GAO-15-404SP: General government: 5. Nonemergency Medical Transportation

General government > 5. Nonemergency Medical Transportation

To mitigate the effects of overlap, the Department of Transportation should take steps to enhance federal, state, and local coordination among 42 programs that provide nonemergency medical transportation to individuals who cannot provide their own transportation due to age, disability, or income constraints.

Why This Area Is Important

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. In particular, transportation to medical care, including nonemergency medical transportation (NEMT), 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 servicemembers return from wars needing medical care.[1] 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. 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. In addition, the Census Bureau estimated that in 2010 there were about 40 million people age 65 and over and about 46 million people in poverty. The Census Bureau has also estimated that, in 2012, 3.6 million of the 21 million veterans had a service-connected disability. Some or all of these individuals may have need of NEMT to access medical services.

In June 2012, GAO reported that a number of federal programs are authorized to use federal funds for “transportation-disadvantaged” individuals in accessing human service programs, including NEMT. Federal agencies, including the Departments of Agriculture (USDA), Education (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 December 2014, GAO reported that 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.[2] In June 2012, GAO 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. The Coordinating Council has taken some actions to address human service-transportation program coordination. In 2012, GAO 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 2011 through 2013, 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.[3] In general, progress had been made in a number of areas, including establishing a coordinated human service-transportation planning process and developing a policy statement about vehicle sharing.



[1] NEMT is defined in this report section as those federal programs that provide nonemergency, nonmilitary, surface transportation services of any kind to beneficiaries or clients for the purpose of receiving medical care. This includes transportation in a private vehicle or public transportation, such as a bus, to medical appointments or services.

[2]The amount reported as spent by Medicaid 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. Data on the number of states that report NEMT as an optional service, an administrative expense, or both were not available since CMS does not break out this information. It should be noted that CMS began tracking NEMT expenses for states that cover this cost as an administrative expense in the fourth quarter of fiscal year 2013.

[3]Coordinating Council on Access and Mobility, Report to the President, Human Service Transportation Coordination, Executive Order 13330 (2005).

What GAO Found

In December 2014, GAO found that fragmentation, overlap, and the potential for duplication exist across NEMT programs. Forty-two programs across six federal departments—HHS, Education, HUD, DOT, VA, and USDA—can provide funding for NEMT service, although NEMT is not their primary mission. Twenty-one of these programs, including Medicaid, 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 USDA administers one program. 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. In addition, the potential for duplication in NEMT programs exists because two or more programs provide the same services to the same beneficiaries.

GAO’s December 2014 report also found that coordination of NEMT programs at the federal level is limited. The Coordinating Council has taken some actions to improve coordination, such as developing a strategic plan. The strategic plan identified the council’s goals, priorities, and objectives for 2011 through 2013. However, the council has provided limited leadership—for example, it has not met since 2008. In addition, the council has not issued key guidance documents that could promote coordination, including an updated strategic plan, and finalized a cost-sharing policy that would allow agencies to identify and allocate costs among programs. In March 2011, GAO found that agencies providing similar transportation services to similar client groups may lead to duplication and overlap when coordination does not occur.[1]

The strategic plan that the Coordinating Council issued covers 2011 through 2013 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 through 2013 strategic plan. GAO has previously found that a number of key practices enhance and sustain collaboration, including strategic plans.[2] In addition, the goals and priorities outlined in the previous strategic plan did not specifically address NEMT. Instead, the goals 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.

In addition, Coordinating Council officials said the Heath, Wellness, and Transportation working group is trying to analyze the cost of trips and cost sharing, which according to a Coordinating Council official, remain a barrier to coordination. The absence of a key document, such as a policy on cost sharing, impacts the ability of agencies to identify and allocate costs among programs and services.Coordinating Council officials told GAO that a draft cost-sharing policy had been formulated; however, this policy has not been finalized. According to these officials, there are no plans at the current time to finalize this policy, and the Coordinating Council plans to leave the draft cost-sharing plan as it is until it determines where the Coordinating Council’s efforts will be focused over the next couple of years. Without developing federal cost allocation principles for transportation providers, federal agencies may be unable to address cost-sharing issues across agencies. A cost-sharing policy could also help facilitate ride and vehicle sharing.

GAO found that states and localities use a variety of ways to facilitate coordination of transportation and human service programs, including programs that provide NEMT. These include, for example, state and regional coordinating bodies, cost and ride sharing, and one-call/one-click centers.[3] However, GAO found that two programs—Medicaid and VA NEMT programs—largely do not participate in NEMT coordination activities in the states GAO visited. GAO found a number of challenges to coordination for these programs. For example, both programs are designed to serve their own populations of eligible beneficiaries. In addition, officials at the Centers for Medicare & Medicaid Services, which administers Medicaid, told GAO that using certain coordination strategies—in particular, cost or ride sharing—could increase the risk of Medicaid funds being spent for individuals who do not qualify for Medicaid benefits. The officials explained 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. Medicaid and VA are important to NEMT, as they provide services to potentially over 90 million individuals. 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.



[1]GAO, Opportunities to Reduce Potential Duplication in Government Programs, Save Tax Dollars, and Enhance Revenue, GAO‑11‑318SP (Washington, D.C.: Mar. 1, 2011).

[2]GAO, Results-Oriented Government: Practices That Can Help Enhance and Sustain Collaboration among Federal Agencies, GAO‑06‑15 (Washington, D.C.: Oct. 21, 2005).

[3]Ride sharing refers to the sharing of vehicles and rides. 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.

Actions Needed

To promote and enhance federal, state, and local NEMT coordination activities, GAO recommended in December 2014 that the Secretary of Transportation, as 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 ongoing 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.

Financial benefits associated with these actions cannot be quantified because federal departments do not separately track spending for NEMT services. However, implementation of these actions could improve coordination 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.

How GAO Conducted Its Work

The information contained in this analysis is based on findings from the products in the related GAO product section.  GAO searched the Catalog of Federal Domestic Assistance for 2013 to identify NEMT programs that offer transportation services. Program information was verified with department officials, who provided spending data, when available. GAO interviewed program officials from USDA, Education, HHS, HUD, DOT, and VA. GAO spoke with the Coordinating Council and reviewed relevant Coordinating Council reports. GAO visited selected states and interviewed state and local officials, and interviewed representatives from relevant industry and advocacy groups. States were chosen based on a variety of considerations, including geographic diversity and existence of a coordinating body.

Table 3 in appendix V lists the programs GAO identified that might have similar or overlapping objectives, provide similar services, or be fragmented across government missions. Overlap and fragmentation might not necessarily lead to actual duplication, and some degree of overlap and duplication may be justified.

Agency Comments & GAO Contact

GAO provided a draft of its December 2014 report to DOT, USDA, Education, HHS, HUD, and VA. 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 NEMT 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 Centers for Medicare & Medicaid Services. DOT also said the Federal Transit Administration (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 under way 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,[1] 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 depend on their receptiveness to adopting a cost-sharing strategy. USDA and Education had no comments on the report. HHS, HUD, and VA made technical comments, which were incorporated as appropriate.

GAO provided a draft of this report section to DOT, USDA, Education, HHS, HUD, and VA. None of the agencies had comments.

For additional information about this area, contact David Wise at (202) 512-2834 or wised@gao.gov.



[1]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).