Vikki Wachino, AVIA Advisor and Former Deputy Administrator and Director of the Center for Medicaid and CHIP Services at CMS

Non-emergent medical transportation (NEMT) continues to be an area of interest and priority expressed by Members of the Medicaid Transformation Project (MTP). As part of the MTP’s Emergency Department Initiative, 11 health systems engaged in the Building a Comprehensive Transportation Strategy work group.

The regulatory environment for NEMT benefits for Medicaid beneficiaries continues to evolve, with some notable developments at both the federal and state levels. Read on to see Vikki Wachino’s perspective on the following questions, which address these developments and their potential implications for AVIA Network Members:

• Why is NEMT a priority for AVIA’s health system Members and Medicaid beneficiaries?
• What policy developments might systems want to be tracking? How are states and CMS approaching NEMT?
• What advice would you provide to health systems waiting for policy changes before making investments in NEMT?
• How can providers think about offering transportation as a financial opportunity despite the uncertainty of reimbursement?
• If you were a purchaser in the space, what qualities/features would you look for and prioritize?

Q: Why is NEMT a priority for AVIA’s health system Members and Medicaid beneficiaries?

A: In 2017, more than 2 million Medicaid beneficiaries under age 65 said they had delayed care due to lack of transportation.1 Medicaid beneficiaries, by virtue of their low incomes, face significant transportation barriers – they are less likely to own a vehicle and more likely to be unable to pay out of pocket for public or private transportation. Medicaid’s NEMT benefit is designed to overcome these barriers by requiring states to ensure Medicaid beneficiaries transportation to obtain the healthcare services Medicaid covers.

While this NEMT benefit had flown under the radar for much of its history, suddenly, transportation is in the spotlight, as healthcare industry and policy leaders work to better understand and address the “social determinants of health” that help drive people’s quality of life, use of healthcare services, and healthcare spending. There is a growing recognition that transportation, like food and affordable housing, is a social determinant of health. And there is a close relationship between transportation and healthcare: healthcare-related transportation can have a direct impact on access to and use of needed services, including primary care, preventive care, and behavioral health services.

Many payers, service providers, or policy makers are intrigued by the potential that expanding access to transportation can have on improving health outcomes and managing costs. This coincides with disruptive local transport innovation – namely the role that transportation network companies (TNCs, rideshare companies like Uber and Lyft) are playing and the impact that they are having on the wider transportation market. These developments make for a ripe environment for advancing transportation policy and practice in Medicaid right now.

Q: What policy developments might systems want to be tracking? How are states and CMS approaching NEMT?

A: I don’t own a crystal ball, but if I did its outlook for future federal NEMT policy would be cloudy. Here’s why: although there is a lot of discussion and interest in expanding access to transportation across sectors, recent federal policy may be moving in the opposite direction. The Trump budget for fiscal year 2020 committed to making the NEMT benefit optional for states, rather than a required part of state Medicaid programs. But, recently, CMS received some pushback from Capitol Hill, and it deferred its plans to change NEMT regulations for several years.2

This potential transportation policy evolution was preceded by two states, Indiana and Iowa, receiving federal approval under the Obama Administration to exclude NEMT as a benefit for the low-income adults covered by Medicaid expansions.3 Those approvals came as part of broader 1115 waivers that set the policy parameters for those two states’ Medicaid expansion programs.4 Allowing these states to exclude NEMT was controversial, and advocates, transportation providers, and others were concerned that not providing NEMT to some people would diminish their access to care.

There is currently a big question mark hanging over these transportation issues and other Medicaid policies: whether CMS will approve “block grants” of funding for state Medicaid programs. Under a block grant, the federal government limits its financial contribution to a state Medicaid program and expands state flexibility in ways that can reduce Medicaid’s affordability and coverage standards, allowing potential reductions in eligibility, benefits, and provider payments. Any CMS guidance could include state flexibility to change the NEMT benefit. States currently have a great deal of flexibility in how they administer their NEMT benefits – they can use capitation, fee for service, direct service delivery, or voucher programs. Would additional flexibility permit states to stop offering NEMT to some Medicaid beneficiaries, following Indiana and Iowa’s approach? Would it be broader than that? Again, my crystal ball is decidedly cloudy.

Q: What advice would you provide to health systems waiting for policy changes before making investments in NEMT?

A: There is opportunity for policy and operational leadership in the transportation space. That leadership could come from working with state health leaders – both those in the legislative and executive branches – to educate them on the importance of having a strong Medicaid transportation benefit that works for consumers and providers, its role in ensuring access, and its link to provider success in meeting the sometimes complex health needs of low-income populations.

Beyond that, there are clear opportunities for transportation innovation for systems that want to supplement the state-provided NEMT benefit, which could provide greater assurance that their specific patients are able to access care. Innovation could be driven by the state, systems, plans, and/or the transportation providers themselves. One approach could be for a system to pilot and evaluate a new transportation approach on some or all of its members, then use that to inform its future transportation investment, and potentially to inform state policy more broadly.

There is sometimes a tendency to “wait and see” what the policy is before acting. The downside to that approach is that, given the competing policy cross-currents that I’ve described above, it could be some time before open policy questions are resolved. In the meantime, the transportation market is evolving – as ridesharing grows, the market for competing forms of transportation, like taxis, may be smaller, and that may have an impact on transportation service access in some areas or for some populations. In other words, there is risk in acting. But there also may very well be risk in not acting.

Q: How can providers think about offering transportation as a financial opportunity despite the uncertainty of reimbursement?

A: The key question is, “What is the return on investing in transportation, or strengthening an existing transportation program, relative to the size of the investment?” For specific chronic conditions, improving access to transportation can be cost-effective and, in some cases, even cost-reducing.5 There may be some services or populations where a new investment or a redesign may have particular impact: transportation can be part of a broader strategy to overcome shortages of behavioral health providers, for example, or to help individuals access treatment for substance use disorder. It can also be part of the solution set for improving maternal and infant health. Initially, AVIA slated transportation as part of the MTP ED Initiative, but it is equally relevant to all areas of the Medicaid Transformation Project.

Q: If you were a purchaser in the space, what qualities/features would you look for and prioritize?

A: Clearly, there are basic requirements that transportation providers should meet to ensure quality services are being provided – timeliness, verification, driver licensure, and background checks.

But those are just the basics: additional capabilities are needed to meet the needs of people with complex health conditions. Specialized vehicles and training may be needed to help individuals who are disabled, blind, or otherwise medically frail. One analysis estimated that seniors and people with disabilities represent two-thirds of Medicaid fee-for-service transportation users, so being able to meet these populations’ needs is paramount.6 NEMT providers also must be able to serve people with mental health conditions or intellectual or developmental disabilities. Arizona recently expanded its NEMT program to include TNCs (rideshare companies). But its policy limits rideshare services to people who do not need personal assistance. Many of the most complex populations Medicaid serves do need personal assistance. TNCs may find that they face a choice – they can evolve to accommodate the needs of complex populations, form strategic partnerships, or cede that market to others.

Finally, health systems should also look at their own policies and practices to identify and mitigate any hidden barriers to their patients accessing transportation. Policies that prohibit children from riding with parents, for example, can impede access for a low-income parent with few child care options.7

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1 Medicaid and CHIP Payment and Access Commission, Medicaid Coverage of Non-Emergency Medical Transportation. https://www.macpac.gov/wp-content/uploads/2019/05/Medicaid-Coverage-of-Non-Emergency-Medical-Transportation.pdf. May 2019.
2 Baker T. Medicaid and non-emergency medical transportation. Medicaid & the Law. https://www.medicaidandthelaw.com/2019/06/28/medicaid-and-non-emergency-medical-transportation. June 28, 2019.
3 CMS also approved a waiver of NEMT services as part of an 1115 waiver in Kentucky, but CMS’ approval of major provisions of the waiver has been set aside by a federal court.
4 The author served as Director of the Center for Medicaid and CHIP Services from 2015 to 2017 for the Obama Administration, where, among other responsibilities, she oversaw the Iowa and Indiana Medicaid expansion waivers.
5 Transportation Research Board. Cost-benefit analysis of providing non-emergency medical transportation. https://www.nap.edu/download/22055. October 2005.
6 MACPAC, May 2019. The analysis was performed on 2012 data, prior to the implementation of the Affordable Care Act and Medicaid expansion.
7 Texans Care for Children. Healthy moms raising healthy babies: Central Texas and statewide challenges and opportunities to support maternal behavioral health during the first year after childbirth. https://static1.squarespace.com/static/5728d34462cd94b84dc567ed/t/5d11353a6a18f70001eec726/1561408833020/healthy – moms-healthy-babies.pdf. June 2019.

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