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Medicaid Non-Emergency Medical Transportation

Medicaid is generally recognized as the U.S. government’s largest entitlement program. As a partnership between the Federal government and the states, the individual states have been provided great latitudes in structuring the Medicaid program within the respective states. Each state structures and manages its NEMT program differently.

To understand common elements, a fact sheet for Medicaid beneficiaries provides basic information about the NEMT benefit.14 It advises what a beneficiary is to do when a ride is needed, explaining that there will be state- by-state variations in what rides are permitted and how to schedule rides. It provides the rules that beneficiaries must follow, including how to cancel unneeded rides in advance and refrain from using NEMT for any trip purpose other than for going to an approved medical appointment. Information about fraudulent and abusive use of NEMT is provided with contact information for reporting incidents to the U.S. Department of Health and Human Services.

A booklet written for providers of NEMT service summarizes the general scope of Medicaid-covered emergency transportation and NEMT benefits and reviews principles applicable to such coverage. It also explains three modes for States to provide or arrange for covered NEMT (through brokers, managed care organizations, or directly with independent transportation providers), common Medicaid transportation fraud and abuse issues, and provider tips to help prevent fraud and abuse. To prevent fraud, providers are advised to document all trips provided accurately and maintain records, verify beneficiaries’ use of medical services, and bill accurately for trips. Providers are also advised to screen new hires, as well as all existing employees every month, to determine whether they are excluded from participation in Federal health care programs.15

An issue brief from The Center for Health Care Strategies, a nonprofit public policy organization focused on promoting innovations publicly financed health care, summarizes the current state of Medicaid NEMT services, its challenges, and opportunities for improvement.16 It explores alternative transportation models piloted by states and health plans across the country, including the use of transportation network companies, such as Uber and Lyft, to augment NEMT services. The authors identify five key challenges in the provision of the NEMT benefit: complaints by beneficiaries of poor customer service, including the inability of customers to choose their transportation provider in states that classify NEMT as an administrative expense; inadequate transportation system responses to time-sensitive transportation needs, such as appointment time changes; service data collection and oversight; fraud and abuse; and, structural inefficiencies such as low reimbursement rates for transportation companies and administrative difficulties with transporting beneficiaries across county lines.

The issue brief describes several innovations that demonstrate the potential to improve NEMT. Transportation network companies such as Uber and Lyft that offer on-demand service may help NEMT provide timely service in time-sensitive situations, and some for-profit brokerages have adopted convenient technologies such as app-based ride request features. These uses of technology are promising not only for service delivery but may also offer advancements in reporting and program analytics. Some states are seeing legislative efforts to address NEMT concerns, including laws to ease the licensing process for NEMT providers and the ability of managed care organizations to assume responsibility for NEMT. Also, some states have restricted access to NEMT for populations covered under Medicaid expansion programs authorized by the Affordable Care Act, enabling research studies to examine the health outcomes of populations receiving NEMT vs. those who do not receive the benefit. The authors advocate
for brokers, vendors, and/ or health plans to use more technologically advanced data collection systems to improve program oversight and quality assurance, and recommend that Medicaid programs consider increasing investments in their NEMT information technology infrastructure as a way to strengthen existing programs’ efficiency and oversight, and potentially decrease exposure to Federal audits.

A 2016 GAO report reviews NEMT services under Medicaid and Medicare and how they are administered, CMS oversight of NEMT under both programs, and the challenges that exist in providing NEMT under Medicaid, including ways that States have addressed these challenges.17 States are responsible for the daily operations of their Medicaid programs and have discretion in how they deliver NEMT and use a variety of models, including transportation brokers, which are entities that contract with States to administer NEMT services. CMS uses regular program integrity activities, such as claims reviews, to oversee Medicare NEMT. Under Medicaid, CMS also uses regular oversight activities, including overseeing states’ program integrity activities and periodically issuing guidance, but this guidance is sometimes outdated and does not reflect legislative and other changes. The report summarizes some states’ responses to common challenges with Medicaid NEMT. To contain growing NEMT costs, states have used methods such as capitated payments, coordinating with public transit, and limiting allowable trip distances. Over billing, improper payments, and other program integrity concerns are common issues. In response, states have enhanced their provider enrollment processes, required additional trip documentation, audited claims, added provider contract provisions, and conducted provider training.  States have also taken measures to increase monitoring and oversight of NEMT brokers, address provider and beneficiary no-shows, and broaden the network of NEMT providers, including paying mileage reimbursements to beneficiaries or their family members, coordinating with non-NEMT transportation providers, and using volunteer drivers.

State Medicaid programs were given the option to establish brokerages to administer NEMT while retaining the ability to receive Federal matching funds for NEMT at the Federal medical assistance matching rate (FMAP) in 2008. The published Federal final rule, “Medicaid program: State option to establish non-emergency medical transportation program”, implements section 6083 of the Deficit Reduction Act of 2005, which provides additional State plan flexibility to establish NEMT brokerage programs.18 That section of the law contains four provisions that enable a state to:

  • Select an NEMT broker through a competitive bidding process, provided the factors of experience, performance, references, resources, qualifications, and costs are used in the evaluation process;
  • Monitor beneficiary access and complaints and ensure that transport personnel are licensed, qualified, competent, and courteous;
  • Audit and provide oversight to ensure the quality of the transportation services provided and the adequacy of beneficiary access to medical care and services; and
  • Comply with the prohibitions on referrals and conflict of interest as the Secretary shall establish.

Since the publication of the final rule, many states have opted to establish NEMT brokerages. The effects of brokerage systems on transportation coordination have been documented in two key publications.

A 2014 GAO report addresses the Federal programs that are authorized to provide funding for NEMT services, how Federal agencies are coordinating NEMT services, whether there is fragmentation or duplication of services, and how NEMT services are coordinated at the state and local levels and the challenges to coordination in states and localities. The report identifies 42 funding programs in six Federal departments that fund NEMT and documents CCAM activities to address the coordination of NEMT. CCAM’s interagency working group on Health, Wellness, and Transportation is trying to analyze the issue of trip costs and cost sharing, which remains a barrier to coordination, according to a CCAM official.19

The report repeats the observation from previous GAO reports that CCAM exercises little executive leadership in the area of coordination and needs to promulgate a policy on the allocation of costs among disparate transportation programs and services. The report found that cost and ride sharing are occurring in some locations in the absence of Federal guidance and that this has facilitated the coordination of NEMT service in two of the report’s case study states, Oregon and Texas. The report documents barriers to the coordination of Medicaid NEMT, including state Medicaid programs’ perceptions that program requirements limit their ability to share rides or costs with non-Medicaid programs, as well as the use of private brokers who do not participate in local coordination efforts. The report documented similar barriers to coordination with VA NEMT services, which were found to preclude the use of community transportation resources to support NEMT for veterans because the VA is unable to pay these providers due to funding restrictions. The report’s recommendations suggested that CCAM update its strategic plan to clearly outline a strategy for addressing NEMT coordination, finalize and issue a cost-sharing policy and identify how it can be applied to programs that fund NEMT, and develop strategies for coordination with Medicaid and VA NEMT programs that address program integrity and fraud prevention.20

A recent Transit Cooperative Research Program (TCRP) discusses state models for providing non-emergency medical transportation (NEMT) to Medicaid beneficiaries, providing information to better understand what influences state Medicaid agencies to establish separate NEMT brokers and the resulting effects on NEMT customers, human services transportation, and public transportation.

The report also addresses the trend of states to include NEMT as part of Medicaid managed care and discusses why human services and public transportation providers encourage coordination with NEMT with other transportation services. States use one, or a combination, of three models for NEMT service delivery: in-house management at a state, regional, or county level, typically contracting with transportation providers on a fee-for-service basis; statewide or regional brokerages that perform NEMT administrative functions and contract with transportation providers for rides; and managed care organizations, which may integrate NEMT into the health care system (known as “carved-in” NEMT).21

A companion document to the report describes each State’s model. The report documents the effects of these models on public transit and human service transportation coordination, noting the advantages of coordination: expanded overall access to transportation; leveraging of public transit expertise and resources in NEMT service delivery; increased efficiency in shared-ride transportation; improved productivity and cost-effectiveness for fixed route public transit; increased accessibility of NEMT for individuals with disabilities; and, the availability of NEMT revenue as local match for Federal Transit Administration grants.

The report provides strategies to coordinate NEMT with public and human services transportation to achieve the common desired
outcomes of improved health, better quality of service, and maximization of services delivered within available resources. In particular, the report recommends the implementation of a transparent cost allocation methodology to show how shared-ride public transportation can lower the cost for an NEMT trip.

Public transportation providers can adopt a comprehensive cost accounting system that identifies all costs incurred and all services rendered to establish and implement cost allocation to identify direct costs for coordinated services, including NEMT. The report outlines a range of strategies to affect a greater degree of coordination among public transit and NEMT.

Cost accounting challenges were identified in the report, including those imposed on a public entity that requires: (a) maintenance a separate cost accounting system for NEMT; and (b) excluding of shared costs or indirect costs/central services allocated from another governmental entity.22

 

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