Transportation Disadvantaged Populations:

Nonemergency Medical Transportation Not Well Coordinated, and Additional Federal Leadership Needed

GAO-15-110: Published: Dec 10, 2014. Publicly Released: Jan 9, 2015.

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What GAO Found

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.

Why GAO Did This Study

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.

What GAO Recommends

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.

For more information, contact Dave Wise at (202) 512-2834 or wised@gao.gov.

Recommendations for Executive Action

  1. Status: Open

    Comments: The Federal Transit Administration (FTA) concurred with this recommendation. The Department of Transportation (DOT), which chairs the Coordinating Council on Access and Mobility (Coordinating Council) and provides administrative support and staff, has made some progress to enhance coordination of NEMT programs through the development of a new or updated strategic plan, as GAO recommended in December 2014, but coordination at the federal level remains limited. DOT identified steps that would address GAO's recommendation, but it has not yet taken concrete steps, and some steps are only under consideration. In March 2017, DOT officials confirmed that Administrator-level members of the Coordinating Council met in July 2016 to begin the process of developing a strategic plan. A follow-up meeting of the Coordinating Council was held in December 2016 that resulted in some changes to the draft strategic plan framework. In February 2019, the Department of Transportation (DOT) stated that FTA and the Coordinating Council continue to gather industry input regarding transportation coordination issues in formal and informal ways in support of the development of the strategic plan and cost sharing policy. The expected completion date is September 2020.

    Recommendation: To promote and enhance federal, state, and local NEMT coordination activities, the Secretary of Transportation, as the chair of the Coordinating Council, should convene a meeting of the member agencies of the Coordinating Council and 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.

    Agency Affected: Department of Transportation

  2. Status: Open

    Comments: FTA concurred with this recommendation. The Department of Transportation (DOT), which chairs the Coordinating Council and provides administrative support and staff, has made minimal progress to develop and issue a cost-sharing policy, as GAO recommended in December 2014, which would allow agencies to identify and allocate costs among programs. DOT has informed GAO about plans to address the recommendation, but has not yet taken concrete steps to develop and issue a cost-sharing policy as GAO recommended. In March 2017, DOT officials confirmed that the development of a cost-sharing policy and proposed model is anticipated to be an objective in the Coordinating Council's strategic plan, to be implemented through interagency working groups. In February 2019, DOT said that FTA and the Coordinating Council continue to gather industry input regarding transportation coordination issues in formal and informal ways in support of the development of the strategic plan and cost sharing policy. The expected date of completion is September 2020.

    Recommendation: To promote and enhance federal, state, and local NEMT coordination activities, the Secretary of Transportation, as the chair of the Coordinating Council, should convene a meeting of the member agencies of the Coordinating Council and 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.

    Agency Affected: Department of Transportation

  3. Status: Open

    Comments: FTA said they concurred in part with this recommendation. The Fixing America's Surface Transportation (FAST) Act requires the Coordinating Council on Access and Mobility (Coordinating Council) to develop and publish a strategic plan. The Department of Transportation (DOT), which chairs the Coordinating Council and provides administrative support and staff, has made some but minimal progress to address the challenges associated with coordinating Medicaid and VA NEMT programs and other federal programs, as GAO recommended in December 2014. In March 2017, DOT officials confirmed that they announced the selection of 19 Rides to Wellness Demonstration and Innovative Coordinated Access and Mobility pilot program projects, totaling approximately $7.3 million, in September 2016. Seven of the 19 projects have a NEMT focus. DOT officials also said that in 2016 outreach sessions were held to build commitment and engage key stakeholders in the health and transportation industries to discuss partnership opportunities. In February 2019, DOT said FTA and the Coordinating Council were continuing to gather industry input regarding transportation coordination issues in formal and informal ways in support of the development of the strategic plan and cost sharing policy. The expected date of completion is September 2020.

    Recommendation: To promote and enhance federal, state, and local NEMT coordination activities, the Secretary of Transportation, as the chair of the Coordinating Council, should convene a meeting of the member agencies of the Coordinating Council and 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.

    Agency Affected: Department of Transportation

 

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