DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop: S2-26-12 
Baltimore, Maryland   21244-1850 
 
 
 
                SMD# 23-006 
 
RE:  Assurance of Transportation: 
A Medicaid Transportation 
Coverage Guide   
 
September 28, 2023 
 
Dear State Medicaid Director: 
 
The Centers for Medicare & Medicaid Services (CMS) is issuing this guidance, the Medicaid 
Transportation Coverage Guide, to serve as a consolidated and comprehensive compilation of 
both current and new Medicaid transportation policy, providing a one-stop source of guidance on 
federal requirements and state flexibilities.  In addition, the issuance of this guidance addresses 
the statutory requirements outlined in the Consolidated Appropriations Act (CAA), 2021, 
Division CC, Title II, Section 209(a)1 (section 209(a)), and responds to the recommendation 
from the U.S. Government Accountability Office (GAO) to the Secretary of the Department of 
Health and Human Services (HHS) that CMS assess current Medicaid non-emergency medical 
transportation (NEMT) guidance and update it as needed.2  Most importantly, this guidance 
addresses requirements and flexibilities regarding Medicaids transportation assurance so states 
are better able to provide beneficiaries greater access to Medicaid benefits.  
 
This Medicaid Transportation Coverage Guide addresses the transportation assurance 
requirement in section 1902(a)(4)(A) of the Social Security Act (the Act), and includes new 
guidance to improve access to necessary transportation services in more complex scenarios, 
including where beneficiaries may encounter extended wait times and need to make long-
distance trips.  The guidance also provides references and greater context on certain overlapping 
requirements so states are better able to navigate complex issues and consider impacts across 
their Medicaid programs. 
 
Medicaid transportation is a critical service that assists beneficiaries with accessing covered 
Medicaid services and has a direct impact on health outcomes.  CMS encourages states to 
consider how to fully operationalize the transportation assurance and to ensure it is regularly 
monitored and considered for improvements.  CMS is part of the Coordinating Council on 
Access and Mobility (CCAM),3 working with the Federal Transit Administration on ways to 
 
 
1 Consolidated Appropriations Act, 2021 Division CC, Title II, Section 209(a) (Public Law 116-260): 
https://www.congress.gov/116/plaws/publ260/PLAW-116publ260.pdf. 
2 Nonemergency Medical Transportation: Updated Medicaid Guidance Could Help States, GAO-16-238 
(Washington, D.C.: Feb.  2, 2016) https://www.gao.gov/products/gao-16-238. 
3 For more information about the CCAM, please visit: https://www.transit.dot.gov/coordinating-council-access-and-
mobility. 
 
  State Medicaid Director Page 2 
coordinate Medicaid and public transit programs.  In addition, CMS encourages states, managed 
care plans, and transportation providers to work collaboratively to ensure beneficiaries are 
educated and informed about transportation options available to them. 
All references to the Medicaid program in this letter and the accompanying Medicaid 
Transportation Coverage Guide encompass Medicaid expansion Childrens Health Insurance 
Programs (CHIP).  In general, this guidance does not apply to separate CHIPs, except those that 
provide the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit.  Those 
separate CHIPs should follow the guidance about EPSDT in this guide (see 42 C.F.R. 
457.496(b)).  We also remind states that all separate CHIPs must provide emergency services
pursuant to 42 C.F.R.  457.410(b)(3).
CMS encourages states to follow this document as a guide to developing and updating 
appropriate policies and procedures that facilitate robust transportation programs.  While states 
can engage vendors and managed care plans, and can delegate the many aspects of the operation 
of transportation programs to other entities, the single state Medicaid agency ultimately is 
responsible for ensuring transportation that meets all statutory and regulatory requirements, 
regardless of whether the beneficiary receives necessary transportation through a Medicaid fee-
for-service or managed care delivery system, and whether transportation is offered as an optional 
medical service or an administrative activity. 
CMS is eager to work with states to assure transportation and ensure access to care.  For 
additional information about this letter, or for states requesting technical assistance, please 
contact Kirsten Jensen, Director of the Division of Benefits and Coverage, at 
kirsten.jensen@cms.hhs.gov.   
Sincerely,
/s/ 
Daniel Tsai 
Deputy Administrator and Director
2   
 
 
 
 
 
 
 
 
 
 
Medicaid Transportation Coverage Guide 
2023     
 
  Medicaid Transportation Coverage Guide 
 
Executive Summary 
Overview of the Assurance of Transportation  
The Medicaid transportation assurance encompasses both emergency transportation and non-
emergency medical transportation (NEMT) when necessary to enable the beneficiary to access a 
covered service.4  The assurance of transportation is not a requirement for states to pay for a ride, 
but rather a requirement to make certain that every Medicaid beneficiary who has no other means 
of transportation has access to transportation needed to receive covered care.  Accordingly, it is a 
critical part of access to care for many beneficiaries, and has a key role in health equity by 
ensuring beneficiaries can attain the highest level of health and have a meaningful opportunity to 
attain optimal health regardless of race, ethnicity, disability, sex (including sexual orientation 
and gender identity),5 socioeconomic status, geography, preferred language, and other factors 
that can affect access to care and health outcomes.6  
 
Medicaid Transportation Background 
 
Historically, the transportation assurance was based on the principles identified in section 
1902(a)(4)(A) of the Social Security Act (the Act), which requires that state plans provide such 
methods of administration... as are found by the Secretary to be necessary for proper and 
efficient operation of the plan and was promulgated in regulation in 42 C.F.R.  431.53.  This 
regulation established the transportation assurance as a state plan requirement, providing that the 
plan must [s]pecify that the Medicaid agency will ensure necessary transportation for 
beneficiaries to and from providers; and [d]escribe the methods that the agency will use to 
meet this requirement.   
 
Recently, the Consolidated Appropriations Act (CAA), 2021, Division CC, Title II, Section 2097 
(section 209), codified in statute at section 1902(a)(4) of the Act8 the longstanding regulatory 
interpretation described above, adding a statutory requirement that state plans must include a 
specification that the single State agency...will ensure necessary transportation for beneficiaries 
under the State plan to and from providers and a description of the method that such agency will 
use to ensure such transportation. 
 
Together, the new statutory and existing regulatory construct for and approach to defining 
transportation as an administrative activity or optional medical service remain the same.  When 
provided pursuant to 42 C.F.R.  431.53, transportation is covered as an administrative activity 
under the state plan and is matched at the standard 50 percent Federal Financial Participation 
(FFP) rate provided under section 1903(a)(7) of the Act for administrative expenditures.  
However, the transportation assurance may also be covered as an optional medical service under 
 
 
4 Throughout this guide, the terms medical services and covered services include all physical health, mental health, 
and substance use disorder services that Medicaid covers under the state plan. 
5 See https://www.hhs.gov/civil-rights/for-individuals/section-1557/index.html 
6 https://www.cms.gov/files/document/health-equity-fact-sheet.pdf. 
7 Consolidated Appropriations Act, 2021 Division CC, Title II, Section 209 (Public Law 116-260): 
https://www.congress.gov/116/plaws/publ260/PLAW-116publ260.pdf. 
8 Section 1902(a)(4) of the Act (42 U.S.C.  1396a(a)(4)): https://www.ssa.gov/OP_Home/ssact/title19/1902.htm. 
1  Medicaid Transportation Coverage Guide 
 
42 C.F.R.  440.170(a), which is based on section 1905(a)(31) of the Act.9  When provided as an 
optional medical service, transportation expenditures are matched at the states applicable 
Federal Medical Assistance Percentage (FMAP). 
 
In section 209, Congress also made corresponding amendments to section 1937(a)(1) of the Act, 
adding a new subparagraph (F) and applying substantially the same assurance of transportation 
requirements for benchmark and benchmark-equivalent coverage, also known as Alternative 
Benefit Plan (ABP) coverage.  Prior to this amendment, the assurance of transportation in ABPs 
was required by regulation under 42 C.F.R.  440.390, which references the state plan assurance 
of transportation requirement in 42 C.F.R.  431.53.  Additionally, section 1903(i) of the Act 
was amended to include a new paragraph (9), providing that, with respect to any amount 
expended for non-emergency transportation authorized under section 1902(a)(4), no payment 
may be made unless the State plan provides for the methods and procedures required under 
section 1902(a)(30)(A). 
 
In addition to the new statutory requirements, section 209 obligated CMS to perform the 
following required activities10: 
 
  Convene a series of meetings with interested parties to obtain feedback and facilitate 
discussion on, and to enable shared learning of, the leading practices for improving 
Medicaid program integrity with respect to NEMT to medically necessary services, 
taking into account the unique considerations of specific groups of Medicaid 
beneficiaries, such as American Indians, individuals who reside and/or seek services 
on Tribal lands, and individuals with disabilities who need special accommodations 
(section 209(b)(2)); 
  Assess CMS guidance issued to states11 relating to federal Medicaid requirements 
under Title XIX of the Act for NEMT to medically necessary services and update 
such guidance as necessary to ensure states have appropriate and current guidance in 
designing and administering coverage of NEMT (section 209(b)(3)); and 
  Submit a report to Congress on recommendations for Medicaid coverage of NEMT to 
medically necessary services based on an analysis of the nation-wide data set under 
the Transformed Medicaid Statistical Information System (T-MSIS) (section 
209(b)(5)). 
 
To meet the requirements of section 209(b)(2), CMS held a series of listening sessions for 
interested parties between March and May of 2022 to obtain input and facilitate shared learning 
about the leading practices for improving Medicaid program integrity for NEMT.  A total of four 
public and five focused listening sessions were held on various topics with specific groups, 
 
 
9 Section 1905(a)(31) of the Act provides the Secretary the authority to include in the definition of medical 
assistance any other medical care, and any other type of remedial care recognized under State law, specified by the 
Secretary.     
10 In addition to assuring transportation and performing the required activities, section 209(b)(4) established provider 
and driver requirements and provided that states that establish an NEMT brokerage may consult with relevant 
interested parties.  CMS issued a CMCS Informational Bulletin summarizing all the requirements in 2021: 
https://www.medicaid.gov/federal-policy-guidance/downloads/cib071221.pdf.   
11 State refers to U.S states, territories, and the District of Columbia. 
2  Medicaid Transportation Coverage Guide 
 
including state associations, advocates, providers, drivers, government entities, managed care 
plans, broker organizations, the Tribal Technical Advisory Group, public transit agencies, 
beneficiaries, members of the public, and others.  Prior to each session, CMS encouraged 
interested parties to bring forward suggestions, recommendations, and innovations that could 
improve NEMT for Medicaid beneficiaries.  These listening sessions provided insight into which 
policy topics were confusing or difficult to navigate, illuminated operational challenges, and 
highlighted effects of these issues on beneficiaries experiences and access to care as well as the 
experiences of NEMT providers and medical service providers.   
 
This Medicaid Transportation Coverage Guide serves to satisfy the requirements of section 
209(b)(3) and has been informed by feedback from interested parties as discussed above, 
technical assistance requests from states, and other inquiries submitted to CMS.  We have 
considered the questions and concerns we have heard, as well as the best practices, 
recommendations, and innovative approaches that have been shared, in developing this updated 
guidance as a comprehensive compilation of information on Medicaid transportation and related 
policies.  This guide is also designed to help states better understand transportation federal 
requirements and available flexibilities, and to inform state operational and policy decisions.  
Topics that were discussed in the listening sessions are indicated by an asterisk (*) throughout 
the guide.  Throughout the listening process, CMS also identified key areas where new policy 
was needed to help bolster access to care regarding wait times, long-distance trips, and 
transportation for the direct benefit of an EPSDT-eligible beneficiary. 
   
3  Medicaid Transportation Coverage Guide 
 
Table of Contents  Transportation Policy Summaries 
 
Assurance of Transportation ....................................................................................................... 7 
Assuring Access to Necessary Transportation* ........................................................................................ 7 
Emergency Medical Transportation .......................................................................................................... 7 
Transportation Authorities: Flexibilities Under the State Plan ............................................... 7 
Transportation Provided as an Optional Medical Service......................................................................... 8 
Transportation Provided as an Administrative Activity............................................................................ 8 
Providing Transportation as Both an Administrative Activity and Optional Medical Service ................. 9 
Broker as an Optional Medical Service * ................................................................................................. 9 
Broker as an Administrative Activity * .................................................................................................... 9 
Transportation Authorities: Other Flexibilities in the Medicaid Program ............................. 9 
Alternative Benefit Plan ............................................................................................................................ 9 
Managed Care Authorities* ...................................................................................................................... 9 
Home and Community-Based Services (HCBS) and Non-Medical Transportation* ............................. 10 
Transportation as a Medicaid Program Requirement ............................................................ 10 
Transportation is an Underlying Medicaid Program Component* ......................................................... 11 
Access and Availability of Services* ...................................................................................................... 12 
Ensuring Transportation Means States Have Oversight Responsibilities and Accountability* ............. 12 
Transportation Access Requirements ....................................................................................... 13 
Least Costly/Most Appropriate* ............................................................................................................. 13 
Nearest Qualified Medical Provider* ..................................................................................................... 13 
Necessary Transportation ........................................................................................................................ 14 
Processes to Improve Passenger and Provider Relations ........................................................................ 14 
Consideration for Special Populations* .................................................................................... 16 
Beneficiaries with Disabilities* .............................................................................................................. 16 
Beneficiaries with Behavioral Health Needs* ........................................................................................ 16 
Tribal Transportation* ............................................................................................................................ 16 
Rural Areas* ........................................................................................................................................... 17 
Transportation Under Specific Circumstances ........................................................................ 17 
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Transportation* ............................ 18 
Transportation for the Direct Benefit of Children Under 21 ................................................................... 18 
Transportation for Visitation* ................................................................................................................. 19 
Transportation for Optional Benefits* .................................................................................................... 19 
Transportation for Beneficiaries Dually Eligible for Medicaid and Medicare* ..................................... 19 
4  Medicaid Transportation Coverage Guide 
 
School-Based Transportation .................................................................................................................. 20 
Coverage of Emergency Transportation for Individuals with Unsatisfactory Immigration Status ......... 21 
Coverage of Transportation to Services not Provided by a Medicaid Provider ...................................... 21 
Ground Emergency Medical Transportation (GEMT) ............................................................................ 21 
Treatment at the Scene without Transport* ............................................................................................ 22 
Law Enforcement as a Mode of Transportation* .................................................................................... 22 
Transportation Network Companies (TNCs) Also Known as Ridesharing Organizations* ................... 23 
Broker .......................................................................................................................................... 23 
Competitive Bidding* ............................................................................................................................. 23 
Broker Conflict of Interest and Exception Requests* ............................................................................. 24 
Public/Governmental Entities as Brokers* ............................................................................................. 25 
Broker Payments to Providers* .............................................................................................................. 25 
Beneficiary Support .................................................................................................................... 26 
Oversight of Transportation Services for Beneficiaries* ........................................................................ 26 
Scheduling Assistance* .......................................................................................................................... 26 
No-show Providers, Replacements, and Reschedules*........................................................................... 27 
Provider and Vehicle Requirements ......................................................................................... 27 
State Driver and Vehicle Standards* ...................................................................................................... 27 
Provider Enrollment, Screening and Background Checks* .................................................................... 28 
Disaster Policy* ...................................................................................................................................... 29 
Payment ....................................................................................................................................... 29 
No Load Miles or Unloaded Miles* ....................................................................................................... 29 
Long-Distance Trips* ............................................................................................................................. 29 
Long Wait Times* .................................................................................................................................. 29 
Related Travel Expenses* ....................................................................................................................... 30 
Flexibilities for Coverage of Wait Times and Long Distances* ............................................................. 30 
General Payment ..................................................................................................................................... 31 
Cost Principles ........................................................................................................................................ 32 
NEMT Cost Sharing ............................................................................................................................... 34 
Payment for Transportation During Retroactive Eligibility Periods ....................................................... 34 
Costs that are Not Part of Medicaid Transportation*.............................................................................. 34 
Public Transit Agencies .............................................................................................................. 35 
Americans with Disabilities Act (ADA) Paratransit* ............................................................................. 35 
Fixed Route Public Transit* ................................................................................................................... 36 
Public Transit Passes* ............................................................................................................................. 36 
5  Medicaid Transportation Coverage Guide 
 
Coordination of Transportation* ............................................................................................................. 37 
SPA Content Requirements ....................................................................................................... 37 
Transportation State Plan Pages* ............................................................................................................ 37 
Attachments 3.1-A and 3.1-B ................................................................................................................. 38 
Attachment 3.1-D Page(s) - Methods of Transportation ......................................................................... 38 
Attachment 3.1-D Page - Section 1902(a)(87) Attestation ..................................................................... 38 
Attachment 4.19-B Page(s) ..................................................................................................................... 39 
Appendix A: Additional Resources for Meeting the Needs of Medicaid Beneficiaries with 
Limited English Proficiency ....................................................................................................... 40 
   
6  Medicaid Transportation Coverage Guide 
 
Assurance of Transportation 
The assurance of transportation is an essential feature of the Medicaid program that ensures 
beneficiaries access to health care.  The transportation assurance includes non-emergency and 
emergency transport provided through multiple modes of transportation.  CMS recognizes 
variation across states in the type of terrain and geography through which transportation occurs, 
such as air, water, roadways, rough land terrain, subway, and other environments.  For purposes 
of this Medicaid Transportation Coverage Guide (Coverage Guide), the term vehicle is used.  
It should be noted that a vehicle can include anything used to provide transportation such as car, 
plane, bus, train, subway, specialized vehicles, or other mode of transport.   
 
Assuring Access to Necessary Transportation*   
States are required to assure that beneficiaries have transportation necessary to access 
covered medical services.  This assurance is not a requirement to pay for a ride, but rather a 
requirement to make certain that every beneficiary who has no other means of transportation 
has access to transportation needed to receive covered care.  States implementation of the 
required assurance of necessary transportation can take into account operational limitations 
and parameters, such as describing when air travel may be considered, but limitations must 
be reasonable in meeting the needs of the beneficiary and cannot be so restrictive as to 
conflict with the state's responsibility to assure necessary transportation so that a beneficiary 
can access a covered service.   
 
Emergency Medical Transportation   
The federal Medicaid transportation assurance requirement does not recognize emergency 
medical transportation (EMT) services separately from the overall assurance of transportation 
requirement.  Under section 1902(a)(4) of the Act and implementing regulations, including 
42 C.F.R.  431.53, states must ensure both emergency and non-emergency medical 
transportation where necessary for the beneficiary to receive covered services.  Additionally, 
though there may be state regulations or policy restricting transportation to an alternate 
destination, federal Medicaid law and regulations do not specify that emergency 
transportation must be to an emergency department of a hospital.  Examples of alternative 
destination locations may include urgent care, freestanding behavioral health facilities, group 
practices, ambulatory care settings, crisis centers, and community clinics.   
Transportation Authorities: Flexibilities Under the State Plan 
States have considerable flexibility in the design and operation of the assurance of transportation.  
Generally, states may assure transportation as an administrative activity, as an optional medical 
service, or a combination of these.  Regardless of whether transportation is claimed as an 
administrative activity, optional medical service, or as a combination in different circumstances, 
matching funds may not be claimed for direct expenditures for transportation infrastructure (e.g., 
roads, rails, purchase of vehicles, etc.).  The following sections provide guidance on how states 
may effectuate different transportation flexibilities within the state plan.   
 
 
 
   
7  Medicaid Transportation Coverage Guide 
 
Transportation Provided as an Optional Medical Service 
Transportation can be assured as an optional medical service if included in the states 
approved state plan, but only when provided by a provider to whom a direct vendor payment 
can be made by the Medicaid agency, as required under 42 C.F.R.  440.170(a)(2).  States 
can receive the states regular FMAP rate for NEMT and EMT when furnished as an optional 
medical service under an approved state plan, which may be higher than the administrative 
claiming rate.   
 
As an optional service, the NEMT and/or EMT must meet the definitions outlined in 
Medicaid regulations at 42 C.F.R.  440.170(a) and all other requirements relating to 
Medicaid medical services.  These include the beneficiary freedom of choice requirement 
(section 1902(a)(23) of the Act and 42 C.F.R.  431.51), which permits a beneficiary to 
obtain services from any qualified and willing Medicaid provider; the comparability 
requirement (section 1902(a)(10)(B) of the Act and 42 C.F.R.  440.240), which specifies 
that services available to any categorically needy beneficiary under the plan may not be less 
in amount, duration, and scope than those services available to any other categorically needy 
beneficiary or to a medically needy beneficiary (and any services available to a medically 
needy group may not be less in amount duration, and scope than those services available to 
any other covered medically needy group); and the statewideness requirement (section 
1902(a)(1) of the Act and 42 C.F.R.  431.50), which indicates that a state plan must be in 
effect throughout the state.  If covered under the state plan as an optional medical service, 
states cannot pay beneficiaries directly for transportation as required under 42 C.F.R.  
440.170(a)(2).  
 
Transportation Provided as an Administrative Activity 
Administrative claiming provides states with greater flexibility in designing their 
transportation program because state plan requirements for medical services, such as freedom 
of choice, comparability, statewideness, and direct vendor payment, do not apply.  Instead, 
states are allowed to provide payment for transportation services directly to the beneficiary 
under this authority.  States that elect to provide NEMT, EMT, or both, as an administrative 
activity may need to submit and have approved a Medicaid Administrative Claiming Plan 
depending on the complexity of the states program.  Regardless, states must include 
transportation in their Public Assistance Cost Allocation Plans (45 C.F.R. 95 Subpart E) if 
they intend to claim transportation as an administrative expenditure.  In addition, the state 
plan (in Attachment 3.1-D Assurance of Transportation) must describe the methods the 
state will undertake to meet this assurance, whether as an administrative activity or as a 
medical service or both.  Transportation as an administrative activity allows the state to claim 
FFP at the 50% administrative claiming rate.12  Note states may also claim FFP in 
administrative expenditures for assisting an individual to obtain transportation to Medicaid 
covered services or arranging for transportation for beneficiaries (separately from any 
Medicaid expenditure for the transportation itself).   
   
 
 
12 Section 1903(a)(7) of the Act. 
8  Medicaid Transportation Coverage Guide 
 
 
Providing Transportation as Both an Administrative Activity and Optional Medical Service 
There is nothing in federal Medicaid law or regulation that would preclude a state from 
providing NEMT or EMT as a medical service in one area of the state and claiming it as an 
administrative activity in another part of the state.  However, providing transportation as a 
medical service requires that it be offered in compliance with the basic Medicaid tenets, 
including statewideness, comparability, and freedom of choice of provider, as discussed 
above.  States may seek a waiver of one or more of these requirements described in the 
preceding sentence under section 1915(b) or section 1115 of the Act, which must be 
approved by CMS.  Providing transportation as a medical service also requires direct vendor 
payment.  Due to this requirement, states must claim any direct payment to beneficiaries as 
an administrative activity as required under 42 C.F.R.  440.170(a)(2). 
 
Broker as an Optional Medical Service * 
Section 1902(a)(70) of the Act provides state plan authority to establish an NEMT brokerage 
program and receive the states regular FMAP rate for medical assistance.  This authority 
allows states to amend their Medicaid state plans to include an NEMT brokerage program 
without regard to the statutory requirements for comparability, statewideness, and freedom of 
choice of provider, without the need for waivers under section 1915(b) or section 1115 of the 
Act.  Regulations at 42 C.F.R.  440.170(a)(4) further define this state plan option.   
 
Broker as an Administrative Activity * 
It should be noted that expenditures for broker-arranged NEMT can also be claimed as an 
administrative activity. 
Transportation Authorities: Other Flexibilities in the Medicaid Program 
In addition to the state plan authorities described above, there are other authorities under which 
states cover transportation for certain beneficiaries.   
 
Alternative Benefit Plan 
While section 1937(a)(1)(A) of the Act provides for an Alternative Benefit Plan to the 
traditional state plan governed by section 1902, this does not absolve the state of its existing 
obligation to provide coverage of emergency and non-emergency transportation to 
beneficiaries receiving Medicaid services in Alternative Benefit Plans.  See section 
1937(b)(5) of the Act and implementing federal regulations at 42 C.F.R.  440.390 requiring 
the provision of emergency services and an assurance of NEMT.  The assurance of necessary 
transportation under this authority can include limitations and restrictions on amount, 
duration, and scope, but limitations must be reasonable in meeting the needs of the 
beneficiary and cannot be so restrictive as to conflict with the states responsibility to assure 
transportation.   
 
Managed Care Authorities* 
States may cover transportation as an optional medical service under managed care 
authorities, such as a section 1932(a) State Plan Amendment (SPA), section 1915(b) waiver, 
or section 1115 demonstration authority under the Act.  If the service is covered under the 
State plan as a medical service, this service can be included in the Medicaid managed care 
9  Medicaid Transportation Coverage Guide 
 
capitation rates per 42 C.F.R.  438.3(c)(1)(ii).  The foregoing managed care authorities can 
be used to waive freedom of choice of provider, statewideness, and/or comparability 
requirements.  Section 1932(a) SPAs are approved for an indefinite period, but states 
generally may not require certain beneficiaries, including Medicare beneficiaries, American 
Indians, and certain children with special needs, to enroll in a managed care plan established 
under this authority.  Section 1915(b) waivers are initially approved and renewed for two-
year periods, unless the covered population includes dually eligible beneficiaries, in which 
case the program can be approved for an initial period of up to five years and renewed for up 
to five years.  Transportation delivered through managed care as an optional medical service 
must follow applicable Medicaid managed care rules in 42 C.F.R Part 438 and must be 
included in an actuarially certified capitation rate if included in a managed care plans risk 
contract.   
 
If transportation is not covered under the State plan as a medical service, the managed care 
plan could voluntarily choose to cover transportation as an additional benefit, consistent with 
42 C.F.R  438.3(e)(i), although the cost of the service could not be included when 
developing the capitation rates.  Like other services, states may choose to carve 
transportation out of a managed care delivery system.  If the State only covers transportation 
as an administrative activity, the State could enter into a separate arrangement with a 
managed care plan to provide it as an administrative activity as an administrative service 
organization.   
 
Home and Community-Based Services (HCBS) and Non-Medical Transportation* 
HCBS are designed to meet the medical and non-medical needs of people who prefer to 
receive long-term services and supports in their home or community, rather than in an 
institutional setting.  Transportation to access state plan medical services provided to HCBS 
participants is provided through the states transportation program.  In addition, states have 
the option to cover non-medical transportation to enable HCBS participants to access 
community services, activities, and resources when other options are unavailable.  At the 
states discretion, non-medical transportation services may be covered separately under a 
section 1915(c) waiver, a section 1915(i) SPA, a section 1915(j) SPA, a section 1915(k) 
SPA, or a demonstration project under section 1115 of the Act.  For additional information 
on how Medicaid may pay for non-medical transportation for HCBS participants, please refer 
to the section 1915(c) HCBS waiver technical guide13 and State Health Official Letter 
(SHO)# 21-001.14 
Transportation as a Medicaid Program Requirement 
The assurance of transportation is mandatory in Medicaid and the methods a state uses to meet 
this requirement must be described in the state plan.  While some states delegate some 
transportation functions to external entities, the state is ultimately responsible for ensuring that 
beneficiaries are able to access necessary transportation to enable them to receive covered 
services. 
 
 
13 https://wms-mmdl.cms.gov/WMS/help/35/Instructions_TechnicalGuide_V3.6.pdf.   
14 https://www.medicaid.gov/federal-policy-guidance/downloads/sho21001.pdf. 
10  Medicaid Transportation Coverage Guide 
 
 
Transportation is an Underlying Medicaid Program Component* 
Transportation is a Medicaid program component and providers who furnish transportation 
services are directly or indirectly15 Medicaid providers through fee-for-service and managed 
care.  This is true whether transportation organizations and drivers are enrolled as individuals 
or, for provider types not eligible to enroll under the state plan, furnishing services through 
another enrolled provider such as a vendor or a county authority, or another organization, 
entity, or individual.   
 
Whether transportation organizations and drivers are enrolled as participating providers 
through a provider agreement, or, if not eligible to enroll directly, are furnishing services 
under the auspices of another enrolled provider, states are responsible for ensuring Medicaid 
program requirements are met.  This includes; for instance, availability of necessary 
transportation for all beneficiaries16 including those living with disabilities,17,18 free from 
discrimination;19,20 availability of clear procedural steps related to filing grievances and 
appeals and beneficiary right to a fair hearing;21 prohibition on balance billing; 22 language 
assistance for individuals with Limited English Proficiency (LEP);23,24 and, an expectation of 
courteous, respectful, and professional behavior25 and cultural competency.26   
 
 
 
15 The term indirect refers to providers who are not a provider type eligible to enroll with the state Medicaid 
agency, but regardless of enrollment status, deliver direct services to Medicaid beneficiaries. 
16 See 42 C.F.R.  431.53. 
17 Section 504 of the Rehabilitation Act of 1973 requires that no qualified individual with a disability in the United 
States shall be excluded from, denied the benefits of, or be subjected to discrimination under" any program or 
activity that either receives Federal financial assistance.  
18 Title II of the Americans with Disabilities Act of 1990 at 42 U.S.C.  12132 requires that no qualified individual 
with a disability shall, by reason of such disability, be excluded from participation in or be denied the benefits of the 
services, programs, or activities of a public entity, or be subjected to discrimination by any such entity. 
19 See section 1557 of the Patient Protection and Affordable Care Act.  Additional information found at: 
https://www.hhs.gov/civil-rights/for-individuals/section-1557/index.html. 
20 For additional requirements for managed care, see 42 C.F.R.  438.3(d)(4) and 42 C.F.R.  438.206(c)(2). 
21 Section 1902(a)(3) of the Act requires that a State plan provide an opportunity for a fair hearing to any person 
whose claim for assistance is denied or not acted upon promptly.  See 42 C.F.R.  431 Subpart E, and 42 C.F.R  
438 Subpart F for more information related to grievances, appeals, and fair hearings. 
22 See 42 C.F.R.  447.15. 
23 Considerations for individuals with LEP include availability of qualified interpreters and translators (including the 
availability of telecommunication devices), or having state websites, emails, and documents made available in 
languages other than English.  Additional resources are included in Appendix B. 
24 HHS, Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National 
Origin Discrimination Affecting Limited English Proficient Persons found at https://www.hhs.gov/civil-rights/for-
individuals/special-topics/limited-english-proficiency/guidance-federal-financial-assistance-recipients-title-
vi/index.html. 
25 The Medicaid Non-Emergency Medical Transportation Booklet for Providers includes information about Program 
integrity, including the expectation for courteous and respectful behavior and professional drivers.  
https://www.cms.gov/medicare-medicaid-coordination/fraud-prevention/medicaid-integrity-
education/downloads/nemt-booklet.pdf. 
26 See requirements at 42 C.F.R.   440.262 indicating states must have methods to promote access and delivery of 
services in a culturally competent manner to all beneficiaries, including those with limited English proficiency, 
diverse cultural and ethnic backgrounds, disabilities, and regardless of sex.  These methods must ensure that 
beneficiaries have access to covered services that are delivered in a manner that meets their unique needs. 
11  Medicaid Transportation Coverage Guide 
 
Access and Availability of Services* 
Medicaid operates as a partnership between states and the federal government, through which 
states have broad latitude and flexibility in operationalizing the delivery of Medicaid services 
and setting payment rates.  For transportation provided as an optional medical service, 
section 1902(a)(30)(A) of the Act generally requires the state plan to provide methods and 
procedures as may be necessary to ensure that payments are consistent with efficiency, 
economy, and quality of care and are sufficient to enlist enough providers so that care and 
services are available under the plan at least to the extent that such care and services are 
available to the general population in the geographic area[.]  Under section 1903(a)(7) of the 
Act, transportation provided as an administrative activity must be provided in a manner 
consistent with the proper and efficient administration of the State plan.  When 
determining and updating state plan rates for transportation, states should evaluate and set the 
rates so that beneficiaries will have access to transportation at least consistent with the 
availability of transportation services to non-Medicaid individuals in geographic areas of the 
state.  For states that use a managed care delivery system, 42 C.F.R.  438.206(a) requires 
that each state ensure that all services covered under the state plan are available and 
accessible to enrollees of managed care plans27 in a timely manner.  As such, if states include 
transportation as a covered service in a managed care contract, states should carefully 
analyze their contracts and capitation rates to ensure that they provide for adequate access 
and availability of services and require compliance with all applicable provisions in 42 
C.F.R. part 438. 
 
Ensuring Transportation Means States Have Oversight Responsibilities and Accountability* 
Each state administers its Medicaid program in accordance with a CMS-approved state plan.  
Although the state has considerable flexibility in designing and operating its Medicaid 
program, it must comply with applicable federal requirements.  These requirements include 
but are not limited to the requirement to ensure that its provider agreements require that 
providers of services maintain records to fully disclose the extent of services provided to 
Medicaid beneficiaries28 and that transportation services for which Medicaid payment is 
made are furnished only to eligible beneficiaries when necessary to allow the beneficiary to 
travel to and from a provider to receive a covered service.29  Additionally, state claims for 
transportation services must be in accordance with all state requirements.  States may 
delegate or contract for the operation of the NEMT program to another governmental entity, 
such as a state transportation board or a county government, or a non-governmental entity, 
provided it complies with applicable state and federal requirements. 
 
For more information about oversight of transportation provided through other vendors, 
managed care plans, brokers, or other entities, please refer to the Oversight of 
Transportation Services for Beneficiaries section. 
   
 
 
27 The term managed care plans includes managed care organizations, prepaid inpatient health plans, and prepaid 
ambulatory health plans as defined in 42 C.F.R.  438.2 unless otherwise noted. 
28 See 42 C.F.R.  431.107. 
29 See 42 C.F.R.  431.53. 
12  Medicaid Transportation Coverage Guide 
 
Transportation Access Requirements 
Medicaid transportation has two main requirements to ensure it is the most suitable and 
economic means of providing transportation when there is no other option available to the 
beneficiary: (1) that it is the least costly and most appropriate mode suited to the needs of the 
beneficiary, and (2) that it provides transport to the nearest qualified provider.  Transportation is 
covered only when it is necessary.  States may impose additional processes to navigate provider 
and beneficiary relationships, but those processes must be reasonable so as not to restrict access.   
 
Least Costly/Most Appropriate* 
The requirement for the least costly and most appropriate ride was first stated in a March 7, 
1991 State Medicaid Director (SMD) letter, which interpreted the provision in section 
1902(a)(4) of the Act that the plan must provide for methods of administration as found 
necessary by the Secretary for the proper and efficient operation of the plan to require the 
state to first attempt to use any available free services (for example, access to a ride from 
family, friends, etc.) to satisfy a beneficiarys transportation needs.30  This letter also 
interpreted this statutory provision to require that, when several modes of transportation are 
available, states must use the least costly mode that is appropriate for the physical and 
emotional condition of the beneficiary.  States should note that the least costly and most 
appropriate mode must continue to ensure quality of services.  Please refer to the Americans 
with Disabilities Act (ADA) and Paratransit, Beneficiaries with Disabilities, and 
Beneficiaries with Behavioral Health Needs sections for additional information. 
 
Nearest Qualified Medical Provider* 
In general, it is not proper and efficient31 to transport a beneficiary a lengthy distance to see a 
provider when there are closer qualified participating providers.  For that reason, unless there 
is a medical need to see a more distant provider, the state generally must ensure the 
availability of necessary transportation to the nearest qualified provider of the services the 
beneficiary needs.  However, it is important to note that there are circumstances when the 
state could be in violation of the freedom of choice requirement if it holds too closely to this 
concept.  For example, if the state denied transportation to the participating provider of 
choice when the cost of the ride is equal to the cost of a ride to a closer provider, or varies by 
only a de minimis amount, it could be a violation of the freedom of choice of provider 
requirement.32  Additionally, if preserving a beneficiarys relationship with the distant 
provider is necessary because leaving that provider would harm the beneficiary or the 
provider has special capabilities/capacities that are necessary for the beneficiarys care, 
denial of transportation to that provider may also violate freedom of choice or could 
constitute denial of the underlying medical service itself where other providers lack the 
special capabilities/capacities necessary for the beneficiarys care.   
 
 
 
30 SMDL guidance on payment for of transportation and the assurance of transportation issued March 7, 1991. 
31 Section 1902(a)(4)(A) of the Act requires that A State plan for medical assistance must...provide...such 
methods of administration...as are found by the Secretary to be necessary for the proper and efficient operation of 
the plan. 
32 See section 1902(a)(23) of the Act. 
13  Medicaid Transportation Coverage Guide 
 
When transportation is denied to a particular provider because there are closer qualified 
providers, assistance should be given by the state to identify which additional providers are 
available in closer proximity to the beneficiary.  The state should determine a geographic 
distance within which transportation is generally provided along with any criteria for 
extenuating circumstances when transportation will be covered outside the usual geographic 
distance.  The state should also have a review process for requests for transport to providers 
whose distances are beyond the transport zone.   
 
Necessary Transportation 
States are generally granted considerable flexibility in meeting the assurance of necessary 
transportation.  Ensuring necessary transportation to and from services does not mean that the 
state must provide transportation without considering if a beneficiary has a personal vehicle 
available.  A general expectation that a beneficiary uses their own personal vehicle for 
transportation is permissible as long as the individuals circumstances would not preclude the 
use of their own personal vehicle.  Circumstances such as maintenance and fuel costs may 
impede use of the beneficiarys vehicle as a transportation option.  States have an obligation 
to ensure that payment is made only where transportation is not otherwise available to the 
beneficiary to access Medicaid-covered services.   
  
Processes to Improve Passenger and Provider Relations  
The assurance of transportation to enable beneficiaries to reach their Medicaid providers is 
not a requirement to pay for a ride but rather a requirement to ensure that every beneficiary, 
regardless of additional needs or challenges, is able to access transportation to Medicaid-
covered services.  A negative transportation experience can have a direct impact on both a 
drivers willingness to accept a passenger and a beneficiarys willingness to accept a ride.  To 
ensure transportation providers, such as drivers, have the necessary tools to engage 
beneficiaries and ensure a positive experience, CMS recognizes there may be a need for 
additional steps to help manage the transportation provider-beneficiary relationship. 
 
For instance, a driver may be scheduled to transport a beneficiary for whom a ride has been 
arranged, needing no accommodation for physical or behavioral health.  The passenger may 
have exhibited past conduct which impacted a drivers ability to drive safely or without 
distraction, or may have not been respectful.   
 
To address this situation, the state may need to implement processes to prepare beneficiaries 
for their transportation pickup appointments or otherwise take steps to promote a positive and 
effective transportation provider-beneficiary relationship when relationships may be a barrier 
to a driver providing future services.  Examples include, but are not limited to: 
 
  Restricting beneficiaries to a single provider who may accommodate additional 
passenger challenges when there are no other willing transportation providers;  
  Requiring beneficiaries to be transported in a specialized transport appropriate for 
the beneficiarys behaviors and needs; 
  Requiring the beneficiary to follow special prior authorization procedures, as 
warranted, to arrange for transportation; 
  Allowing beneficiaries to arrange their own ride as reasonable accommodations; or  
14  Medicaid Transportation Coverage Guide 
 
  Consulting with a beneficiarys treating practitioners, including physical and 
behavioral health providers, on how to best serve the individual.   
 
Beneficiaries may not receive necessary care when appointments are missed.  To ensure a 
beneficiarys receipt of medical services is not hindered or discouraged, states may not deny 
transportation due to beneficiary no-shows or lateness, even if frequently occurring.  States 
and providers may also not impose a charge on a beneficiary for no-shows.33,34  However, 
CMS recognizes there may be a need for additional steps in scheduling and confirming a ride 
for passengers who exhibit chronic lateness or no-shows, such as, but not limited to:  
 
  Counseling the beneficiary; 
  Requiring the beneficiary to confirm the ride the morning of or the night before, or 
the ride will not be provided; 
  Requiring the beneficiary to use a single provider who is assigned by the state and 
then requiring the beneficiary to confirm the ride shortly before it is to be provided or 
the ride will not be provided; or 
  Allowing the beneficiary to arrange their own transportation which the state will 
reimburse or make other payment arrangements, as appropriate.  States can offer this 
option but cannot force beneficiaries to arrange their own transportation.   
 
It is important to note that before implementing any action to limit transportation in any way, 
states should send a letter to the beneficiary documenting the efforts made to accommodate 
the beneficiary, along with the behaviors that have resulted in the additional process.   
Transportation experiences can have an impact and influence on the decision a beneficiary 
makes in scheduling a service and the frequency of scheduling.  Beneficiaries who have a 
negative experience may see obstacles related to transportation as a deterrent to receiving 
medically necessary care.  Improving the experience in being informed and educated about 
transportation, arranging for transportation, ride experience, interaction with customer 
service representatives, ease in scheduling, and clear processes in rescheduling are all 
important considerations.  As with other Medicaid services, rescheduling is a common part of 
service delivery and can be related to factors such as illness, another life event, or a provider 
scheduling conflict.  It is important that the scheduling and rescheduling process for the 
beneficiary is administratively simple and that any arising provider and driver issues are 
regularly monitored and managed by the transportation provider and the state, as appropriate.  
Please refer to the Beneficiary Support section for additional information on Oversight of 
Transportation Services for Beneficiaries, Scheduling Assistance, and No-show Providers, 
Replacements, and Reschedules. 
   
 
 
33 FFP is not available for the cost of transportation to a beneficiary who does not appear for their ride (referred to as 
a no-show beneficiary).   
34 https://www.hhs.gov/guidance/sites/default/files/hhs-guidance-documents/1995%2520-
%2520billing%2520%26%2520missed%2520appointments.pdf. 
15  Medicaid Transportation Coverage Guide 
 
Consideration for Special Populations* 
States may experience unique challenges in providing transportation to specific groups of 
Medicaid beneficiaries, including but not limited to American Indian and Alaska Native (AI/AN) 
beneficiaries, beneficiaries with disabilities, and, more generally, beneficiaries living in rural 
areas.35  States should design a transportation program that ensures each beneficiary can access 
medical care and in a manner that optimizes adherence to treatment regimens.  The following 
policies may help states in the development and administration of their assurance of 
transportation to address the challenges faced by special populations. 
  
Beneficiaries with Disabilities* 
Beneficiaries with disabilities may require alternative modes of transportation to meet their 
unique needs and, in many cases, require more than curb-to-curb services.  States must 
consider a beneficiarys support needs in determining the most appropriate mode of 
transportation.  For example, if a beneficiary uses a wheelchair, then the state must ensure 
that the transportation provider transports the beneficiary in a wheelchair-accessible vehicle.  
In addition, states must ensure oversight of the transportation entities that provide or 
coordinate transportation to ensure beneficiaries with disabilities are provided with modes of 
transportation that meet their needs.   
 
Beneficiaries with Behavioral Health Needs* 
Beneficiaries with behavioral health needs (mental health conditions and substance use 
disorders), especially those experiencing a behavioral health crisis, may require alternative 
modes of transportation to meet their particular needs.  States must consider a beneficiarys 
behavioral health needs in determining the most appropriate mode of transportation.  States 
are encouraged to cover transportation services specifically tailored for beneficiaries with 
behavioral health needs.  For example, a state may cover behavioral health transportation 
services and require transportation providers that provide those services to be trained and 
credentialed in serving beneficiaries with behavioral health needs.   
 
Tribal Transportation* 
Health programs operated by the Indian Health Service (IHS) or operated by Tribes and 
Tribal Organizations under the Indian Self-Determination and Assistance Act can provide 
Medicaid covered services, including transportation, to American Indian and Alaska Natives 
(AI/AN) if they generally meet the states qualifications for providing these services (they 
are not, however, required to obtain a state license).36 If qualified, Urban Indian 
Organizations can also provide these services.  We refer to health programs operated by 
Indian Health Service, Tribes, and Urban Indian Organizations collectively as I/T/Us.  Many 
AI/AN Medicaid beneficiaries face difficulties in accessing transportation and as a result, 
may not receive needed medical services.  For example, there may be barriers unique to 
Tribal communities, such as not having formal street addresses (which may make it more 
difficult for a provider to find the beneficiarys residence), homes that are isolated from 
roadways, and unpaved and rugged roadways that cannot be traveled without special 
 
 
35 These sub-populations were frequently mentioned in the listening sessions. 
36 See 42 C.F.R.   431.110.  This regulation also explains that when state licensure is normally required, the facility 
need not obtain a license but must meet all applicable standards for licensure. 
16  Medicaid Transportation Coverage Guide 
 
vehicles.  Many Tribal communities located on tribal land may be situated in mountainous 
regions that are difficult to navigate in inclement weather.   
 
States have flexibility to design methods of administering the transportation assurance to 
meet the unique needs of beneficiaries, including AI/AN beneficiaries, who are experiencing 
these barriers.  For example, drivers can use odometer readings or GPS coordinates to 
navigate to a location and calculate mileage if there is no street address.  In some instances, 
because of the time and distance to medical care, it may be necessary to authorize overnight 
stays (including meals and/or lodging).37   
 
Tribes and Tribal organizations may have unique experience in navigating these barriers.  
Additionally, 42 C.F.R.  440.170(a)(4) permits governmental entities to serve as 
transportation brokers, including Tribes and Tribal organizations.  States are encouraged, 
where possible, to use existing providers servicing Tribal areas including I/T/Us.  Each state 
Medicaid agency has an internal Tribal liaison who state agency staff can consult and whom 
an I/T/U and individual AI/AN Medicaid beneficiaries can contact if they need assistance 
with accessing transportation.  CMS also encourages states to consult with Tribes and Tribal 
organizations as they review their policies and procedures and evaluate rate methodologies 
that recognize the unique transportation issues faced by Tribal transportation providers.   
 
Rural Areas* 
States face unique challenges in meeting their obligation to assure transportation for 
beneficiaries residing in rural areas.  More time and distance are generally needed to provide 
transportation services, as public transportation is generally absent or difficult to access and 
communication methods may be more limited than in urban areas.  For example, a 
transportation provider may travel many miles to transport a beneficiary to a covered medical 
service, and the time required to travel this distance may mean that the transportation 
provider is unable to transport any other beneficiaries on that day.  Additionally, 
beneficiaries who do not show up for the ride may be more costly for rural transportation 
providers than those in urban or suburban areas, given the long distances and time that can be 
involved.  CMS strongly encourages states to evaluate rate methodologies that recognize the 
unique transportation issues faced by rural transportation providers.  States have the 
flexibility to set higher base rates or establish supplemental payments for transportation 
providers to recognize the higher cost of doing business in rural areas.  Please refer to the 
following sections: Related Travel Expenses, "Long Wait Times, Long-Distance Trips, 
No Load Miles or Unloaded Miles, and Flexibilities for Coverage of Wait Times and 
Long Distances for additional information. 
Transportation Under Specific Circumstances 
The following guidance provides information about federal policies regarding transporting for 
specific trips or under certain conditions or circumstances.   
 
   
 
 
37 See policy regarding Related Travel Expenses for more information. 
17  Medicaid Transportation Coverage Guide 
 
Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Transportation* 
The EPSDT benefit mandates Medicaid coverage of services described in section 1905(r) of 
the Act for EPSDT-eligible beneficiaries,38 including medically necessary medical, dental, 
mental health, substance use disorder, personal care, and long-term services and supports, 
regardless of whether the particular services are covered under the state plan.  Transportation 
is an essential part of making medically necessary health care available to children.  Beyond 
the general transportation assurance requirement, the Medicaid EPSDT benefit further 
specifies in 42 C.F.R.  441.62 that states must offer and provide beneficiaries of EPSDT 
services with necessary assistance with transportation as required under  431.53[.] As 
required under EPSDT,39 states must inform beneficiaries and families in a clear and 
nontechnical manner that necessary assistance with transportation is available.  In 
determining what constitutes necessary transportation for children under 21, the state should 
consider the needs and best interests of the child when providing additional assistance with 
transportation to covered services.  If, in order to effectuate transportation for the child, the 
child needs to be accompanied to their medical services(s), the state must cover the cost of 
transportation for the person accompanying the child.  Transportation for the person 
accompanying the child includes coverage for trips to and from the service (e.g., roundtrip 
for admission, roundtrip for discharge), including in cases of out-of-state trips.   
 
Transportation for the Direct Benefit of Children Under 21 
The goal of the EPSDT benefit is to ensure that children under 21 receive timely access to 
medically necessary section 1905(a) services.  CMS issued prior guidance40 that linked the 
medically necessary treatment services provided for the direct benefit of the child with the 
childs parent(s), family member(s), or caregiver(s) in order to play an integral role in 
effectively treating the child.  However, if the participation of a parent, family member, or 
other caregiver is necessary to a childs care and such caregiver cannot access the child to 
participate in the care, then the Medicaid program cannot ensure that the child is receiving 
the necessary care.  For example, where a child is receiving residential or facility-based care 
(e.g., inpatient, neonatal intensive care unit (NICU), psychiatric residential treatment facility 
(PRTF), etc.) and the presence of the parent, family member, or other caregiver is necessary 
so that they can actively participate in the treatment/intervention for the direct benefit of the 
child, then state may pay for transportation for the parent, family member, or caregiver in 
order to ensure the childs medically necessary services are provided (e.g., to provide breast 
milk or breastfeed, participate in family therapy, medical decision making and consent for  
surgery, etc.). 
 
Alternatively, the cost of transportation could be considered part of the cost of the medical 
service (e.g., inpatient hospital benefit, etc.) and included in another service payment, rather 
than paid separately as a distinct service.  For example, if a child is admitted to a facility to 
obtain treatment and it is medically necessary for the parent, family member, or other 
 
 
38 EPSDT-eligible beneficiaries include, but may not be limited to, all beneficiaries under age 21 who are eligible 
for a categorically needy eligibility group. 
39 Section 1902(a)(43) of the Act and implementing regulations at 42 C.F.R.   441.56 require states to inform 
eligible Medicaid beneficiaries under the age of 21 and their families about EPSDT, generally within 60 days 
following an eligibility determination.  This is known as the informing process. 
40 https://www.medicaid.gov/federal-policy-guidance/downloads/cib051116.pdf. 
18  Medicaid Transportation Coverage Guide 
 
caregiver to participate in receipt of the treatment, then parent, family member, or other 
caregivers transportation could be included in the payment for the institutional services as a 
component of the facility service provided to the child.   
 
Transportation for Visitation* 
Transportation for parents, family members, or other caregiver(s), referred to as visitors in 
this context, who are visiting a beneficiary who is hospitalized or otherwise receiving 
residential or facility-based treatment (in-state or out-of-state) generally is not necessary for 
the beneficiary to receive the covered medical service and is thus not part of the assurance of 
transportation requirement.  Visitor transportation is not eligible for Medicaid coverage, 
regardless of whether the state is ensuring necessary transportation as an administrative 
activity or as an optional medical service.  
 
Transportation for Optional Benefits* 
Transportation must be assured for both mandatory benefits and optional benefits that the 
state has chosen to cover.  For instance, while the prescribed drug benefit is an optional state 
plan benefit, if the state chooses to cover prescribed drugs, it must also assure that 
beneficiaries have necessary transportation to pick up covered prescriptions.  In this specific 
example, however, since NEMT should be cost efficient, a state may adopt a policy of not 
providing NEMT to a pharmacy location when there is an available pharmacy mail order 
program or an available pharmacy with timely delivery service that is able to reliably deliver 
prescriptions directly to the beneficiary.  Whenever possible and to the extent it would 
promote efficiency and economy, state programs should attempt to combine a return trip 
from a provider when the beneficiary has received a prescription with a stop at the nearest 
participating pharmacy to fill (or at least drop off) the new prescription before returning the 
beneficiary home.  Please refer to the Flexibilities for Coverage of Wait Times and Long 
Distances section for additional information. 
 
Transportation for Beneficiaries Dually Eligible for Medicaid and Medicare* 
Medicare is the primary payer for services that are payable by both Medicare and Medicaid.  
However, Medicare has a limited non-emergency ambulance transportation benefit.  If a full 
benefit dually eligible individual41 is obtaining a Medicaid-coverable service for which 
Medicare is the primary payer, the state must ensure necessary transportation to the medical 
service.  
 
If the beneficiary is obtaining a non-Medicaid coverable service that is covered by Medicare, 
the state has the option to cover transportation to that service.  For example, states have the 
option (by specifying in the state plan) to cover transportation for full benefit dually eligible 
beneficiaries to the pharmacy to obtain Part D drugs, if it would be cost effective to do so.  
The transportation to obtain Part D drugs is optional because Part D drugs are expressly 
excluded from coverage in Medicaid under section 1935(d)(1) of the Act.  Because Part D 
drugs are expressly not covered by Medicaid, the transportation to obtain these drugs 
 
 
41 Full benefit dually eligible individuals are those individuals enrolled in the Qualified Medicare Beneficiary Plus 
(QMB Plus), Specified Low Income Medicare Beneficiary Plus (SLMB Plus), and Full Benefit Dual Eligible 
(FBDE) Medicaid options. 
19  Medicaid Transportation Coverage Guide 
 
becomes optional.  Please see the section titled Coverage of Transportation to Services not 
Provided by a Medicaid Provider for additional information. 
 
School-Based Transportation 
As a general rule, ordinary transportation of Medicaid beneficiaries to school is not covered 
by Medicaid because education is the primary purpose of attending school, even when a 
Medicaid-covered health service is provided in the school.  However, Medicaid payment is 
available for transportation to onsite school-based services for children receiving services 
under the Individuals with Disabilities Education Act (IDEA). 
 
Section 1903(c) of the Act provides that states may not be prohibited or restricted from 
receiving payment...  for medical assistance for covered services...  because such services are 
included in the childs Individual Education Plan (IEP) or Individual Family Service Plan 
(IFSP).  When specialized transportation is necessary primarily to ensure the childs 
medical needs are met and the need for such specialized transportation is specified in a 
childs IEP, then Medicaid payment is available for specialized transportation to and from 
school for days when the child receives a Medicaid-covered service (see Medicaid Payment 
for Services Provided without Charge (Free Care) SMD letter #14-00642, the school-based 
health services manual43, and a 1999 SMDL44).  CMS policy related to payment for 
specialized transportation expressed in prior guidance remains unchanged.  Non-specialized 
transportation and transportation not specified in an IEP is not covered because the primary 
benefit from ordinary school transportation is for school attendance.  Ordinary school 
transportation is not targeted to address the students medical needs and is not covered by 
Medicaid.  The fact that a provider was at the school and provided care to a Medicaid-
covered student does not create the need for Medicaid non-emergency medical 
transportation. 
 
FFP may be claimed for the cost of transportation services when the Medicaid-eligible child 
must leave the school and go into the community to receive medical services covered and 
paid for under Medicaid.  FFP is available for the cost of transporting the child from school 
to the community provider and back to school or home and for transporting the child from 
the home to the provider and then to school.  This includes the cost of transporting an 
attendant when an attendant is necessary to accompany the child.45   
 
School-based specialized transportation is transportation to a medically necessary service (as 
outlined in the IEP of an enrolled Medicaid beneficiary) provided in a specially adapted 
vehicle that has been physically adjusted or designed to meet the needs of the individual 
student (e.g., special harnesses, wheelchair lifts, ramps, specialized environmental controls, 
specialized suspension systems etc.) to accommodate students with disabilities in the school-
 
 
42 https://www.medicaid.gov/federal-policy-guidance/downloads/smd-medicaid-payment-for-services-provided-
without-charge-free-care.pdf. 
43 Medicaid and School Health: A Technical Assistance Guide, August 1997. 
44 State Medicaid Director Letter, May 21, 1999. 
45 Please note a transportation attendant is not the same as a personal care attendant/aide.  If a personal care aide is 
provided as a covered service to the beneficiary and will accompany the beneficiary on a medical appointment, 
including during transport, then an additional transportation attendant is not necessary. 
20  Medicaid Transportation Coverage Guide 
 
based setting.  Note: the presence of only an aide (on a non-adapted bus/vehicle) or simple 
seat belts do not make a vehicle specially adapted.  In all cases, the medical need for physical 
or environmental adaptations during transport from home to school and back home (or to an 
alternative site to receive the IEP service) must be identified in the IEP.  FFP is not available 
for the cost of transporting a student who rides a physically adapted bus or other vehicle, but 
does not have a medical reason documented in an IEP to make use of the particular 
bus/vehicle adaptation.  For a more complete discussion on Medicaid services in schools, 
see: Delivering Services in School-Based Settings: A Comprehensive Guide to Medicaid 
Services and Administrative Claiming, 2023.46 
 
Coverage of Emergency Transportation for Individuals with Unsatisfactory Immigration 
Status 
Section 1903(v)(2) of the Act requires that payment be made for care and services necessary 
for the treatment of an emergency medical condition for individuals who are otherwise 
eligible for Medicaid in the state, but who do not have a satisfactory immigration status.  
These emergency medical conditions include medical conditions that could endanger the 
beneficiarys health/life (including the cost for emergency labor and delivery) and services 
could include provision of EMT. 
 
Coverage of Transportation to Services not Provided by a Medicaid Provider  
States may choose to cover transportation to access otherwise covered services paid for by 
other payers and/or services provided by non-participating providers, when it is cost effective 
to do so.  States may choose to exercise this option because it could be more cost effective 
and efficient to cover an individuals transportation to an otherwise covered medical service 
when the medical service is not paid for by Medicaid.  For example, a state may choose to 
cover trips to otherwise covered services furnished by the Department of Veterans Affairs 
(VA) for a beneficiary who is a veteran and enrolled in VA health care, because the 
beneficiarys obtaining the service from the VA without charge to the Medicaid program is 
cost effective and efficient. 
 
Ground Emergency Medical Transportation (GEMT) 
The cost of fire and rescue personnel and their equipment is generally not related to Medicaid 
covered services.  As such, Medicaid cost identification methodologies that inappropriately 
allocate costs associated with fire and rescue personnel and their equipment could be 
unallowable under the federal cost allocation requirements.  Similarly, costs associated with 
other emergency response personnel, vehicles, and equipment that are not involved in the 
provision of a Medicaid-covered service, such as police and their vehicles and equipment, 
should not be included in GEMT cost identification and allocation methodologies for 
Medicaid payment, and potentially would be unallowable.  CMS encourages states to look to 
the current federal cost allocation regulations to appropriately and accurately define and 
allocate costs to the relevant Medicaid cost objectives, which are costs incurred for the 
purpose of delivering allowable Medicaid services to Medicaid beneficiaries.  For example, 
costs associated with fire and rescue personnel who do not provide Medicaid covered 
 
 
46 https://www.medicaid.gov/medicaid/financial-management/downloads/sbs-guide-medicaid-services-
administrative-claiming.pdf. 
21  Medicaid Transportation Coverage Guide 
 
services to Medicaid beneficiaries on the scene of an emergency but who are present during 
the emergency as required by state law or local code would potentially be unallowable.  
However, all personnel who meet applicable Medicaid provider qualifications (such as 
Medicaid-participating, licensed or certified emergency medical technicians) and provide 
Medicaid -covered services at an emergency site to beneficiaries may be included in the 
GEMT cost allocations, provided the unit of government can identify the portion of costs 
properly allocable to the providers furnishing of Medicaid-covered services (as opposed to 
conducting other duties or functions that do not constitute a Medicaid-covered service) and 
allocate that portion of costs to the Medicaid program.  The CMS Informational Bulletin 
titled Applicable Federal Cost Principles for Ground Emergency Medical Transportation 
(GEMT) provides additional information related to coverage of GEMT.47 
 
Treatment at the Scene without Transport* 
When no transportation occurs, such as when any necessary treatment is provided at the 
scene of an accident or medical event, states cannot claim FFP for the treatment as a 
transportation service.  Whether claimed as an optional medical service or as an 
administrative activity, transportation necessarily requires transport of a Medicaid 
beneficiary to a provider site for the receipt of a covered Medicaid service, and when no 
transportation of a beneficiary has occurred, Medicaid payment for transportation is not 
available.  States have the flexibility to cover services provided at the scene (with no 
transport) under various Medicaid coverage authorities. 
 
A number of states have used section 1905(a)(6) of the Act, sometimes referred to as the 
other licensed practitioner benefit, to cover the services of certain professionals, such as 
paramedics, typically associated with the provision of emergency services rendered on the 
scene.  Other licensed practitioner services, defined at 42 C.F.R.  440.60, are ... medical or 
remedial care or services, other than physicians services, provided by licensed practitioners 
within the scope of practices as defined under State law.  States could consider submitting a 
SPA to cover the services of licensed paramedics under section 1905(a)(6) of the Act in order 
to make payment for services furnished on the scene when no transport takes place.  This 
benefit can also include the services of unlicensed professionals who furnish covered services 
under the supervision of licensed practitioners.  In these instances, states should assess the 
type of professionals furnishing services and their qualifications to determine the appropriate 
coverage authorities.  For more information about treatment at the scene and an example 
model for aligning service delivery and transportation at the scene, please see Medicaid 
Opportunities in the Emergency Triage, Treat, and Transport (ET3) Model issued on August 
8, 2019.48 
 
Law Enforcement as a Mode of Transportation* 
Section 1902(a)(4) of the Act requires that states provide for methods of administration that 
the Secretary finds necessary for the proper and efficient operation of the State plan.  While 
states and localities may require particular vehicles and/or equipment (e.g., fire trucks, 
police, and ambulance) to be dispatched to the scene of an emergency, Medicaid FFP is not 
 
 
47 https://www.medicaid.gov/federal-policy-guidance/downloads/cib08172022.pdf. 
48 https://www.medicaid.gov/federal-policy-guidance/downloads/cib080819-3.pdf. 
22  Medicaid Transportation Coverage Guide 
 
available in expenditures for personnel, vehicles, or equipment not directly involved in the 
provision of Medicaid-covered services.  In circumstances where law enforcement personnel 
transport Medicaid beneficiaries to a provider of covered services, they typically do so only 
incidentally to their law enforcement activities, which are the primary purpose for their 
dispatch to and presence on the scene.  In general, costs of law enforcement personnel and 
equipment are not directly involved in the provision of a Medicaid-covered service, and 
Medicaid payment for them would not be consistent with the proper and efficient operation 
of the plan or with applicable cost allocation principles.  Additionally, if transportation is 
claimed as an optional medical service, section 1902(a)(23) of the Act would apply.  This 
section provides that beneficiaries may obtain services from any willing and 
qualified Medicaid provider that undertakes to provide the services to them.  When law 
enforcement transports an individual, the individual is typically taken involuntarily or 
without an opportunity to select another qualified and willing provider.  Since individuals in 
these circumstances are not given their free choice of provider, Medicaid payment for 
transportation by law enforcement as an optional medical service would be inconsistent with 
section 1902(a)(23) of the Act.  Please refer to the Ground Emergency Medical 
Transportation (GEMT) section for more information.   
 
Transportation Network Companies (TNCs) Also Known as Ridesharing Organizations*  
TNCs, also known as ridesharing organizations, are a type of transportation provider.  The 
state has flexibility in determining and designing how it will provide and pay for 
transportation services in accordance with the transportation regulations described in 42 
C.F.R.  431.53 and 42 C.F.R.  440.170(a).  In implementing TNCs as an option, states 
must be cognizant of the Medicaid policy that requires that the ride be the least costly, most 
appropriate ride that meets the medical needs of the beneficiary.  Furthermore, payment for a 
ride must be consistent with efficiency, economy, and quality of care.  As applied to TNCs, 
this means the state would need to account for the medical appropriateness of the ride and the 
financial efficiency of using a TNC to furnish Medicaid-covered transportation (e.g., 
including any economies of scale that might be realized through a contractual agreement with 
a TNC).   
Broker 
Under section 1902(a)(70) of the Act and implementing regulations at 42 C.F.R.  440.170(a)(4), 
states may establish a broker program to ensure necessary NEMT.  The following sections seek 
to clarify broker requirements and states obligations. 
 
Competitive Bidding* 
Regulations at 42 C.F.R.  440.170(a)(4) require that a broker contract be competitively bid 
and awarded based on a state's evaluation of the broker's experience, performance, 
references, resources, qualifications, and costs.  In addition, it must include oversight 
procedures to monitor beneficiary access and complaints and ensure that transport personnel 
are licensed, qualified, competent, and courteous.  State and local entities that wish to serve 
as brokers may compete on the same terms as non-governmental entities.   
 
   
23  Medicaid Transportation Coverage Guide 
 
Broker Conflict of Interest and Exception Requests* 
42 C.F.R.  440.170 (a)(4)(ii) provides that, in general, brokerage contracts must prohibit the 
broker (including certain related parties) from providing transportation under the contract 
with the state, and the broker may not refer or subcontract to a transportation service provider 
with which it has a financial relationship, unless certain exceptions as discussed below are 
approved through the SPA process.   
 
CMS may grant an exception for a non-governmental broker to provide transportation 
services under three circumstances per 42 C.F.R.  440.170(a)(4)(ii)(B):  
 
  The transportation is provided in a rural area, and there is no other available 
Medicaid-participating provider or other qualified provider except the non-
governmental broker; 
  The transportation is so specialized that there is no other Medicaid-participating 
provider or no other qualified provider except the non-governmental broker; or  
  Except for the non-governmental broker, the availability of other Medicaid-
participating providers or other qualified providers is insufficient to meet 
transportation need.   
 
If a state wishes to implement one of the exceptions to the broker conflict of interest rules, 
the state must submit a SPA proposal to implement the exception, which must include 
documentation to support that the criteria for the exception are met.  States must be able to 
show precise, up-to-date, and accurate statistical data to support the need for the broker to 
transport in each county or subdivision in which the state is requesting to effectuate the 
exception.  States should also consider including the following in the documentation 
submission: 
 
  What steps have been taken by the relevant transportation broker(s) to contract with 
an adequate supply of network providers, and what barriers prevent the broker(s) 
from contracting with an adequate number of network providers?  States should 
include the estimated timeframe needed for the broker(s) to contract with adequate 
providers, as well as the timeframe the state is requesting to apply the exception.   
  How would the state ensure the broker(s) only supplement available transportation 
from network providers as necessary, and do not supplant or diminish the available 
pool of qualified providers who contract with the broker(s)? 
  What metrics will the state use to determine that the exception sought is no longer 
necessary?   
 
If an exception is granted, the state should contractually require its broker(s) to limit the use 
of these vehicles to only those trips for which an appropriate contracted transportation 
network provider is not available.   
 
   
24  Medicaid Transportation Coverage Guide 
 
Public/Governmental Entities as Brokers* 
A broker that is a public/governmental unit49 (e.g., regional transportation authority, state 
department of transportation (DOT), or transit agency) must competitively bid to become a 
Medicaid NEMT broker.  When the governmental entity also provides transportation 
services, or arranges for NEMT by referring to or subcontracting with another government-
owned or operated transportation provider (e.g., public transit providers), it is exempted from 
the conflict of interest prohibition when certain requirements are met, which ensure an arms-
length transaction.  These include: 
 
  The contract with the governmental broker provides for payment that does not exceed 
the actual costs calculated as though the broker were a distinct governmental unit 
(excluding from payments any personnel or other costs shared with or allocated from 
parent or related entities); the governmental broker must maintain 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 documents that the governmental provider was the most appropriate and 
lowest cost alternative for each individual trip, in consideration of the beneficiarys 
specific needs; and 
  The broker documents that Medicaid is paying for  
i.  public fixed route transportation at a rate that is no more than the rate charged 
to the general public; and 
ii.  ADA paratransit and demand response at a rate that is no more than the rate 
charged to any other state human services agencies for comparable services.   
 
For a more complete discussion about Governmental Entities as Brokers, please refer to the 
preamble to 73 FR 77519.50  Please also refer to the Fixed Route Public Transit section. 
 
Broker Payments to Providers* 
States that contract with a broker to assure necessary transportation are still obligated to 
ensure beneficiary access to necessary transportation services under section 1902(a)(70) of 
the Act.  States may direct brokers to use specific provider payment methodologies to help 
ensure beneficiary access to necessary transportation services.  States are also expected to 
provide sufficient oversight to ensure that when contracting with transportation providers the 
broker does not offer payment that is so low that local transportation providers are unwilling 
to participate, thus creating a need for the broker to provide transportation.  States have the 
flexibility to explore a broad array of innovative payment models. 
   
 
 
49 For more information about distinct governmental units please refer to the preamble 73 FR 77521 at 
https://www.govinfo.gov/content/pkg/FR-2008-12-19/pdf/E8-29662.pdf. 
50 Id.   
25  Medicaid Transportation Coverage Guide 
 
Beneficiary Support 
As in all Medicaid services, the delivery of transportation services should be person-centered.  In 
order for the transportation assurance to serve its intended purpose, the state must have in place a 
reasonable process for providing and managing transportation.  While some of these functions 
are often delegated, the state has ultimate responsibility to provide oversight.  Interested parties 
who participated in the section 209 listening sessions emphasized the importance of state 
oversight, as well as more reasonable processes to avoid having to reschedule medical 
appointments, which can impact health outcomes. 
 
Oversight of Transportation Services for Beneficiaries* 
States have ultimate oversight responsibility to monitor beneficiary access and complaints, 
ensure transportation is timely, and ensure that transport personnel are licensed, qualified, 
competent, and courteous.  States have a responsibility to ensure beneficiaries are aware of 
the processes and policies regarding accessing transportation, filing complaints and 
grievances, and requesting a fair hearing.  State Medicaid agencies should have in place 
robust oversight programs that include conducting regular audits to ensure all state and 
federal Medicaid law, regulations, and policies are followed.  States also have an obligation 
of oversight for all Medicaid-covered transportation, including where transportation is 
arranged by local jurisdictions.   
 
The state, the broker, and the transportation company should monitor any complaints made 
by beneficiaries related to transportation access and quality including, but not limited to, 
courteous and respectful drivers and scheduling staff, clean vehicles, timely rides, etc., and 
hold accountable the operational organizations that administer day-to-day transportation, 
such as transportation companies, brokers, counties, managed care plans, and drivers.51  Most 
importantly, state Medicaid agencies must ensure the adequacy of beneficiary access to 
covered medical care and services.   
 
Scheduling Assistance* 
As stated previously, states are required to assure that beneficiaries who have no other means 
of transportation have access to necessary transportation to and from Medicaid-covered 
services.  Also, states should inform Medicaid beneficiaries of available services, and states 
should provide information to beneficiaries about assistance with necessary transportation.  
States are expected to provide clear and effective communication with beneficiaries and 
providers to ensure beneficiaries do not miss appointments and avoid long wait times, to 
accommodate adjustments in appointment times, and to efficiently match beneficiaries with 
appropriate transportation.  States may need to replace and/or reschedule rides for many 
reasons, including to accommodate beneficiary needs.  In general, states should have 
processes in place to ensure timeliness, effective communication, and efficient resolution for 
unanticipated interruptions in services.  Please refer to the Processes to Improve Passenger 
and Provider Relations section for additional information.  
 
 
 
51 https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-
Education/Downloads/nemt-booklet.pdf. 
26  Medicaid Transportation Coverage Guide 
 
No-show Providers, Replacements, and Reschedules* 
Providers who do not arrive for a pick-up (referred to as no-show providers) affect a states 
ability to assure necessary transportation to covered services for beneficiaries with no other 
means of transportation.  No-show providers lead to missed medical appointments, which 
impact beneficiary health and outcomes.  States and their Medicaid transportation partners 
must have adequate oversight and processes in place to ensure that scheduled transportation 
is furnished as arranged.  As such, states should have mechanisms in place to monitor 
performance to reduce the number of no-show providers and allow for replacement 
transportation providers with short notice.  Beneficiaries should also be informed about and 
have ready access to information on how to report a no-show and arrange for a replacement 
provider. 
 
FFP is not available in payments for no-show providers as no Medicaid-covered service is 
delivered or activity performed in the case of a no-show provider.  States have the 
responsibility to take any necessary oversight actions to help prevent future no-shows and to 
ensure impacted beneficiaries are able to access necessary transportation.   
Provider and Vehicle Requirements 
Transportation to medical services is vital to ensure that individuals can receive covered services 
needed to improve or maintain their health status.  States must establish qualifications and safety 
standards for drivers, use appropriate screening and credentialing methods, and ensure that 
Medicaid-covered transportation is appropriately accessible, including during disasters.   
 
State Driver and Vehicle Standards* 
Section 209 added section 1902(a)(87) to the Act 52 and requires that states provide for a 
mechanism, which may include attestation, that ensures that, with respect to any provider 
(including a transportation network company) or individual driver of nonemergency 
transportation to medically necessary services receiving payments under such plan (but 
excluding any public transit authority), at a minimum  
(A) each such provider and individual driver is not excluded from participation in any 
Federal health care program (as defined in section 1128B(f) of the Act) and is not listed 
on the exclusion list of the HHS Inspector General; 
(B) each such individual driver has a valid drivers license;  
(C) each such provider has in place a process to address any violation of a state drug law; 
and 
(D) each such provider has in place a process to disclose to the State Medicaid program 
the driving history, including any traffic violations, of each such individual driver 
employed by such provider, including any traffic violations. 
  
Beyond the requirements at 1902(a)(87) of the Act, Federal Medicaid law does not establish 
additional basic driver and vehicle standards.  Instead, these standards are generally 
determined by state agencies responsible for motor vehicle management.  Drivers must have 
the appropriate, current licenses for the types of vehicles they drive when transporting others.  
 
 
52 https://www.medicaid.gov/federal-policy-guidance/downloads/cib071221.pdf. 
27  Medicaid Transportation Coverage Guide 
 
For example, states may require a chauffeurs license (or equivalent) for taxis and vans.  A 
state Medicaid agency may also require additional qualifications for drivers to ensure that 
Medicaid beneficiaries receive high-quality transport.  Standards might include limiting the 
number of penalty/violation points drivers can have against their license, certifying the health 
of a driver, carrying vehicle liability insurance, and complying with state safety and 
inspection standards. 
 
Provider Enrollment, Screening and Background Checks*  
Sections 1902(a)(77) and (kk) of the Act require that states comply with the process for 
screening providers and suppliers, and section 1902(a)(78) requires enrollment of all 
providers furnishing items or services under the state plan.  These statutory provisions are 
implemented by regulations at 42 C.F.R.  455 Subpart E, which require states to enroll and 
screen providers according to categorical risk level, including at a minimum verifying 
compliance with state and federal requirements and conducting certain licensure and 
database checks.  Section 1902(a)(27) of the Act and the regulation at 42 C.F.R.  431.107 
also require an agreement between the Medicaid agency and each provider or organization 
furnishing services under the state plan.   
 
States have discretion to require enrollment of transportation providers at the organizational 
or individual level53 or to add additional screening requirements,54 but must be consistent in 
application of such requirements.  However, if states recognize drivers as a provider type 
eligible to enroll, individual drivers must be enrolled, even if the organization is also required 
to be enrolled.  States may also impose additional requirements, such as provider and driver 
standards to assure that drivers are qualified and appropriate.  For instance, states may 
elevate the risk level for this provider type from the minimum limited level to moderate 
or high, which incurs additional screening such as site visits and/or a fingerprint-based 
criminal background check, or impose additional background checks on drivers regardless of 
whether or not transportation is ranked as high risk.  States can also add additional vehicle 
requirements, inspections, and other Medicaid provider enrollment policies.   
 
As discussed in State Medicaid Director Letter (SMDL) #09-001,55 transportation providers 
are also required to screen their employees to ensure they are not excluded, regardless of 
whether the state chooses to enroll the organization or individual drivers within the 
organization.  Additionally, section 209 added section 1902(a)(87) to the Act, which requires 
states to attest in the state plan that any provider, including TNCs and individual drivers, 
meet specific minimum requirements regarding exclusions, licensure, violation of drug law, 
and disclosures.56  Please refer to the Attachment 3.1-D Page - Section 209 Attestation 
section for additional information about the section 209 provider and driver requirements. 
 
   
 
 
53See page 43 of the Medicaid Provider Enrollment Compendium (MPEC) 
https://www.medicaid.gov/sites/default/files/2021-05/mpec-3222021.pdf. 
54 See 42 C.F.R.  455.452. 
55 https://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD011609.pdf. 
56 https://www.medicaid.gov/federal-policy-guidance/downloads/cib071221.pdf. 
28  Medicaid Transportation Coverage Guide 
 
Disaster Policy* 
Regulations at 42 C.F.R.  431.53 require that states must ensure necessary transportation for 
beneficiaries to and from providers of covered services.  During a disaster, it may be 
necessary to move Medicaid beneficiaries from one location to another so that they can 
receive covered services.  For example, if the beneficiary is residing in a nursing facility or 
any other medical facility within an area that is impacted by a disaster, NEMT is available to 
move the beneficiary from a nursing facility or other medical facility that is no longer safe to 
another nursing facility or other medical facility not rendered unsafe or unavailable by the 
disaster, even when the closest available facility is out of state.  The state must cover the 
transportation of a beneficiary from one nursing facility to another nursing facility to obtain 
services, or from a nursing facility to a community setting where the beneficiary can continue 
to receive services, when necessary, even when the placement is in another state.  However, 
NEMT is not available to move a beneficiary from one community setting to another for 
personal reasons such as because the beneficiary would like to be closer to family or friends. 
Payment 
When covering necessary transportation, states must pay for the least costly mode of 
transportation that most appropriately meets the needs of a beneficiary to access covered 
services.  However, states must also ensure that payment is adequate to ensure beneficiary access 
to covered services.  The following sections provide guidance on which are covered 
transportation services,  and new policy on wait times and long-distance trips.   
 
No Load Miles or Unloaded Miles* 
The terms no load miles or unloaded miles refer to the mileage the driver travels without 
a Medicaid beneficiary in the vehicle.  This situation includes the drivers return trip in the 
case of beneficiaries who do not appear for their ride (referred to as beneficiary no-shows).  
Generally, no load miles cannot be paid as a direct service or administrative activity.  
Recognizing that no load miles result in significant costs to transportation providers and 
failure to account for them would negatively affect potential transportation providers 
willingness to transport Medicaid beneficiaries, states may build the cost of no load miles 
and beneficiary no-shows into their transportation payment methodology.  States may also 
separately cover no load miles in limited circumstances if they exercise the flexibilities 
described in the section below, titled Flexibilities for Coverage of Wait Times and Long 
Distances. 
 
Long-Distance Trips* 
Drivers, especially in rural areas and Tribal lands, sometimes travel many miles away from 
their operational base or standard travel routes to take beneficiaries to covered medical 
services.  In instances of overnight long-distance trips, states are required to cover related 
travel expenses.  Please refer the Flexibilities for Coverage of Wait Times and Long 
Distances section below for additional information.  
 
Long Wait Times* 
Beneficiaries, especially those with complex medical needs, may need to travel to covered 
medical services that take hours to complete (e.g., dialysis treatment, outpatient surgery, 
etc.).  Drivers who are also providing the beneficiarys return transportation may experience 
29  Medicaid Transportation Coverage Guide 
 
long wait times when transporting beneficiaries to and from such covered medical services.  
Generally, states may not cover long wait times as a distinct service, as the assurance of 
transportation is intended to assure transportation for beneficiaries to access medically 
necessary covered services, thus a beneficiary must be present with the driver.  Additionally, 
it may not be consistent with economy and efficiency for a driver to wait for a beneficiary to 
finish receiving a covered service, as opposed to the first driver leaving and a second driver 
providing the beneficiarys return transportation after the covered service is finished.  
However, in some cases, even a long driver wait time may be the most economic and 
efficient means to provide a return trip to the beneficiary, and such wait times involve 
significant costs to the transportation provider that must be considered in establishing 
adequate transportation payment methodologies and rates.  Consistent with the above 
guidance on no load miles, states may build the cost of long wait times into their 
transportation payment methodology.  States may separately cover wait times as a travel 
expense in limited circumstances if they exercise the flexibilities described in the section 
below titled Flexibilities for Coverage of Wait Times and Long Distances. 
 
Related Travel Expenses* 
As described in regulations at 42 C.F.R.  440.170(a), transportation includes travel related 
expenses determined to be necessary by the agency to secure covered services.  Related 
travel expenses include the cost of meals, lodging, and the cost of a transportation attendant57 
when necessary, as well as the potential to cover wait times if states exercise the flexibilities 
described in the section below titled Flexibilities for Coverage of Wait Times and Long 
Distances.  The cost of a transportation attendant may include transportation, meals, 
lodging, and if the attendant is not a family member, salary.  Coverage of related travel 
expenses, when necessary for accessing covered services, is required regardless of whether 
the state is providing transportation as an optional medical service or as an administrative 
activity.   
 
Flexibilities for Coverage of Wait Times and Long Distances* 
CMS recognizes that beneficiaries may live in areas without sufficient medical providers and 
may require long-distance transportation to access covered services, and some beneficiaries 
locations may be so remote that travel distance and travel times make it economically 
infeasible to enlist an adequate network of transportation providers when transportation 
payment rates and methodologies do not account for the unusually high costs of transporting 
these beneficiaries.  CMS interprets the definition of transportation as an optional medical 
service at 42 C.F.R.  440.170(a) to include related travel expenses determined to be 
necessary by the state to secure medically necessary services for the beneficiary.  Consistent 
with the historical application of least costly, most appropriate transportation and coverage of 
other related travel expenses, such as meals and lodging, during long-distance trips, we 
interpret necessary transportation to include, in the limited circumstances described below, 
wait time and/or unloaded mileage.  Under section 1903(a)(7) of the Act, this policy applies 
in the case of transportation provided as an administrative activity as necessary for the 
proper and efficient administration of the State plan. 
 
 
57 Attendant refers to transportation attendant as described in 42 C.F.R.  440.170(a)(3)(iii) and not an attendant 
provided through another section 1905(a) benefit under the Act, such as personal care. 
30  Medicaid Transportation Coverage Guide 
 
 
Effective on the date of issuance of this Coverage Guide, wait times and/or unloaded mileage 
expenses can be covered at the states option, while the beneficiary is not in the vehicle, 
solely under these circumstances: 
 
  For wait time, the travel distance and transport time (for trips to and from services) 
make it more economically feasible for the transportation provider to remain at the 
medical provider while the beneficiary receives covered services, and   
  For unloaded mileage, the most appropriate and economical transportation provider 
must incur extraordinary costs for time and/or mileage to pick up or drop off the 
beneficiary for the beneficiary to receive covered services.  This means the expense 
of the unloaded portion of the trip that is not accounted for in the states usual 
transportation payment rate or methodology would be prohibitive for the 
transportation provider, and the transportation provider is the most economical 
available resource capable of providing appropriate transportation.  
States must submit a state plan amendment (SPA) with coverage and payment pages before 
claiming FFP for expenditures that require these flexibilities.  Coverage pages should 
indicate which flexibilities the state is implementing under their description of related travel 
expenses.  Payment pages should include the methodologies states will use for payment using 
these flexibilities.  While not required in the state plan, states should develop operational 
criteria under which the flexibilities would apply.   
 
Consistent with section 1902(a)(30)(A) of the Act, CMS will review proposed SPAs 
modifying Medicaid transportation payment methodologies for consistency with the 
requirements of efficiency, economy, quality of care, and sufficient access to providers, when 
the state is paying for transportation as an optional medical service.  When the state is paying 
for transportation as an administrative activity, we will review related SPAs for consistency 
with the proper and efficient administration of the plan, as specified in section 1903(a)(7) of 
the Act.  Please refer to the General Payment and Cost Principles sections for more 
information. 
 
Driver shortages impact access to care for beneficiaries who need in-person services.  These 
policy updates are intended to increase access to care and to alleviate some of the concerns 
related to driver retention and workforce development that may negatively affect 
beneficiaries ability to access transportation to and from needed services.   
 
General Payment 
Section 1902(a)(30)(A) of the Act requires Medicaid state plans to provide for methods and 
procedures relating to the utilization of, and payment for, Medicaid-covered services as may 
be necessary to safeguard against unnecessary utilization and to assure that payments are 
consistent with efficiency, economy, and quality of care.  Further, state payment rates or 
methodologies must be sufficient to enlist enough providers so that care and services are 
available under the plan at least to the extent that such care and services are available to the 
general population in the geographic area.  These state plan requirements apply when 
transportation is covered as an optional medical service.  When a state covers transportation 
as an administrative activity, section 1903(a)(7) of the Act requires that expenditures for 
31  Medicaid Transportation Coverage Guide 
 
transportation must be as found necessary by the Secretary for the proper and efficient 
administration of the State plan.  Within these parameters, states have considerable 
flexibility to establish their payment methodologies and rates for transportation. 
 
As with most non-institutional Medicaid services, there is no applicable upper payment limit 
(UPL) for payment for these services.  The following are a few examples of ways that states 
may pay for transportation: 
 
  States can adopt Medicare rates, or a percentage thereof, when a comparable 
Medicare rate exists; 
  States may set their own rates (i.e., state-developed fee schedule rates) based on their 
own unique circumstances; and 
  States may also elect to use an interim payment methodology that is reconciled to the 
providers final actual costs of providing transportation.   
The suggested coverage flexibilities in this guidance allow for states to similarly apply this 
flexibility to the manner in which states pay for transportation to the location of the 
beneficiary, otherwise referred to as unloaded miles, and wait times associated with the 
driver waiting for the patient while the patient is in their appointment for a covered Medicaid 
service.  In setting a rate for these circumstances, states must consider appropriate methods of 
payment, and may rely upon existing rate structures when doing so.  For example, the 
Internal Revenue Service establishes a federal mileage rate for determining deductible cost 
associated with transportation.58  Likewise, Medicare establishes a mileage rate for 
ambulance providers, which is geographically adjusted on Medicares published fee 
schedules. 
 
Cost Principles 
The cost principles associated with transportation services were described in detail in the 
CMCS Informational Bulletin, Applicable Federal Cost Principles for Ground Emergency 
Medical Transportation (GEMT).59  While the guidance provided herein addresses 
transportation generally (not limited to ground emergency medical transportation), the 
federal regulations associated with cost identification are the same.   
 
In order to be approved, as required by regulations at 42 C.F.R  430.10 and  447.201 and 
as described in the above referenced informational bulletin, a SPA must comprehensively 
describe payment methodologies and contain all information necessary for CMS to determine 
whether it can be approved to serve as a basis for FFP.  The regulations further require that a 
state plan describe the policies and methods to be used to set payment rates for each type of 
service included in the states Medicaid program.  Accordingly, for an allowable cost 
identification methodology that includes an interim payment methodology with cost 
reconciliation, a payment SPA must comprehensively describe the cost identification and 
 
 
58 Internal Revenue Service Standard Mileage Rates: https://www.irs.gov/tax-professionals/standard-mileage-rates.   
59 CMCS Informational Bulletin Applicable Federal Cost Principles for Ground Emergency Medical Transportation 
(GEMT).  Aug.  17, 2022.  https://www.medicaid.gov/federal-policy-guidance/downloads/cib08172022.pdf.  
32  Medicaid Transportation Coverage Guide 
 
reconciliation methodology that will be used to determine interim and final payments to 
providers.  Such a transportation payment SPA must describe:  
 
  The interim rate that will be paid to providers during the cost reporting period;  
  The allowable direct and indirect costs associated with furnishing Medicaid-covered 
transportation services;  
  The cost identification and allocation processes used to determine the portion of 
provider costs claimed for Medicaid payment; and  
  The procedures and timing for cost report completion and submission, and cost 
reconciliation with the providers. 
For activities beyond the transportation of a beneficiary to a covered service, states will be 
required to develop allocation statistics to account for the time the driver of a vehicle spent 
driving to or from the beneficiarys location as well as the time spent waiting for the 
appointment to be completed.  States could use mileage as a statistic in this instance to 
allocate a portion of the allowable costs of the unloaded mileage, and could use time, 
collected through a worker log, to identify the amount of time spent on site with the patient in 
order to create reasonable allocation statistics, if the state chooses to pursue including these 
activities in the overall reconciled cost methodology.  Please refer to the section below titled  
Flexibilities for Coverage of Wait Times and Long Distances for an additional option for 
states. 
 
As always, the states cost identification procedures and associated state-developed cost 
report templates and instructions must be consistent with federal cost allocation regulations 
under 45 C.F.R. part 75.  CMS reviews the states cost report template and instructions prior 
to approving proposed SPAs to ensure that they are consistent with the applicable federal 
cost regulations; however, it is incumbent upon states to ensure that reported costs and 
associated claims for FFP are accurate and represent only costs associated with the provision 
of Medicaid-covered services.  Costs that are claimed improperly may be subject to federal 
financial reviews and/or audit findings and place states at financial risk of liability to repay 
the federal share of any identified overpayments. 
 
To properly allocate transportation costs to the Medicaid program, states must rely on data 
that appropriately apportion costs to the Medicaid transportation cost objective, and then 
allocate only those transportation costs to the Medicaid program according to the Medicaid 
program's share of the provider's total services - that is, allocate only the proportion of the 
providers activities that benefitted the Medicaid program.  Federal regulations at 42 C.F.R.  
431.107(b) require that [a] State plan must provide for an agreement between the Medicaid 
agency and each provider or organization furnishing services under the plan in which the 
provider or organization agrees to: (1) Keep any records necessary to disclose the extent of 
services the provider furnishes to beneficiaries; (2) On request, furnish to the Medicaid 
agency, the Secretary, or the state Medicaid fraud control unit (if such a unit has been 
approved by the Secretary under  455.300 of this chapter), any information maintained 
under paragraph (b)(1) of this section and any information regarding payments claimed by 
the provider for furnishing services under the plan[.] CMS has advised states to use such 
relevant documentation in assigning costs to Medicaid for cost-based payment 
methodologies.  For instance, localities that operate NEMT providers and wish to claim 
33  Medicaid Transportation Coverage Guide 
 
payment from payers, including Medicaid payment, must gather claims data by payer status 
for all individuals who receive NEMT services from the locality-operated provider during the 
cost reporting period. 
 
Additionally, documentation of transportation services is useful not only when billing for 
services, but also in the event that an audit takes place.  Consistent with 42 C.F.R.  
433.32(a), states must maintain an accounting system and supporting fiscal records to assure 
that claims for federal funds are made in accordance with applicable federal requirements.  
The main goals of documentation are to support that submitted claims represent necessary 
transportation furnished to a beneficiary to transport the beneficiary to and/or from covered 
services.  To meet these goals, records should be accurate and complete. 
 
NEMT Cost Sharing 
Cost sharing is permitted for NEMT only if covered as an optional medical service under the 
state plan, consistent with all applicable federal requirements for cost sharing for covered 
services.  Any Medicaid cost sharing assessed must be nominal and comply with 
requirements at sections 1916 and 1916A of the Act and regulations at 42 C.F.R.  447.50-
57, including mandatory exempted populations.  Providers may not deny services to an 
eligible individual on account of the individuals inability to pay the cost sharing, unless the 
individual has family income above 100 percent of the Federal Poverty Level (FPL) and the 
individual is not part of an exempted group, as described at 42 C.F.R.  447.52(e)(1).  
Additionally, Medicaid cost sharing and premiums incurred by all individuals in the 
Medicaid household may not exceed an aggregate limit of 5 percent of the family's income 
pursuant to 42 C.F.R.  447.56(f).  Cost sharing is not permitted for NEMT claimed as an 
administrative activity.60 
 
Payment for Transportation During Retroactive Eligibility Periods 
States must process and pay claims for covered services received by a beneficiary who is 
found eligible during the retroactive eligibility period, including for necessary transportation, 
regardless of whether transportation is furnished as an administrative activity or as a medical 
service.  This requirement includes scenarios for which services have already been paid.  
Operationalizing this process may require the provider to first return any money collected 
from the beneficiary/family and then submit a claim to the state for the unpaid service.  No 
payment is required when the transportation is available without cost to the beneficiary, such 
as from family, friends, or other public agencies.   
 
Costs that are Not Part of Medicaid Transportation* 
The cost of transportation for a provider of medical services, such as a paid personal care 
attendant, case managers or nurses conducting home visits, or a provider traveling to a rural 
area, is not coverable under the assurance of transportation.61  Transportation is only 
available to assist a beneficiary who has no other means of transportation to access a medical 
service.   
 
 
60 Under sections 1902(a)(14), 1916 and 1916A of the Act, Medicaid cost sharing is only permitted for services 
covered under the state plan.  Administrative activities are not a coverable Medicaid service and therefore cost 
sharing is not authorized. 
61 Depending on the 1905(a) benefit, these costs may be able to be factored into rates for particular services. 
34  Medicaid Transportation Coverage Guide 
 
 
State employees using their private vehicle to provide transportation to beneficiaries can be a 
Medicaid-covered activity.  If the beneficiary is being transported for more than one reason, 
then there must be an allocation of the transportation cost to assure that the Medicaid agency 
is paying only for the portion of the transportation expenditure allocable to transportation to a 
Medicaid-covered service.  States paying for necessary transportation as an administrative 
activity in this scenario may claim FFP at the 50% administrative activity rate for a payment 
made directly to the employee for transportation provided to the beneficiary to access 
covered Medicaid services.   
 
FFP is not available for the advance of capital funds to providers for the purchase of 
transportation vehicles.  Under section 1903(a) of the Act, FFP is limited to expenditures 
specifically authorized by Title XIX for medical assistance and administrative activities 
necessary for the proper and efficient administration of the plan.  Advanced funds for the 
purchase of capital assets is not within the definition of a covered medical assistance service 
or an allowable administrative activity.  States may consider the costs of capital assets 
properly attributable to Medicaid-covered services and administrative activities in 
determining payment methodologies and rates for necessary transportation. 
Public Transit Agencies 
Public transit agencies are often utilized in state Medicaid transportation programs and 
recognized as one of the least costly options.  State departments of transportation (DOTs) and 
Medicaid agencies should explore partnerships to better serve the Medicaid population.62  This 
section clarifies the requirements related to the identification of the least costly and most 
appropriate transportation and public transit costs, to ensure states and other interested parties 
understand when and how public transit agencies may be used to provide transportation to 
beneficiaries. 
 
Americans with Disabilities Act (ADA) Paratransit*  
As noted previously, the assurance of transportation to Medicaid providers is not a 
requirement to pay for a ride but rather a requirement to ensure that every beneficiary, 
regardless of support needs, or travel distance, is able to access transportation to Medicaid 
providers to receive covered services.  If using paratransit, states should ensure that the 
paratransit agency provides sufficient reliability and timeliness to allow Medicaid 
beneficiaries to access Medicaid providers and receive covered services.  
 
The ADA requires public transit agencies that provide fixed route services to provide 
complementary paratransit services to people with disabilities when these individuals 
cannot use the fixed route bus or rail service because of their disability.  However, states 
should ensure that the fiscal burden of transporting beneficiaries is not unfairly placed on 
paratransit services.  Recognizing the higher costs of operating a paratransit system, 
Medicaid may pay more than the rate charged to individuals with disabilities for a paratransit 
 
 
62 States should consider how public providers and Medicaid agencies can work together to understand transit and 
Medicaid policies and definitions. 
35  Medicaid Transportation Coverage Guide 
 
ride.  The rate paid for paratransit trips must represent a reasonable amount and be no more 
than the rate paid for similar paratransit trips paid by other state human services agencies.   
 
Fixed Route Public Transit* 
States may set rates for transportation services in a manner that is determined to be economic 
and efficient to enlist enough providers so that care and services are available to Medicaid 
beneficiaries in the same manner as they are available to the general population (section 
1902(a)(30)(A) of the Act) or necessary for the proper and efficient operation of the state 
plan (section 1903(a)(7) of the Act), as applicable.  Other third-party payers (for example, 
state human service agencies) often cover and pay for similar trips for their clients but 
generally pay the same amount that the public is charged for these rides.  States using fixed 
route public transit for the provision of Medicaid should not include payment for:  
  public fixed route transportation at a rate that is more than the rate charged to the 
general public; and 
  ADA paratransit and demand response at a rate that is more than the rate charged to 
any other state human services agencies for comparable services.   
The state Medicaid agency is only required to pay for necessary transportation when the 
beneficiary has no other means to access a covered service.  Thus, when there are other non-
Medicaid resources available to assist the beneficiary, then the Medicaid program is not 
required to pay for a ride. 
 
Public Transit Passes* 
States may utilize public transit passes and claim FFP for the cost of bus, rail, ferry, or other 
public transit passes as long as the cost of the pass is consistent with section 1902(a)(30)(A) 
or section 1903(a)(7) of the Act, as applicable, as discussed above.  As described in a 
December 26, 1996, SMDL letter titled Non-emergency Transportation,63 determination of 
cost effectiveness requires that the cost of the public transit pass for the individual be no 
more than the cost of other payment methods for the trips.  The costs of the public transit 
pass (whether monthly or other basis) must, therefore, be compared to the cost of single trips 
the beneficiary would make to Medicaid providers to obtain medical service.  The cost of a 
monthly public transit pass should not exceed the cost of the individual trips taken during 
that month.   
 
For example, the cost of a public transit pass where a beneficiary lives is $40 per month for 
unlimited rides or $10 for each round trip.  If the beneficiary has four scheduled medical 
appointments, during the month for which transportation was needed (and the appointments 
were verified as being scheduled), the total cost for the individual trips would also be $40 
($10 x 4=$40).  In this scenario, the cost of the public transit pass would not be greater than 
the cost of the individual rides taken that month so the public transit pass would be an 
economic and efficient means to ensure necessary transportation for the beneficiary to access 
covered services for that month.  Whether the beneficiary uses the pass for non-medical-
related trips would not be relevant because the cost of the individually purchased trips to and 
from covered services was not less than the cost of the pass.  This applies to all modes of 
public transit whether it is a bus, rail, ferry, or other public transit.   
 
 
63 https://www.medicaid.gov/Federal-Policy-Guidance/downloads/Non-EmergencyTransportation.pdf.   
36  Medicaid Transportation Coverage Guide 
 
 
Coordination of Transportation* 
State Medicaid agencies and public transit agencies have opportunities to partner and 
dialogue about transportation on an ongoing basis to further collective understanding and 
help to serve beneficiaries who will utilize public transit to access Medicaid services and 
care.  State Medicaid agencies may participate in efforts to coordinate the use of 
transportation resources as long as those efforts recognize the Medicaid programs 
responsibility is limited to ensuring necessary transportation for beneficiaries to and from 
covered services.  NEMT services may be provided through a brokerage program under 
contract with individuals or entities selected through a competitive bidding process (as 
specified in the broker rules at 42 C.F.R.  440.170(a)(4)).  States may utilize public transit 
agencies to coordinate NEMT in order to provide the services more efficiently and cost 
effectively as long as there is no conflict with the polices and rules of the Medicaid program.  
As such, public transit agencies must be selected through a competitive bidding process.   
 
It is important to note that Medicaid is the payer of last resort.  In terms of financing, 
Medicaid is not responsible for the general operation or deficit financing of public or private 
transportation programs or providers.  Federal funds may not be used as the non-federal share 
of Medicaid expenditures unless there is express authority under federal law for the federal 
funds to be used as the non-federal Medicaid share.  Medicaid may be used to pay for a ride 
but may not be used to purchase or subsidize the transportation infrastructure (e.g., purchase 
a vehicle).  Medicaid-paid transportation should only be used when there are no other means 
for the beneficiary to be transported to their medical appointment.  For additional 
information, please refer to the section Costs that are Not Part of Medicaid Transportation. 
SPA Content Requirements  
Regulations at 42 C.F.R.  430.10 describe the state plan as a comprehensive written statement 
submitted by the state Medicaid agency describing the nature and scope of its Medicaid program.  
The state plan contains all the information necessary for CMS to determine whether the plan can 
be approved to serve as a basis for FFP.  When a state is planning to make a change to its 
program policies or operational approach, states send SPAs to CMS for review and approval.  
The following are descriptions of what is needed in the state plan.   
Transportation State Plan Pages* 
The state plan pages describe, in sufficient level of detail, the methods the state will employ 
to ensure necessary transportation.  Current federal guidelines related to the assurance of 
transportation require the state plan to: 
 
  Specify that the Medicaid agency will ensure necessary transportation for 
beneficiaries to and from providers of covered services and describe the methods that 
the agency will use to meet this requirement (42 C.F.R.  431.53); 
  Effectively inform all EPSDT eligible individuals (or their families) that necessary 
transportation and scheduling assistance under EPSDT is available upon request and 
provide necessary assistance with transportation when requested (section 1905(r) of 
the Act and 42 C.F.R.  441.62); 
  Identify how the state will pay for necessary transportation; and 
37  Medicaid Transportation Coverage Guide 
 
  Include the section 1902(a)(87) of the Act required provider and driver attestations.   
 
The items below describe where these descriptions are typically located in the state plan. 
 
Attachments 3.1-A and 3.1-B  
If states elect to claim NEMT or EMT as an optional medical service, all the requirements at 
42 C.F.R.  440.170, as well as comparability, statewideness, and freedom of choice, would 
apply.  As with all optional medical services, states are to describe the amount, duration, and 
scope of services on the 3.1-A/3.1-B pages.  The state may include operational limitations 
and parameters, such as describing when air travel may be considered, but any limitations 
must be reasonable in meeting the needs of the beneficiary and cannot be so restrictive as to 
conflict with the state's responsibility to assure transportation.   
 
Attachment 3.1-D Page(s) - Methods of Transportation  
States should list on the state plan 3.1-D pages the transportation delivery model for both 
NEMT and EMT.  These pages describe, in a logical flow, the types of transportation 
provided and how they are made available to beneficiaries, the types of providers (e.g., a 
broker, vendor(s), managed care plan(s), or private contracted or independent network of 
drivers) that provide the service, and any combination of providers that will be used.  These 
pages essentially provide the narrative story of how the state assures and ensures 
transportation.  Detail must be sufficient to understand what the state Medicaid program 
offers to beneficiaries as options for transportation when a ride is needed.  If transportation is 
provided under managed care authority or under section 1115 demonstration authority, a 
general description should be included in the 3.1-D pages, but content should also indicate 
where precisely to look by referencing those approved authorities for more detailed 
information on how transportation is provided through the authorities other than the state 
plan.   
 
These pages also describe how the state will claim for expenditures for transportation, 
whether it will be an administrative activity, medical service, or both.  States are to clearly 
describe the delivery model used to assure transportation to and from services on the 3.1-D 
page.  The state may contract with individuals, corporations, taxicab, bus companies, airlines, 
etc. to provide transportation to eligible individuals. 
 
Attachment 3.1-D Page - Section 1902(a)(87) Attestation  
Section 1902(a)(87) of the Act, requiring the Medicaid state plan to provide for a mechanism 
that may include an attestation that ensures any provider, including transportation network 
companies and individual drivers, meet specific minimum requirements.  States must include 
an attestation that all the minimum requirements outlined in section 1902(a)(87) of the Act 
are met on the 3.1-D page.64  This attestation is usually a separate page as part of the state 
plan 3.1-D pages.  Specifically, states must attest that they ensure any provider (including a 
transportation network company or individual driver) of NEMT to medically necessary 
services receiving payments under the plan (but excluding any public transit authority) meets 
specified minimum requirements that: 
 
 
64 https://www.medicaid.gov/federal-policy-guidance/downloads/cib071221.pdf. 
38  Medicaid Transportation Coverage Guide 
 
 
  Each provider and individual driver are not excluded from participation in any federal 
health care program (as defined in section 1128B(f) of the Act) and are not listed on 
the exclusion list of the HHS Inspector General; 
  Each such individual driver has a valid drivers license; 
  Each such provider has in place a process to address any violation of a state drug law; 
and 
  Each such provider has in place a process to disclose to the state Medicaid program 
the driving history, including any traffic violations, of each such individual driver 
employed by such provider. 
 
Attachment 4.19-B Page(s) 
As with all other benefits in the state plan, states must provide detail on provider payments.  
This includes the rate methodology as well as the cost reporting methodology, as applicable, 
for transportation services as described in the 3.1-A and 3.1-B pages.   
 
Please note that prior to this Coverage Guide, in the case of a state plan broker that is 
operating under regulations at 42 C.F.R.  440.170(a)(4), payment of such broker was 
described in the coverage pages.  For new state plans submitted after issuance of this 
guidance, states are required to submit a comprehensive transportation methodology in the 
4.19-B pages to be consistent with non-broker transportation SPA pages.   
39  Medicaid Transportation Coverage Guide 
 
Appendix A: Additional Resources for Meeting the Needs of Medicaid Beneficiaries with 
Limited English Proficiency 
  National Standards for Culturally and Linguistically Appropriate Services (CLAS) in 
Health and Health Care: https://thinkculturalhealth.hhs.gov/clas.   
 
  CMS Guide to Developing a Language Access Plan to help providers consider the 
specific needs of individuals with limited English proficiency at 
https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/Language-
Access-Plan-508.pdf. 
 
  Introduction to Language Access Plans free training available to states and transportation 
providers to consider how best to meet the transportation and communication needs of 
individuals with limited English proficiency: https://www.cms.gov/outreach-and-
education/medicare-learning-network-mln/mlnproducts/webbasedtraining.  
40