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.

Additional Materials:

Contact:

Dave Wise
(202) 512-2834
wised@gao.gov

 

Office of Public Affairs
(202) 512-4800
youngc1@gao.gov

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: Closed - Implemented

    Comments: Access to transportation services is essential for millions of Americans to fully participate in society and access human services, including medical care. Nonemergency medical transportation (NEMT) is nonemergency, nonmilitary, surface transportation service of any kind provided to beneficiaries or clients for the purpose of receiving medical care. Since 1986, federal efforts to coordinate transportation for the transportation disadvantaged population has rested with the federal Interagency Transportation Coordinating Council on Access and Mobility (Coordinating Council) made up of 11 federal agencies, including HHS and VA. Among other things, the council is tasked with promoting interagency cooperation and establishing appropriate mechanisms to minimize duplication and overlap of federal programs so transportation-disadvantaged persons have better access to cost-effective transportation services. In December 2014, GAO reported that, while the Coordinating Council had taken some steps to increase transportation coordination, it exercised little leadership in this area, including NEMT. This included the absence of key guidance documents such as a current strategic plan. The previous plan had expired in 2013 and had not been updated. In addition, the goals and priorities in the previous plan did not specifically address NEMT. Instead, they focused things such as mobility and expanding the coordinated human-service-transportation infrastructure. GAO reported that by not updating or issuing a new strategic plan the Coordinating Council may have been 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. Therefore, GAO recommended that the Coordinating Council complete and publish a new or updated strategic plan that, among other things, clearly outlined a strategy for addressing NEMT and how NEMT could be coordinated across federal agencies. In 2020, GAO confirmed that the Coordinating Council adopted a new strategic plan covering the fiscal year 2019 through 2022 period. This plan, among other things, established a goal of improving access to the community for members of the transportation disadvantaged population and an objective of reducing federal policy barriers to coordinated transportation. The council indicated these actions apply to NEMT as well as other coordinated transportation services. The Coordinating Council's new strategic plan responds to GAO's recommendation that the council issue a new plan. The plan also clearly outlines a strategy for addressing NEMT by focusing on ways to reduce policy barriers to coordinated transportation. With these actions, the Coordinating Council is in a much better position to identify issues surrounding coordination of NEMT across federal agencies and identifying ways to best achieve the benefits of coordination.

    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: Closed - Implemented

    Comments: Access to transportation services is essential for millions of Americans to fully participate in society and access human services, including medical care. Nonemergency medical transportation (NEMT) is nonemergency, nonmilitary, surface transportation service of any kind provided to beneficiaries or clients for the purpose of receiving medical care. Since 1986, federal efforts to coordinate transportation for the transportation disadvantaged population, including NEMT, has rested with the federal Coordinating Council on Access and Mobility (Coordinating Council) made of 11 federal agencies, including HHS and VA. This council is tasked, among other things, with formulating and implementing policy and procedural mechanisms that enhance transportation services at all levels. In December 2014, GAO reported that, while the Coordinating Council had taken some steps to increase transportation coordination, it exercised little leadership in this area, including NEMT. This included the absence of key guidance documents such as a policy on cost sharing-that is, the ability to identify and allocate costs among programs and services. This is a long standing issue since in 2005 the Coordinating Council recommended that standard cost-allocation principles for transportation be developed and endorsed by federal human-service and transportation agencies. GAO reported that without developing such principles federal agencies would be unable to address cost sharing issues across agencies or facilitate ride and vehicle sharing. Therefore, GAO recommended that the Coordinating Council finalize and issue a cost-sharing policy and clearly identify how it could be applied to programs under the purview of member agencies. In 2020, GAO confirmed that, the Coordinating Council issued a cost-sharing policy statement to its member agencies. The statement included both general principles that apply to any local transportation cost-allocation agreement, as well as specific principles for Medicaid and VA. The statement also covered ride and vehicle sharing and pointed to FTA's Cost Allocation Handbook for guidance on how to determine and allocate shared costs. The Coordinating Council stated that fully coordinating transportation through ride and vehicle sharing could result in increases in passengers per revenue hour and cost savings for federal, state, and local agencies. The cost sharing policy issued by the Coordinating Council is not only a step in the right direction, but will substantially improve the ability of federal, state, and local agencies that provide NEMT to better use their resources and do so in a more cost effective manner. This action will also greatly facilitate the ability of member agencies to not only address cost sharing issues, but to better achieve the benefits of NEMT coordination such as reduced costs and increased service.

    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: Closed - Implemented

    Comments: Access to transportation services is essential for millions of Americans to fully participate in society and access human services, including medical care. Nonemergency medical transportation (NEMT) is nonemergency, nonmilitary, surface transportation service of any kind provided to beneficiaries or clients for the purpose of receiving medical care. Since 1986, efforts to coordinate transportation for the transportation disadvantaged population across federal agencies has rested with the federal Interagency Transportation Coordinating Council on Access and Mobility (Coordinating Council), which is made up of 11 federal agencies, including the Departments of Health and Human Services (HHS) and Veterans Affairs (VA). In December 2014, GAO reported that two programs-Medicaid and collectively VA's NEMT-largely did not participate in the coordinated transportation-human services planning process and, therefore, are not fully sharing in the benefits of program coordination such as reduced cost and increased service. In part, this was because both programs have specific federal requirements for how their funds can be spent and that benefits like NEMT may only be provided to those individuals that meet certain eligibility criteria. GAO reported other challenges as well, including how NEMT service is provided (e.g. use of brokers to arrange service) and the necessity for proper controls to prevent improper payments and fraud. 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. As a result, GAO recommended that the Secretary of Transportation, as chair of the Coordinating Council, identify the challenges associated with coordinating Medicaid and VA NEMT, develop recommendations to address these challenges, and report the recommendations to Congress. In 2020, GAO confirmed that, the Coordinating Council submitted a report to the President and Congress on its activities. This report responds to our recommendation and identifies challenges with coordinating NEMT, including for Medicaid and VA. The report states that challenges with coordinating NEMT administered by Medicaid and VA were mainly associated with program regulations that restrict vehicle and ride sharing. The report also incorporated potential recommendations on eliminating barriers to local transportation coordination, including for NEMT. The report did not propose any specific changes to federal laws or regulations, but indicated that if any such changes were necessary Congress would be notified. It is clear the Coordinating Council has acted to implement our recommendation. The council has identified challenges to better coordinating NEMT across all federal programs, including Medicaid and VA, and consulted with relevant stakeholders to identify these challenges. The council's action should also help facilitate identification of potential solutions to these challenges and development of recommendations to implement these solutions. It will likely take time to thoroughly assess the challenges, identify how they can best be addressed, and develop implementation actions. The Coordinating Council is now in a much better position help achieve the benefits offered by NEMT coordination across all federal programs, including Medicaid and VA.

    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

 

Explore the full database of GAO's Open Recommendations »

Looking for more? Browse all our products here