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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.

Summary: 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. 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. 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.