular for Medicaid beneficiaries. In 66 of 67 counties in Pennsylvania, the county MATP coordinator arranges transportation for eligible Medicaid beneficiaries to approved medical services using the coordinated transportation system. In Philadelphia County, MATP is admin- istered through a private, for-profit broker. As discussed above, shared-ride coordinators seek opportunities to provide cost-effective transportation through more productive service (more passenger trips per hour). Coordinating MATP service with other human services transportation improves overall productivity and lower cost per passenger trip. Some transportation providers expressed concerns when PA-DHS introduced one-hour maximum pick-up and drop-off windows for all MATP trips, regardless of distance or desti- nation. Some transportation providers in rural areas find it challenging to guarantee 1-hour windows without providing more expensive single-passenger rides on accessible vans. However, PA-DHS believes that without a reasonable guaranteed window, some passengers might not make the trip at all, increasing the likelihood of negative health outcomes and potentially creating larger health care costs later. For example, in Allegheny County, ACCESS is able to coordinate MATP with human services transportation programs. As described above, ACCESS subcontracts to six different transporta- tion providers throughout the county to provide MATP trips. The cost allocation model used by ACCESS provides the transparency that contributes to successful outcomes for coordination of human services transportation and MATP. Coordination with Public Transportation The county MATP coordinator arranges transportation for eligible Medicaid beneficiaries to approved medical services using fixed-route public transportation if available, mileage reimbursement, or local transportation providers for shared-ride transportation. The county

A-50 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination MATP coordinator or a local transportation provider may be the public transportation agency for the county. For example, CPTA (rabbittransit) is the shared-ride coordinator for a multi- county region in south-central Pennsylvania. As reported by PA-DHS, approximately 7.2 percent of all Medicaid enrollees in 2013 used MATP to make 11.5 million trips. PA-DHS estimates that 41 percent of MATP trips are on public transportation. Reported expenditures for NEMT were $148.6 million in 2013, or $12.96 per passenger trip, one-third the average cost of NEMT per passenger trip reported by other states. One reason for the lower cost per passenger trip is the use of public transportation. A fare on fixed-route transit is the lowest cost transportation for a MATP passenger trip. In the two most populous counties in Pennsylvania, a significant percent of MATP passenger trips is made on public transit. In Philadelphia County, the broker reported over 74 percent of MATP trips were on public transit in fiscal 2013. In Allegheny County (Pittsburgh), the MATP coordinator, Allegheny County DHS reported 57 percent of MATP trips were on fixed-route transit in 2015. Summary of the Pennsylvania Case Study In Pennsylvania, NEMT is called MATP. MATP provides transportation to medical appoint- ments for eligible Medicaid beneficiaries. The Department of Human Services currently con- tracts for coordination of MATP services through agreements with 66 counties and one full-risk broker with capitated payment in Philadelphia County. Pennsylvania has not made substantial changes in MATP service delivery in recent years, except to encourage regional coordination of services. The case study for Pennsylvania focused on three MATP examples: the full-risk private broker in Philadelphia County (Philadelphia); the Allegheny County DHS using the ADA paratransit provider for the Port of Authority of Allegheny County (Pittsburgh); and CPTA. Following is a summary of effects: • Access to Medicaid services: – As reported by PA-DHS, approximately 7.2 percent of Medicaid enrollees in 2013 used MATP to make 11.5 million trips. This is the most NEMT trips of any state, including states with more population and more Medicaid enrollees. – Reported expenditures for NEMT were $148.6 million in 2013, or $12.96 per passenger trip, which is one-third the average cost of NEMT per passenger trip reported by other states. – One reason for the lower cost per passenger trip is the use of public transportation. PA-DHS estimates that 41 percent of MATP trips are on public transportation statewide. • Coordination with human services transportation: – The Pennsylvania Lottery supports public transit for persons 65 years of age and older. Lottery funds pay for 85 percent of the shared-ride trip fare for individuals eligible to use the PennDOT Shared Ride Program for Senior Citizens under federal statute and Medicaid regulations. Medicaid is the payer of last resort for MATP trips. When a Medicaid beneficiary who is also a senior citizen is approved for a MATP trip on a shared ride, lottery funds pay for the first 85 percent of the cost of the trip. MATP pays the co-payment amount (15 percent). – In 66 of 67 counties in Pennsylvania, the county coordinator of human services trans- portation arranges transportation for eligible Medicaid beneficiaries to approved medical services using the coordinated transportation system. – Each federal, state, or local agency that funds human services transportation independently communicates with local transportation providers, develops policies, manages services, and sets requirements for each program. The result is that local human services transporta- tion is unique to every county.

State Case Study Summaries A-51 – Transportation service should be easy to use; however, the unique attributes of each county’s human services transportation and the complexities of the various programs may make it difficult for local human services agencies and consumers to understand. – In case study research, discussions with health care providers and patient advocates revealed that these stakeholders want MATP to be held to higher standards of performance (than other shared-ride human services transportation programs) for on-time performance, wait times, maximum travel times, and missed trips. • Coordination with public transportation: – Philadelphia County is the most urbanized county in the state, and the one county where MATP is administered through a for-profit broker with capitated payment. While the number of MATP trips provided by the broker roughly equals the number provided in the rest of the state, the brokerage accounts for just over 30 percent of annual MATP expen- ditures, reflecting the cost effectiveness of fixed-route public transportation to transport Medicaid beneficiaries to required medical appointments. In FY 2013, over 74 percent of MATP trips in Philadelphia County were on public transit. – ACCESS in Allegheny County uses a cost allocation model that provides transparency for the cost of services and the way money is spent. ACCESS also uses the cost allocation model to demonstrate how operating policies can lower (or increase) costs. – With a multicounty service area, CPTA represents a regional approach to human services transportation management and service delivery. With the coordinated approach, CPTA is better equipped to fulfill trips across county lines and can provide additional mobility services for the region. Cost efficiencies are realized by eliminating duplicative administra- tive costs for county-specific programs. References for the Pennsylvania Case Study Hoesch, K. “What’s my Fair Share? A Cost Allocation Model for a Coordinated System.” Easter Seals Project ACTION MPS, April 2008. Pennsylvania Department of Human Services, Office of Medical Assistance Programs, Division of Medical Assistance Transportation Programs. Medical Assistance Transportation Program: Standards & Guidelines. Commonwealth of Pennsylvania, November 2016. http://matp.pa.gov/PDF/MATPStandardsGuidelines.pdf. Accessed December 12, 2017. Pennsylvania Department of Public Welfare, Office of Medical Assistance Programs, Division of Medical Assistance Transportation Programs. 2010 Medical Assistance Transportation Program Surveys: Overview of Survey Results. Commonwealth of Pennsylvania, November 29, 2010. http://matp.pa.gov/PDF/2010MATP ConsumerSurveyResults.pdf. Accessed December 12, 2017. Pennsylvania Department of Public Welfare, Office of Medical Assistance Programs, Division of Medical Assistance Transportation Programs. Medical Assistance Transportation Program: Instructions & Require- ments. Commonwealth of Pennsylvania, October 2012. http://matp.pa.gov/PDF/MATP_Handbook.pdf. Accessed December 12, 2017. PennDOT, Pennsylvania Department of Public Welfare, Pennsylvania Department of Aging, and Pennsylvania Office of the Budget. Human Service Transportation Coordination Study: Summary Report. Commonwealth of Pennsylvania, July 17, 2009. http://www.penndot.gov/Doing-Business/Transit/InformationandReports/ Documents/HST%20Coordination%20Study%207-16-09.pdf. Accessed December 12, 2017. PennDOT, Bureau of Public Transportation. Act 89 of 2013. January 2014. https://www.dot.state.pa.us/public/ Bureaus/PublicTransportation/GeneralInformation/Act%2089%20of%202013.pdf. Accessed December 12, 2017. PennDOT. Comprehensive Transportation Funding Plan—Act 89. http://www.penndot.gov/about-us/Documents/ FINAL_Trans_Funding_Plan_Summary.pdf. Accessed December 11, 2017. PennDOT. South Central Pennsylvania Transit Regionalization Study. December 3, 2015. http://www.penndot. gov/Doing-Business/Transit/InformationandReports/Documents/South%20Central%20Regionalization %20Study%20Report.pdf. Accessed December 12, 2017. Pennsylvania General Assembly, House Appropriations Committee. “Lottery Fund: Budget Briefing.” 2016/17 Budget Briefing Report on Key Issues, January 31, 2017. http://www.pahouse.com/Files/Documents/ Appropriations/series/2937/LotteryFund_BB_013117.pdf. Accessed December 11, 2017.

A-52 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination Pennsylvania General Assembly, Legislative Budget & Finance Committee. A Performance Audit of Penn- sylvania’s Medical Assistance Transportation Program for Methadone Maintenance. Commonwealth of Pennsylvania, February 2011. http://www.paproviders.org/archives/Pages/DA_Archive/MATP_Performance_ Audit_021011.pdf Accessed December 12, 2017. Rabbittransit. Rabbittransit Annual Report 2014. no date. http://www.rabbittransit.org/dotnetnuke/Portals/ 0/docs/AnnualReport/AnnualReport2014.pdf. Accessed December 12, 2017. Rabbittransit. Rabbittransit Annual Report 2015. no date. http://www.rabbittransit.org/dotnetnuke/Portals/ 0/docs/AnnualReport/AnnualReport2015.pdf. Accessed December 12, 2017. Rabbittransit. Rabbittransit Annual Report 2016. no date. http://www.rabbittransit.org/dotnetnuke/Portals/ 0/docs/AnnualReport/AnnualReport2016.pdf. Accessed December 12, 2017. Williams, T. E. Medical Assistance Transportation Program (MATP) Operations Memorandum. MATP OPS # 05-2014-032, May 23, 2014. http://matp.pa.gov/Pdf/memos/MATP_Ops_Memo_05_2014_032.pdf. Accessed December 12, 2017. Texas: Change to Regional Brokers (For Profit and Not for Profit) and In-House Management (One Region) Key Data Key Data Demographic Features • State Population (2015) 26,538,614 • Urban Population (2010) 75% • Rural Population (2010) 25% • Population at or below poverty line (2015) 16% NEMT Oversight Health and Human Services Commission, Medical Transportation Program Medicaid & NEMT Enrollment Data • Medicaid & CHIP Enrollment (December 2013) 4,441,605 • Medicaid & CHIP Enrollment (December 2016) 4,768,961 • Percent Increase 2013–2016 7.4% • Medicaid Enrollees that Used NEMT (2013) N/A NEMT Model Regional Brokers and In-House Management (1 region) Operating Authority 1902(a)(70) State Plan Amendment Section 1915(b) Freedom of Choice Waiver Medicaid Match Federal Medical Assistance (56.2%) Expanded Medicaid under Affordable Care Act No Medicaid Enrollees in a Managed Care Program 88% • NEMT under Managed Care NEMT carved out of Managed Care NEMT Expenses & Activity Data • Annual Medicaid Expenses (2015) $35,802,825,013 • Estimate Annual NEMT Expenses (2015) $260,679,919 • NEMT as % of Medicaid Expenses 0.7% • Estimate Annual NEMT Passenger Trips (2014) 9,290,567 • % of NEMT Trips on Public Transit (2014) 0.3% • NEMT Expenses per Trip Statewide (2014) Est $28 NEMT Description The Health and Human Services Commission (HHSC) is responsible for the planning and delivery of health and human services programs in Texas. HHSC provides direct administration of some programs, including the Medical Transportation Program. Through the Medical Transportation Program, HHSC is responsible for arranging NEMT services for Medicaid-eligible beneficiaries in Texas. HHSC changed NEMT from contracts with transportation service providers to regional brokers in 2012 and 2014 as summarized below: • Fee for service. Prior to 2012–2014, HHSC provided demand-response NEMT through FFS contracts with transportation providers in 24 transportation service areas. HHSC authorized

State Case Study Summaries A-53 and arranged other transportation services (e.g., call center operations, mileage reimburse- ment to individuals, payments for meals and lodging, and airline travel). • Full-risk brokers (FRBs). In 2012, HHSC implemented FRBs in two service delivery areas (SDAs): Dallas/Fort Worth (SDA 1) and Houston (SDA 2). HHSC pays the two FRBs a capi- tated payment to provide transportation and related services such as call center operations; contracted demand-response transportation; tickets for mass transit; individual mileage reimbursement; meals and lodging; advanced funds; and out-of-state travel and commercial airline transportation services. • Managed transportation organizations (MTOs). Effective September 1, 2014 (beginning state FY 2015), HHSC implemented regional brokers in 11 regions not served by the two existing FRBs, changing from an FFS model for NEMT to a system of regional brokers with capitated payment. The regional brokers are called MTOs. The MTOs are responsible for providing transportation and related services similar to the FRBs in the two SDAs. Capitated rates are adjusted annually for MTOs and FRBs to reflect actual broker experience. The next section will provide the background and context for the change from NEMT as an FFS to regional brokers in Texas. Brief History for NEMT in Texas The following provides a brief history of key events for NEMT in Texas during the four decades 1974 through 2014: 1974 NEMT added as a benefit in the state Medicaid plan administered by the Department of Human Services. 1991 HHSC created to oversee the Texas health and human services programs. 1993 Texas Medicaid transferred to the Texas Department of Health (TDH). The Frew et al. v. McKinney et al. (Frew) lawsuit was filed against the commissioners of HHSC and TDH. The Frew lawsuit was filed as a class action lawsuit for children eligible for Medicaid. The lawsuit sought to enhance the availability of health care services, effectively inform beneficiaries that services are available, and eliminate barriers that have the effect of preventing access to services, such as inadequate NEMT. 1995 The parties resolved the Frew litigation by entering into an agreed consent decree, which the court approved in 1996. The decree sets out numerous state obligations relating to Medicaid services (including NEMT) for children less than 21 years of age. 2003 The 78th Texas Legislature approved House Bill 2292 and House Bill 3588 that transferred NEMT from TDH to HHSC. The legislative direction also required HHSC to contract medical transportation services to the Texas Department of Transportation (TxDOT). Oversight of NEMT was assigned to HHSC. 2006 TxDOT restructured service delivery for NEMT effective June 2006. Formerly, TDH had 52 contracts and a complex rate structure (300+ rates). TxDOT used a competitive process to award 15 contracts for 24 transportation service areas providers (TSAPs). The TSAPs operated under FFS contracts. TxDOT simplified the rate structure to two rates per service area (an in-county rate and an out-of-county rate). 2007 Parties to the Frew lawsuit agreed to 11 corrective action orders to bring the state into compliance with the consent decree and increase access to Medicaid services. The 80th Texas Legislature approved Senate Bill 10 that transferred the operation of NEMT from TxDOT back to HHSC beginning May 1, 2008. The TxDOT contracts with TSAPs were assigned to HHSC.

A-54 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination 2009 The 81st Texas Legislature included Rider 55 to the Appropriations Act to implement a regionalized FRB using a pre-payment methodology (capitation) to reimburse the broker or brokers. To implement this change, the legislature authorized HHSC to secure approval from CMS for a state plan amendment as provided for in the Social Security Act, Section 1902(a)(70). 2012 HHSC authorized FRBs in two SDAs (Dallas/Fort Worth and Houston). 2013 The 83rd Texas Legislature approved Senate Bill 8 to authorize the MTO model for NEMT. 2014 HHSC implemented the new NEMT model for MTO in 11 regions in addition to the two SDA brokers, changing from the TSAP FFS model to the MTO capitated rate system. 2015 HHSC terminated the contract with one regional broker and reinstated FFS in that region. Significance of the Frew Lawsuit On September 1, 1993, the Frew lawsuit was filed against the commissioners of HHSC and TDH in their official capacities. The allegation of the Frew lawsuit was that medical and dental preventive checkups were not provided in accordance with the recognized early and periodic screening, diagnostic and treatment (EPSDT) benefits for children under age 21 who are enrolled in Medicaid (known as Texas Health Steps). Other allegations include the following: • Texas does not effectively inform children enrolled in Medicaid about the benefits of the EPSDT program. • Texas does not provide adequate case management services. • The Medical Transportation Program (NEMT) fails to meet the needs of children enrolled in Medicaid. • EPSDT program access is denied or limited because of an inadequate supply of providers. The suit was brought to enhance the availability of health care services, effectively inform Medicaid beneficiaries that services are available, and eliminate barriers that have the effect of preventing access to service, such as inadequate transportation. The contention was that many children who are eligible for Medicaid do not receive needed services simply because they have no way to get to medical appointments. NEMT is meant to address this need. Services to children eligible for Medicaid represent approximately 40 percent of NEMT call center volume. The Frew case was filed as a class action suit. In 1994, the U.S. District Court certified the class. The parties negotiated a settlement agreement, reaching agreement in 1995. The parties resolved the Frew litigation by entering into an agreed consent decree, which the court approved in 1996. The decree sets out numerous state obligations relating to Texas Health Steps. The decree also provides that the federal district court will monitor compliance with the orders by HHSC and the Department of State Health Services (formerly TDH) and that the federal district court will enforce the orders if necessary. In 2007, the parties agreed to 11 corrective action orders to bring the state into compliance with the consent decree and increase access to Texas Health Steps services. The corrective action orders touch upon many program areas and generally require the state to take actions intended to assure access to or measure access to Medicaid services for children. The Texas Medicaid program must consider these obligations in policy and program decisions for Medicaid services

State Case Study Summaries A-55 available for persons from birth through 20 years of age. These obligations include, among others, the requirement to meet stricter call center standards for NEMT. A number of the corrective actions continue. The performance standards in the NEMT contracts with the FRBs and MTOs reflect these corrective actions. Many of the performance standards address the call center function. The court continues to monitor the agencies’ compliance with the orders. The consent decree does not have a specific end date, although the corrective action orders are intended to create potential endpoints as the agencies obligations are met. Transportation Service Area Providers (2006–2014) Under the TSAP model, each TSAP provided the transportation service directly and by sub- contract. Fifteen different TSAPs served the 24 transportation service areas. Of the 15 TSAPs, 10 were rural or urban public transit districts, three were for-profit transportation companies, and two were nonprofit human services agencies that provided transportation services. HHSC authorized and arranged other services (e.g., call center operations, individual transportation reimbursement, meals and lodging, and airline travel). Full-Risk Broker (2012) The two FRBs in Dallas/Fort Worth (SDA 1) and Houston (SDA 2) receive a capitation payment to provide all transportation services (call center operations, demand-response trans- portation, individual transportation reimbursement, meals and lodging, and airline travel) to NEMT clients in the specified geographic areas. Both FRBs are private for-profit transportation companies that operate regional or statewide brokerages in other states. The brokers do not operate transportation services directly but instead contract with transportation service providers that may be private companies, nonprofit agencies, or public transportation districts. Managed Transportation Organization (2014) The Texas Legislature approved Senate Bill 8 (2013) requiring HHSC to provide NEMT on a regional basis through MTOs under a capitated rate system. The bill further requires HHSC to procure MTOs through a competitive bidding process for each managed transportation region as determined by HHSC. The bill was consistent with CMS guidance implementing NEMT brokers under the Deficit Reduction Act of 2005. The purpose of the change from TSAPs to MTOs was to improve transportation service delivery to eligible Medicaid beneficiaries, contain program cost, and reduce the incidence of fraud, waste, and abuse. The legislation authorized HHSC to delay providing medical trans- portation program services through the MTO model in regions of the state operating as FRBs (SDA 1 and SDA 2). Effective September 1, 2014, HHSC implemented the MTO service delivery model in 11 regions in addition to the two SDAs, changing NEMT from an FFS model by TSAPs to a capitated rate system by MTOs. The MTOs must meet the following program requirements: • Operate under a capitated rate system, • Assume financial responsibility under a full-risk model, • Operate a call center, • Use fixed routes when available and appropriate, • Agree to provide data as determined necessary by HHSC, and

A-56 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination • Attempt to contract with providers that are considered significant traditional providers, meet the minimum quality and efficiency measures determined by HHSC, and agree to accept the prevailing contract rate of the MTO (HHSC sets the contract rate). Five MTO regional brokers were authorized to operate in 10 of 11 regions. (See discussion in the next section about the MTO in the 11th region.) The brokers included four private for-profit transportation companies and one regional human services agency (not for profit). Two MTO regional brokers are also the FRB brokers in Dallas/Fort Worth and Houston. Effective September 1, 2017, the private for-profit broker responsible for Regions 1 and 10 was terminated by HHSC. One of the other for-profit brokers (that already operated in SDA 1 and three MTO regions) assumed responsibility for Regions 1 and 10. This leaves three private for- profit brokers and one non-for-profit broker active in Texas. The not-for-profit MTO broker owns a fleet of vehicles to provide self-referred services under a Section 1915(b) Freedom-of-Choice Waiver. Three for-profit MTO brokers do not operate vehicles directly. The brokers contract with nonprofit or private transportation providers. Brokers contract with public transit districts in some but not all regions. Return to FFS in One Region HHSC contracted with a public transit district to serve as the MTO for Region 4 (Texoma area north of Dallas/Fort Worth) effective September 1, 2014. HHSC terminated the agreement with the transit district in November 2015 for failure to maintain adequate financial records and client encounter data. HHSC now arranges and schedules NEMT in Region 4 and contracts with transportation providers on an FFS basis. Effects of NEMT as Regional Brokers The case study research for Texas addresses the impacts of the change in delivery of NEMT from an FFS model to regional brokers. The case study information is based on a review of the HHSC request for proposals for MTOs and interviews with stakeholders from the HHSC Medical Transportation Program, TxDOT Public Transportation Division, MTO brokers, public transit districts that operated FFS as TSAPs, and public transit districts that currently subcontract to MTOs and FRBs. The purpose of the interviews was to hear different perspectives on the impacts of the change in how NEMT is operated in Texas. Access to Medicaid Services HHSC identified the following objectives for regional brokers in the MTO request for proposals: • Reduce the cost of medical transportation by using a capitation payment methodology; • Increase program efficiencies through the establishment of a regional network of transporta- tion providers; • Increase efficiencies through data analytics collected and reported by providers and analyzed by HHSC; • Eliminate potential for fraud, waste, and abuse; and • Comply with the obligations of the Frew lawsuit. Effective the beginning of state FY 2015 (September 1, 2014), HHSC named a broker in each of 11 MTO regions (in addition to the existing FRBs in two regions) to provide NEMT to eli- gible Medicaid beneficiaries that have no other means of transportation. As stated above, HHSC

State Case Study Summaries A-57 terminated the agreement with the broker in Region 4 in November 2015. HHSC now manages NEMT in Region 4 in house on an FFS basis. Benefits. The HHSC Medical Transportation Program representatives said the change to regional brokers has benefited the program in the following ways: • Reduced the cost of NEMT. An objective for the change to regional brokers was to reduce the cost of medical transportation by using a capitated payment. HHSC employs a private actuarial service to set rates each year under the full-risk capitated arrangement. Rates are set for adults and children in urban and rural counties for each region. All transportation services are included in the rate analysis. For example, demand-response transportation, mileage reimbursement, fixed-route transit tickets, out-of-state travel, and commercial airline transportation services are included in the rate analysis. Table A-13 documents the actuary’s rate setting for FY 2015, 2016, and 2017. The data in Table A-13 identify the actuary’s projected costs for capitated payment, not actual costs. In the table, capitated payment is represented by per member per month (PMPM). In Table A-13, an adjustment in the rates per person per month for children in Region 10 (South Texas) was documented to reflect the parental accompaniment rule. Effective Febru- ary 1, 2014, the parental accompaniment rule was fully enforced; MTO Region 10 was the only region impacted by this policy change. In order to adjust for the cost impact of fully enforcing the parent accompaniment rule in FY 2015, the rates PMPM for children were reduced by 60 percent in MTO Region 10. The data in Table A-13 show the following trends for NEMT changes from 2015 to 2017: – 5.4 percent fewer projected Medicaid person months in FY 2017 as compared to FY 2015, – 7 percent lower projected weighted average rate per person per month in FY 2017 as compared to FY 2015 (adjusted for Region 10); and – 12.1 percent lower projected total cost for capitated payments in FY 2017 as compared to FY 2015 (adjusted for Region 10). • Established minimum standards for vehicles and drivers. The regional brokers are con- tractually responsible to ensure that eligible Medicaid beneficiaries have safe access to trans- portation services. HHSC established minimum requirements for brokers to certify vehicle State FY Medicaid Member Months Weighted* Average PMPM Total Projected Cost Weighted Average PMPM Adjusted for Region 10** Total Projected Cost Adjusted for Region 10** 2015 50,893,018 $4.154 $211,412,482 $3.818 $194,295,584 2016 48,219,398 $3.604 $173,776,679 $3.604 $173,776,679 Change -2,673,620 -$0.550 -$37,635,803 -$0.214 -$20,518,905 % Change -5.3% -13.2% -17.8% -5.6% -10.6% 2017 48,128,282 $3.550 $170,874,224 $3.550 $170,874,223 Change -91,116 -$0.054 -$2,902,455 -$0.054 -$2,902,456 % Change -0.2% -1.5% -1.7% -1.5% -1.7% 2015 to 2017 Change -2,764,736 -$0.604 -$40,538,258 -$0.268 -$23,421,361 % Change -5.4% -14.5% -19.2% -7.0% -12.1% All data exclude Region 4. HHSC manages NEMT in Region 4 as FFS. * Weighted for PMPM for adults and PMPM for children by region. ** In order to adjust for the cost impact of the parental accompaniment rule, the rates PMPM for children are reduced by 60% in MTO Region 10 for FY 2015. Source: HHSC Medical Transportation Program. Table A-13. Texas trends for NEMT after implementation of MTO regional brokers.

A-58 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination condition and driver qualifications and training for each NEMT demand-response transpor- tation provider. These requirements mean that brokered transportation services are required to meet at least a minimum standard of safety that is comparable for all public, nonprofit, and private transportation providers. • Increased oversight through data analytics. HHSC requires each broker to collect and report, by transportation provider, encounter data for each NEMT client and each NEMT trip. The data are analyzed by HHSC to verify compliance with the broker agreements and to ensure performance according to financial and service quality requirements, including com- pliance with the obligations of the Frew lawsuit. The HHSC agreements with MTO brokers call for liquidated damages if an MTO or transportation provider does not provide quality performance consistent with the service standards. While the implementation of regional brokers has not eliminated the potential for fraud, waste, and abuse, HHSC Medical Transportation Program representatives said the state agency’s oversight is more rigorous in the review of encounter data to identify evidence of fraud or waste. Challenges. From the perspective of HHSC, there are continuing challenges in delivering NEMT in Texas: • Broker performance. HHSC terminated the MTO broker in Region 4 for failure to main- tain adequate financial records and client encounter data. The circumstances were a disap- pointment to many stakeholders because the broker was the one public transit district named as an MTO by HHSC. HHSC also reassigned Region 8 from one MTO broker to another (existing) MTO broker. In September 2017, the private for-profit broker responsible for Regions 1 and 10 was terminated by HHSC. One of the other for-profit brokers assumed responsibility for Regions 1 and 10. Some of the brokers are new to the MTO model and had significant issues submitting encounter data and financial information to HHSC (at least) the first year of the MTO agree- ments. In the opinion of the actuary, the data for the MTOs were not reliable enough to use in rate setting for FY 2016. For this reason, the actuary relied solely on FFS data for the period September 1, 2013, through August 31, 2014 (FY 2014), in order to set rates for FY 2016. • Higher per-trip costs for demand-response transportation. For FY 2015, the actuary assumed that the MTOs would pay less than FFS for the same services, especially for demand- response transportation. The actuary assumed a 10 percent discount factor for all MTO regions. Based on actual operating data, the actuary found some MTOs reimbursed demand-response transportation providers a higher payment per trip than under FFS. For rate setting purposes in FY 2017, the cost per trip for demand-response transportation was capped at 120 percent of FFS for the base period (2014) claims. • Limited transportation providers in rural areas. Rural areas of Texas do not have access to a large number of subcontractors. The MTO in Regions 3 and 6 was forced to suspend a private subcontractor due to compliance issues. A replacement subcontractor was selected but at a higher reimbursement rate. This is expected to increase cost for demand-response services by 15 percent in those regions. Coordination with Human Services Transportation In 2003, Texas policy makers perceived a lack of coordination between providers of human services transportation and public transportation, leading to inefficient practices and an underserved population in need of transportation. In order to address these concerns, the 78th Texas Legislature enacted House Bill 3588 in 2003 requiring each of 24 regions in Texas to adopt a plan identifying opportunities to coordinate

State Case Study Summaries A-59 human services transportation and public transportation. House Bill 3588 created Chapter 461 of the Texas Transportation Code, titled Statewide Coordination of Public Transportation. The purpose of Chapter 461 is to encourage coordination of human services transportation and public transportation by requiring regionally coordinated transportation plans in each of the 24 regions of the state. The regional plans were originally developed in 2006 and are updated every five to six years (2011 and 2017). The TxDOT Public Transportation Division is respon- sible for administering statewide coordination, and TxDOT has identified a lead entity in each region to work with other stakeholders to prepare and update the regionally coordinated trans- portation plans. Lead entities responsible for preparing the regional plans are encouraged to involve MTO brokers and NEMT transportation providers as stakeholders in the process. HHSC does not require or encourage MTO brokers to coordinate with other human services transportation service providers and public transportation agencies. In a review of the 2017 regional plans, the MTO broker in four of 24 planning regions participated on stakeholder committees. The lack of participation by MTO brokers and NEMT transportation providers in regionally coordinated transportation planning reduces the effec- tiveness of the process and the outcomes. In Region 2 (Far West Texas), the MTO is a human services transportation agency and is actively involved in coordinated transportation planning. The same agency can offer Medicaid beneficiaries transportation for other trip purposes, using funding resources rather than Medicaid. One purpose of coordination for transportation services is to benefit individuals who need transportation for multiple trip purposes. With the exception of the MTO in Region 2, any Medicaid beneficiary in Texas must schedule NEMT trips through the regional broker and separately schedule transportation for any other trip purpose with a different transpor- tation provider. Coordination with Public Transportation Texas has three categories of public transportation systems: • Transit authorities and municipal transit departments. Texas has six metropolitan (regional) transit authorities, two municipal transit departments, and one county transit authority. Each transit authority operates fixed-route transit and ADA paratransit. In Dallas and Houston, the transit authorities operate bus and light rail fixed routes. • Urban transit districts. An urban transit district is a local governmental body or political subdivision of the state that operates a public transportation system in an urbanized area. In 2016, Texas had 29 urban transit districts. • Rural transit districts. A rural transit district is a political subdivision of the state that pro- vides and coordinates rural public transportation in its territory. In 2016, Texas had 37 rural transit districts. Before the change to regional brokers, HHSC provided NEMT through 15 TSAPs based on an FFS. Of the 15 TSAPs, 10 were public transit districts; three were private, for-profit companies; and two were human services agencies. Eight rural transit districts and two urban transit districts operated as TSAPs. Other public transit districts subcontracted to TSAPs. Effective state FY 2015, HHSC implemented the MTO service delivery model in 10 regions (originally 11 regions) in addition to the FRBs in two regions. Five brokers operate in the 12 regions. Four of the brokers are private, for-profit companies, and one broker is a human services agency that operates transportation services in Region 2. Pursuant to state law, MTOs

A-60 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination may own, operate, and maintain a fleet of vehicles or contract with an entity that owns, operates, and maintains a fleet of vehicles. Two MTO brokers own and operate a fleet of vehicles and are approved to provide transportation services under a Section 1915(b) waiver for self-referral. Three MTO brokers do not operate vehicles directly and subcontract all NEMT service. Rural Transit District Report Fewer NEMT Passengers and Revenue. All of the brokers contract with at least one public transit district and other not-for-profit or for-profit transporta- tion providers. The brokers that operate in more than one region do not necessarily contract with a public transit agency in each region. Rural transit districts reported NEMT ridership and rev- enues have dropped since implementation of MTOs. Twenty of 37 rural transit districts reported NEMT data at least one year, 2014–2016, to the TxDOT Public Transportation Division. As shown in Table A-14, rural transit districts reported 41 percent fewer NEMT passengers and 41 percent less NEMT revenue in FY 2016 as compared to FY 2014 before the change to MTOs. Data for urban transit districts could not be verified for accuracy and so are not included in the table. NEMT revenues from Medicaid are eligible as a source of local match for federal transit grants. A loss of NEMT revenues also reduces this source of funds for a rural transit district to match federal Section 5311 funds or other federal transit grants. Challenges for Coordination of NEMT and Public Transportation. Stakeholders represent- ing transportation authorities and public transit districts identified the following additional chal- lenges for coordination of NEMT and public transportation after the change to regional brokers: • Brokers may not be using fixed-route transit to full advantage. HHSC requires MTOs and FRBs to use fixed routes when available and appropriate for the NEMT client. Texas transit authorities and urban transit districts are supportive of NEMT trips on fixed-route transit. Public transit agencies can accommodate NEMT trips on fixed-route transit at no increase in cost because seats are available to additional passengers on a scheduled service. A fare on fixed-route transit is the lowest cost to the broker for an NEMT trip. However, when asked for information, five transit authorities did not report any significant sale of fare media to NEMT brokers for fixed route, although brokers may have made small purchases of fare media. One metropolitan transit authority reported sale of fare media to the NEMT broker for 100 to 200 trips per month on fixed-route bus or rail. • Demand for ADA paratransit increasing but cannot be directly attributed to the NEMT change to regional brokers. Researchers asked transit authorities in nine larger urban areas if the change to the FRB in the Dallas/Fort Worth and Houston regions or the change to the State FY Rural Transit District NEMT Passengers Rural Transit District NEMT Revenue 2014 446,554 $20,685,168 2015 284,860 $13,180,590 Change -161,694 -$7,504,578 % Change -36.2% -36.3% 2016 262,222 $12,128,753 Change -22,638 -$1,051,837 % Change -7.9% -8.0% 2014–2016 Change -184,332 -$8,556,415 % Change -41.3% -41.4% Source: TxDOT Public Transportation Division, PTN-128. Table A-14. Texas Rural Transit District change in NEMT passengers and revenue after implementation of regional brokers.

State Case Study Summaries A-61 MTO model resulted in an increase in trips on complementary ADA paratransit. The transit authorities reported that demand for paratransit increased over the time reviewed. However, none of the transit authorities could directly track an increase in ADA paratransit applicants or an increase in paratransit trips directly to the change to regional brokers for NEMT. • Coordination of NEMT and public transportation is not encouraged or incentivized. HHSC does not require, incentivize, or encourage brokers to contract with public transit districts for demand-response NEMT trips. The broker’s incentive under a capitated rate model is to use a qualified, lower cost transportation provider when possible. The public transit district is not always the lower cost provider. • Fewer shared rides mean higher cost per passenger trip. Some urban and rural public tran- sit districts that provide NEMT reported fewer shared rides, making each NEMT trip more expensive to deliver. • Higher costs in rural areas. MTOs operating in rural areas of Texas do not have access to a large number of subcontractors. The rural transit districts may be one of a limited number of possible subcontractors for the broker. Rural transit districts report rates for NEMT trips tend to be higher in these areas due to the trip distance (origin to destination) and less opportunity for shared rides. • Performance standards may require dedicated NEMT service. The HHSC contract with each MTO includes performance standards to ensure timely service for NEMT clients: – Ensure that clients arrive to health care facilities at least 15 minutes but no more than one hour prior to the scheduled appointment, – Pick up the client from an appointment within one hour from time of notification, and – Ensure the client does not remain in the vehicle for one hour longer than the average travel time for direct transportation of that client. For rural transit districts, the performance standard for maximum travel time for an NEMT passenger often means scheduling a vehicle and driver for just one NEMT passenger. Summary of the Texas Case Study Prior to 2012–2014, HHSC provided demand-response NEMT through FFS 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 agencies that provided transportation services. HHSC implemented FRBs with capitated payment in two SDAs in Dallas/Fort Worth and Houston in 2012. Effective 2014, HHSC implemented MTOs in 10 regions (originally 11 regions), changing from an FFS model to a system of regional brokers with capitated payment. The purpose of the change was to improve transportation service delivery to eligible NEMT clients, contain program cost, and reduce the incidence of fraud, waste, and abuse. The broker in one region was terminated, and HHSC assumed responsibility for in-house management in that one region. Following is a summary of effects: • Access to Medicaid services: – From the perspective of the state Medicaid agency, the change to regional brokers lowered the capitated payments 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. – Performance standards for NEMT may require transportation providers to operate single- passenger trips, reducing shared rides and increasing cost. • Coordination with human services transportation: – Lead entities develop regionally coordinated transportation plans; however, most NEMT regional brokers are not actively involved in the efforts to coordinate transportation services.

A-62 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination – NEMT clients do not have the ability to arrange transportation for multiple trip purposes with one call, one click. • Coordination with public transportation: – Rural transit districts reported data show that NEMT ridership and revenues have decreased 41 percent from 2014 to 2016 after the change to regional brokers. Data for urban transit districts could not be verified for accuracy. – Fewer passengers and fewer shared rides led to higher cost per passenger trip for public transportation 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. References for the Texas Case Study Keel, J. An Audit Report on The Medical Transportation Program at the Texas Department of Transportation, SAO Report No. 08-006. October 2007. LeFleur website. http://www.lefleur.net/texas/ Accessed December 15, 2017. Levinson, D. R. Texas Nonemergency Medical Transportation Program, A-06-12-00053. U.S. Department of Health and Human Services, October 2014. Ngo, K. D. State of Texas Medical Transportation Program Rate Setting State Fiscal Year 2015. Texas Health and Human Services Commission, May 30, 2014. Ngo, K. D. State of Texas Medical Transportation Program Rate Setting State Fiscal Year 2016. June 26, 2015. https://rad.hhs.texas.gov/sites/rad/files/documents/managed-care/2015/2015-09-mtp.pdf. Accessed February 3, 2016. Ngo, K. D. State of Texas Medical Transportation Program Rate Setting State Fiscal Year 2017. June 29, 2016. https://rad.hhs.texas.gov/sites/rad/files/documents/managed-care/2016/2016-09-mtp.pdf. Accessed April 9, 2017. Public Consulting Group for Texas Health and Human Services Commission. Medical Transportation Program: Business Process Review, Final Report. August 25, 2009. Smith, C. Letter Announcing New Company to Provide Transportation Services in MTO Region 1 and 10, July 10, 2017. http://www.lefleur.net/texas/PDFs/ClientLetterEng.pdf. Accessed December 15, 2017. TxDOT, Public Transportation Division. PTN-128 Data Reports, Fiscal Years 2013 through 2016. Texas Health and Human Services Commission. Application for 1915(b) Waiver: TX.0024.R00.01—MTO Nonemergency Medical Transportation. June 1, 2015. Texas Health and Human Services Commission. Texas Medicaid and CHIP in Perspective, Tenth Edition. February 2015. Texas Health and Human Services Commission. Request for Proposals (RFP) for Nonemergency Medical Transpor- tation Services, RFP No. 529-15-0002. November 25, 2013. Summary: What Are the Effects of the Different Models for Providing NEMT? The purpose of this appendix is to use case study research to document the effects of the dif- ferent models for providing NEMT on access to Medicaid services, on coordination with other human services transportation, and on public transportation. The previous sections have dis- cussed the experience of seven states that use different models for NEMT. The following three tables summarize the effects of the different models for providing NEMT as identified in the case studies: • Table A-15 summarizes the effects of different NEMT models on access to Medicaid services for Medicaid beneficiaries. • Table A-16 summarizes the effects of different NEMT models on coordination with human services transportation and options for general mobility. • Table A-17 summarizes the effects of different NEMT models on coordination with public transportation.

State Case Study Summaries A-63 State Case Study and Models for NEMT Effects on Access to Medicaid Services Florida Change to managed care with carved-in NEMT • The change to managed care with carved-in NEMT has enabled private brokers to increase NEMT coverage across multiple regions. • From the perspective of the state Medicaid agency, the change to managed care has curtailed the increase in the costs of Medicaid. Massachusetts Coordinated transportation with RTAs as regional brokers • The use of RTAs to broker coordinated human service transportation has produced positive results by containing costs per passenger trip and ensuring service quality. • Massachusetts reports a low cost per passenger trip for NEMT. New Jersey Change to statewide broker • 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. • New Jersey reports a higher cost per passenger trip as compared to other states. North Carolina In-house management (county-based) with community transportation • Each county DSS may contract with the local community transportation provider for NEMT on an FFS basis. • The state Medicaid agency solicited proposals from NEMT brokers in 2012. The proposals were rejected because the existing service model (community transportation FFS) was less expensive. • Subject to approval from CMS, the state has decided to change the Medicaid program to managed care with carved-in NEMT (2019). Oregon Change to managed care (coordinated care) with carved-in NEMT • Managed care is delivered through CCOs. • The goals for coordinated care are the Triple Aim: better health, better care, and lower costs. • The CCOs have included NEMT into fully integrated care, and most reduced avoidable emergency room visits. • From the perspective of the state Medicaid agency, the change to coordinated care with carved-in NEMT contributed to the Triple Aim. Pennsylvania In-house management (county-based) with coordinated transportation and Regional broker (one county) • Coordinated transportation service delivers more NEMT trips than any state with comparable population. • The cost per passenger trip for NEMT is lower than other states. • Medicaid is the payer of last resort. The statewide lottery pays 85 percent of the cost of a shared-ride trip for NEMT for seniors. • Customers and advocates want NEMT to be held to higher standards of performance than other shared-ride human services transportation programs for on-time performance, wait times, maximum travel times, and missed trips. Texas Change to regional brokers • From the perspective of the state Medicaid agency, the change to regional brokers lowered the capitated payments 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 cost. Table A-15. Effects on access to medicaid services.

A-64 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination State Case Study and Models for NEMT Effects on Coordination with Human Services Transportation Florida Change to managed care with carved-in NEMT • CTD reports a decline in coordination of NEMT trips with other transportation services since the change to managed care. • The CTCs report higher per passenger trip costs with fewer NEMT shared rides. • The CTCs in rural counties report there are not consistent operating standards for different NEMT brokers, different MCOs, and different funding programs. • NEMT clients no longer have the ability to arrange transportation for multiple trip purposes with one call, one click. Massachusetts Coordinated transportation with RTAs as regional brokers • 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. New Jersey Change to statewide broker • There has been a decline in the degree to which NEMT trips are coordinated with other transportation services since the change to a statewide NEMT broker. • Fewer NEMT trips are on county-based transportation services. The broker contracts with 6 of the 21 county community providers. • NEMT clients no longer have the ability to arrange transportation for multiple trip purposes with one call, one click. North Carolina In-house management (county-based) with community transportation • Community transportation increases operating efficiencies for shared rides on demand-response transportation services. • Coordinating NEMT trips with community transportation achieve increased productivity (passengers per hour) estimated at 5 percent. • NEMT clients can arrange transportation for multiple trip purposes with one call, one click. Oregon Change to managed care (coordinated care) with carved-in NEMT • For those CCOs that continue to work with the regional community broker, coordination with human services transportation continues. • Transportation coordination is more difficult if the regional 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. Pennsylvania In-house management (county-based) with coordinated transportation and regional broker (one county) • Human services transportation is unique in each 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. Texas Change to regional brokers • Lead entities develop regionally coordinated transportation plans; however, most NEMT regional brokers are not actively involved. • NEMT clients cannot arrange transportation for multiple trip purposes with one call, one click. Table A-16. Effects on coordination with human services transportation.

State Case Study Summaries A-65 Table A-17. Effects on coordination with public transportation. State Case Study and Models for NEMT Effects on Coordination with Public Transportation Florida Change to managed care with carved-in NEMT • The loss of NEMT revenue may reduce a source of match for federal transit funds for public transit, particularly in rural counties. • JTA 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. Massachusetts Coordinated transportation with RTAs as regional brokers • RTAs 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 NEMT costs per trip. New Jersey Change to statewide broker • 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. 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. North Carolina In-house management (county-based) with community transportation • Community transportation increases operating efficiencies for shared rides on demand-response transportation services. • 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 by providing NEMT are used for local share for federal transit grants. Oregon Change to managed care (coordinated care) with carved-in NEMT • For those CCOs that continue to work with the regional community broker, public transportation serves a role in providing 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, the public transit authority was the regional community broker but is no longer involved in NEMT in any capacity after the change to a COO. Pennsylvania In-house management (county-based) with coordinated transportation and regional broker (one county) • NEMT coordinated with public transportation reduces the cost per passenger trip. A fare on fixed-route public transportation is the lowest cost transportation for an NEMT trip. • Forty-one percent of NEMT trips stateside are on public transportation. Over 74 percent of NEMT trips in Philadelphia are on public transit. Texas Change to regional brokers • 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.