Frequently Asked Questions

Medicaid beneficiaries without access to transportation to their medical appointments are eligible for NEMT. Most states that have expanded Medicaid under the Affordable Care Act (ACA) have chosen to offer NEMT to their Medicaid expansion population as well. States work within the broad federal requirements to establish the specifics of their own NEMT programs.

NEMT covers a wide array of medical visit types as long as the services being provided are Medicaid compensable. Some of the most common medical needs of the Medicaid population that require NEMT are:

• Dialysis services for patients with End-Stage Renal Disease (ESRD)
• Substance abuse counseling sessions
• Behavioral health or mental health appointments
• Visits with primary care physicians or specialists
• Chemotherapy or other recurring infusion treatments

NEMT is a relatively small component of the Medicaid program. In 2014, total Medicaid spending on NEMT was estimated to be $3 billion, which accounted for less than one percent of total Medicaid spending that year.[1]

[1] Transit Cooperative Research Program, Impact of the Affordable Care Act on Non-Emergency Medical Transportation: Assessment for Transit Agencies at 2 (Oct. 2014), available at: http://onlinepubs.trb.org/onlinepubs/tcrp/tcrp_rrd_109.pdf.

The cost of a trip varies based on a number of factors including time/distance from a patient’s home to the appointment and back, the mode of transportation required, and the availability of transportation options in a given area. For example, a lengthy trip to a dialysis center for a non-ambulatory or wheelchair-bound patient in a rural area of the nation will be more expensive than a short trip to a primary care provider for an ambulatory patient in a suburban community. States that employ NEMT brokers usually pay a set per-beneficiary fee to the brokers who provide necessary transport to Medicaid beneficiaries using the most clinically appropriate and cost-effective transportation option.

A number of third-party studies over the years have validated the positive impact of NEMT services. A 2008 study by Florida State University found that Florida’s investment in NEMT for low-income, elderly, and disabled residents yielded a 1,108 percent return on the state’s investment. This calculation was based on a conservative estimate that one out of every 100 trips (1 percent) prevents a one-day stay in a hospital.[1] Additionally, when Congress established the NEMT brokerage option through the Deficit Reduction Act (PL 109-171), the Congressional Budget Office (CBO) estimated this model would reduce federal Medicaid spending by $235 million over 10 years.[2]

[1] Florida Transportation Disadvantaged Program, Return on Investment Study at 6 (Mar. 2008), available at: http://tmi.cob.fsu.edu/roi_final_report_0308.pdf.

[2] See: https://www.cbo.gov/sites/default/files/109th-congress-2005-2006/costestimate/s1932conf0.pdf, Page 36

The majority of states now use one or more brokers to administer their NEMT Medicaid benefit. Brokers take on full responsibility for managing a defined beneficiary population, making sure beneficiaries have access to the most appropriate means of transportation delivered by transportation providers with records of safety. Brokers also help prevent fraud and abuse through a host of program integrity measures.

Researchers who study transportation programs have found that capabilities like computer-aided scheduling and tight controls on eligibility – all common services provided by NEMT brokers – can increase the capacity of available service by reducing average trip length, transporting multiple passengers simultaneously and decreasing the number of ineligible trips, thereby reducing average trip cost and allowing the program to run efficiently.[1]

[1] Wallace, R., P. Hughes-Cromwick, H. Mull, and S. Khasnabis, Access to Health Care and Nonemergency Medical Transportation: Two Missing Links, Transportation Research Record Journal of the Transportation Research Board, January 2005, available at: https://www.researchgate.net/publication/39967547_Access_to_Health_Care_and_Nonemergency_Medical_Transportation_Two_Missing_Links

Distinguishing between the traditional Medicaid population and the expansion population is often difficult to assess in many markets given how states file and record such information. However, based on the experiences of major NEMT brokers, utilization by expansion population members has steadily increased month over month as more members become aware of the benefit for the first time. Having never been eligible for transportation services in the past, this steady increase in ridership is considered natural.

Both expansion population members and traditional Medicaid beneficiaries use NEMT services for Mental Health/Substance Abuse visits as their top two treatment needs. Data reflects that the expansion population uses NEMT services to access most of the same targeted and non-repetitive medical care services as the traditional Medicaid population. When looking at preventative care trips specifically, the expansion population uses NEMT services to access preventive care on average 65 percent more than the traditional population. This data reflects pent up demand and underscores the benefits of providing access to primary and preventative health services rather than acute or critical care.

The President’s FY 2019 budget includes a reference to using regulatory authorities to make NEMT an optional rather than a required benefit. MTAC has not seen any more detailed information on the proposal, but is working to better understand what the administration may be planning to do. The President’s budget, of itself, does not change NEMT in any way. But language in the budget ((see page 85) does say that the Administration will seek to publish a regulation that would change NEMT from a mandatory to an optional benefit. If this were to happen, it would be easier for states to curtail NEMT if inclined to do so.

The President’s budget contains many proposals – some of which likely will not come to pass. If the Centers for Medicare and Medicaid Services, the federal agency responsible for Medicaid, publishes a draft regulation on NEMT, that regulation will be subject to public comment and cannot be finalized without consideration of public comments. Supporters of NEMT will want to comment on any proposed regulation. If NEMT becomes an optional benefit, states will still need to consider what changes, if any, to make to their NEMT benefit. To date, a few states have curtailed, or proposed to curtail, NEMT for Medicaid Expansion populations.

MTAC will continue providing evidence that access to NEMT results in better health outcomes for beneficiaries while also controlling costs by avoiding or minimizing the use of more intensive – and higher cost – healthcare services. MTAC is also encouraged that in a recent speech, Health and Human Services Secretary Alex Azar specifically recognized the benefits of providing persons in need with access to low-cost transportation to get them to their healthcare appointments and that such services provide a sizable return on investment.

While some states have pursued or are pursuing waivers to provide NEMT to the Medicaid expansion population, research by MJ Simon & Company indicates that no states have pursued waivers limiting NEMT to the core Medicaid population. MTAC believes this is because states largely recognize the return-on-investment of well-managed NEMT to help beneficiaries manage their healthcare needs and prevent them from needing more intensive and more expensive healthcare services.

Yes. As more hospitals and providers embrace value-based reimbursement models based on a lump sum payment for an episode of care, free transportation to follow up appointments is increasingly common. But there are regulatory barriers to limit how and when providers can offer transportation.

HHS Secretary Alex Azar discussed this problem in a March 2018 speech to the Federation of American Hospitals: “Many providers have taken advantage of the recent rise of ride-sharing services to provide reliable, low-cost transportation to appointments. But an array of federal regulations has limited the degree to which this can occur: The amount of free rides that can be provided to a patient in a given year, for instance, is strictly limited. These are the kinds of wraparound services that can often improve outcomes at incredibly low cost. We’re devoted to figuring out ways for providers to take advantage of them.”

MTAC hopes to work with Secretary Azar and other stakeholders to reassess regulations that limit the provision of NEMT by healthcare providers.