Transportation Disadvantaged Populations: Nonemergency Medical Transportation Not Well Coordinated, and Additional Federal Leadership Needed
Published: 2014-12-10T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Access to transportation services is essential for millions of Americans to fully participate in society and access human services, including medical care. NEMT is nonemergency, nonmilitary, surface transportation service of any kind provided to beneficiaries or clients for the purpose of receiving medical care. GAO was asked to review the coordination of NEMT services. This report addresses (1) the federal programs that provide funding for NEMT services, (2) how federal agencies are coordinating NEMT services, and (3) how NEMT services are coordinated at the state and local levels and the challenges to coordination.
GAO analyzed a compendium of federal programs that provide assistance to the public; reviewed program information from the six departments that fund NEMT; interviewed officials of DOT, HHS, and VA; and interviewed state and local officials in five states, chosen based on a variety of considerations, including geographic diversity and existence of a coordinating body.
section_title: What GAO Found
paragraphs: Forty-two programs across six federal departments—Agriculture, Education, Health and Human Services (HHS), Housing and Urban Development, Transportation (DOT), and Veterans Affairs (VA)—can provide funding for nonemergency medical transportation (NEMT) service, although NEMT is not their primary mission. Twenty-one of these programs, including Medicaid, are administered or overseen by HHS. The type of funding provided by these programs varies, but includes capital investments (such as bus purchases) and reimbursements of transportation costs (e.g., bus passes). Total federal spending on NEMT is unknown because federal departments do not separately track spending for these services. In some cases data were not available or NEMT was incidental to a program's mission. However, one of the six departments (HHS) was able to provide estimates indicating that its spending totaled at least $1.3 billion in fiscal year 2012—most of this attributable to Medicaid.
Coordination of NEMT programs at the federal level is limited, and there is fragmentation, overlap, and potential for duplication across NEMT programs. The federal Interagency Transportation Coordinating Council on Access and Mobility (Coordinating Council)—chaired by the Secretary of DOT and tasked with promoting interagency cooperation and establishing mechanisms to minimize duplication and overlap of programs for the transportation disadvantaged—has taken some actions to improve coordination, such as developing a strategic plan. The strategic plan identified the council's goal, priorities, and objectives for 2011 to 2013. However, the council has provided limited leadership and has not issued key guidance documents that could promote coordination. For example, the council has not met since 2008 and has not finalized a cost-sharing policy that would allow agencies to identify and allocate costs among programs. GAO has previously found that agencies providing similar transportation services to similar client groups may lead to duplication and overlap when coordination does not occur. This review found instances of fragmentation, overlap, and the potential for duplication, although the extent could not be quantified.
State and local officials in the selected states GAO visited identified a variety of ways they facilitate coordination of NEMT. These include state coordinating bodies (two states GAO visited), regional coordinating bodies (two states GAO visited), local metropolitan planning organizations, and local transit agencies. Cost and ride sharing and one-call/one-click information centers were also used to coordinate NEMT services. However, GAO found two programs—Medicaid and VA NEMT programs—largely do not participate in coordination activities. Requirements to serve only eligible individuals and ensuring proper controls are in place to prevent improper payments and fraud are among the challenges to coordination for these programs. These important NEMT programs provide services to potentially over 90 million individuals and coordination without the Medicaid and VA programs increases the risk for potential overlap and duplication of services.
section_title: What GAO Recommends
paragraphs: GAO recommends that the Secretary of Transportation, as chair of the Coordinating Council, should publish a new strategic plan, issue a cost-sharing policy, and address the challenges associated with coordinating Medicaid and VA NEMT programs with other federal NEMT programs. DOT concurred in part with developing a new strategic plan and issuing a cost-sharing policy, and it concurred with identifying challenges of coordinating NEMT, particularly with HHS agencies.

section_title: Letter
paragraphs: Access to transportation services is essential for millions of Americans to  fully participate in society and to access human services, including  education, job training, and medical care. Transportation to medical care,  in particular, is becoming more important as an increasing number of  people develop conditions that require access to medical services, the  percentage of the population that is older continues to grow, and more  service members return from wars needing medical care. According to  the U.S. Census Bureau (Census Bureau), people with disabilities often  rely on forms of government assistance to remain active in the  community, including transportation to medical appointments and  services. The Census Bureau reported there were almost 57 million  people with disabilities in 2010 with about 38 million of these people  having a severe disability.
We have previously found that there are a number of federal programs  that are authorized to use federal funds for “transportation- disadvantaged” individuals in accessing human service programs,  including nonemergency medical transportation (NEMT). Federal  agencies, including the Departments of Agriculture, Education, Health  and Human Services (HHS), Housing and Urban Development (HUD),  Transportation (DOT), and Veterans Affairs (VA), have programs that  provide funding to state and local agencies that can be used for NEMT to  help individuals’ access medical services. In June 2012, we  recommended that the federal Interagency Transportation Coordinating  Council on Access and Mobility (Coordinating Council)—the body tasked  with developing policies and procedures for coordinating federal  transportation and human-service programs and chaired by the Secretary  of DOT—take actions to enhance federal, state, and local coordination  activities. We have reported in the past, and most recently in April 2014,  that coordination is one way to help reduce, eliminate, or better manage  duplication, overlap, or fragmentation among federal programs and can  lead to greater efficiency and effectiveness and achieve cost savings.
You asked that we review NEMT programs and coordination at the  federal, state, and local levels. This report addresses (1) the federal  programs that are authorized to provide funding for NEMT services, (2)  how federal agencies are coordinating NEMT services and whether there  is fragmentation, overlap, or duplication of services, and (3) how NEMT  services are coordinated at the state and local levels and the challenges  to coordination in selected states and localities.
The Catalog of Federal Domestic Assistance is a governmentwide compendium of  federal programs, projects, services, and activities that provide assistance or benefits to  the American public. It contains financial and nonfinancial assistance programs  administered by departments and other entities of the federal government. and transportation brokers.be generalized to all states. Appendix I contains a more detailed  discussion of our objectives, scope, and methodology.
Information obtained in our site visits cannot  We conducted this performance audit from January 2014 to December  2014 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: The transportation-disadvantaged population generally includes those  individuals who cannot provide their own transportation due to age,  disability, or income constraints. Although the size of this population can  vary over time, this population is large. The Census Bureau estimated  that in 2010 there were about 40 million people age 65 and over and  about 46 million people in poverty.estimated that, in 2012, 3.6 million of about 21-million veterans had a  service-connected disability. Some or all of these individuals may have  need of NEMT to access medical services.
In addition, the Census Bureau has  While a variety of federal agencies have programs that can provide  funding for NEMT service, DOT, HHS, and VA play key roles related to  NEMT. These roles are summarized below.
The Federal Transit Administration (FTA), a modal administration  within DOT, provides funding for public transportation, which can  include services such as NEMT. Among FTA programs that support  NEMT are the following: Urbanized Area Formula Program, the  Formula Grants for the Enhanced Mobility of Seniors and Individuals  with Disabilities program, and the Formula Grants for Rural Areas  program. In fiscal year 2014, FTA apportioned $4.8 billion, $257.5  million, and $618.4 million, respectively for these programs. In  general, funding from these programs is provided to states and  localities for public transportation, including transportation services for  the elderly and disabled. FTA funds can be used, among other things,  for capital projects, such as bus purchases, and operating expenses,  such as fuel and maintenance. FTA also provides administrative  support and staff for the Coordinating Council and, as discussed later  in this report, is involved with several council initiatives related to  coordination of transportation and human service programs.
Within HHS, Medicaid is a joint federal/state health-financing program  for certain low-income individuals overseen by the Centers for  Medicare and Medicaid Services (CMS). States administer their  Medicaid programs, which must operate within broad federal  guidelines. Under the Medicaid program, states are required to assure  that Medicaid beneficiaries have access to necessary medical  services. This includes arranging for transportation to medical  appointments and other services when beneficiaries cannot transport  themselves. In fiscal year 2013, the Medicaid program provided health  care coverage to about 72 million individuals.
VA operates the largest integrated health-care delivery system in  America. VA operates 150 medical centers and 820 community-based  outpatient clinics. Under federal regulations, VA is authorized to pay  for transportation to medical services for those veterans who meet  certain eligibility criteria. These criteria include having a service- connected disability or meeting certain income and other criteria. In  general, VA provides NEMT through mileage reimbursements, direct  provision of transportation for special needs patients (such as those in  wheelchairs or on stretchers), and using veterans’ service  organizations (such as the Disabled American Veterans).
Federal efforts to coordinate transportation for the transportation  disadvantaged, including NEMT, began during the 1970s and since 1986,  responsibility for coordination has rested with the Coordinating Council on  Access and Mobility, which was created under a memorandum of  understanding between DOT and HHS. In 2004, Executive Order 13330  renamed the council the federal Interagency Transportation Coordinating  Council on Access and Mobility and expanded membership to include 11  federal agencies, including VA. Among other things, the Coordinating  Council is tasked with promoting interagency cooperation and  establishing appropriate mechanisms to minimize duplication and overlap  of federal programs and services so that transportation-disadvantaged  persons have access to more transportation services, facilitating access  to cost-effective transportation services, and formulating and  implementing policy and procedural mechanisms that enhance  transportation services at all levels. In 2003, the Coordinating Council  launched the “United We Ride” initiative to act as a forum for interagency  communication and help states and communities overcome obstacles to  coordination. In June 2012, we reported the Coordinating Council had  taken a number of actions through this initiative aimed at improving  coordination at the federal level and providing assistance for state and  local coordination.reports on efforts taken and supporting technical assistance efforts.
This included issuing policy statements and progress  Congress has also supported coordination of human service- transportation programs. As we have previously reported, the Safe,  Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for  Users (SAFETEA-LU), which was enacted in 2005, amended several  human services transportation coordination provisions, sharpening the  focus on transportation services for persons with disabilities, older adults,  and individuals with lower incomes. SAFETEA-LU also required that  projects funded by FTA’s Formula Grants for Special Needs of Elderly  Individuals and Individuals with Disabilities program come from a locally  developed, coordinated public transit-human services transportation  plan. More recently, the Federal Public Transportation Act of 2012 (part  of the Moving Ahead for Progress in the 21st Century Act (MAP-21)),  enacted in 2012, continued certain requirements of SAFETEA-LU. In  particular, it continued the requirement that recipients of federal funds  under the Formula Grants for the Enhanced Mobility of Seniors and  Individuals with Disabilities program certify that projects selected for  funding are included in a locally developed, coordinated public transit- human services transportation plan. The act also required recipients to  certify that (1) the plan is developed and approved through a process that  includes participation by seniors, individuals with disabilities, and  representatives of public, private, and nonprofit-transportation and  human-services providers, among others, and (2) to the maximum extent  feasible, the services funded under this program are coordinated with  transportation services assisted by other federal departments and  agencies, including those of HHS. Finally, the Federal Public  Transportation Act of 2012 also authorized funding for mobility  management activities consisting of short-range planning and  management activities and projects for improving coordination among  public transportation and other transportation providers.
GAO-12-647 and Pub. L. No. 109-59, 119 Stat. 1144 (2005).
In March 2011, we found that agencies providing transportation services  to transportation-disadvantaged persons often provide similar services to  similar client groups leading to potential duplication and inefficiency. We  have also previously found that many federal efforts transcend more than  one agency, yet agencies face a range of challenges and barriers when  they attempt to work collaboratively. Both Congress and the executive  branch have recognized this, and in January 2011, the GPRA  Modernization Act of 2010 (GPRAMA) was enacted, updating the original  Government Performance and Results Act. GPRAMA established a new  framework aimed at taking a more crosscutting and integrated approach  to focusing on results and improving government performance. In  February 2012, we found that effective implementation of this act could  play an important role in clarifying desired outcomes; in addressing  program performance spanning multiple organizations; and in facilitating  future actions to reduce unnecessary duplication, overlap, and  fragmentation.
section_title: Various Federal Programs Can Fund NEMT Services, but Total Spending Is Unknown
subsections: section_title: Forty-two Federal Programs May Fund NEMT
paragraphs: We identified 42 federal programs in six federal departments that may  provide funding for NEMT (see fig. 1). Twenty-one of these programs are  administered or overseen by HHS. The Department of Education  (Education) administers seven programs; HUD administers six programs  (three of which are statutory components of the Community Development  Block Grant program); DOT administers four programs, VA administers  three programs, and the Department of Agriculture administers one  program. A full description of the identified programs is included in  appendix II.
None of the programs we identified has NEMT as a primary mission. For  example, all funds of the 4 DOT programs we identified are used to  support public transportation, which may include NEMT. The remaining  38 programs we identified primarily provide a variety of human services  such as job training, employment, education, medical care, or other  services, which incorporate transportation as an eligible program expense  to ensure participants can access a service. In addition, the types of  eligible transportation expenses funded by these programs vary, and may  include capital investments (e.g., purchasing vehicles, such as buses),  reimbursement of transportation costs (e.g., transit fares, gasoline, and  bus passes) or direct provision of transportation service to program  clients (e.g., operating vehicles), travel training, and mobility  management.
Examples of transportation services and capital investments authorized  for funding under the programs we identified include the following:
HHS’s Health Center Program provides funding that is used for bus  tokens, vouchers, transportation coordinators, and drivers to medically  underserved populations to access health care services.
DOT’s Enhanced Mobility of Seniors and Individuals with Disabilities  program can be used by recipient agencies to purchase vehicles such  as vans to improve access to transportation for any purpose, including  NEMT.
VA’s Veterans Transportation Program (VTP) provides funds that can  be used to purchase vans that transport veterans to VA medical  centers.
HUD’s Congregate Housing Services program provides funds for  accessible taxis, local transportation programs, and buses for the  elderly and disabled to access medical appointments, among other  things.
section_title: Total Federal Spending on NEMT Is Unknown
paragraphs: Total federal spending on NEMT in fiscal year 2012 is significant but  unknown because in many cases, federal departments do not separately  track spending for these services. Only one of the six departments (8 of  the 42 programs) for which NEMT is an eligible expense were able to  provide information about NEMT spending.
According to agency  officials, in fiscal year 2012, Medicaid spent at least $1.3 billion and other  HHS programs spent over $51 million—a total of over $1.3 billion. The  amount reported as spent by Medicaid is incomplete; it includes spending  by those states that have selected to report NEMT as an optional service,  but does not include spending by states that chose to report NEMT as an  administrative expense since this information was not available in fiscal  year 2012. No other agencies were able to specifically identify NEMT  spending.
According to federal officials, information on NEMT spending may not be  available for various reasons.
Data not available. FTA officials told us the agency does not track  NEMT expenditures and does not track NEMT trips because its  transportation funding serves multiple populations and trip types. As a  result, data are not available on NEMT spending. This is largely the  result of FTA’s programs being used to fund capital expenditures or  operating expenses that support public transportation systems, not  NEMT specifically. FTA officials said the Enhanced Mobility of Seniors  and Individuals with Disabilities program is the one program that most  likely uses its funds to support NEMT since it is focused on  transportation services for those who are disabled or seniors.  However, FTA does not collect specific information about NEMT for  this program.
NEMT incidental to program mission. Several agencies—including the  Department’s of Agriculture, Education, and HUD—have programs for  which NEMT is incidental to a broader program mission. Each of  these agencies told us they do not track NEMT spending and could  not provide specific spending amounts, even though NEMT is an  eligible expense for each of the programs we identified for those  agencies.
Difficulties in identifying specific expenditures for particular program  services is similar to what we found in 2012 when we reported on  services for the transportation disadvantaged population. In that report  we found that spending for transportation disadvantaged programs was  not tracked because (1) some programs allow for transportation spending  as an optional service and program grantees are not asked to provide  spending information, and (2) some federal programs give states and  localities broad flexibility to administer program funds and program  structures may not lend themselves to tracking transportation spending.  We also found that resources necessary to track this information in some  departments may outweigh the potential benefits. For example, HUD  officials told us that for some HUD programs, requiring grantees to report  transportation expenses would require a new reporting effort and  resource constraints could limit analysis of any information collected.
section_title: Coordination of NEMT Service is Limited and There is Fragmentation, Overlap, and Potential for Duplication
subsections: section_title: Coordinating Council
paragraphs: The Coordinating Council has taken some actions to address human  service-transportation program coordination. In 2012, we found that there  had been a lack of activity at the leadership level of the Coordinating  Council and the absence of key guidance documents for furthering  agency coordination efforts. To better promote and enhance federal,  state, and local coordination activities, we recommended the Coordinating  Council complete and publish a strategic plan and report on the progress  of recommendations made in the Coordinating Council’s 2005 Report to  the President. The Coordinating Council has taken actions to address  our recommendations. For example, the Coordinating Council developed  a strategic plan that covered the 2011 to 2013 period, and in 2013 it  published a progress report providing an update on accomplishments and  progress that had been made on the recommendations made in the 2005  report. Among other things, the strategic plan identified the Coordinating  Council’s priorities and objectives over the covered period, identified the  council’s strategic goal, and outlined various strategies for achieving the  goal. The goal was to continue to improve mobility, employment  opportunities, and access to community services for persons who are  transportation disadvantaged. The priorities included demonstrating  federal leadership on transportation coordination and expanding the  coordinated human service-transportation infrastructure. Strategies for  demonstrating federal leadership in coordination included developing and  approving cost-sharing guidance that facilitated the sharing of vehicles  and rides. Strategies for expanding the coordination of human service- transportation infrastructure included strengthening the coordinated  planning process, in part by improving stakeholder participation. The  progress report provided updates on five recommendations that were  made in the council’s 2005 report to the President. In general, progress  had been made in a number of areas, including establishing a  coordinated transportation-human service planning process and  developing a policy statement about vehicle sharing.
According to the Coordinating Council, other activities to help increase  coordination among federal transportation and human service programs  are also underway. These activities include:
Enhancing mobility management: Mobility management consists of a  variety of measures designed to increase accessibility to  transportation for transportation disadvantaged persons. The National  Center for Mobility Management (NCMM) is an initiative of the  Coordinating Council’s United We Ride program and is supported  through a 5-year cooperative agreement with FTA. NCMM was  established in 2013 and its primary activities support FTA grantees,  mobility managers, and others in developing and adopting mobility  management practices, including one-call/one-click transportation- information centers. FTA also funds technical assistance centers such  as the National Center on Senior Transportation and NCMM.
Establishing one-call/one-click centers: One-call/one-click centers are  central information sources that individuals can call into or access  from their computers to obtain information on transportation options in  a locality (see fig. 2). Coordinating Council officials told us the  Veteran’s Transportation and Community Living Initiative (VTCLI)  program, led by FTA, in collaboration with VA and HHS, focuses on  improving access to jobs and services, including medical services, for  America’s military veterans and families. The program makes grants  available to states and localities to establish, among other things, one- call/one-click centers. The program only awarded grants in fiscal  years 2011 and 2012. In that period, VTCLI awarded approximately  $64 million for 119 grant projects for a wide range of activities and  technology improvements, including mobility management tools, such  as one-call or one-click centers. This program was identified by the  Coordinating Council as the most significant council-led outcome of  the current administration. VTCLI projects were underway in four of  the five states we visited—Florida, Oregon, Pennsylvania, and Texas.  In each case one-call/one-click centers were being established to  provide information about transportation options to both  disadvantaged populations and veterans. In general, funds were  being used to develop computer software to collect data on  transportation services.
Creating a more inclusive planning effort: Coordinating Council  officials identified the Transportation 4 All initiative, which is a joint  effort by FTA and HHS’s Administration for Community Living (ACL),  to foster creation of an inclusive planning effort in local communities.According to program documents, the purpose of the program is to  identify models and approaches that would empower people with  disabilities and others to be actively involved in designing coordinated  transportation systems that are responsive to the needs of people with  disabilities and older adult populations.
The Coordinating Council also uses interagency working groups to  accomplish its activities. However, the interagency working group most  directly related to NEMT is just beginning to address the challenges of  coordinating transportation and healthcare programs. Of the Coordinating  Council’s two active interagency working groups, the Health, Wellness,  and Transportation group is most related to NEMT. This group includes  representatives from the Department of Labor, HHS, and VA and  functions to bring interagency collaboration to areas of interest to partner  agencies and foster collaboration across the federal government.  According to Coordinating Council officials, working groups assist in  developing policy statements and initiatives and are activated in response  to specific needs that arise for collaboration between the Council’s  member agencies. Coordinating Council officials said the Health,  Wellness, and Transportation group has met monthly since September  2013 and began examining barriers to coordinating transportation and  healthcare programs over a year ago. Various groups, including CMS,  have provided presentations on healthcare programs, how they operate,  and their regulatory requirements. One of the issues the working group is  trying to analyze is the cost of trips and cost sharing, which according to a  Coordinating Council official, remains a barrier to coordination.
While the Coordinating Council has taken some steps to increase  coordination, it continues to exercise little leadership in this area,  including NEMT. This includes the lack of executive leadership and the  absence of key guidance documents. In 2012, we found that the  Secretary-level leaders of the 11 Coordinating Council members had not  met since 2008, and the Executive Council designees had not met since  2007. This inaction is still the case. We previously found that, according  to some agency officials, this lack of direction and visible activity on  coordination from agency leaders contributes to a lack of buy-in from  federal program officials, which may affect how program coordination is  undertaken at the state and local levels. For example, some agency  officials told us that direction and formal buy-in at the executive level is  needed for improvements to coordination to occur. The absence of key  guidance documents include the lack of a strategic plan and a policy on  cost sharing—that is, the ability to identify and allocate costs among  programs and services.
The strategic plan that the Coordinating Council issued covers the 2011  to 2013 period but expired in 2013, and has not yet been updated.  According to a Coordinating Council official, a decision has not been  made as to whether a new plan will be prepared to continue to implement  many of the priorities identified in the 2011 to 2013 strategic plan.  Instead, FTA is in the process of developing a 2-year strategy. This  process will include a decision as to the future role of the Coordinating  Council and whether there will be a new or updated strategic plan. We  have previously found that a number of key practices enhance and  sustain collaboration, including agency plans and reports such as a  strategic plan. Such a plan can reinforce accountability for the  collaboration by aligning agency goals and strategies with those of the  collaborative efforts.previous strategic plan did not specifically address NEMT. Instead, the  goal focused on such things as improved mobility and employment  opportunities and the priorities focused on such things as demonstrating  federal leadership on transportation coordination and expanding the  coordinated human service-transportation infrastructure. In the context of  NEMT, by not updating or issuing a new strategic plan the Coordinating  Council may be missing an opportunity to identify and align goals and  strategies for increased NEMT coordination with the benefits of  coordination, such as increased program efficiency or reduced costs. As  discussed later, lack of coordination may have resulted in fragmentation,  overlap, or duplication of NEMT services.
Transit Cooperative Research Program, Transportation Research Board, Sharing the  Costs of Human Services Transportation, Volume 1: The Transportation Services Cost  Sharing Toolkit, TCRP Report 144, (2011), and Transit Cooperative Research Program,  Transportation Research Board, Sharing the Costs of Human Services Transportation,  Volume 2: Research Report, TCRP Report 144, (2011). across agencies. A cost sharing policy could also help facilitate ride and  vehicle sharing.
section_title: Federal Agencies Have Taken Action to Coordinate Transportation Planning, but This Action May Not Lead to Coordination of NEMT
paragraphs: Similar to the Coordinating Council, federal agencies have also taken  actions to coordinate transportation planning, including:
FTA issued guidance in June 2014 for the public transit-human  service transportation-planning process under the Enhanced Mobility  of Seniors and Individuals with Disabilities program. Among other  things, FTA is required to make sure these plans are prepared and  that there is participation by a wide range of stakeholders in the  coordinated planning process. The stakeholders are to include local  transportation and human-service agencies, as well as the general  public.
HHS’s ACL, in conjunction with FTA, initiated a program in 2012 that  seeks to foster inclusive planning efforts in local communities.  Seventeen projects were initially selected in June 2013 to serve as  demonstrations in planning, developing, and testing replicable and  sustainable community models of inclusive planning that include  participation of people with disabilities and older adults in the design  and implementation of coordinated transportation systems that are  responsive to their needs. An initial evaluation of the program found  that all of the project’s activities had actively involved organizations  and consumers with a focus on ensuring responsiveness to the needs  of people with disabilities and older adults.
In 2010, VA established the Veterans Transportation Service (VTS),  which provides funding to VA medical centers to acquire vehicles, hire  a mobility manager, and purchase vehicle routing/scheduling  software. VTS had been established at three of the five VA medical  centers we visited—Lake City, Florida, Dallas, Texas, and Portland,  Oregon. In general, VTS funds were being used to provide additional  NEMT service. Separately, in July 2013, VA also began accepting  applications for its Transportation of Veterans in Highly Rural Areas  grant program. This program made approximately $3 million available in fiscal year 2014 to fund projects that will create innovative  ways to transport veterans in highly rural areas to VA medical facilities  or other VA or non-VA facilities in connection with the provision of VA  medical care.
While the above federal actions may help improve the conditions for  coordination or the provision of NEMT services, such actions may not  increase NEMT coordination. Although there is a coordinated  transportation-planning process for certain FTA programs, full stakeholder  participation may not take place because human service agencies do not  have a similar program requirement. For example, recipients of funds  under FTA’s Enhanced Mobility for Seniors and Individuals with  Disabilities program are required to certify that, to the maximum extent  feasible, the services funded under the program are coordinated with  transportation services assisted by other federal departments and  agencies and come from a locally developed coordinated public transit- human service transportation-planning process. However, FTA officials  told us that non-DOT federal agencies that administer programs under  which NEMT services may be an eligible expense do not have human  services-transportation coordination requirements as part of laws  authorizing these programs. In addition, states and localities can invite  human service agencies to participate in the transportation-planning  process but it is up to the agencies to actually participate. Coordinating  Council officials told us that one of the challenges in coordinating federal- transportation and human-service programs is the inability to reconcile  requirements for transportation agencies with requirements for human  service agencies. We found evidence that not all stakeholders participate  in the coordinated transportation-planning process. CMS officials told us  they encourage state agencies administering the Medicaid program to  coordinate their transportation services with other non-Medicaid agencies.  However, none of the Medicaid agencies in the five states we visited  participated in the coordinated transportation planning process. Similarly,  in a March 2007 letter from VA, the agency’s medical centers were  encouraged to participate in the coordinated transportation planning  process but we found that none of the five VA medical centers we visited  participate in this process or make assets, such as vehicles, available to  other federal agencies.
Coordination may also be difficult due to internal problems and budget  constraints within federal agencies. For example, VA officials told us that  there are management “silos” within VA that make it difficult to coordinate  NEMT. They said even the simplest of problems like connecting VTS to a  medical center’s budget office, which might administer the program, can  be complex due to the many groups within VA, such as vehicle fleet  managers and hospital management that are part of the internal  coordination process. In addition, budget constraints often limit VA’s  ability to reach the community of veterans whom it seeks to serve. These  challenges were illustrated at one VA medical center we visited where the  NEMT fleet manager told us he had spent most of the first year in his  position trying to coordinate NEMT service among the various internal VA  components. Officials at two VA medical centers also told us NEMT  service was funded within the medical center’s budget and any increases  in NEMT service meant that there was less money for other medical  services offered by the center.
section_title: Fragmentation, Overlap, and Potential for Duplication of NEMT Services
paragraphs: Our work indicated that as with other transportation services for the  transportation disadvantaged, fragmentation, overlap and potential  duplication of NEMT service exist. Fragmentation refers to those  circumstances where more than one federal agency is involved in the  same broad area. Overlap occurs when agencies or programs have  similar goals, engage in similar activities or strategies to achieve them, or  target similar beneficiaries. Duplication occurs when two or more  agencies or programs are engaged in the same activities or provide the  same services to the same beneficiaries. We have previously found that  the multiple agencies providing transportation services to transportation- disadvantaged persons has resulted in fragmented services that can be  difficult for clients to navigate and that narrowly focused programs may   We have also found those agencies providing  result in service gaps.transportation services to transportation-disadvantaged persons often  provide similar services to similar client groups, leading to potential  duplication and overlap and service inefficiencies when coordination does  not occur. Fragmentation, overlap, and duplication can result in service  inefficiencies or increased costs when coordination does not occur.
NEMT services are fragmented because there is more than one federal  agency involved in the same broad area. As discussed earlier in this  report, six federal agencies administer 42 different programs for which  NEMT is an eligible expense. Overlap exists because programs that  provide NEMT have similar goals and target potentially similar  beneficiaries. Both Medicaid and VA have similar goals of helping their  respective beneficiaries access medical services (some individuals could  be eligible for both Medicaid and VA), serve potentially similar  beneficiaries—those individuals with disabilities, who are low income or  who are elderly—and engage in similar activities, such as providing  NEMT transportation directly or indirectly. The potential for duplication in  NEMT programs exists because two or more programs provide the same  services to the same beneficiaries.
The Coordinating Council has not directly addressed duplication, overlap,  or fragmentation issues. The strategic plan did not specifically address  these issues or establish a goal to help minimize or reduce them. In  addition, the Coordinating Council has no on-going activities regarding  these issues. Coordinating Council officials told us the council’s purpose  is to promote coordination efforts at the federal level, and that in general,  there are no specific activities related to identifying and reducing  duplication, overlap, or fragmentation. We have also previously found that  the Coordinating Council could play a more active role in helping to  reduce duplication and overlap by developing the means for collecting  and sharing program information by establishing agency roles and  responsibilities and developing a strategy to reinforce cooperation. In  regard to NEMT, as discussed earlier, some agencies have disseminated  guidance and policies regarding coordination of programs but few  agencies have collected information on NEMT expenditures. In at least  one case, an agency did not think it was cost effective to collect  transportation expenditures. For example, in our 2012 report on  transportation programs for disadvantaged persons, HUD officials told us  that reporting transportation expenses would require a new reporting  effort and the resulting information may not be analyzed due to resource  constraints.
State and local officials told us there is duplication, overlap, or  fragmentation among NEMT programs, particularly for the Medicaid  program. Officials in all five states we visited told us duplication and  overlap existed among NEMT programs. Officials we spoke with at a  private, not-for-profit agency in Florida that provides NEMT service in St.  Augustine and St. John’s counties told us there is overlap and  fragmentation because Medicaid and non-Medicaid NEMT services are  not coordinated. They said many of the Medicaid rides are single  passenger trips instead of multi-passenger trips because providers  handling the Medicaid trips are not coordinating trips for passengers  going to the same place. Similarly, officials at the Texas Department of  Transportation told us there is duplication, overlap, and fragmentation and  NEMT can be a part of the service that public transit agencies can  provide. However, they said Medicaid is a challenge since it has little  leeway in coordinating its service with other programs. For example, the  Medicaid service provider is given a passenger manifest each day,  provides the transportation service, and then moves on to the next day.  The officials said there is no room to coordinate schedules or to trip plan  which could facilitate sharing of services and costs with public transit  agencies or others. CMS officials said the use of Medicaid funds are for  specific purposes, and this specification may limit how much states or  brokers can coordinate with non-Medicaid programs. However, they said  states are not prohibited from participating in the transportation planning  and coordination process.
We were unable to quantify the extent of duplication, overlap, and  fragmentation of NEMT programs. In general, this is because there are no  data on the extent of duplication or overlap. In addition, other factors that  make it difficult to quantify duplication, overlap, or fragmentation include:
Presence or lack of transportation options: Some programs may  provide services that are duplicative in some locations because, for  example, there is already public or other transportation present, but  not duplicative in other locations where there is no other available  service. For example, urban locations tend to have more  transportation options, whereas rural locations tend to have fewer  options.
Nature of population served: A service may be duplicative for some  portion of the population using NEMT service but not for other  portions. For example, ambulatory individuals (those who can walk or  otherwise move themselves) may be able to avail themselves of a  number of transportation options. Those portions of the population  who are not ambulatory (e.g., in a wheelchair) may have fewer, if any,  options.
section_title: States and Localities Facilitate Coordination in Various Ways but Two Programs in Selected States Largely Do Not Participate in Coordination Efforts
subsections: section_title: States Use Variety of Ways to Facilitate Coordination of NEMT
paragraphs: States and localities use a variety of ways to facilitate coordination of  transportation and human service programs, including programs that  provide NEMT. These include state and regional coordinating bodies,  cost and ride sharing, and one call/one-click centers. In March 2013, the  National Council on State Legislatures (NCSL) reported that at least 28  states had established state-level coordinating councils and 29 states had  established regional coordinating organizations. According to NCSL,  these organizations—which can be established by state legislation,  executive order, or are voluntary associations of various groups that  come together to facilitate planning efforts—facilitate cooperation among  government agencies and stakeholder groups. Two of the states we  visited, Florida and Maryland, had established state-level bodies to lead  coordination efforts for transportation and human service programs,  including NEMT. Two other states, Oregon and Texas, had regional  bodies that facilitated coordination, while the fifth state, Pennsylvania,  primarily relied on local metropolitan planning organizations to facilitate  coordination.
In the states we visited, the activities of state and local coordinating  bodies vary. For example, Florida’s Commission for the Transportation  Disadvantaged (CTD) coordinates transportation statewide in Florida for  persons with disabilities, older adults, low-income persons, and those  who do not have access to healthcare, education, or other life sustaining  activities. CTD coordinates transportation by contracting with Community  Transportation Coordinators in Florida counties. According to CTD  officials, Florida has a highly coordinated transportation system,  particularly since the local Community Transportation Coordinators are  responsible for knowing the transportation system in their area and  preparing the public transit-human service transportation coordinated  plan. One Community Transportation Coordinator we spoke with told us  the coordinated transportation planning process included NEMT. In  contrast, officials with the Maryland State Coordinating Committee for  Human Service Transportation (SCC) told us that although they are  responsible for coordinating transportation and human service programs  in the state, the committee had not been active in recent years and state  agencies mainly leave coordination of programs to local agencies and  transportation providers. This includes Medicaid; state Medicaid agency  officials told us they leave coordination of transportation services like  NEMT to local health departments. Officials at two local health  departments that we spoke to, one in Baltimore, Maryland, and one in a  rural Maryland county, told us they do not participate in the coordinated  transportation-planning process and do not coordinate their NEMT with  non-Medicaid NEMT programs.
Cost and ride sharing and one-call/one-click information centers, among  other efforts, are also used in some states to coordinate NEMT programs.  For example, although the Coordinating Council has not finalized cost- sharing methodologies, we found that cost and ride sharing is occurring in  some locations and this has promoted coordination of NEMT service. Two  Oregon transit agencies we spoke with said they have coordinated  Medicaid NEMT and non-Medicaid NEMT using cost and ride sharing.  One agency developed software that it uses to schedule transportation,  record customer eligibility for transportation programs, including Medicaid  NEMT, and coordinate Medicaid and non-Medicaid NEMT by  implementing ridesharing, when feasible. We also found transit agencies  in Texas that were using cost and ride sharing to coordinate NEMT  service. On the other hand, one-call/one-click information centers do not  always promote coordination of NEMT. Projects were under way in all five  states we visited, in some instances funded by VTCLI grants, to establish  one-call/one-click information centers. Officials with the VA medical  center in Lake City, Florida, told us they were aware of the one-call/one- click center being established and were interested in participating in this  center and thought it might be a way to coordinate NEMT. However,  Medicaid and VA officials in Texas and Maryland told us they do not  participate in one-call/one-click centers but rather have established their  own call centers to handle eligible NEMT program beneficiaries. An  official with a Medicaid agency in Baltimore thought one-call/one-click  centers might be more efficient but wait times for NEMT could be longer  than if calls were handled directly by Medicaid.
section_title: Medicaid and VA NEMT Programs in Selected States Largely Do Not Participate in the Coordination Process
paragraphs: As discussed earlier, one of the priorities identified in the Coordinating  Council’s 2011-2013 strategic plan was expanding the coordinated  human service-transportation infrastructure. In part, this was to be  accomplished by developing and promoting strategies for improving  stakeholder participation in the coordinated planning process required by  law. In its 2013 progress report, the Coordinating Council stated that  more efforts were needed to ensure all federally-assisted programs  funding transportation participated in the process since participation  varied from community to community. The coordinated transportation  planning process is based on a locally developed coordinated public  transit-human service transportation plan and is intended to be an  inclusive process that involves participation by a wide variety of  stakeholders. This includes individuals with disabilities and  representatives of public, private, and non-profit transportation and  human services agencies. The coordinated public transit-human service  transportation plans produced by this process are required to assess  available transportation resources, including federal, state, and local  transportation programs (which would include NEMT programs), gaps in  service for individuals with disabilities, seniors, and others, and identify  strategies and projects to coordinate transportation resources and  programs to best address the service gaps.
In the states we visited, we found that two programs —Medicaid and  collectively VA’s NEMT programs—largely do not participate in the  coordinated transportation-planning process. Both Medicaid and the VA  NEMT programs are locally administered. States administer the Medicaid  program and local medical centers administer VA’s NEMT program.  These programs are important to NEMT, as they provide services to  potentially over 90 million individuals. As of fiscal year 2013, about 72  million individuals were enrolled in Medicaid (which includes some  enrollees in the CHIP) and, as of fiscal year 2012, VA served a population  of over 20-million veterans—about 9 million of whom were enrolled in VA  health care in fiscal year 2013. In general, these programs provide their  own NEMT service that is focused on serving eligible beneficiaries. In  part, this is driven by federal requirements. Specifically, for Medicaid,  states are required to assure that necessary transportation will be  provided to eligible beneficiaries to and from medical providers. Medicaid  regulations also require that transportation be furnished by a provider to  which state agencies can make a direct vendor payment and that  payment for transportation service be used only to benefit eligible  Medicaid beneficiaries. These requirements make clear that federal  Medicaid funding for NEMT services must be applied to the individuals  who qualify for the program and not to the broader public that would use  public transportation.
While program requirements drive the structure of the Medicaid NEMT  program, they also present a challenge to coordinating Medicaid NEMT  with other programs. CMS officials told us that using strategies such as  cost or ride sharing could increase the risk of Medicaid funds being spent  for individuals who do not qualify for Medicaid benefits. The officials  added that, without proper controls, cost or ride sharing with other non- Medicaid programs could allow for improper payments for individuals who  do not qualify for Medicaid. Past GAO studies have identified concerns  about Medicaid’s improper payments, citing concerns about the  appropriateness of states’ claims for transportation and other services,  such as those provided in schools that merge Medicaid funds with other  programs. Federal and state Medicaid officials largely confirmed that  these program requirements and integrity issues limit their ability to  participate in the coordinated transportation-planning process or engage  in cost or ride sharing with other non-Medicaid programs. For example,  Medicaid officials in all five states we visited said program requirements  limit their ability to participate in the coordinated transportation-planning  process or share rides or costs with non-Medicaid programs.
Another challenge to coordination of Medicaid NEMT with other NEMT  programs is state use of brokers to arrange NEMT service. By law, states  may, at their option, use brokers to arrange NEMT service. Brokers can  be either public or private entities. CMS officials told us they do not keep  track of which states use brokers; however, states are required to amend  their state Medicaid plan to show the use of brokers to provide  transportation service. Officials in all five states we visited said they  contracted with brokers to arrange NEMT services for Medicaid  beneficiaries. In four of the five states we visited, private entities were  being used as brokers. By contrast, in Oregon, public transit agencies  were the brokers in the two areas we visited. However, Oregon could use  private brokers in these areas in the future depending on decisions on  how NEMT would be provided by the Coordinated Care Organizations  being established to administer the Medicaid program. In general, brokers  may have less incentive to participate in the coordinated transportation- planning process than public transit agencies. First, private brokers are  not required to participate in the coordinated-planning process and may  choose not to do so. Second, Medicaid regulations require transportation  be provided to beneficiaries to access Medicaid providers, and this is the  service that brokers are contracted to provide, not coordinate rides with  non-Medicaid programs. Public transit agencies, on the other hand, are  required to participate in the coordinated planning process if they receive  funds from FTA’s Formula Grants for Enhanced Mobility of Seniors and  Individuals with Disabilities. We spoke with two private Medicaid NEMT  brokers operating in different states and neither participated in the  coordinated transportation-planning process. Both said the coordination  process deals with policy decisions that are left to the agency they  contract with. One of the companies was being paid on a fee-for-service  basis (e.g., paid for each trip provided), while the other was being paid on  a flat capitation basis based on the number of eligible Medicaid  beneficiaries in the area it served.
Finally, recent Medicaid reform efforts in some states may also present a  challenge to coordination of NEMT with non-Medicaid programs. Three of  the five states we visited—Florida, Texas, and Oregon—are in the midst  of making significant changes to their Medicaid programs. In general,  these reforms are aimed at moving to managed-care organizations  making decisions about medical services. In some states, decision  making will include how NEMT is provided. For example, Oregon officials  told us that Coordinated Care Organizations were being created to better  coordinate and integrate medical benefits provided to Medicaid recipients.  According to officials with the state Medicaid agency in Oregon, these  organizations must provide access to all Medicaid state plan services  included in their contracts, and are accountable for administering benefits  to beneficiaries in whatever manner will achieve the best outcome with  cost effectiveness, including NEMT. Local transit authorities and private  brokerages may be used by the Coordinated Care Organizations, and the  activity related to coordinating the NEMT benefit with the delivery of other  Medicaid services may be performed by the Coordinated Care  Organization, or subcontracted to the brokerage, according to the terms  of their agreements. In Texas, regional transportation management areas  are being created and competitively selected transportation managers will  provide NEMT for each area. Transportation managers could be either  public or private entities.
In each of the three states, the Medicaid reforms will likely affect the way  NEMT is provided, primarily by increasing the role of brokers in arranging  service. For example, prior to May 2014, the Florida CTD provided  Medicaid NEMT through contracts with Community Transportation  Coordinators and subcontracted transportation providers in each of  Florida’s 67 counties. Community Transportation Coordinators also  provided much of the non-Medicaid NEMT services in their respective  counties and were able to coordinate Medicaid NEMT and non-Medicaid  transportation services using ride and cost sharing. After February 2015,  CTD will no longer provide Medicaid NEMT under Florida’s new Medicaid  system. Instead, managed-care organizations will provide Medicaid  NEMT in each of Florida’s 11 Medicaid regions, using private  transportation brokers. Similarly, transportation and local transit officials in  Texas anticipated that the state’s transition to a brokerage system for  providing Medicaid NEMT will decrease coordination between Medicaid  and non-Medicaid NEMT services. The officials said that, unlike transit  agencies that also provide non-Medicaid NEMT services using their own  vehicles and participate in the coordinated transportation-planning  process, transportation brokers might not coordinate Medicaid and non- Medicaid NEMT through ride and cost sharing and may choose not to  participate in the coordinated-planning process because they are not  required to do so.
VA’s NEMT programs also largely operate outside of the coordinated  transportation-planning process. Similar to Medicaid, VA NEMT programs  are standalone and designed to serve only eligible VA clients. In addition,  like Medicaid, VA’s NEMT programs are client based and provide NEMT  only for qualified persons who need NEMT services for VA medical  appointments. Federal statute authorizes the Secretary of Veterans  Affairs to pay the transportation costs of eligible persons to or from VA  facilities or other places for the purpose of receiving medical services.  However, this transportation is limited to eligible participants. In general,  eligible veterans must have a service-related disability, receive a VA  pension, or not exceed specified annual income thresholds.
VA officials in the states we visited told us these funding and mission  requirements pose a challenge to coordinating NEMT services with other  federal programs. For example, VA medical center officials in Maryland  and Oregon stated that they do not provide VA subsidized bus passes  because those passes could be used for non-medical purposes—which  are non-authorized uses under program rules. Accordingly, they said VA  provides transportation to veterans for NEMT only, even if the VA’s costs  for providing NEMT is higher than the cost for a public transit bus pass.  VA officials in Pennsylvania told us that even if they wanted to they  cannot use other transportation programs, such as community-based  programs, to transport veterans who are eligible for VA NEMT services to  medical appointments. This is because the cost of the services cannot be  determined and they cannot handle bills from agencies providing  community-based services. VA officials in Texas stated that the various  NEMT programs have different rules for eligibility and that the differing  rules make it difficult for them to institute ride-sharing arrangements with  other non-VA NEMT programs. At the five medical centers we visited,  none of the officials told us that they shared resources with non-VA  NEMT programs and officials at two of the centers stated that using  community-based resources to provide NEMT for veterans could raise  legal questions about how federal funds are being spent since VA  program rules limit NEMT to eligible veterans.
At the VA medical centers we visited, VA coordination with non-VA NEMT  programs was mainly limited to consultation with local transit agencies  about using VTCLI grants to establish one-call/one-click information  centers to benefit transportation disadvantaged populations, including  veterans. For example, officials at the VA medical centers in Dallas,  Texas, and Portland, Oregon, have consulted with local transit agency  officials who are using VTCLI grant funds to establish one-call/one-click  centers that will serve their metropolitan areas. These centers will arrange  NEMT and other transportation services for veterans and other  transportation-disadvantaged populations. The officials told us that they  worked with the transit agencies to identify veterans’ transportation  needs, as well as how to make veterans aware of the mobility  management centers and the transportation options they offer.
It is clear there are a number of challenges in increasing Medicaid and VA  participation in the coordinated transportation-planning process. Important  factors include ensuring that program integrity is maintained and proper  controls are in place to prevent improper payments and fraud. However,  coordination of NEMT without the Medicaid and VA programs increases  the risk of potential program overlap and duplication. In addition, given  the significance of these programs to the provision of NEMT service,  coordination that does not include these programs makes it more difficult  for the Coordinating Council to achieve its goal of promoting interagency  cooperation to enhance the access of transportation-disadvantaged  persons to both more and cost effective transportation services.
section_title: States and Localities Cited Additional Challenges to NEMT Coordination
paragraphs: State and local officials in the five states we visited identified additional  challenges to NEMT coordination. These challenges include:
Lack of leadership or guidance at the federal level. State and local  transportation officials in four of the five states we visited told us that  federal leadership on NEMT coordination issues and coordination  guidance are inadequate or lacking. For example, Maryland SCC  officials told us neither FTA nor the Coordinating Council had provided  clear policies or guidance to Maryland on how to coordinate programs  that fund NEMT service. In addition, Oregon Department of  Transportation officials told us that among the changes needed at the  federal level are making more transportation-coordination policy  information available, including policies regarding coordination with  human services programs.
State and local officials’ perceptions of agency rules and effects of  improved NEMT coordination. Transportation and human services  agency officials in three of the five states we visited told us that many  state and local officials for human-services agencies and  transportation are reluctant to coordinate NEMT services with other  agencies because they interpret their agencies’ policies as prohibiting  coordination activities such as cost and resource sharing. In addition,  the officials told us that some local transportation and human-service  agency officials believe increased NEMT coordination could result in  loss of NEMT funding for their jurisdictions.
section_title: Conclusions
paragraphs: NEMT is an important and growing part of America’s transportation  service as millions of Americans who are elderly, have disabilities, or are  low income depend on government-funded transportation to get to  medical appointments and other medical services. However, NEMT  services are not well coordinated, and little is being done at the federal  level to help ensure that those who provide NEMT services can achieve  the benefits of coordination, such as reduced trip costs and more efficient  use of vehicles. The Coordinating Council, the organization tasked with  promoting interagency coordination of federal-transportation and human- service programs, has exercised little leadership and provided little  guidance. The executive council, which provides top management  direction, has not met since 2007, the strategic plan that outlines the  goals and strategies for coordination did not specifically address NEMT  and expired in 2013, and the Coordinating Council’s interagency working  group on transportation and healthcare, which develops guidance for  agencies, is just now starting to look at the challenges associated with  coordinating transportation and healthcare programs. The Coordinating  Council has also not provided the tools for coordinating NEMT programs.  In particular, it has not finalized a cost-sharing methodology that could  facilitate ride and vehicle sharing. As a result, the federal government is  missing opportunities to save costs, use funds more efficiently, and  provide more services to those who depend on federally funded programs  for NEMT.
Efforts to coordinate NEMT will also need to address those programs not  currently fully participating in the coordinated transportation-human  services planning process, notably the Medicaid and VA programs. These  programs are major funders of NEMT yet generally operate their own  NEMT service and do not coordinate their service with other programs.  The Coordinating Council is tasked with promoting interagency  cooperation and establishing appropriate ways to minimize duplication  and overlap of federal programs so transportation-disadvantaged persons  have access to more transportation services. Since both Medicaid and VA  are major players in providing NEMT, it is incumbent on the Coordinating  Council and its member agencies to both identify the challenges some  programs have in participating in the coordination process and developing  approaches to address these challenges so all programs can share in the  benefits of program coordination, yet do so in ways that maintain program  integrity and prevent fraud.
section_title: Recommendations
paragraphs: To promote and enhance federal, state, and local NEMT coordination  activities, we recommend that the Secretary of Transportation, as the  chair of the Coordinating Council, convene a meeting of the member  agencies of the Coordinating Council and take the following three actions:
Complete and publish a new or updated strategic plan that, among  other things, clearly outlines a strategy for addressing NEMT and how  it can be coordinated across federal agencies that fund NEMT  service.
Finalize and issue a cost-sharing policy and clearly identify how it can  be applied to programs under the purview of member agencies of the  Coordinating Council that provide funding for NEMT.
Using the on-going work of the Health, Wellness, and Transportation  working group and other appropriate resources, (1) identify the  challenges associated with coordinating Medicaid and VA NEMT  programs with other federal programs that fund NEMT, (2) develop  recommendations for how these challenges can be addressed while  still maintaining program integrity and fraud prevention, and (3) report  these recommendations to appropriate committees of Congress. To  the extent feasible, the Coordinating Council should implement those  recommendations that are within its legal authority.
section_title: Agency Comments
paragraphs: We requested comments on a draft of this report from the Departments of  Agriculture, Education, HHS, HUD, Transportation, and VA. DOT  provided its comments in an e-mail from their Deputy Director for Audit  Relations. DOT stated that it concurred in part with recommendations to  develop a new strategic plan and to finalize a cost-sharing policy. It  concurred with the recommendation to identify and report to Congress  challenges with NEMT coordination and said it agreed that more work is  needed to increase coordination activities with all HHS agencies,  especially CMS. DOT also said FTA is asking its technical assistance  centers to assist in developing responses to NEMT challenges.  Regarding development of a strategic plan, DOT said efforts were  underway at FTA to develop a new 2-year Coordinating Council  implementation strategy. As part of developing this strategy, FTA would  determine what governing framework is most effective and what, if any,  updates were needed to the strategic plan. Regarding the cost-sharing  policy, DOT said, expanding upon past efforts and building on the 2011  Transportation Research Board’s cost-sharing study discussed earlier in  this report, FTA plans to further refine a cost-sharing model with the  Coordinating Council. However, DOT said final acceptance of the policy  by non-DOT council members would be dependent on their receptiveness  to adopting a cost-sharing strategy. The Departments of Agriculture and  Education had no comments on the report. HHS, HUD, and VA made  technical comments, which were incorporated as appropriate.
We believe DOT’s efforts regarding the strategic plan and cost-sharing  policy, in addition to identifying the challenges of coordinating Medicaid  and VA NEMT programs with other federal programs that fund NEMT, are  steps in the right direction toward providing the leadership necessary to  help ensure the benefits of coordination are realized by all federal  programs that fund NEMT services. Going forward, it will be important to  (1) complete a new or updated strategic plan, (2) finalize and issue a  cost-sharing policy, and (3) identify and report to Congress the challenges  with coordinating NEMT, particularly with the Medicaid and VA NEMT  programs.
As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution of this report until 30  days from the report date. At that time, we will send copies of this report  to interested congressional committees and the Secretaries of  Agriculture, Education, Health and Human Services, Housing and Urban  Development, Transportation, and Veterans Affairs. We will also make  copies available to others upon request. In addition, this report will be  available at no charge on GAO’s website at http://www.gao.gov.
If you or your staff have any questions about this report, please contact  David Wise at 202-512-2834 or wised@gao.gov. Contact points for our  Office of Congressional Relations and Public Affairs may be found on the  last page of this report. GAO staff who made major contributions to this  report are listed in appendix III.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: The objectives of this report were to (1) identify the federal programs that  can or may provide funding for nonemergency medical transportation, (2)  describe how federal agencies are coordinating nonemergency medical  transportation services and providing potentially duplicative or  overlapping services, and (3) describe how nonemergency medical  transportation services are coordinated at the state and local levels and  the challenges to coordination in select states and localities.
To identify federal programs that provide funding for nonemergency  medical transportation services, we examined prior GAO work that  identified federal programs that provide funding and services for  transportation disadvantaged populations, conducted a search of the  Catalog of Federal Domestic Assistance, and requested program  information from the six federal departments—the Departments of  Agriculture, Education, Housing and Urban Development, Health and  Human Services, Transportation, and Veterans Affairs—for the programs  identified. We included only programs that provide nonemergency,  nonmilitary, surface transportation services of any kind for the purposes  of receiving medical care; this includes programs that fund infrastructure- related costs for NEMT as well as those that fund the actual transport in a  private vehicle, van, or public transportation, such as a bus, to medical  appointments or services. We limited our scope to federal agencies that  are members of the federal Interagency Transportation Coordinating  Council on Access and Mobility (Coordinating Council) because these  agencies were identified by executive order to participate in coordinationand administered programs that play a key role in funding nonemergency  medical transportation. Other federal agencies may also have programs  that provide funding for NEMT. However, we did not systematically  identify every program governmentwide that could provide such funding  as part of this review. We subsequently asked program administrators to  review and verify the programs identified and the program information  collected, including the general target population, allowable uses of  program funds, types of transportation services and trips typically  provided, and program spending on nonemergency medical  transportation services in fiscal year 2012. We chose fiscal year 2012  since it was the most recent year for which full year data were available  about the Medicaid program. Agency officials provided requested  spending data when available, but we did not independently verify the  data provided. We supplemented and modified the inventory based on  this information. In addition, we reviewed the relevant federal laws  governing these programs including their popular title or original source of  program legislation and the U.S. Code or other provisions cited as  authorizing nonemergency medical transportation.
To describe how federal agencies are coordinating nonemergency  medical-transportation services and providing potentially duplicative or  overlapping services, we conducted interviews with program officials from  DOT, HHS, and VA and reviewed relevant documentation provided by  agency officials. We chose these agencies because they administered  programs that are authorized to provide funding for nonemergency  medical-transportation services in fiscal year 2012 and provide significant  funding for such services. We also interviewed officials from the   and reviewed relevant Coordinating Council policy  Coordinating Councildocuments, its strategic plan, and the council’s 2013 progress report. We  also interviewed state and local officials in the locations we visited, and  interviewed representatives from relevant industry and advocacy groups,  including the following:
Center for Urban Transportation Research at the University of South
Community Transportation Association of America
Easter Seals Project ACTION
National Center for Mobility Management
National Conference of State Legislatures  To describe how nonemergency medical transportation services are  coordinated at the state and local levels and the challenges to  coordination in selected states and localities, we reviewed relevant  literature and prior GAO and Congressional Research Service reports  and conducted interviews with state and local officials from five states— Florida, Maryland, Oregon, Pennsylvania, and Texas. We based our  selection of these states on a variety of considerations, including size of  target populations per state, geographic diversity, existence of state and  regional coordinating bodies, and states deemed notable for their  transportation coordination efforts. As part of our state and local  interviews, we spoke with officials from state and local human services  and transportation agencies, VA medical centers, state and regional  coordinating bodies, metropolitan planning organizations, transportation  providers, transportation brokers, interest and advocacy groups, and  others and reviewed relevant documentation. Since we only visited  selected states, our findings cannot be generalized to all states and  cannot be used to make inferences about states we did not select. Table  1 provides more detailed information about the state and local entities we  interviewed.
We conducted this performance audit from January 2014 to December  2014 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
section_title: Appendix II: Inventory of Federal Programs Where Nonemergency Medical Transportation Is an Eligible Expense
paragraphs: The following is an inventory of federal programs identified by GAO  where NEMT is an eligible program expense.
Routine medical  appointments,  shopping,  entertainment, etc.
Program funds are  available for health  care projects  (assisted living,  nursing homes,  etc.) and may be  used to purchase  vehicles to  transport  patients/residents  for medical  appointments and  shopping.
subsections: section_title: Catalog of Federal Domestic Assistance Number Department of Education 84.126
paragraphs: How can program  funds be used for  NEMT or to  support NEMT  29 U.S.C. §  723(a)(8)
To access  vocational  rehabilitation  services. This may  include medical  services such as  corrective surgery  or therapeutic  treatment.
Transport for  services to medical  appointments.
29 U.S.C. §§ 796f- 4(b)(2) and  705(18)(xi)
To access  independent living  services. This may  include medical  services such as  physical  rehabilitation or  therapeutic  treatment.
Transport for  services to medical  appointments.
29 U.S.C. §§ 796e- 2(1) and  705(18)(xi)
To access  independent living  services. This may  include medical  services such as  physical  rehabilitation and  therapeutic  treatment.
Transport for  services to medical  appointments.
section_title: Catalog of Federal Domestic Assistance Number 84.177
paragraphs: U.S. Code or  other provision  cited as  authorizing  transportation  29 U.S.C. §  796k(e)(5)
Purpose of trips  as reported to  GAO by program  officials  To access  independent living  services. This may  include medical  services such as  physical  rehabilitation and  therapeutic  treatment.
How can program  funds be used for  NEMT or to  support NEMT  Transport for  services to medical  appointments.
Individuals with  Disabilities  Education Act 20 U.S.C. §§1433  and 1432(4)(E)(xiv)
To access  services, when  transportation is  specifically  identified as an  early intervention  service on the  eligible child’s  individualized  family service plan.  This may include  medical services  such as medical  appointments to  developmental  pediatricians.
Transport for  services to medical  appointments.
section_title: Catalog of Federal Domestic Assistance Number 84.187
paragraphs: U.S. Code or  other provision  cited as  authorizing  transportation  29 U.S.C. §§ 795g  and 705(36)
Purpose of trips  as reported to  GAO by program  officials  To access work,  training, and  vocational  rehabilitation  services. This may  include medical  services such as  physical  rehabilitation and  therapeutic  treatment.
How can program  funds be used for  NEMT or to  support NEMT  Transport for  services to medical  appointments.
29 U.S.C. §§  741(a) and  (b)(1)(B) and  723(a)(8)
To access  vocational  rehabilitation  services. This may  include medical  services such as  physical  rehabilitation and  therapeutic  treatment.
Transport for  services to medical  appointments.
section_title: Catalog of Federal Domestic Assistance Number Department of Transportation 20.507
paragraphs: NEMT and any  other type of trips  are allowable, as  general public  transportation trips  are not  differentiated by  purpose.
NEMT and any  other type of trips  are allowable, as  general public  transportation trips  are not  differentiated by  purpose.
section_title: Catalog of Federal Domestic Assistance Number 20.513
paragraphs: Typical use of  transportation  funds as reported  to GAO by  program officials  Purchase of capital  and other activities  to provide public  transportation  projects planned,  designed, and  carried out to meet  the special needs  of seniors and  individuals with  disabilities when  public  transportation is  insufficient,  inappropriate, or  unavailable.  Effective with MAP- 21, New Freedom  programs were  included and  project eligibility  was expanded to  include operating  assistance in some  circumstances.
How can program  funds be used for  NEMT or to  support NEMT  Grants and other  programs can be  developed at the  local level through  the locally  developed  coordinated  planning process  that can serve to  address  transportation gaps  for seniors and  people with  disabilities and  could include  partnerships with  NEMT funded  programs like  Medicaid.
section_title: Catalog of Federal Domestic Assistance Number 20.521
paragraphs: Typical use of  transportation  funds as reported  to GAO by  program officials  Capital and  operating  expenses for new  public  transportation  services and new  public  transportation  alternatives beyond  those required by  the American with  Disabilities Act of  1990, that are  designed to assist  individuals with  disabilities.
How can program  funds be used for  NEMT or to  support NEMT  Grants and other  programs can be  developed at the  local level through  the locally  developed  coordinated  planning process  that can serve to  address  transportation gaps  for people with  disabilities and  could include  partnerships with  NEMT funded  programs like  Medicaid.
section_title: Department of Health and Human Services 93.044
paragraphs: Older Americans  Act of 1965 42 U.S.C. §  3030d(a)(2)
These funds are  flexible and can be  used for both  medical and non- medical  transportation.
section_title: Catalog of Federal Domestic Assistance Number 93.047
paragraphs: U.S. Code or  other provision  cited as  authorizing  transportation  42 U.S.C. §§ 3057,  3030d(a)(2)
How can program  funds be used for  NEMT or to  support NEMT  Transportation to  access needed  services which may  include medical  appointments and  medical  treatments.
Transportation to  access needed  services which may  include medical  appointments for a  child with mental  health issues.
Transportation  services for an  eligible individual to  access HIV-related  health services,  including services  needed to maintain  the client in HIV  Medical care,  directly or through  voucher.
section_title: Catalog of Federal Domestic Assistance Number 93.193
paragraphs: Typical use of  transportation  funds as reported  to GAO by  program officials  Public  transportation,  mileage  reimbursement,  GSA lease, etc.
Purpose of trips  as reported to  GAO by program  officials  Public  transportation,  mileage  reimbursement,  GSA lease, etc.
How can program  funds be used for  NEMT or to  support NEMT  Vehicle purchase  or lease, bus  token, taxi fare.
Health centers are  required to provide  services that  enable individuals  to use the services  of the health center  (including outreach  and transportation  services).
Public  transportation,  mileage  reimbursement,  etc.
Public  transportation,  mileage  reimbursement,  and purchase of  motor vehicles.
Bus tokens/pass,  cab fare, gas card.
section_title: Catalog of Federal Domestic Assistance Number 93.550
paragraphs: How can program  funds be used for  NEMT or to  support NEMT  Transport to  medical  appointments, for  employment  training, school,  and other services  identified.
42 USCA §  9835(a)(5)(B)
Head Start  grantees have  flexibility to provide  nonemergency  medical  transportation to  children to medical  and dental  appointments.
42 U.S.C. §  1397a(a)(2)(A)
Travel to obtain  medical care; may  include special  modes of  transportation.
42 U.S.C. §§  1397jj(a)(26), (27)
Transportation to  primary and  preventative health  care services for  eligible low-income  women.
section_title: Catalog of Federal Domestic Assistance Number 93.778
paragraphs: U.S. Code or  other provision  cited as  authorizing  transportation  42 U.S.C. §§  1396a,  1396n(e)(1)(A)
How can program  funds be used for  NEMT or to  support NEMT  State Medicaid  Agencies are  required to assure  transportation for  beneficiaries to  covered medical  care when the  beneficiary has no  other means of  transportation.  Depending on the  claiming authority,  the state has many  options to structure  their NEMT  program but  Federal Financial  Participation is only  available for this  specific purpose.
section_title: Catalog of Federal Domestic Assistance Number 93.912
paragraphs: How can program  funds be used for  NEMT or to  support NEMT  Program funds can  be used to support  NEMT costs such  as personnel,  contractual  services (with  NEMT service  providers) and/or  promotion of NEMT  services.
Program funds can  be used for the  provision of  transportation  services for an  eligible individual to  access HIV-related  health services,  including services  needed to maintain  the client in HIV  Medical care,  directly or through  voucher.
section_title: Catalog of Federal Domestic Assistance Number 93.917
paragraphs: How can program  funds be used for  NEMT or to  support NEMT  Program funds can  be used for the  provision of  transportation  services for an  eligible individual to  access HIV-related  health services,  including services  needed to maintain  the client in HIV  Medical care,  directly or through  voucher. Services  are conveyance  services provided,  directly or through  a voucher, to a  client to enable him  or her to access  health care  services.
section_title: Catalog of Federal Domestic Assistance Number 93.918
paragraphs: Target population  reported to GAO  as defined by  program officials  Persons living with  HIV/AIDS  (PLWHA)
How can program  funds be used for  NEMT or to  support NEMT  Program funds can  be used for the  provision of  transportation  services for an  eligible individual to  access HIV-related  health services,  including services  needed to maintain  the client in HIV  Medical care,  directly or through  voucher.
Program funds can  be used for bus  tokens, taxi  vouchers,  reimbursement of  own vehicle.
ADAMHA  Reorganization Act  of 1992  42 U.S.C. § 300x- 1(b)(1)
If the individual  requires this  services and it  cannot or is not  funded by  Medicaid, States  can use the  funding for this  service.
section_title: Catalog of Federal Domestic Assistance Number 93.959
paragraphs: How can program  funds be used for  NEMT or to  support NEMT  Authorizing  legislation neither  prescribes nor  prohibits funding of  NEMT. The  exception is Interim  Final Rule (45 CFR  96. 120-137)  explicitly prescribes  transportation for  substance using  pregnant women  and women with  dependent  children.
42 U.S.C.   § 701(a)
States have broad  discretion in  implementing  program.
If a state identifies  this service as one  that relates to an  identified priority  need, it may  choose to support  such an activity.
section_title: Catalog of Federal Domestic Assistance Number Department of Housing and Urban Development 14.170
paragraphs: Accessible taxis,  local transportation  programs, buses,  etc.
Housing and  Community  Development Act  of 1974  42 U.S.C. §  5305(a)(8)
To access social  services, medical  services, jobs, etc.
The grant can be  used for up to 40  percent of the cost  of supportive  services which can  include NEMT.  NEMT could qualify  as an eligible  service.
Housing and  Community  Development Act  of 1974 42 U.S.C. §  5305(a)(8)
To access social  services, medical  services, jobs, etc.
NEMT could qualify  as an eligible  service.
Housing and  Community  Development Act  of 1974 42 U.S.C. §  5305(a)(8)
To access social  services, medical  services, jobs, etc.
NEMT could qualify  as an eligible  service.
section_title: Catalog of Federal Domestic Assistance Number 14.241
paragraphs: U.S. Code or  other provision  cited as  authorizing  transportation  42 U.S.C. §  12907(a)(3)
Typical use of  transportation  funds as reported  to GAO by  program officials  Bus tokens, taxi  fares, and any  related  organizational  transportation  expenses.
Purpose of trips  as reported to  GAO by program  officials  To access  supportive  services, such as  medical treatment,  employment or job  training, etc.
How can program  funds be used for  NEMT or to  support NEMT  NEMT could qualify  as an eligible  service.
Reasonable out-of- pocket expenses  for local  transportation for  residents to assist  in meeting self- sufficiency goals.
Transportation  related to purpose  of the program, i.e.  to get to a job  interview, or  medical  appointments that  can assist with  employment, i.e.  for eyeglasses,  dental needs.  Ongoing  transportation  needs for any  resident would not  be considered  eligible.
Public housing  residents including  adults,  elderly/disabled.
Expenses to  support residents  participating in the  program obtain  medical services  such as obtaining  eyeglasses for  work.
section_title: Catalog of Federal Domestic Assistance Number Department of Veterans Affairs 64.009
paragraphs: Mileage  reimbursement;  special mode  (ambulance,  wheelchair van);  common carrier  (air, bus, train,  boat, taxi)
Low-income and  service-connected  Veterans and  certain other  special group  beneficiaries $470 million  (obligated)
The Beneficiary  Travel Program  (BT) has authority  to provide both  emergency and  nonemergency  transport to eligible  beneficiaries in  relation to VA or  VA authorized non- VA care.
Funds granted to  community  homeless providers  may be used to  purchase vehicles  to provide NEMT.
Provide  transportation to  VA Medical  Facilities/CBOC  enrolled veterans $28.3 million  (obligated)
Transportation of  Veterans to VA  Medical Centers  and CBOC’s.
On July 22, 2014, this program was transferred to HHS by the Workforce Innovation and  Opportunity Act and is being administered by the Department of Education during this  transition.  On July 22, 2014, this program was transferred to HHS by the Workforce Innovation and  Opportunity Act and is being administered by the Department of Education during this  transition.  The Over-the-Road Bus Program was repealed by MAP-21, effective October 2012. The  Federal Public Transportation Act of 2012 repealed the New Freedom program (49 U.S.C. §  5317) as a separate program and instead merged the program into the Enhanced Mobility of  Seniors and Individuals with Disabilities program (49 U.S.C. § 5310), effective October  2012.  Fiscal year 2012 federal spending for Catalog of Federal Domestic Assistance program  64.009 includes Veterans Transportation Program/Beneficiary Travel only.  Fiscal year 2012 federal spending for Catalog of Federal Domestic Assistance program  64.035 includes Veterans Transportation Program/Veterans Transportation Service only.
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: In addition to the individual named above, other key contributors to this  report were Heather MacLeod, Assistant Director; Rashmi Agarwal;  Lorraine Ettaro; Delwen Jones; Richard Jorgenson; Michael Mgebroff;  Cheryl Peterson; Lisa G. Shibata; Hemi Tewarson; Sarah Veale; and  Carolyn Yocom.