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Suggested Citation:"Chapter 7 - Strategies to Achieve Common Desired Outcomes." National Academies of Sciences, Engineering, and Medicine. 2018. Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination. Washington, DC: The National Academies Press. doi: 10.17226/25184.
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Suggested Citation:"Chapter 7 - Strategies to Achieve Common Desired Outcomes." National Academies of Sciences, Engineering, and Medicine. 2018. Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination. Washington, DC: The National Academies Press. doi: 10.17226/25184.
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Suggested Citation:"Chapter 7 - Strategies to Achieve Common Desired Outcomes." National Academies of Sciences, Engineering, and Medicine. 2018. Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination. Washington, DC: The National Academies Press. doi: 10.17226/25184.
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Suggested Citation:"Chapter 7 - Strategies to Achieve Common Desired Outcomes." National Academies of Sciences, Engineering, and Medicine. 2018. Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination. Washington, DC: The National Academies Press. doi: 10.17226/25184.
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Suggested Citation:"Chapter 7 - Strategies to Achieve Common Desired Outcomes." National Academies of Sciences, Engineering, and Medicine. 2018. Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination. Washington, DC: The National Academies Press. doi: 10.17226/25184.
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Suggested Citation:"Chapter 7 - Strategies to Achieve Common Desired Outcomes." National Academies of Sciences, Engineering, and Medicine. 2018. Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination. Washington, DC: The National Academies Press. doi: 10.17226/25184.
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Suggested Citation:"Chapter 7 - Strategies to Achieve Common Desired Outcomes." National Academies of Sciences, Engineering, and Medicine. 2018. Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination. Washington, DC: The National Academies Press. doi: 10.17226/25184.
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Suggested Citation:"Chapter 7 - Strategies to Achieve Common Desired Outcomes." National Academies of Sciences, Engineering, and Medicine. 2018. Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination. Washington, DC: The National Academies Press. doi: 10.17226/25184.
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Suggested Citation:"Chapter 7 - Strategies to Achieve Common Desired Outcomes." National Academies of Sciences, Engineering, and Medicine. 2018. Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination. Washington, DC: The National Academies Press. doi: 10.17226/25184.
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Suggested Citation:"Chapter 7 - Strategies to Achieve Common Desired Outcomes." National Academies of Sciences, Engineering, and Medicine. 2018. Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination. Washington, DC: The National Academies Press. doi: 10.17226/25184.
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Suggested Citation:"Chapter 7 - Strategies to Achieve Common Desired Outcomes." National Academies of Sciences, Engineering, and Medicine. 2018. Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination. Washington, DC: The National Academies Press. doi: 10.17226/25184.
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Suggested Citation:"Chapter 7 - Strategies to Achieve Common Desired Outcomes." National Academies of Sciences, Engineering, and Medicine. 2018. Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination. Washington, DC: The National Academies Press. doi: 10.17226/25184.
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Suggested Citation:"Chapter 7 - Strategies to Achieve Common Desired Outcomes." National Academies of Sciences, Engineering, and Medicine. 2018. Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination. Washington, DC: The National Academies Press. doi: 10.17226/25184.
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Suggested Citation:"Chapter 7 - Strategies to Achieve Common Desired Outcomes." National Academies of Sciences, Engineering, and Medicine. 2018. Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination. Washington, DC: The National Academies Press. doi: 10.17226/25184.
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Suggested Citation:"Chapter 7 - Strategies to Achieve Common Desired Outcomes." National Academies of Sciences, Engineering, and Medicine. 2018. Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination. Washington, DC: The National Academies Press. doi: 10.17226/25184.
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64 This chapter identi- fies 14 strategies to coordinate NEMT with human services transportation and public transporta- tion in order to move toward the common desired outcomes. The previous chapter explains different stakeholder perspectives about NEMT and coor- dinated transportation. It also identifies the common expected outcomes for NEMT that are agreed upon by all stakeholders: improved health for Medicaid beneficiaries who need transpor- tation assistance, better quality of transportation service, and the ability to maximize transporta- tion services delivered within available resources. This chapter identifies 14 strategies to coordinate NEMT with human services transportation and public transportation in order to move toward the common desired outcomes. First, the 14 strategies are briefly identified according to desired outcome. Following the brief summary, each strategy is presented as a dedicated page with details of the opportunities, challenges, and roles of stakeholders for a successful strategy implementation. Examples for each strategy are described from the case study research in Chapter 5 and useful resources are suggested. All strategies do not necessarily apply to every state or every NEMT model. If stakeholders look for opportunities that apply best to specific circumstances, collaboration and coordination are possible. Collaboration and coordination will help to achieve common desired outcomes. What Strategies Focus on Common Desired Outcomes? The first three strategies can help stakeholders with different perspectives to focus on com- mon desired outcomes: 1. Align goals and objectives to achieve common desired outcomes. By establishing goals and objectives based on what stakeholders share as common desired outcomes, rather than on where there is disagreement among specific objectives, collaboration can be more effectively pursued. 2. Include NEMT stakeholders when preparing or updating a locally developed, coordinated human services transportation–public transportation plan. The federal transportation authorization bill, the FAST Act, stipulates that public transit agencies should coordinate public transportation services with human services transportation. The coordination of NEMT with public transportation and other human services transportation can better meet the needs of transportation-disadvantaged individuals for all trip purposes to improve their quality of life. Coordinated transportation can improve the efficiency of transportation services. 3. Adopt common geographic boundaries for service areas. Coordination is more likely to improve the efficiency of transportation services if Medicaid and transportation agencies can find a way to adopt common geographic boundaries for NEMT and public transportation service areas. At a minimum, common boundaries for different types of transportation ser- vices will improve the ability to communicate available services to customers. State Medicaid C H A P T E R 7 Strategies to Achieve Common Desired Outcomes

Strategies to Achieve Common Desired Outcomes 65 agencies are typically responsible for defining NEMT service areas. Public transportation service areas may be defined by the state DOT (in particular, for rural transit), or by regional or local decision makers according to city or county boundaries, or by voter approval for specific jurisdictions. What Strategies Can Help to Document Better Health Outcomes? Access to medical services and general mobility are important to improve health outcomes and lower medical costs; however, more data are needed to accurately measure transportation- related benefits and actual reduced health costs. NEMT in rural areas is a particular challenge and rural public transit can help to serve the unique requirements of Medicaid beneficiaries living in rural areas. Innovations in technology and transportation may help to provide better access to medical appointments. Three strategies help to demonstrate how NEMT and transportation to other services and activities contribute to better health outcomes: 4. Measure the contribution of transportation to better health outcomes and reduced health care costs. More research is needed to quantify transportation’s contribution to improved health quality and related cost savings. Both medical and transportation providers can develop experience-based data to confirm the value of NEMT and transportation to other services and activities to keep people healthy. 5. Coordinate NEMT with public transportation to meet the unique requirements of Medicaid beneficiaries, particularly in rural areas. NEMT is necessary for access to medi- cal care, particularly for Medicaid beneficiaries living in rural areas where travel distances to medical services can be long and transportation options are limited. State Medicaid agencies, brokers, and MCOs can coordinate with public transit agencies that operate rural public transportation to provide demand-response NEMT. 6. Demonstrate and evaluate the value of a ridesourcing program for NEMT medical appointments. Mobile technologies and ridesourcing companies are transforming trans- portation. Ridesourcing is a type of transportation that provides a vehicle for hire on demand from a pool of private passenger vehicles. Passengers source rides through a smartphone app. Ridesourcing companies are sometimes called transportation network companies (TNCs) or ride-hailing services. Health care providers and benefits managers are providing patients with transportation via ridesourcing for preventive and chronic care services. Demonstration projects will provide the opportunity to address concerns and evaluate the value of ridesourcing programs for NEMT. What Strategies Contribute to a Better Quality of Service for NEMT? Stakeholders agreed that providing dependable NEMT service that is safe and on time will improve Medicaid beneficiary access to medical services, contribute to improved health out- comes, and lead to a better quality of life. Two strategies contribute to providing a better quality of service through coordinated transportation: 7. Use technology to enhance NEMT program administration and verify medical trips. Available technology can enhance NEMT program administration and facilitate transporta- tion coordination. 8. Identify the key data required and establish standard procedures for data collection and reporting of NEMT performance. Obtaining high-quality, consistent data is a key to measuring performance, monitoring compliance, and addressing the other components of

66 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination transportation program management. Particularly in situations where state Medicaid agen- cies contract with other entities—for example, brokers or MCOs—standard procedures for collecting data and reporting performance for NEMT will help to inform all stakeholders. What Strategies Maximize Transportation Services Delivered Within Available Resources? Delivering efficient transportation can help to maximize transportation services delivered within available resources. CMS and state Medicaid agencies expect NEMT to be provided at the lowest cost for the most appropriate transportation service for the Medicaid beneficiary. More efficient NEMT will help to achieve the lowest cost. Public transit agencies seek to coor- dinate transportation services with human services agencies to improve the efficiency of public transportation services. Economies of scale can be realized by reducing unnecessary redundancies in service and more efficiently using transportation assets. Six strategies are identified to help to maximize transportation services delivered within available resources by coordinating NEMT with public transportation: 9. Use fixed-route transit for appropriate NEMT trips at the lowest cost. If available for the trip and appropriate for the Medicaid beneficiary, fixed-route transit is the lowest cost for NEMT. If a Medicaid beneficiary makes an NEMT trip on fixed-route public transit, the cost to Medicaid is the transit fare. 10. Coordinate shared-ride, demand-response NEMT with other transportation programs to reduce costs per trip. Coordinating shared-ride, demand-response transportation can reduce the costs per NEMT trip by more efficiently using existing transportation resources (e.g., vehicles, drivers, and administrative staff). 11. Implement a transparent cost allocation methodology to show how shared-ride public transportation can lower the cost for an NEMT trip. Public transportation providers can adopt a comprehensive cost accounting system that clearly identifies all costs incurred and all services rendered in order to establish and implement cost allocation to identify direct costs for coordinated services, including NEMT. A comprehensive cost allocation methodology can help to document accurately the direct costs of providing NEMT. The transparency of such a model ensures accountability for NEMT. 12. Establish a procedure to set a rate for NEMT trips on ADA paratransit that is consistent with Medicaid guidelines. When NEMT is provided for individuals with disabilities, a state Medicaid agency or an NEMT broker may have an opportunity to work with a public transit agency to establish a cost-effective rate per NEMT trip on ADA paratransit. CMS has stated that DRA will permit a state Medicaid agency or broker to pay more than the public transit fare for an NEMT trip using ADA paratransit but no more than the rate charged to other human services agencies for similar trips. Public transit agencies can work with other stake- holders to establish an appropriate procedure to set a rate for the use of ADA paratransit that applies to human services agencies and NEMT. 13. Negotiate operations practices and reimbursement rates for transportation providers to recover the direct costs of delivering NEMT service. Public transit agencies and NEMT brokers can work effectively together to the benefit of both if there is a mutual business interest and if both parties have the opportunity to negotiate operational practices and reimbursement rates (pricing) to reflect the direct costs of delivering NEMT service. 14. Adopt procedures and timelines for invoicing and payment for NEMT. Public and pri- vate stakeholders for NEMT recognize the benefits of good business practices, includ- ing the preparation of accurate and complete invoices and timely payment. Providers of NEMT need prompt payment of invoices to ensure cash flow for incurred expenses such as payroll, fuel, and parts and supplies for vehicle maintenance. Buyers of NEMT service can

Strategies to Achieve Common Desired Outcomes 67 ensure positive relationships with transportation providers and benefit from lower prices based on good business practices. Description of Strategies In the following boxes, each strategy is described—its opportunities, challenges, stakeholder roles, examples, and useful resources. Strategy 1. Align goals and objectives to achieve common desired outcomes. Opportunities Stakeholders find it is increasingly important to consider how improved coordination and collaboration can help to meet the growing need for NEMT within the constraints of limited financial resources. By establishing goals based on what stakeholders share as common desired outcomes, rather than on where there is disagreement among specific objectives, collaboration can be more effectively pursued. The common desired outcomes are improved health, better quality of service, and maximum services delivered within available resources (more efficient delivery of NEMT service). Stakeholders involved in funding and providing NEMT reflect different perspectives. For example, the Medicaid perspective focuses on getting eligible beneficiaries to and from approved medical services with the most appropriate mode of transportation at the lowest cost, while avoiding the risks of fraud and abuse. Reflecting a different perspective, public transportation agencies focus on getting all riders to and from a variety of destinations, including medical services, through shared rides and coordinated funding programs. Stakeholder roles Transportation to improve access to medical services for individuals and families with low incomes requires the efforts of state officials, regional and local transportation providers, statewide or regional brokers (in a growing number of states), and MCOs. All stakeholders can participate in the effort to align goals and objectives from different stakeholder perspectives. Human services program managers and mobility managers can serve as facilitators. Massachusetts. The Commonwealth coordinates human services transportation, including NEMT, and public transportation under brokerages operated by regional transit authorities. A regional mobility manager in each of nine regions works to coordinate the goals and objectives for community transportation in each region. North Carolina. Community transportation providers are required to have a Transportation Advisory Board (TAB). The TAB includes stakeholders with a variety of perspectives that participate in an open dialogue about the objectives for coordination of all transportation with a single provider within a county or region. Oregon. Lane Transit District (LTD) is the public transit agency for Eugene-Springfield and the NEMT broker for the CCO in Lane County. LTD attributes the successful collaboration to the effort to align goals and objectives of public transit with the CCO when the partnership began. Resources U.S. General Accountability Office. 2006. Practices That Can Help Enhance and Sustain Collaboration among Federal Agencies, GAO-06-15. https://www.gao.gov/assets/250/248219.pdf. U.S. General Accountability Office. 2012. Managing for Results: Key Considerations for Implementing Interagency Collaborative Mechanisms, GAO-12-1022. https://www.gao.gov/products/GAO-12-1022. Schlossberg, M. 2003. “Developing Coordination Policies for Paratransit and the Transportation Disadvantaged,” Transportation Research Record: Journal of the Transportation Research Board, No. 1841. http://trrjournalonline.trb.org/doi/abs/10.3141/1841-08. Challenges Highlights from case study examples

68 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination Opportunities The federal transportation authorization bill, the FAST Act, stipulates public transit agencies should coordinate public transportation services with human services transportation. The coordination of NEMT with public transportation and other human services transportation can better meet the needs of transportation-disadvantaged individuals for all trip purposes to improve quality of life. Coordinating transportation can improve the efficiency of transportation services by reducing unnecessary redundancies in service and more efficiently using existing transportation resources. State agencies responsible for Medicaid NEMT and public transportation may not currently align programs for the purpose of meeting the transportation needs of the transportation disadvantaged (older adults, individuals with disabilities, and individuals with low income). In states with in-house management, coordination of NEMT with public transportation may be a missed opportunity. In other states where a statewide or regional broker is the NEMT model, the state Medicaid agency may not require or encourage brokers to consider public transportation providers. Stakeholder roles The purpose of CCAM is to reduce duplication among federally funded transportation services, increase the efficient delivery of such services, and expand transportation access for older adults, individuals with disabilities, and persons with low income. The FAST Act directs CCAM to develop a strategic plan that outlines the role and responsibilities of each federal agency with respect to local transportation coordination, including NEMT, to strengthen interagency collaboration. FTA requires projects funded under the Section 5310 Enhanced Mobility of Seniors and Individuals with Disabilities Program to be included in a locally developed, coordinated human services transportation–public transportation plan. Regional and local transportation providers, NEMT brokers, MCOs, human services program managers, and mobility managers can contribute to locally developed, coordinated transportation plans. Texas. State statute requires each of 24 regions to develop regionally coordinated human services–public transportation plans to promote strategic partnerships among local and state agencies. A lead entity in each region works with other stakeholders to prepare and update the coordinated transportation plans. Lead entities are encouraged to involve NEMT brokers and transportation providers in the regional coordination effort. Participation varies by region. When the NEMT regional broker does participate, the effectiveness of the process is enhanced. Resources U.S. General Accountability Office. 2012. Transportation-Disadvantaged Populations, Federal Coordination Efforts Could Be Further Strengthened, GAO-016-15. http://www.gao.gov/assets/600/591707.pdf. FTA. “Coordinating Council on Access and Mobility.” https://www.transit.dot.gov/ccam. National Center for Mobility Management. http://nationalcenterformobilitymanagement.org/. Challenges Highlights from case study examples Strategy 2. Include NEMT stakeholders when preparing or updating a locally developed, coordinated human services transportation–public transportation plan.

Strategies to Achieve Common Desired Outcomes 69 Strategy 3. Adopt common geographic boundaries for service areas. Opportunities Coordination is more likely to improve the efficiency of transportation services if Medicaid and transportation agencies can find a way to adopt common geographic boundaries for NEMT and public transportation services. At a minimum, common boundaries for different types of transportation services will improve the ability to communicate available services to customers. State agencies use a variety of means to determine the geographic boundaries for delivery of transportation services. For example, some state Medicaid agencies may define NEMT service areas according to metropolitan areas, county jurisdictions, health care catchment areas, or a variety of other boundaries. Public transit agencies may be defined by city or county boundaries, or by voter approval for specific jurisdictions. Complex and overlapping service areas may confuse customers and make coordination of NEMT with public transportation more difficult. Sometimes the differences in service coverage areas or policies for crossing jurisdiction boundaries may present challenges. For example, if public transportation is not available throughout an entire state, the state Medicaid agency has no choice but to find other providers. Medicaid trips in rural areas are likely to cross the boundaries of a public transit agency. In some instances, public transit agencies cannot, by statute or by policy, provide service outside jurisdiction boundaries. Stakeholder roles State Medicaid agencies can consider public transportation geographic service areas when deciding regions for delivery of NEMT services by fee for service or broker. State, regional, and local public transportation agencies can more effectively collaborate with the state Medicaid agency if service areas can be flexible to accommodate NEMT trips. This may mean finding operational solutions for trips that cross jurisdiction boundaries or seeking legislative relief if statutes or local ordinances prohibit this type of coordination. Massachusetts. The state Medicaid agency provides NEMT through a coordinated transportation program. Six regional public transit authorities serve as brokers to provide transportation services in nine regions. North Carolina. Each county Department of Social Services may contract with the local community transportation provider for NEMT. Pennsylvania. The broker for MATP (NEMT) in Allegheny County is ACCESS, the ADA paratransit provider for the Port Authority of Allegheny County (Pittsburgh). ACCESS provides NEMT by subcontracting to six different transportation providers. Resources KFH Group, Inc. 2008. TCRP Report 124: Guidebook for Measuring, Assessing, and Improving Performance of Demand-Response Transportation. http://www.trb.org/Publications/Blurbs/159758.aspx. Ellis, E., and KFH Group, Inc. 2009. TCRP Report 136: Guidebook for Rural Demand- Response Transportation: Measuring, Assessing, and Improving Performance. http://www.trb.org/Publications/Blurbs/162701.aspx. Challenges Highlights from case study examples

70 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination Opportunities More research is needed to quantify transportation’s contribution to improved health outcomes and related cost savings. Both medical and transportation providers can develop experience-based data to confirm the value of NEMT and transportation to other services and activities to keep people healthy. Improved mobility is an important factor in keeping people healthy. Mobility involves more than an occasional trip to the doctor. Preventive health care and community- based rehabilitation services, for example, contribute to maintaining good health. Access to fresh and affordable groceries, pharmacies, and recreational and socialization activities helps to keep people healthy. Within some age groups, access to employment is a key to maintaining good health. Mobility and access to services are important to improve health outcomes and lower (or at least control) medical costs; however, more research is needed to accurately measure transportation-related benefits and actual reduced costs. Stakeholder roles All stakeholders can participate in projects to measure the contribution of transportation to better health outcomes and reduced health care costs. CCAM can encourage related research. State Medicaid agencies can document the reduced number and duration of hospital visits and reduced use of ambulances for emergency transportation. Brokers and transportation providers can document NEMT trips. MCOs, human services program managers, and mobility managers can document experience-based data and link to evidence of health outcomes. Florida. Medicaid recipients in Florida now enroll in a health plan provided by an MCO. NEMT is carved in to each health plan. The MCOs are responsible for health outcomes. Oregon. The CCOs in Oregon have made significant progress integrating required services and encounter data into the information systems. Some CCOs have integrated NEMT service data and health services encounter data. Resources Cheung, P. T., J. T. Wiler, R. A. Lowe, and A. A. Ginde. 2012. “National Study of Barriers to Timely Primary Care and Emergency Department Utilization Among Medicaid Beneficiaries,” Annals of Emergency Medicine, Vol. 60, No. 1. http://www.annemergmed.com/article/S0196-0644(12)00125-4/pdf. National Center for Mobility Management. http://nationalcenterformobilitymanagement.org/. Hughes-Cromwick, P., R. Wallace, H. Mull, et al. 2005. TCRP Web-Only Document 29: Cost-Benefit Analysis of Providing Non-emergency Medical Transportation. https://www.nap.edu/catalog/22055/cost-benefit-analysis-of-providing-non-emergency- medical-transportation. Wallace, R., P. Hughes-Cromwick, and H. Mull. 2006. “Cost Effectiveness of Access to Nonemergency Medical Transportation: Comparison of Transportation and Health Care Costs and Benefits,” Transportation Research Record: Journal of the Transportation Research Board, No. 1956. http://trrjournalonline.trb.org/doi/abs/ 10.3141/1956-11. Challenges Highlights from case study examples Strategy 4. Measure the contribution of transportation to better health outcomes and reduced health care costs.

Strategies to Achieve Common Desired Outcomes 71 Opportunities NEMT is necessary for access to medical care, particularly for Medicaid beneficiaries living in rural areas where travel distances to medical services can be long and transportation options are limited. Fewer transportation providers are available for NEMT in rural areas. State Medicaid agencies, brokers, and MCOs can contract with public transit agencies that operate rural public transportation to provide demand-response NEMT. Coordination with public transportation can leverage FTA Section 5311 funds and make full use of required compliance with federal and state regulations, increasing the safety and quality of service for NEMT in rural areas. Federal cost principles enable public transit agencies to share the use of vehicles to provide NEMT. FTA requires public transit agencies to operate wheelchair-accessible vehicles, which can benefit NEMT clients who use mobility devices. A public transit agency may incur additional costs to meet the NEMT service challenges in rural areas. Rural NEMT trips tend to be longer, and there is less opportunity for shared rides to medical appointments. Due to long distances and limited ability to share rides, one passenger trip can take several hours for travel to/from the medical appointment, requiring the dedication of a driver and vehicle for several hours. Performance standards for wait time and travel time may be difficult or not possible to meet for long-distance travel and shared rides. Stakeholder roles Brokers and MCOs that receive capitation payments have some flexibility to adapt service strategies and reimbursement rates to meet NEMT challenges in rural areas. MCOs can demonstrate strategies that reduce costs associated with long-distance medical trips (e.g., group scheduling for medical appointments). Public transit agencies can demonstrate through a transparent cost allocation methodology and proven performance that rural public transportation can be cost effective and add value for NEMT with qualified, trained drivers and well-maintained, accessible vehicles that meet federal and state transit regulations. North Carolina. By coordinating NEMT with rural public transit, community transportation systems in North Carolina achieve increased productivity estimated at 5 percent (expressed in terms of passengers per hour and passengers per mile). Texas. Regional NEMT brokers serving very rural areas in Texas do not have access to many transportation providers. A rural transit district may be one of the few possible NEMT providers. Rural transit districts report that the cost for NEMT passenger trips tends to be higher in very rural areas due to the longer trips and less opportunity for shared rides due to limits on total NEMT passenger travel time. Resources Mattson, J. 2011. “Transportation, Distance, and Health Care Utilization for Older Adults in Rural and Small Urban Areas,” Transportation Research Record: Journal of the Burkhardt, J. E., C. A. Nelson, G. Murray, et al. 2004. TCRP Report 101: Toolkit for Rural Community Coordinated Transportation Services. http://onlinepubs.trb.org/onlinepubs/tcrp/tcrp_rpt_101.pdf. Challenges Highlights from case study examples Strategy 5. Coordinate NEMT with public transportation to meet the unique requirements of Medicaid beneficiaries, particularly in rural areas. Transportation Research Board, No. 2265. http://trrjournalonline.trb.org/doi/abs/10.3141/2265-22.

72 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination Opportunities The Medicaid program is changing from traditional, state-administered fee-for-service medicine to managed care or coordinated care that rewards medical providers for keeping people healthy and out of costly emergency facilities. At the same time, mobile technologies and ridesourcing companies are transforming transportation. Ridesourcing companies are also known as TNCs or ride-hailing services. The concurrence of these emerging developments has implications for NEMT. Ridesourcing for NEMT may offer opportunities, but there is a need to evaluate potential challenges surrounding the use of nontraditional transportation and new technologies. The same socioeconomic and demographic factors that create transportation barriers for Medicaid beneficiaries may also mean the same individuals do not have access to technology such as smartphones. NEMT clients may require personal assistance, which can lead to slower service at odds with the financial incentives for ridesourcing drivers. Ridesourcing companies have been reluctant to enter into the NEMT business because of requirements for driver credentialing and data sharing. These and other challenges require evaluation and resolution to confirm the value of a ridesourcing program for NEMT. Stakeholder roles Health care providers and benefits managers are providing patients with transportation via ridesourcing for preventive and chronic care services. MCOs have the flexibility to demonstrate and adapt policies and procedures for use of ridesourcing for NEMT. Brokers can serve as intermediaries to resolve some NEMT challenges. For example, the broker’s call center can accept requests for transportation from NEMT clients and then relay the request via a secure platform to dispatch a ridesource driver. In some states, public transit agencies are demonstrating use of ridesourcing to provide ADA paratransit. These experiences can contribute to finding ways to optimize the use of public transportation and ridesourcing for NEMT. Pennsylvania. The Central Pennsylvania Transportation Authority (rabbittransit) announced in 2017 that the agency is working with TNCs to create a program in which senior citizens, people with disabilities, and Medicaid beneficiaries can use ridesourcing services if rabbittransit is overbooked or short on vehicles. Officials of rabbittransit say ridesourcing services are sometimes used to free up public transit vehicles in urban areas, and other times ridesourcing services are used for single trips in more rural areas that cannot be combined with other trips in a shared ride. Resources National Center for Mobility Management. http://nationalcenterformobilitymanagement.org/. TRB. 2015. Special Report 319: Between Public and Private Mobility: Examining the Rise of Technology-Enabled Transportation Services. http://www.trb.org/Publications/Blurbs/173511.aspx. Challenges Highlights from case study examples Strategy 6. Demonstrate and evaluate the value of a ridesourcing program for NEMT medical appointments.

Strategies to Achieve Common Desired Outcomes 73 Strategy 7. Use technology to enhance NEMT program administration and verify medical trips. Opportunities Available technology can enhance NEMT program administration in several ways: • Verify the client requesting NEMT services is eligible and the trip is for an approved, valid medical purpose. • Assign the trip to a transportation provider qualified to offer the appropriate level of service at the lowest cost. • Document the date, time, and location for each NEMT encounter. • Track and report transportation performance metrics. • Schedule NEMT and other trips with one call/one click. • Provide real-time transportation information to riders. • Connect transportation and health care datasets to measure health outcomes. Medicaid will permit NEMT funds to be used only for transportation for eligible Medicaid beneficiaries to authorized medical services. NEMT requires verification that the Medicaid-eligible passenger receives an authorized medical service on the date of transportation and consistent with the time of the medical appointment. Medicaid expects to pay only the direct costs for the eligible NEMT trip. Stakeholder roles State Medicaid agencies and state DOTs can provide funding support or incentivize brokers and transportation providers to develop technology applications for NEMT. Public transit agencies deploy technology to improve the customer experience and increase operating efficiency and effectiveness; advancements in technology for public transportation can be applied to benefit NEMT. MCOs have the flexibility to develop and implement new technology. Massachusetts. Montachusett Regional Transit Authority (MART) brokers NEMT and other human services transportation in four regions. MART uses a web-based, real- time, competitive bidding system to keep prices affordable. Oregon. The benefit of coordinated care is the flexibility of some CCOs to adopt software enhancements to collect encounter data while protecting personal information under privacy provisions of the Health Insurance Portability and Accountability Act. Pennsylvania. FindMyRidePA is a Pennsylvania-based service designed to help anyone to identify and evaluate options to meet their transportation needs. In some cases, users can even book a trip directly. The transportation services available through FindMyRidePA are fixed-route buses and shared-ride services. Shared-ride services include the Shared-Ride Program for Senior Citizens, Rural Transportation for Persons with Disabilities Program, and MATP (NEMT). Resources National Center for Mobility Management. 2013. “Transportation Coordination Enabled by Technology and Innovative Design.” http://nationalcenterformobilitymanagement.org/wp- content/uploads/2013/11/Promising-Practices_Transportation-Coordination-Enabled- by-Technology.pdf. Schweiger, C. L. 2011. TCRP Synthesis 91: Use and Deployment of Mobile Device Technology for Real-Time Transit Information. http://www.trb.org/Publications/Blurbs/166249.aspx. Challenges Highlights from case study examples

74 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination Opportunities Obtaining high-quality, consistent data is a key to measuring performance, monitoring compliance, and addressing the other components of good transportation program management. Particularly in situations where state Medicaid agencies contract with other entities—for example, brokers or MCOs—standard procedures for collecting data and reporting performance will help to inform all stakeholders. The NTD serves as an example of an effective way to gather consistent data from many transportation providers. The NTD is a reporting system that collects public transportation financial and operating information every year from all public transit agencies that receive federal funding from FTA. Each year, NTD performance data are used to apportion $5 billion of FTA formula funds to public transit agencies. FTA submits annual NTD reports to Congress summarizing transit service and safety data. Consistent data for NEMT across states do not exist. Federal and state funding for NEMT is not consistently tracked and reported at the state level. Without standardized and consistent data collection, tracking, and reporting practices, measuring performance in meeting goals is difficult, and decision makers lack good information to make policy and operating decisions. Stakeholder roles CCAM could sponsor an initiative to identify the data that are appropriate for NEMT reporting. CMS could promote a national effort for consistent data collection and reporting, similar to the NTD. CMS and FTA could enter into a cooperative agreement, perhaps through the National Center for Mobility Management, to train and provide technical backup to state Medicaid agencies, brokers, transportation providers, and other organizations to collect and report quality performance data for NEMT. State Medicaid agencies could incorporate standard procedures for collecting data and reporting NEMT data in requests for proposals and contracts with transportation providers, brokers, and MCOs. States could report annual data on standard forms to CMS. Massachusetts. EOHHS established the Human Service Transportation Office to coordinate transportation for multiple health and human services agencies, including NEMT for the state Medicaid agency (MassHealth). Each year, the Human Service Transportation Office compiles system performance measures for all transportation services provided through regional brokerages. The performance measures are reported in an annual report by region, by the Human Service Transportation Office program, and by totals. Universal performance measures apply to all state programs operating under the brokerage. New Jersey. DMAHS requires that the statewide broker provide data to enable DMAHS to compile a substantial monthly Transportation Broker Report. This report is a valuable tool for monitoring the Medicaid NEMT program and provides current and historical data. Resources National Center for Mobility Management. http://nationalcenterformobilitymanagement.org/. FTA. 2017. 2017 NTD Policy Manual. https://www.transit.dot.gov/node/57981. Strategy 8. Identify the key data required and establish standard procedures for data collection and reporting of NEMT performance. Challenges Highlights from case study examples

Strategies to Achieve Common Desired Outcomes 75 Strategy 9. Use fixed-route transit for appropriate NEMT trips at the lowest cost. Opportunities If available for the trip and appropriate for the Medicaid beneficiary, fixed-route transit is the lowest cost for NEMT. If a Medicaid beneficiary makes an NEMT trip on fixed- route public transit, the cost to Medicaid is the transit fare. Public transit agencies benefit from NEMT riders on fixed routes to increase productivity (passengers per hour) and cost-effectiveness (cost per passenger). Brokers and MCOs benefit from the lowest cost for NEMT trips. If the state Medicaid agency directly contracts for NEMT, the state benefits from the low cost for NEMT. Fixed-route public transportation is not available in all communities. Fixed-route bus and rail transit services are most common in more densely populated urban areas. Not every Medicaid beneficiary can use fixed-route transit. Some individuals cannot use fixed-route transit or get to fixed-route stops due to a disability. For these individuals, fixed-route transit is not appropriate for an NEMT trip. When fixed-route bus and rail public transportation is available for convenient travel, brokers and MCOs do not always take full advantage of this lower-cost option for NEMT. Stakeholder roles All stakeholders can participate in the effort to use fixed-route transit for appropriate NEMT trips at a lower cost. CMS can update the guidance on use of bus passes to reflect current technology for smart fare cards. State Medicaid agencies can require or incentivize brokers and MCOs to use fixed-route transit when appropriate. Public transit agencies can facilitate by providing customer information for ease of planning and scheduling NEMT trips on transit. Human services program managers and mobility managers can provide travel training for Medicaid beneficiaries to take advantage of fixed-route transit for greater mobility. New Jersey. Because of the extensive public transit system in urban counties in New Jersey, many Medicaid beneficiaries can use fixed-route rail or bus service to travel to medical appointments. In urban areas, public transportation represents 23.5 percent of NEMT trips. The use of fixed-route transit reduced the cost of NEMT in New Jersey. Oregon. In Lane County, the CCO (Trillium) elected to continue contracting with the established regional community broker (RideSource) for a service of the public transit agency, LTD. As the NEMT broker, RideSource assigns appropriate trips to LTD fixed route. Under the CCO model, passenger trips assigned to LTD fixed route increased 117 percent. Pennsylvania. The Department of Health Services estimates that 41 percent of NEMT trips are on fixed-route public transportation statewide. Reported expenditures for MATP (NEMT) were an average $12.96 per passenger trip in 2013, which is one-third the average cost of NEMT per passenger trip reported by some other states. Resources Thacher, R., C. Ferris, D. Chia, et al. 2013. TCRP Report 163: Strategy Guide to Enable and Promote the Use of Fixed-Route Transit by People with Disabilities. http://www.trb.org/Publications/Blurbs/170626.aspx. Challenges Highlights from case study examples

76 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination Opportunities Coordinating shared-ride, demand-response transportation can reduce the costs per NEMT trip by more efficiently using existing transportation resources (e.g., vehicles, drivers, and administrative staff). Obstacles impeding coordination include concerns of program sponsors that their own participants might be negatively affected by shared rides, program rules that limit use by others, real and perceived regulatory barriers, and limited guidance and information on coordination. Coordination of services is also challenging due to differences in federal program requirements and statutory barriers. Stakeholder roles All stakeholders can participate in efforts to ensure that real and perceived obstacles are addressed through good program coordination, improved quality of service, and demonstrated efficiencies. Members of CCAM can propose changes to federal regulations that will eliminate barriers to transportation coordination. Public transit agencies can demonstrate the advantages of coordinating to make full use of required compliance with federal and state regulations, increasing the safety and quality of service for NEMT. Massachusetts. The use of regional transit authorities to broker coordinated human services transportation in Massachusetts has produced positive results for the NEMT program by containing costs per trip and ensuring service quality. North Carolina. Community transportation increases operating efficiencies for shared rides on demand-response transportation services. Coordinating NEMT trips with community transportation achieves increased efficiencies. Medicaid beneficiaries can arrange transportation for multiple trip purposes with one call/one click. Pennsylvania. rabbittransit is the shared-ride coordinator for a multicounty region in southcentral Pennsylvania. With the coordinated approach, rabbittransit 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 administrative costs for county-specific programs, including MATP (NEMT). Resources KFH Group, Inc. 2008. TCRP Report 124: Guidebook for Measuring, Assessing, and Improving Performance of Demand-Response Transportation. http://www.trb.org/Publications/Blurbs/159758.aspx. Ellis, E., and KFH Group, Inc. 2009. TCRP Report 136: Guidebook for Rural Demand- Response Transportation: Measuring, Assessing, and Improving Performance. http://www.trb.org/Publications/Blurbs/162701.aspx. Burkhardt, J. E., R. Garrity, K. McGehee, et al. 2011. TCRP Report 144: Sharing the Costs of Human Services Transportation. http://www.trb.org/Publications/Blurbs/165015.aspx. Strategy 10. Coordinate shared-ride, demand-response NEMT with other transportation programs to reduce costs per trip. Challenges Highlights from case study examples

Strategies to Achieve Common Desired Outcomes 77 Opportunities Public transportation providers can adopt a comprehensive cost accounting system that clearly identifies all costs incurred and all services rendered in order to establish and implement cost allocation to identify direct costs for coordinated services, including NEMT. A comprehensive cost allocation methodology can help to accurately document the direct costs of providing NEMT. The transparency of such a model ensures accountability for NEMT and helps to make the case for appropriately pricing public transportation. A public transit agency looks to negotiate a price for NEMT demand-response service to cover the fully allocated cost of the NEMT trip. Fully allocated costs include variable costs of the NEMT trip plus direct fixed costs. However, Medicaid expects to pay only the direct costs for the NEMT trip, and Medicaid is the payer of last resort. A fundamental function of an NEMT broker is to arrange the most appropriate and lowest-cost transportation to and from authorized medical services. If the broker is a governmental entity and the individual transportation service is provided by the broker, or is referred to or subcontracted with another government-owned or operated transportation provider, then additional financial conditions must be met. The additional financial conditions are maintaining a separate cost accounting system for NEMT, excluding shared costs or costs allocated from another governmental entity, and documenting the public transportation service as the lowest-cost transportation available. Stakeholder roles CCAM is developing a cost-sharing policy to increase participation by recipients of federal grants in locally developed, coordinated planning processes. The state Medicaid agency and state DOT in each state can develop a cost allocation methodology appropriate for the NEMT model in that state. The state Medicaid agency can encourage private and public NEMT brokers to join the collaboration. The cost allocation methodology can be applicable to human services transportation and public transportation providers that participate in NEMT. North Carolina. The North Carolina Department of Transportation created a standardized cost allocation methodology for use by all community transportation systems. With this spreadsheet tool, all providers had a common methodology to price service provided under contract for NEMT, as well as other human services agencies. Pennsylvania. The cost allocation model used by ACCESS in Allegheny County provides transparency and an explanation for the costs of services. 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 (e.g., NEMT), 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. Resources Burkhardt, J. E., R. Garrity, K. McGehee, et al. 2011. TCRP Report 144: Sharing the Costs of Human Services Transportation. http://www.trb.org/Publications/Blurbs/165015.aspx. Strategy 11. Implement a transparent cost allocation methodology to show how shared-ride public transportation can lower the cost for an NEMT trip. Challenges Highlights from case study examples

78 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination Opportunities When NEMT is provided for individuals with disabilities, a state Medicaid agency or an NEMT broker may have an opportunity to work with a public transit agency to establish a cost-effective rate per NEMT trip on ADA paratransit. CMS has stated that the DRA will permit a state Medicaid agency or broker to pay more than the public transit fare for an NEMT trip using ADA paratransit but no more than the rate charged to other human services agencies for similar trips. Given FTA regulations that prohibit ADA capacity constraints, a public transit agency cannot deny a trip request from an ADA-eligible traveler for an NEMT trip. Typically, the fare for an ADA paratransit trip covers only a small portion (7.5 percent) of the cost of the service. The remainder of the cost of ADA service must come from federal transit grants, state funds, or local subsidies. Growing demand for ADA paratransit service stemming from shifts of NEMT trips to public transportation can be a significant concern for some public transit agencies. A state Medicaid agency or NEMT broker may pay a rate for NEMT trips on ADA paratransit that is more than the public transit fare but no more than what the public transit agency charges other human services agencies for similar trips. Stakeholder roles A state Medicaid agency or broker can pay a public transit agency the rate charged to other human services agencies for similar trips on ADA paratransit. This policy is stated in Medicaid regulations for NEMT, and the state Medicaid agency can include these provisions in the contract with brokers. There is no requirement that ADA paratransit providers be paid at cost for NEMT trips by the state Medicaid agency or brokers. Public transit agencies can work with the state Medicaid agency and brokers to establish a procedure to confirm ADA eligibility using the public transit ADA certification process, document actual NEMT passenger trips on ADA paratransit, and establish a rate for NEMT trips. The rate for an NEMT trip can be more than the public transit fare for ADA paratransit but no more than what the public transit agency charges other human services agencies for similar trips. Florida. The Jacksonville Transportation Authority (JTA) reported an increased number of ADA paratransit trips when the Managed Medical Assistance program went into effect during the Demonstration Pilot Program for Managed Care. Other than the fare for ADA paratransit, JTA received no reimbursement or shared costs from the MCO or the MCO broker. Massachusetts. Executive Order 530 established a Commission for the Reform of Community, Social Service, and Paratransit Transportation Services in the Commonwealth of Massachusetts. In one of 60 recommendations, the commission recommended establishing a working group to develop a mechanism to apply for Medicaid funding for NEMT services provided on Massachusetts Bay Transportation Authority fixed routes and ADA paratransit for Medicaid-eligible beneficiaries. Resources KFH Group, Inc. 2008. TCRP Report 124: Guidebook for Measuring, Assessing, and Improving Performance of Demand-Response Transportation. http://www.trb.org/Publications/Blurbs/159758.aspx. Burkhardt, J. E., R. Garrity, K. McGehee, et al. 2011. TCRP Report 144: Sharing the Costs of Human Services Transportation. http://www.trb.org/Publications/Blurbs/165015.aspx. Challenges Highlights from case study examples Strategy 12. Establish a procedure to set a rate for NEMT trips on ADA paratransit that is consistent with Medicaid guidelines.

Strategies to Achieve Common Desired Outcomes 79 Opportunities Stakeholder roles Resources Burkhardt, J. E., R. Garrity, K. McGehee, et al. 2011. TCRP Report 144: Sharing the Costs of Human Services Transportation. http://www.trb.org/Publications/Blurbs/165015.aspx. Challenges Highlights from case study examples Strategy 13. Negotiate operations practices and reimbursement rates for transportation providers to recover the direct costs of delivering NEMT service. Cost means the total cost of providing transportation services. Price refers to a rate of payment specified in a contract between the broker and the transportation provider. Price can be specified as a cost per trip, per mile, per hour, or some combination of these; additions to the price might be allowed for special or extraordinary service or assistance. Public transit agencies and NEMT brokers can work effectively together to the benefit of both if there is a mutual business interest and if both parties have the opportunity to negotiate operational practices and reimbursement rates (pricing) to reflect the cost of delivering NEMT service. This mutual business interest can be enhanced if the cost allocation methodology is transparent and follows a cost-sharing policy approved at the federal and state levels (see Strategy 11). Reimbursement rates and performance standards should reflect the actual costs of providing NEMT services. For example, a Medicaid standard of one hour or less to pick up and return an NEMT client from a medical service to home might be less than the average time for a shared-ride trip. When the transportation provider has to make a trip for one NEMT client, the per-trip cost increases. Under a fixed-price reimbursement structure, recovering actual trip expenses may be difficult for any transportation provider. If this happens too often, private transportation providers will not be able to sustain the business in the long term. If the actual cost for an NEMT trip is not recovered by a public transportation provider, another source of public revenue will be required to subsidize NEMT trips. State DOTs can work with transit agencies and other NEMT transportation providers to ensure that each provider understands how operational procedures affect the costs of NEMT services and how to negotiate pricing strategies that appropriately and reasonably recover the costs of NEMT services. New Jersey. The general practice of New Jersey’s statewide 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 client). Several public transportation providers are satisfied with the rates they have been offered by the broker. Providers in other areas reported that flat rates do not cover all NEMT-related trip costs. Pennsylvania. The cost allocation model used by ACCESS in Allegheny County provides an explanation for the costs of services as well as transparency about the way money is spent. ACCESS also uses the cost allocation model to demonstrate how sponsors can adopt operating policies that can lower cost. Texas. Some public transit districts that contract with a regional broker(s) have negotiated rates to recover reasonable costs for long-distance NEMT trips where a driver and vehicle are dedicated all day to one or a few NEMT clients.

80 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination Strategy 14. Adopt procedures and timelines for invoicing and payment for NEMT. Opportunities Public and private stakeholders for NEMT recognize the benefits of good business practices, including preparation of accurate and complete invoices and timely payment. Providers of NEMT (for-profit, not-for-profit, and public transportation providers) need prompt payment of invoices to ensure cash flow for incurred expenses such as payroll, fuel, and parts and supplies for vehicle maintenance. Buyers of NEMT service (state Medicaid agencies, brokers, and MCOs) can ensure positive relationships with transportation providers and benefit from lower prices based on good business practices. Paying on agreed terms injects more money into the local economy, helps existing providers to be more sustainable, and benefits public transit agencies that use NEMT revenues to provide local match for federal transit grants. Capitation payments to brokers and MCOs may be paid in advance, but payments to transportation providers are typically for services performed and documented. Too often, payment terms and documentation requirements are not clear in purchase of service contracts between buyers and providers. The providers may not prepare accurate and complete invoices that will withstand audit, delaying payment. The buyers may choose to delay payment to the due date or later as a financial tactic to better the buyer’s position. The cost of paying on time is low compared to almost anything else a buyer can do to maintain a good business reputation and ensure good relationships with transportation providers. Stakeholder roles State Medicaid agencies can require brokers and MCOs to include prompt payment terms in contracts with transportation providers, as well as follow best practices for fee-for-service contracts. Brokers and MCOs can make clear payment terms and documentation requirements in purchase of service contracts and provide training to prepare accurate invoices with proper documentation. Brokers and MCOs can also promptly review invoices to identify any missing information so that providers can address issues right away. Providers must use good business practices to submit accurate and timely invoices with required documentation of performance. Technology can enhance NEMT invoicing and reporting of performance metrics (see Strategy 7). Massachusetts. The broker schedules trips with a computerized scheduling system for all human services transportation trips. For NEMT, automated mapping determines mileage, rate, and low-cost transportation provider, programmed to schedule only trips that have a valid PT-1 form (NEMT) in the system. A daily MassHealth consumer eligibility program is run, and ineligible trips are canceled through the program. Authorized scheduled trips are transferred to the transportation provider’s invoice to ensure authorization of trips billed. Resources Burkhardt, J. E., R. Garrity, K. McGehee, et al. 2011. TCRP Report 144: Sharing the Costs of Human Services Transportation. http://www.trb.org/Publications/Blurbs/165015.aspx. TRB. 2001. Special Report 258: Contracting for Bus and Demand-Responsive Transit Services. http://onlinepubs.trb.org/onlinepubs/sr/sr258.pdf. Challenges Highlights from case study examples

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TRB's Transit Cooperative Research Program (TCRP) Research Report 202: Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination provides background information and describes the different models available to states for providing non-emergency medical transportation (NEMT) for Medicaid beneficiaries. The handbook also discusses why human services transportation and public transportation providers encourage coordination of NEMT with other transportation services.

The report is accompanied by a companion document that explores the state-by-state profiles for examining the effects of NEMT brokerages on transportation coordination.

The Medicaid program is the largest federal program for human services transportation, spending approximately $3 billion annually on NEMT. Because the Medicaid program is administered by states, which are able to set their own rules within federal regulations and guidelines set by the Centers for Medicare and Medicaid Services (CMS), coordination of NEMT with public transit and human services transportation is highly dependent on each state Medicaid agency’s policies and priorities.

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