The CMS is drafting a proposed rule that would give states greater flexibility in paying (or not paying) for non-emergent medical transportation (NEMT) for Medicaid beneficiaries. This proposed rule aligns with CMS’ repeated intentions to create “a new era for the federal and state Medicaid partnership where states have more freedom to design programs that meet the spectrum of diverse needs of their Medicaid population,” as stated in a letter from HHS secretary Tom Price and CMS administrator Seema Vera earlier this year.
The mandatory Medicaid benefit has existed since the program’s inception, however states can limit NEMT’s availability through federal waivers. Due to the expense of these trips, providers are concerned that the proposed rule could mean cuts to their Medicaid revenue. Texas A&M Transportation Institute researchers estimated that in fiscal year 2013 alone, $2.9 billion was spent on NEMT to fund 103.6 million NEMT trips. In 2016, the most common reason found across 32 states for using a NEMT trip was to access behavioral health services, according to the Kaiser Commission on Medicaid and the Uninsured. Other common reasons included PT/rehab, specialty visits, preventive services, adult day health care, and dialysis.
From a fraud and abuse standpoint, the proposed rule could help reduce cases of fraudulent billing, which according to CMS have included an owner of a Massachusetts medical transportation company billing rides for deceased beneficiaries and a Medicaid beneficiary who drove himself and others to dialysis appointments but allowed an ambulance company owner to bill for ambulance rides with their medical IDs. Following a 2016 study published by the GAO noting gaps in NEMT guidance at the state and federal level, CMS published a NEMT Toolkit to provide a general scope of Medicaid-covered emergency transportation and NEMT benefits.
The regulation to make it easier for states to stop paying for NEMT trips could be released as early as May 2019.