Human services transportation helps connect people with mobility limitations to medical services, jobs, social services, and other opportunities within the community.
Nonemergency medical transportation—the availability and cost of nonemergency medical transportation (NEMT) is a major concern for many older adults. Some nonprofit and human services agencies provide such transportation. But there is no targeted transportation funding or program to meet the needs of older adults of all income levels who cannot get to medically-necessary nonemergency medical services such as dialysis or chemotherapy. Medicare does not cover NEMT unless a patient is bedridden. NEMT is expensive, and costs increase when people use ambulances for scheduled appointments. Riders eligible under the Americans with Disabilities Act (ADA) may use complementary paratransit, if available, but very ill riders may need higher-level, more personalized service.
The federal Centers for Medicare & Medicaid Services (CMS) is the largest public payer for NEMT services to older adults and people with disabilities. Medicaid pays for NEMT to ensure access to medical services for individuals with low incomes who receive Medicaid-financed services.
The Deficit Reduction Act of 2006 allows states to contract with brokers to manage NEMT services. Broker arrangements must be cost-effective and selected based on a competitive bidding process. The George Washington University Department of Health Policy found that 38 states used brokers to contain NEMT costs and ensure quality of service as of 2009.
Medicaid 1915(c) waivers—the traditional Medicaid program does not pay for these home- and community-based services (HCBS). However, Medicaid 1915(c) waivers allow states the option to offer some HCBS, such as transportation to adult day-care centers, to target populations, including older adults and adults with physical disabilities. States have the flexibility under waivers to limit the number of waiver recipients, cap the number of hours of services, restrict services to a certain geographical area, or limit services to specific population groups.
Section 5310—the Federal Transit Administration (FTA) Section 5310 funding program targets older adults and people with disabilities. This program provides capital-assistance grants to buy buses and vans used to transport older adults and people with disabilities to places such as senior centers and congregate meal sites. The FTA does not limit the type of trip for which funds can be used.
Congress consolidated the Elderly and Disabled and New Freedom programs into what is now called the Enhanced Mobility of Seniors and Individuals with Disabilities program. Under the consolidated program, funding may cover both capital and operating expenses as long as at least 55 percent of program funds are used on capital projects. These public transportation projects must be planned, designed, and carried out to meet the special needs of older adults and individuals with disabilities at times when public transportation is insufficient, inappropriate, or unavailable. The remaining 45 percent of program funds may be used for public transportation projects that exceed the requirements of the ADA, improve access to fixed-route service, and decrease reliance by individuals with disabilities on complementary ADA paratransit. The funds may also be used to provide alternatives to public transportation that assist older adults and individuals with disabilities.
As is typical for FTA formula programs, the federal share for capital projects is 80 percent, and its share for operations is 50 percent. The purchase of transportation services is considered a capital expense that qualifies for the higher federal match. The local share may be derived from other federal sources not provided by the Department of Transportation, such as Medicaid or Title III-B.
Title III-B of the Older Americans Act—Title III-B of the Older Americans Act (OAA) prioritizes transportation service funding. The Administration for Community Living (ACL) allocates these funds to state aging and disability agencies based on their populations of people age 60 and older. The state agencies then award funds to the local area agencies on aging. The OAA provided about $763 million to states for transportation services in fiscal year (FY) 2014, a reduction of $9 million relative to FY 2010.
State agencies have broad discretion in how they allocate funds. In addition to medical and nonmedical transportation, states can use the funds for case management, home-delivered and congregate meals, and homemaker services. Many OAA state and local programs choose to use part of their federal funding to provide transportation services, often by transit operators under contract with the local area’s agency on aging. Typically, area agencies on aging use Section 5310 funding from the FTA to purchase vehicles. They then operate the vehicles in part with Title III-B funding, along with other federal, state, and local sources, including Medicaid and Head Start. The coordination of funding sources at all levels of government promotes the most efficient and effective use of transportation funds (see also this chapter’s section Coordination of Community Transportation).
Human Services Transportation: Policy
Medicaid nonemergency medical transportation (NEMT)
State and local governments should explore and, as appropriate, take advantage of the flexibility allowed under the Deficit Reduction Act of 2005 to implement nonemergency medical transportation brokerages.
States should implement this national data-tracking system to ensure accurate accounting of state expenditures on Medicaid NEMT. CMS should provide states with administrative funding for collecting this data.
The Centers for Medicare & Medicaid Services (CMS) should provide the public with a readily available database of state Medicaid NEMT programs, including those that use brokers to provide the service, with expenditures by state.
CMS should increase the transparency and cost accountability of the Medicaid NEMT program by requiring states to itemize both their administrative and medical NEMT expenses on Form 64. Data collection systems should be designed so that CMS can accurately report public expenditure on NEMT, emergency transportation, and transportation funded through waivers. These data should be available to Congress, researchers, and the general public.
State and local governments should sufficiently fund public and nonprofit agencies to provide transportation that is planned, designed, and carried out to meet the special needs of older individuals and individuals with disabilities.
The Department of Transportation and the Administration for Community Living (ACL) should monitor and evaluate the adequacy of transportation services for all older adults.
The ACL should encourage the aging-services community agencies to help plan the complementary paratransit services provided for in the Americans with Disabilities Act and should consult in evaluating projects proposed for funding under the New Freedom Initiative.
Congress should require the Federal Transit Administration to evaluate how well the Section 5310 program meets the needs of riders.
Congress should fund the Section 5310 program at a level sufficient for providers to purchase replacement vehicles and expand services.