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Medicaid Non-Emergency Transportation Benefit: Stakeholder Perspectives on Trends and Innovations

This week, our In Focus section reviews key takeaways from the report, Medicaid Non-Emergency Transportation Benefit: Stakeholder Perspectives on Trends and Innovations, prepared by Health Management Associates (HMA) for the Medicaid and CHIP Payment and Access Commission (MACPAC).

The report was written by Principal Sharon Silow-Carroll, Principal Kathy Gifford, Senior Consultant Carrie Rosenzweig, Consultant Anh Pham, and former Managing Principal Kathy Ryland (retired).

States are required to provide non-emergency medical transportation (NEMT) to Medicaid beneficiaries with no other means of transportation. In December 2020, following the completion of this study, Congress added a requirement for states to provide NEMT to the Social Security Act (the Act) through the Consolidated Appropriations Act of 2021 (P.L. 116-260). Previously, NEMT was mandated by federal regulations derived from the general statutory requirement that states must “ensure necessary transportation” for Medicaid beneficiaries to assure access “to and from providers” (42 CFR 431.53). Within these guidelines, states have significant flexibility in how they deliver the NEMT benefit to best meet the unique challenges and needs of their beneficiaries, including the delivery system model, reimbursement approach, and transportation modes.

To better understand the state policy decisions, implementation challenges, and innovative practices related to this critical benefit, HMA conducted an environmental scan of all 50 states and the District of Columbia (DC), focusing on criteria including variation in NEMT delivery system models, geographic diversity, innovations, and notable quality requirements. Based on this scan, HMA and MACPAC selected six states: Arizona, Connecticut, Georgia, Indiana, Massachusetts, and Texas to study further through interviews with
51 NEMT stakeholders, including federal and state officials, NEMT providers, transportation broker representatives, MCO representatives, beneficiary advocates, and NEMT subject matter experts.

States use a variety of NEMT delivery system models and reimbursement approaches. These include: managing the benefit in-house (i.e., within the Medicaid agency) and paying for NEMT on a fee-for-service (FFS) basis; contracting with transportation brokers on a capitated or FFS basis (e.g., trip cost plus administrative fee) to manage all or some aspects of NEMT on a state’s behalf; and carving the NEMT benefit into a capitated managed care arrangement with a Medicaid managed care organization (MCO) that either administers the benefit directly or subcontracts with a broker. Approximately a dozen states employ more than one model, using, for example, different models for different Medicaid populations or for different geographic areas. The delivery system models for each of the six study states are outlined in Table 1 below.

StateModel/Risk ArrangementRecent or Planned Changes
ArizonaMCO Carve-In/MCOs at risk

In-house for American
Indian/Alaska Native
(AIAN) individuals not
enrolled in MCOs/State at
risk
N/A
ConnecticutStatewide Broker/Broker at
risk
2018: Shifted Broker Model
from FFS to capitation
GeorgiaRegional Brokers/Brokers at
risk
N/A
Indiana MCO Carve-In/MCOs at risk

Statewide Broker for FFS
population/ Broker at risk
2018: Transitioned FFS
population from in-house to
broker model
MassachusettsRegional Brokers
coordinating with human
service transportation/State
at risk
2021: New contracts will
reduce number of brokers,
increase performance
incentives
TexasRegional Brokers/Brokers at
risk

In-house for one region/State
at risk
2021: Shift from regional
brokersii to MCO carve-in
model
ii Exception: NEMT is administered by the state in one region.

Report findings and common themes include:

  • Policy Considerations: States consider a wide variety of factors when designing their NEMT program including financial and staff resources, known patterns of care, coordination with managed care or other
    human services transit programs, and a desire to incentivize targets outcomes.
  • NEMT Utilization: The most frequent NEMT utilizers are individuals with physical, intellectual, or developmental disabilities and who routinely attend medical appointments multiple times a week, such as
    those receiving dialysis, Medication for Opioid Use Disorder (MOUD), cancer treatment, or adult day health programs. While the COVID-19 pandemic significantly reduced NEMT utilization and may have long-term effects on NEMT service demand, many beneficiaries will continue to need transportation assistance for critical services that cannot be delivered virtually.
  • Performance Issues: Late pick-ups and no-shows were the primary reasons for complaints by beneficiaries, health care providers, and MCO care managers. Interviewees identified GPS tracking and other technologies as essential to improving timeliness, efficiency, and beneficiary satisfaction.
  • Program Integrity: While contracts for brokers, MCOs, and transportation providers often include NEMT performance standards and incentives, some advocates interviewed expressed frustration about the adequacy of state oversight and enforcement, stressing the need for greater consumer feedback and involvement. Most interviewees did not perceive NEMT fraud, waste, and abuse to be a significant problem, particularly with the shift to broker models and new technologies.
  • Transportation Network: NEMT programs often face significant challenges maintaining an adequate transportation network, particularly in rural areas. Interviewees cited the high cost of insurance as a substantial barrier to NEMT provider participation and reported that Transportation Network Companies (TNCs), such as Uber and Lyft, offer several advantages and opportunities for supplementing NEMT supply for able-bodied, independent beneficiaries. However, most agreed that TNCs are not appropriate for a large segment of the NEMT population, including those who have physical or intellectual and developmental disabilities.
  • Stakeholder’s View on the Value and Role of NEMT: All interviewees emphasized the importance of the NEMT benefit in helping Medicaid beneficiaries access the health care they need. Several highlighted the value or potential value of NEMT in improving health outcomes and reducing disparities, and some
    interviewees opined that NEMT would offer even greater value if beneficiaries and health care providers received more education about the benefit.

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