11/01/2020
Non-Emergency Medical Transportation: A Vital Lifeline for a Healthy Community
Approximately 3.6 million Americans miss or delay medical care because they lack appropriate transportation to their appointments. Many low-income Americans lack the disposable income necessary to have access to a working automobile, and may lack public transit options to get to and from medical appointments. Medicaid provides a nonemergency medical transportation benefit that pays for the least costly and appropriate way of getting people to their appointments whether by taxi, van, public transit or mileage reimbursement.
This brief provides an overview of the different ways states are dealing with the increase in people who need transportation to medical services because of age, chronic conditions or income. It is intended to provide guidance for state lawmakers to consider the vital role transportation plays in positive health outcomes for citizens.
The Increasing Need for Non-Emergency Medical Transportation Services.
Medicaid funds are the single largest transfer of federal money to states, representing an average of 44 percent of all federal revenue received. The transportation component is about $3 billion of that yearly fund transfer, making up less than 1 percent of total Medicaid expenditures. Though a small percentage of Medicaid overall, consistent transportation access to healthcare helps enhance the medical outcomes of Medicaid recipients and leads to cost-savings.
Medicaid Expansion
Under the Affordable Care Act, the population of people eligible for Medicaid is expanding. Based on projections from the 25 states where coverage expansion is underway, it is estimated that 9 million people will be added to the Medicaid program; Medicaid and the Children’s Health Insurance Program (CHIP) have more than 6 million new enrollees as of April 30, 2014. Because the expansion includes people who are 133 percent of the federal poverty rate, they are expected to have relatively fewer NEMT transportation needs. A study from the Transportation Research Board estimates that only 270,000 new enrollees will require NEMT, which nevertheless could potentially strain systems in some states.
Providing Health Care Access
Non-emergency medical transportation is essential for disadvantaged Medicaid recipients, those who are older, or have disabilities or low incomes who have no transportation to access healthcare services.
Growth of Chronic Conditions
Many people with chronic conditions, which include arthritis, asthma, cancer, cardiovascular disease, chronic obstructive pulmonary disease and diabetes, need medical services frequently. Treatment of chronic conditions account for three-quarters of all U.S. healthcare spending. As of 2009, the Centers for Disease Control estimate that 78 percent of the adult population age 55 and older has at least one of these chronic conditions. Additionally, estimates are that states will add more than a half million adults who have serious behavioral health issues that impair their everyday functioning to the Medicaid population. These people will need NEMT to access life sustaining treatments and health care services.
For the nearly 20 million adults with chronic kidney disease who are undergoing dialysis three times a week, NEMT is a reliable way to get to appointments and avoid going to the emergency room if appointments are missed. Sixty-six percent of dialysis patients rely on others for transportation to their appointments, only 8 percent relied on public transportation or taxi services, and 25.3 percent drove or walked to the clinic themselves. A recent study examining Florida’s NEMT costs found that if 1 percent of total medical trips resulted in avoiding an emergency room visit, the state could save up to $11 for each dollar spent in non-emergency medical transportation.
State Solutions to Increasing Need for Non-Emergency Medical Transportation
Coordinating Human Transportation Services can Reduce One-Purpose NEMT Trips
One strategy for NEMT cost savings is to coordinate medical trips with other community transportation providers who are serving similar populations. Few states, however, have successfully coordinated their Medicaid trips with their entire transportation network. This may be because of differing service standards for ADA paratransit and NEMT, differing requirements for drivers of transit and NEMT, jurisdictional issues or restrictive interpretations of federal regulations.
In what has developed as a complex and often fragmented system,
Services can overlap in some areas and be entirely absent in others. Funding shortfalls, policy and implementation failures and lack of coordination can leave many who need transportation with few or no options. The result is that many who need transportation to access essential services and to participate in community activities may be left unserved or underserved. Fortunately, technology developments related to coordination and mobility management have helped maximize resources by successfully managing eligibility standards and shared rides with multiple funding sources.
Yet, in many states, one of the largest human services transportation providers does not have a seat at the coordination table. State Medicaid agencies provide a substantial proportion of NEMT rides to populations that would benefit from coordinated transportation. However, with Medicaid regulations against self-referrals, barriers to effective coordination exist. The Medicaid rules on governmental brokerages provide that if, after winning the competitive bid, a governmental entity provides a brokerage service, the brokerage must be a distinct governmental unit, and it could not be paid for costs other than those unique to the brokerage function.
Additionally, the administrative burden for governmental brokerages is high. For every ride provided through another governmental entity, the broker must provide assurances that sending someone on a state or local transportation service was the most appropriate, effective and lowest cost. In addition, for each individual transportation service, the broker must document that the Medicaid program is not paying more than the rate charged to the general public. The rules were proposed so that state and local bodies would play on an equal playing field as private entities. They may, however, be preventing effective coordination with other agencies because of administrative hurdles.
Because of the complexity of Medicaid NEMT regulations for eligibility and prohibitions on self-referrals, many Medicaid agencies prefer to put the obligation of complying with regulations on a private broker instead of risking losing their funding because of noncompliance.
Some states are finding ways to coordinate their Medicaid transportation with other agencies. Eighteen states coordinate with the Medicaid agency at some level by having them on the state coordinating council. In three states—Kentucky, Massachusetts and Vermont—non-emergency transportation is fully embedded in their coordinated transportation approach. In Vermont, rides are coordinated through the Vermont Public Transportation Association (VPTA), which is composed of nonprofits, municipalities, para-transit providers and members of the general public. VPTA has a contract with the Agency of Human Services, and facilitates coordinated transportation services between nine public transportation providers using fixed route, demand response, taxis and volunteer driver services. VPTA also has recently partnered with a technology provider to increase its transit agencies’ scheduling and dispatching efficiencies and reporting capabilities.
Twenty-eight states do not coordinate transportation with their Medicaid agency at all, because they do not have a state coordinating council. This means that several agencies which are facilitating rides in one neighborhood may be sending a separate vehicle to a disabled veteran, a Medicaid patient, and someone who needs ADA paratransit, who all live a block from one another.
To combat these problems, governmental bodies, human service organizations and transportation planners have advocated improved coordination among human service agencies, providers of public transit and specialized transportation services and other stakeholders. This process, called human services transportation coordination, generally means better resource management, shared power and responsibility among agencies and shared management and funding. When key entities work together to jointly accomplish their objectives, they can achieve more effective, efficient and accessible transportation options for those who need it most: effective, in that they get people where they’re going; efficient, in that they use public dollars economically; and accessible, in that services are easy for travelers to navigate and use.
Although coordination of transportation services can benefit more than just the NEMT population, many Medicaid agencies contract out their transportation services. The contract typically does not include a requirement to coordinate with other state transportation agencies, creating a barrier for efficient use of state transportation funding and effective service for underserved populations. Opportunities exist for states to coordinate services with Medicaid agencies to maximize efficient transportation funding.
Mobility Management for NEMT Trips
Some communities are utilizing Mobility Management in an attempt to better coordinate transportation options. Mobility Management is administered by transit agencies in some communities to improve network efficiencies, for example, through the utilization of a one-call one-click scheduling systems. Other communities utilize staff at human service organizations, such as Aging and Disability Resource Centers, as mobility managers to assist individuals to find the best transit options or provide instruction to people with disabilities on how to use public transit.
State Non-Emergency Transportation Delivery Options
After Congress passed the Deficit Reduction Act of 2005 (DRA), states had more options to deliver their non-emergency medical transportation. The DRA allowed states more flexibility in how they deliver NEMT, without requiring a burdensome administrative waiver process. All states are required to submit a plan to the Centers for Medicare & Medicaid Services (CMS) detailing how they will provide NEMT services and how it will be reimbursed—as either an administrative cost or a medical cost.
Requirements for NEMT under Medicaid regulations
Available in all political subdivisions of the state.
Provided with reasonable promptness to all eligible individuals.
Provided to all individuals in the same amount, duration, and scope.
Recipients must be allowed the “freedom of choice” of their transportation provider.
Administrative Cost vs. Medical Cost
States can claim NEMT as either an administrative cost or a medical cost when submitting their state plans to the Centers for Medicare & Medicaid Services.
Because of the administrative burden, many states submit NEMT as a line item in their overall administrative costs, creating barriers for CMS to analyze data on the prevalence of service delivery modes and their relative effectiveness for health outcomes. These modes of delivery include brokerages, fee-for-service, public transit, managed care organization or a mixture of two or more of the above.
