Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination (2018)

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23 The assurance of transportation to necessary medical care is an important feature that sets Medicaid apart from traditional health insurance. This chapter describes how the Deficit Reduction Act of 2005 (DRA) has influenced how states have decided to deliver NEMT services. The chapter describes the different models avail- able to state Medicaid agencies for providing NEMT and discusses the recent trend to create statewide or regional brokerages for NEMT or to move to MCOs with responsibility for NEMT. Why Is Transportation Important to Medicaid? The Medicaid program provides critical health insurance for millions of people who might not otherwise be able to afford it. The assurance of transportation to necessary medical care is an important feature that sets Medicaid apart from traditional health insurance. The beneficiaries of Medicaid include the nation’s most vulnerable populations: infants and children in low-income families, individuals and families with low incomes or limited resources, individuals of all ages with disabilities, and very-low-income seniors (18). Often, these groups lack the resources to afford a reliable means of getting to medical appointments, have limited options and long travel times, and may have frequent appointments for certain medical condi- tions (e.g., dialysis). In addition to access to health care services, Medicaid beneficiaries also experience mobility challenges in other important areas of life, such as accessing jobs and shopping for basic necessities. These mobility challenges can also affect health outcomes. In a 2015 report, the U.S. Government Accountability Office (GAO) provided data that showed a small percentage of Medicaid-only beneficiaries (those who were not also eligible for Medicare) consistently accounted for a large percentage of the total Medicaid expenditures. According to the GAO report, in each fiscal year from 2009 through 2011, the most expensive 5 percent of Medicaid-only beneficiaries accounted for almost 50 percent of the expenditures for all Medicaid-only beneficiaries (19). Many of the Medicaid-only beneficiaries that fall in the 5 percent group need assistance with transportation to medical services due to the complexity and severity of their needs. State Medicaid programs are required to assure NEMT for Medicaid beneficiaries who need to get to and from medical services and have no other means of transportation. Without NEMT, the individuals who most need medical care might not be able to access critical services. While NEMT is estimated to be less than 1 percent of a state’s total Medicaid expenses, NEMT is important for eligible beneficiaries to access the medical services that can contribute to improved quality of care and lower health care costs. By providing consistent access to medi- cal appointments, states can save money by helping Medicaid beneficiaries to avoid emergency room visits and hospital stays. A study in 2008 examining Florida’s NEMT costs found that if 1 percent of the total trips to medical services resulted in avoiding a hospital stay, the state could save $11 for each dollar spent on NEMT (20). C H A P T E R 3 Non-Emergency Medical Transportation for Medicaid

24 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination Lack of Transportation Can Affect Health Outcomes Interviews with research and advocacy groups confirm that the lack of transportation for Medicaid beneficiaries can impede their ability to access medical services, particularly for individuals living in rural or medically underserved areas, as well as those with chronic health conditions (21). The literature shows two distinct health effects of poor transportation: less use of preventive and primary care and more use of emergency rooms (22). Lack of transportation can restrict access to medical care, affecting health outcomes for indi- viduals and higher costs for medical services. Research finds that missed medical appointments due to transportation issues can lead to costly subsequent medical care, such as hospitalization and the use of an ambulance for emergency transportation (23). Assurance of Transportation The original 1965 Title XIX legislation establishing Medicaid does not mention a requirement to provide transportation. Assurance of transportation appeared in 1966 in federal interpretive guidance, Handbook of Public Assistance (Supplement D) (18). The interpretive guidance provides criteria to ensure a high quality of care and services, including the “provision for necessary trans- portation for a Medicaid-eligible recipient to and from the suppliers of medical and remedial care and service” (18). There is a long-standing regulatory basis for the transportation assurance. The requirement to provide transportation was included in CMS rulemaking in 1968 (24). In 1978, these regulations were codified in the Code of Federal Regulations as 42 CFR Section 431.53 (25). The regulation reads as follows: § 431.53 Assurance of Transportation A state plan must— (a) Specify that the Medicaid agency will ensure necessary transportation for beneficiaries to and from providers; and (b) Describe the methods that the agency will use to meet this requirement (25). Despite the regulatory obligation to assure transportation on behalf of eligible individuals, state Medicaid plans were subject to numerous legal challenges. Different state Medicaid policies and practices resulted in lawsuits regarding a state’s failure to assure transportation to medical care. In most cases, the courts ruled that transportation assurance is an enforceable right and that the state must assure transportation for eligible Medicaid beneficiaries. All states now comply with this regulatory obligation. This requirement to assure transportation is referred to as non-emergency medical transportation because it is for situations that do not involve an immediate threat to the life or health of an individual. Requirements for NEMT to Be Medicaid Covered NEMT is transportation to and from appointments for medical services for Medicaid-eligible beneficiaries who have a medical need for approved services. Each state has broad discretion to determine who is eligible for NEMT. In most states, qualified means eligible to receive medical services through the Medicaid program and eligible for NEMT. In general, NEMT will be covered by Medicaid if the following conditions for medical necessity are met (1): • The beneficiary is eligible for a medical assistance program (Medicaid). • The medical service for which the trip is needed is a Medicaid-covered service. • The beneficiary has no other means of getting to and from the covered medical service. . . . the lack of transportation for Medicaid beneficiaries can impede their ability to access medical services, particularly for individuals living in rural or medically under­ served areas, as well as those with chronic health conditions.

Non-Emergency Medical Transportation for Medicaid 25 • The NEMT trip is authorized in advance by the appropriate agency or broker. • The NEMT trip is to the nearest qualified medical provider as authorized by Medicaid. • The NEMT trip is the lowest cost available transportation mode that is both accessible for the client and appropriate for the client’s medical condition and personal capabilities. Health Care Reasons for Using NEMT Medicaid beneficiaries frequently use NEMT to access behavioral health services, preventive health services, and care for chronic conditions. While there are no comprehensive national data about beneficiary use of NEMT (because states are not required to separately report these data), information is available from one company that provides Medicaid NEMT services in 32 states. As shown in Figure 7, the information indicates that the most frequently cited reasons for using NEMT are to access: • Behavioral health services (including mental health and substance abuse treatment), • Dialysis, • Preventive services (including doctor visits), • Specialist visits, • Physical therapy/rehabilitation, and • Adult day health care services. What Is the Deficit Reduction Act of 2005? More than any other legislation, including ACA, DRA has influenced how states have decided to deliver NEMT services. Approved by Congress and signed into law by President George W. Bush on February 8, 2006, DRA was intended to slow the growth in spending for the Medicare and Medicaid entitlement programs (26). As described by CMS, DRA provides states with the flexibility needed to make significant reforms to their Medicaid programs and to pursue innovative ideas in health care (27). How DRA Impacts NEMT Section 6083 of DRA amended the Social Security Act by adding a new section— Section 1902(a)(70)—which provides states the flexibility to establish an NEMT brokerage Source: LogistiCare Solutions, Medicaid Gross Trips by Treatment Type, 2015. Figure 7. Medicaid trips by treatment type.

26 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination program regardless of the statutory requirements for statewideness, comparability, and freedom of choice (26). States have the following options: • Prior to DRA, unless a state obtained a Section 1915(b) waiver authority or provided NEMT as an administrative expense, the state could not restrict beneficiary freedom of choice in providers and had to provide NEMT uniformly throughout the state. Some states described the process of obtaining a Section 1915(b) waiver every two years as burdensome, and pro- viding NEMT as an administrative expense meant a maximum 50 percent federal match. • Post-DRA, states have an additional option of establishing an NEMT brokerage through a Section 1902(a)(70) state plan amendment. DRA included as an incentive for this NEMT model the ability to receive the federal matching rate (which ranged from 50 percent to 74.6 percent in FY 2017) as a medical service expense (26). NEMT brokerage programs vary from state to state; however, the fundamental function of an NEMT broker is to be the single point of contact for eligible Medicaid beneficiaries and to arrange the most appropriate and lowest-cost transportation to and from authorized medical services. State Option to Establish an NEMT Brokerage Under the new Section 1902(a)(70) of the Social Security Act, a state may establish an NEMT brokerage in order to more cost-effectively provide NEMT services for individuals who are eligible for medical assistance under the state Medicaid plan, who need access to medical services, and who have no other means of transportation. These transportation services include wheelchair vans, taxis, stretcher cars, bus passes, and tickets; transportation to address the needs of individuals with disabilities; and other forms of transportation otherwise covered under the state plan. For example, some states provide mileage reimbursement for an eligible individual or a family member who can drive to appointments, and some states approve airfare for long- distance travel. For approval to implement an NEMT brokerage under a Section 1902(a)(70) state plan amendment, the state Medicaid agency must meet the following requirements (26): • Competitive bidding. Select the broker or brokers though a competitive bidding process based on the state’s evaluation of the broker’s experience, performance, references, resources, qualifications, and costs. • Oversight. Establish oversight procedures to monitor beneficiary access and complaints and ensure that transportation is timely and that the transportation providers are licensed, qualified, competent, and courteous. • Auditing. Provide for regular auditing and oversight by the state in order to ensure the quality and timeliness of the transportation services provided and the adequacy of beneficiary access to medical care and services. • Prohibition of referrals. Impose, through the contract with the broker, requirements related to prohibition of referrals and conflicts of interest that the Secretary of DHHS establishes (based on the Medicaid prohibition of physician referrals). The prohibition of referrals and conflicts of interest were later described in the implementing regulations 42 CFR Section 440.170(a)(4)(ii). Prohibition of Referrals and Conflicts of Interest CMS issued regulations to implement Section 6063 of DRA as 42 CFR Section 440.170(a)(4), effec- tive January 20, 2009. These regulations apply to those states that choose to file a Section 1902(a)(70) . . . the funda­ mental function of an NEMT broker is to be the single point of contact for eligible Medicaid beneficiaries and to arrange the most appropriate and lowest­cost trans­ portation to and from authorized medical services.

Non-Emergency Medical Transportation for Medicaid 27 state plan amendment to obtain authority to provide NEMT as a medical service through a broker (28). A key provision of the regulation is the prohibition against self-referral. This means that the broker cannot assign a trip where the broker has some organizational, financial, or personal relationship with the provider. The basis to include this provision was a matter of law but implemented by discretion of the Secretary of DHHS by regulation. The law directed the Secretary of DHHS to apply the conflict of interest rules issued for physicians to prevent doctors from making referrals to other health care providers where the physician has some type of ownership interest (Section 1877 of the Social Security Act) (26). Under 42 CFR Section 440.170(a)(4)(ii), a broker is prohibited from providing NEMT services or making a referral or subcontract to a transportation provider if: • The broker has a financial relationship with the transportation provider. • The broker has an immediate family member that has a direct or indirect financial relation- ship with the transportation provider (28). Exceptions for Non-governmental Brokers The regulation provides exceptions to the provisions for self-referral. Three exceptions to the self-referral and conflict of interest provisions assume the broker is a non-governmental entity (28): • Rural area. An exception to the self-referral prohibition may apply for transportation pro- vided in a rural area when there are no other available Medicaid providers determined to be qualified except the non-governmental (e.g., private or nonprofit) broker. The definitions of rural and urban areas are consistent with other Medicaid regulation (42 CFR Section 412.62). A rural area is defined as any area outside an urban area, and an urban area is defined as a metropolitan statistical area or New England county metropolitan area. • Specialized transportation. An exception to the self-referral prohibition may apply for transportation so specialized that there is no other available Medicaid-participating trans- portation provider determined to be qualified except the non-governmental broker. • Insufficient to meet the need. An exception to the self-referral prohibition may apply if the state Medicaid agency determines that the availability of other qualified Medicaid-participating transportation providers is insufficient to meet the need for transportation. Exception for Governmental Brokers Another exception to the self-referral and conflict of interest provisions applies if the broker is a governmental entity. If the broker is a governmental entity and the individual transportation service is provided by the broker, or is referred to or subcontracted with another government- owned or -operated transportation provider generally available in the community, then additional financial conditions must be met: • Exclude shared costs. The contract between the state Medicaid agency and the governmental broker provides for payment that does not exceed the actual costs calculated as though the broker were a distinct unit, and excludes from these payments any personnel or other costs shared with or allocated from parent or related entities. Medicaid will not pay costs that are shared with or allocated from other governmental entities (28). • Separate cost accounting system. The governmental unit that acts as a broker maintains an accounting system such that all funds allocated to the Medicaid brokerage program and all costs charged to the brokerage program will be completely separate from any other program. . . . the broker cannot assign a trip where the broker has some organi­ zational, financial, or personal relationship with the provider.

28 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination • Lowest cost. The governmental broker must document that its service (or the service con- tracted to another governmental entity) is the most appropriate and lowest-cost alternative with respect to an individual’s specific transportation needs. • Limits on charges for public transportation. The government broker must document that when setting charges to Medicaid, the entity charges no more than the following for public transportation: – Fixed-route transit—the standard fare charged to the public. – Paratransit—the rate charged to other state human services agencies for comparable services. Other Themes from the DRA That Influence NEMT Rule-setting discussion in the Federal Register for the regulation 42 CFR 440.170(a)(4) to implement Section 6083 of the DRA provided additional Medicaid guidance that influences NEMT policy and practice (29): • NEMT flexibility. States continue to have the flexibility to provide NEMT as an optional medical service expense or as an administrative expense. States that wish to establish an NEMT brokerage without being required to comply with general Medicaid requirements such as freedom of choice, comparability, and statewideness may continue to do so through the Section 1915(b) waiver process every two years. The Section 1915(b) waiver does not prohibit the broker from self-referral, nor does it require that the broker be selected through competitive bidding. Providing NEMT as an administrative expense (maximum 50 percent federal match) provides a state with the greatest flexibility in designing the NEMT program. • Medicaid funding limited to Medicaid services. Medicaid funds may only be used for Medicaid-approved services provided to eligible Medicaid beneficiaries. The Medicaid program’s responsibility is limited to ensuring cost-effective transportation for beneficiaries to and from Medicaid providers. • Protect against fraud and abuse. DRA included provisions that are intended to protect the integrity of the Medicaid program and prevent fraud and abuse. Federal regulations require each state Medicaid agency to establish an integrity program that includes methods for identifying and investigating suspected fraud and abuse cases, including NEMT. Medicaid rules define fraud as “an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person” (30). The Medicaid rules define abuse as practices “inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary” (30). Examples of NEMT provider abuse are billing Medicaid for services when taking a beneficiary to pick up groceries or run other errands or billing for a trip when the beneficiary did not show up for the service. • Coordination should not conflict with the Medicaid program. For initiatives such as coordination of human services transportation and public transportation, coordination is appropriate as long as it does not conflict with the policies and rules of the Medicaid program. Table 1 provides a summary of the impacts of DRA on NEMT. What Is CMS Guidance on the Use of Bus Passes? In 1996, several years before DRA, CMS provided guidance on the purchase of bus (transit) passes for NEMT and the use of transit passes for non-Medicaid purposes. The guidance was in the form of a letter to state Medicaid directors for states that claimed NEMT as an administrative expense (not as a medical service expense) (31). Medicaid funds may only be used for Medicaid­ approved services provided to eligible Medicaid beneficiaries.

Non-Emergency Medical Transportation for Medicaid 29 DRA Provision DRA Impacts NEMT in the Following Ways: NEMT brokerage A state Medicaid agency can establish an NEMT brokerage through a Section 1902(a)(70) state plan amendment regardless of the requirements for statewideness, comparability, and freedom of choice. State Medicaid agencies must select the broker through competitive bidding. Incentive Brokerages established under Section 1902(a)(70) may be claimed by the state as an optional medical service at the FMAP rate (50 percent to 74.6 percent in FY 2017).* Oversight The state Medicaid agency must provide oversight for brokers and must provide for regular audits. An NEMT broker must have oversight procedures to monitor beneficiary access and complaints, to ensure that transportation is timely, and to confirm that transportation providers are licensed, qualified, competent, and courteous. Prohibition against self- referral Non-government brokers (for profit or not for profit) have three exceptions to the prohibition against self-referral: • Transportation provided in a rural area where no other provider is available, • Specialized transportation that is not available from another provider, and • Transportation providers are insufficient to meet the need. Governmental brokers must meet certain requirements in order to be the provider of NEMT transportation: • Maintain a separate cost accounting system for NEMT, • Exclude shared costs or costs allocated from another governmental entity, • Document the government transportation service that is the most appropriate and lowest cost to meet the Medicaid beneficiary’s transportation need, and • Limit charges for public transportation to the standard fare for fixed route or no more than the rate charged to other human services agencies for paratransit. Medicaid funding limited to Medicaid- approved services NEMT is for eligible Medicaid beneficiaries who need to get to authorized medical services and have no other means of transportation. Medicaid funds may only be used for Medicaid services provided to eligible Medicaid beneficiaries. Using Medicaid funds for any NEMT service that is not for an eligible Medicaid beneficiary to an authorized medical service could be identified as fraud or abuse of the Medicaid program. Medicaid is the payer of last resort By law, the Medicaid program is the payer of last resort. If another insurer or program has the responsibility to pay for medical costs incurred by a Medicaid-eligible individual, that entity is generally required to pay the cost of the claim prior to Medicaid making any payment. Transportation coordination For initiatives such as coordination of human services transportation and public transportation, coordination is appropriate as long as it does not conflict with the policies and rules of the Medicaid program. * States may continue to establish an NEMT brokerage through the Section 1915(b) waiver process every two years as an optional medical service. Table 1. DRA impacts on NEMT. According to the guidance, a state can claim federal matching payments for transit passes as an administrative expense if the state can show the pass is cost effective compared to other modes of transportation. The cost of a monthly pass should not exceed the cost of the individu- ally approved NEMT trips in the month. If the transit pass is used by the Medicaid beneficiary for other trip purposes, the state Medicaid agency should determine whether there are other funding sources to allocate a portion of the cost of the pass and prepare a cost allocation plan. If the only or primary need of the Medicaid beneficiary is to obtain transportation to Medicaid- approved medical service providers, and there are no other, or minimal, uses of the pass, no cost allocation is necessary (31).

30 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination What Are the Models for Providing NEMT? After examining the different models to provide NEMT in the 50 states and the District of Columbia, the research team identified the following principal NEMT models: • In-house management, • Brokers, – Statewide broker and – Regional broker • MCOs, and • Mixed NEMT models. In-House Management The Medicaid in-house management model for NEMT is when a state Medicaid agency administers transportation for beneficiaries at a state, regional, or county level: • In-house management. The Medicaid agency responsibilities include operating the call center for Medicaid beneficiaries to request transportation, reviewing and providing transportation authorizations, and assigning trips to qualified private or public transportation providers. • Fee for service. States using the in-house management NEMT model operate on a fee-for- service basis. Transportation providers submit reimbursement requests for services rendered. States that operate using only an in-house management model (not a mix of models) usually claim federal financial participation as an administrative expense (at the 50 percent matching rate) unless they have requested waivers or have amended the state Medicaid plan for approval to use the higher FMAP rate for medical services. Brokers A state Medicaid agency may contract with an NEMT broker to manage preauthorized NEMT services in a designated area. Brokers have several responsibilities: • Confirm the Medicaid beneficiary’s medical eligibility to receive the NEMT benefit; • Verify the trip is to an approved Medicaid destination for a medically necessary service; • Arrange transportation that is most appropriate for the beneficiary at the lowest cost; • Contract with qualified transportation providers to provide the NEMT service; • Confirm transportation providers have proper background checks, licensing, training, and safe driving records for drivers; • Confirm transportation providers have proper licensing and safety inspections for vehicles; • Pay transportation providers for the services provided as agreed upon in the contract but typically on a fee-for-service basis or a fixed rate per mode of transport and/or distance traveled; • Schedule eligible Medicaid beneficiaries’ transportation through one of the qualified trans- portation providers; and • Document that all Medicaid requirements are met. Brokers execute contracts with private, human services transportation or public transportation providers to make authorized trips for eligible Medicaid beneficiaries under the supervision of the broker. Brokers pay transportation providers for the authorized trips by eligible Medicaid beneficiaries. The transportation providers are required to document the authorized Medicaid passenger trips delivered for the broker. According to the requirements of the state Medicaid agency, NEMT brokers may operate statewide or within a region, and they may be full-risk brokers or a shared-risk brokers. NEMT brokers may operate statewide or within a region, and they may be full­risk brokers or shared­risk brokers.

Non-Emergency Medical Transportation for Medicaid 31 Statewide Broker Under a statewide broker NEMT model, the broker manages service statewide, centralizing call centers, eligibility determination, and trip authorization. Statewide brokers are typically for-profit, national brokers. Regional Broker Though it operates much like a statewide broker NEMT model, the regional broker NEMT model uses multiple call centers in a state, each responsible for eligibility determination and trip authorization at a regional level. A broker may operate in one region or several regions, as the state Medicaid agency may specify. States use a variety of means to determine regional bound- aries, including metropolitan statistical area boundaries, health care service areas, public transit service areas, regional planning areas, and county boundaries. Regional brokers may be for-profit, not-for-profit, or human services program brokers. Not-for-profit brokers may be human services agencies, public transit agencies, or other nonprofit organizations serving as a regional broker. Full-Risk Broker A full-risk broker accepts the financial risk for performing all broker responsibilities under the contract with the state Medicaid agency under a capitation payment plan. As previously discussed, capitation is a flat periodic payment per Medicaid enrollee (member) to the broker; it is the sole reimbursement for providing NEMT services to a defined population. Table 2 is an example of capitation payment for a broker. The total capitated pay includes 116,900 members who are both children and adults in rural and urban areas. The capitated rate PMPM is different by age category and if the member is in a rural or urban area. The PMPM capitated payment rate can vary significantly according to the Medicaid category of the NEMT client. If the broker accepts the full risk to provide NEMT services, the capitation payment is $6,294,900 for a population of 116,900 members. Many statewide and regional brokers are full-risk brokers, compensated on a capitated, per-Medicaid-beneficiary basis where the number of people eligible for service, not the amount of service received, determines the payment rate. A full-risk broker takes the risk that the contractual rate agreement will cover all costs, and is responsible for reporting beneficiary and trip data. A full-risk broker contract may have an escalation clause tied to some measures of inflation, but otherwise costs increase only with the number of Medicaid beneficiaries. From the perspective of the state Medicaid agency, full-risk brokers limit state Medicaid agency financial liability and administrative costs. Full-risk brokers provide the advantage of consistent and predictable costs to the state Medicaid agency from year to year. Shared-Risk Broker Shared-risk brokers do not assume all the risks of operating NEMT at a fixed rate. Payments are more directly tied to actual costs, so if the costs are either less or greater than anticipated, Children Adults CapitationPayment Rural Urban Rural Urban Total Members 34,300 55,000 10,100 17,500 116,900 21 21 21 21 shtnoM Member months 411,600 660,000 121,200 210,000 Capitated rate PMPM $2.50 $1.60 $16.75 $10.38 Total payment $1,029,000 $1,056,000 $2,030,100 $2,179,800 $6,294,900 Table 2. Calculation of capitation payment. Full­risk brokers provide the advan­ tage of consistent and predictable costs to the state Medicaid agency from year to year.

32 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination payment adjustments occur. Shared risk is less predictable and may lead to unanticipated, increased costs to the state Medicaid agency; however, the transportation provider has an opportunity to document and request a payment adjustment based on actual cost. Managed Care Organizations Managed care is an organized health care delivery system designed to manage health care cost, use, and quality. Through contracted arrangements with state Medicaid agencies, MCOs seek to improve health care for a population of Medicaid beneficiaries, often with chronic and complex conditions, while also managing the cost of that care. MCOs use: • Capitated payment. Medicaid agencies typically pay MCOs on a capitated payment system (PMPM). This means the MCO receives a lump sum payment per month based on the number of beneficiaries, and all health costs must be covered by that payment. Capitated payment encourages cost control. • Carving in NEMT services. NEMT may be a part of the responsibility of the MCO providing Medicaid services (i.e., carved in). If the MCO does carve in NEMT services, the MCO may provide NEMT in a variety of ways using a combination of the following options: – Operate at a statewide, regional, or local (county) level; – Use for-profit, not-for-profit, or human services program brokers; – Use private, human services, or public transportation providers; and – Pay for NEMT based on capitation or fee for service, or a combination of both. • Carving out NEMT services. If the MCO does not include NEMT (i.e., carved out), the state Medicaid agency uses one of the other NEMT models to provide transportation for Medicaid beneficiaries who need to get to and from medical services and have no other means of transportation. Mixed NEMT Models State Medicaid agencies often do not use just one model for NEMT services. Examples of mixed models include: • In-house management and MCO, • In-house management and statewide broker, • In-house management and regional broker, and • MCO and statewide broker. What Are the Current Trends in NEMT? As previously noted, many states have created a statewide or regional brokerage for NEMT in the years following DRA. There has also been a significant trend toward MCO models with carved-in NEMT. State Medicaid agencies that use broker and MCO models typically use a capitated payment system. The trend to use statewide or regional NEMT brokers also reflects a trend that separates NEMT from locally or regionally coordinated transportation systems. As part of the research for this handbook, the research team conducted a survey of state Medicaid agencies about NEMT in 2014. Participants who responded to the survey said the most important reason for using a transportation broker and/or including NEMT services in an MCO’s capitated payment system is to: • Achieve cost certainty or savings (37 percent), • Improve access to primary care (30 percent),

Non-Emergency Medical Transportation for Medicaid 33 • Reduce fraud and abuse (19 percent), • Other (10 percent), and • Reduce emergency room use (4 percent). Table 3 summarizes the models used by the 50 states and the District of Columbia, and Figure 8 provides a map illustrating the state NEMT models. NEMT Model Number of States States In-house management 8 Alabama, Maryland, Minnesota, North Carolina, North Dakota, Ohio, South Dakota, Wyoming MCO 10 Arizona, Florida, Hawaii, Illinois, Indiana, Iowa, Kansas, New Mexico, Oregon, Tennessee Statewide broker 13 Alaska, Connecticut, Delaware, Idaho, Mississippi, Nebraska, Nevada, New Jersey, Rhode Island, Utah, Vermont, West Virginia, Wisconsin Regional broker 7 Arkansas, Georgia, Kentucky, Maine, Massachusetts, South Carolina, Washington In 4 California, Montana, New Hampshire, New York In-house management and regional broker 4 Colorado, Michigan, Pennsylvania, Texas 5 District of Columbia, Louisiana, Missouri, Oklahoma, VirginiaMCO and statewide broker -house management and MCO Table 3. Summary of NEMT models by state. Figure 8. NEMT models by state.

34 Handbook for Examining the Effects of Non-Emergency Medical Transportation Brokerages on Transportation Coordination Summary More than any other legislation, including the ACA, the DRA has influenced how states have decided to deliver NEMT services. The DRA amended the Social Security Act by adding a new section that provides states the flexibility to establish an NEMT brokerage program. Many states have created a statewide or regional brokerage for NEMT in the years since the DRA. States have also moved to managed care for Medicaid health care and MCOs with carved-in NEMT. The next chapter provides a background to help understand why human services and public transportation providers want to coordinate transportation services with Medicaid NEMT.