MEDICAID

Efforts to Exclude 

Nonemergency 

Transportation Not 

Widespread, but 

Raise Issues for 

Expanded Coverage 

Report to Congressional Requesters

January 2016 

GAO-16-221 

United States Government Accountability Office 
United States Government Accountability Office

Highlights of GAO-16-221, a report to 

congressional requesters

January 2016

MEDICAID

Efforts to Exclude Nonemergency Transportation Not 

Widespread, but Raise Issues for Expanded Coverage

Why GAO Did This Study

Medicaid, a federal-state health 

financing program for certain lowincome individuals, offers NEMT 

benefits to individuals who are unable 

to provide their own transportation to 

medical appointments. This benefit can 

be an important safety net for program 

enrollees as research has identified the 

lack of transportation as affecting 

Medicaid enrollees’ access to services. 

Under PPACA, states can opt to 

expand eligibility for Medicaid to 

certain adults. However, some states 

have excluded the NEMT benefit for 

these newly eligible enrollees by 

obtaining a waiver of the requirement 

under the authority of a Medicaid 

demonstration project.

GAO was asked to explore state efforts 

to exclude the NEMT benefit for newly 

eligible Medicaid enrollees, and the 

potential implications of such efforts. 

This report examines (1) the extent to 

which states have excluded this benefit 

for newly eligible enrollees, and (2) the 

potential implications of such efforts on 

enrollees’ access to services. 

GAO contacted the 30 states that 

expanded Medicaid under PPACA as 

of September 30, 2015; reviewed 

relevant documents and interviewed 

officials in the 3 states that have taken 

efforts to exclude the NEMT benefit; 

reviewed prior research on 

transportation for disadvantaged 

populations; and interviewed officials 

from CMS, the federal agency that 

oversees Medicaid, and 10 research 

and advocacy groups based on 

referrals from subject-matter experts 

and knowledge of the NEMT benefit. 

HHS provided technical comments on 

a draft of this report, which GAO 

incorporated as appropriate.

What GAO Found

States’ efforts to exclude nonemergency medical transportation (NEMT) benefits 

from enrollees who are newly eligible for Medicaid under the Patient Protection 

and Affordable Care Act (PPACA) are not widespread. Of the 30 states that 

expanded Medicaid as of September 30, 2015, 25 reported that they did not 

undertake efforts to exclude the NEMT benefit for newly eligible enrollees, 3 

states reported pursuing such efforts, and 2 states—New Jersey and Ohio—did 

not respond to GAO’s inquiry. However, the Centers for Medicare & Medicaid 

Services (CMS), within the Department of Health and Human Services (HHS), 

indicated that neither New Jersey nor Ohio undertook efforts to exclude the 

NEMT benefit.

State-Reported Actions to Exclude Medicaid’s Nonemergency Medical Transportation (NEMT) 

Benefit for Newly Eligible Enrollees, September 2015

a

As part of Pennsylvania’s efforts to expand Medicaid, the state received approval to exclude the 

NEMT benefit for its newly eligible enrollees; however, the state did not implement this exclusion.

b

CMS provided information about New Jersey and Ohio’s efforts related to the NEMT benefit.

Two of the three states pursuing efforts to exclude the NEMT benefit—Indiana 

and Iowa—have received waivers from CMS to exclude the benefit, and are in 

different stages of evaluating the effect these waivers have on enrollees’ access 

to care.

• Indiana’s draft evaluation design describes plans to survey enrollee and

provider experiences to assess any effect from excluding the NEMT benefit.

• Iowa’s evaluation largely found comparable access between enrollees with

and without the NEMT benefit; however, it also found that newly eligible

enrollees beneath the federal poverty level tended to need more

transportation assistance or have more unmet needs than those with higher

incomes.

Officials from the groups that GAO interviewed identified potential implications of 

excluding the NEMT benefit, such as a decrease in enrollee access to services 

and an increase in the costs of coverage. For example, nearly all of the groups 

indicated that excluding the NEMT benefit would impede access to services, 

particularly for those living in rural areas, as well as those with chronic health 

conditions. 

View GAO-16-221. For more information, 

contact Carolyn L. Yocom at (202) 512-7114 

or yocomc@gao.gov or Mark L. Goldstein at 

(202) 512-2834 or goldsteinm@gao.gov. 
Page i GAO-16-221 Medicaid Nonemergency Transportation Access

Letter 1

Background 4

State Efforts to Exclude Medicaid NEMT Benefits Are Not 

Widespread 6

Two States are Evaluating Implications of Excluding NEMT; 

Researchers and Advocates Raised Concerns about Altering 

the Benefit 10

Agency Comments 17

Appendix I GAO Contact and Staff Acknowledgments 18

Figure

Figure 1: State-Reported Actions to Exclude Medicaid’s 

Nonemergency Medical Transportation (NEMT) 

Benefit for Newly Eligible Enrollees, September 2015 7

Abbreviations

CMS Centers for Medicare & Medicaid Services

FPL federal poverty level

HHS Department of Health and Human Services

NEMT nonemergency medical transportation

PPACA Patient Protection and Affordable Care Act

Contents

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. The published product may be reproduced and distributed in its entirety 

without further permission from GAO. However, because this work may contain 

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necessary if you wish to reproduce this material separately.
Page 1 GAO-16-221 Medicaid Nonemergency Transportation Access

441 G St. N.W.

Washington, DC 20548

January 15, 2016

The Honorable Ron Wyden

Ranking Member

Committee on Finance

United States Senate

The Honorable Frank Pallone, Jr.

Ranking Member

Committee on Energy and Commerce

House of Representatives

Recognizing the importance of transportation for many Americans’ access 

to needed medical services, states are required to provide through their 

Medicaid programs—a federal-state health financing program for certain 

low-income and medically needy individuals—a nonemergency medical 

transportation (NEMT) benefit to individuals who are unable to provide 

their own transportation to medical appointments. A lack of transportation 

can be a barrier to accessing health care, particularly among low-income 

populations. For example, we previously reported that Medicaid enrollees 

most commonly cited a lack of transportation as the reason for delaying 

care, and that the need for transportation to and from providers presented 

a barrier to children receiving Medicaid dental services.1 Other research 

reiterates the effect that a lack of transportation can have on access. For 

example, one study cited an estimate that approximately 3.6 million 

Americans miss or delay care because they lack appropriate 

transportation to reach their medical appointments.2 Another study noted 

that for poorer populations, which tend to encounter more barriers to 

accessing health care generally, transportation can be a significant issue 

 1

See GAO, Medicaid: States Made Multiple Program Changes, and Beneficiaries 

Generally Reported Access Comparable to Private Insurance, GAO-13-55 (Washington, 

D.C.: Nov. 15, 2012); and Medicaid: State and Federal Actions Have Been Taken to 

Improve Children’s Access to Dental Services, but Gaps Remain, GAO-09-723 

(Washington, D.C.: Sept. 30, 2009).

2

See National Conference of State Legislatures, Non-Emergency Medical Transportation: 

A Vital Lifeline for a Health Community, January 2015.

Letter
Page 2 GAO-16-221 Medicaid Nonemergency Transportation Access

to accessing care.3 Given that transportation limitations can 

disproportionately affect low-income individuals’ access to medical 

services, Medicaid’s NEMT benefit can serve as an important safety net 

for program enrollees.

Under the Patient Protection and Affordable Care Act (PPACA), states 

can opt to expand eligibility for Medicaid to most non-elderly, nonpregnant adults who are not eligible for Medicare, and whose incomes 

are at or below 133 percent of the federal poverty level (FPL).4 The 

decision whether to expand Medicaid can be a complex consideration for 

states, involving competing interests, as well as decisions about the 

structure and content of states’ programs—such as the scope of benefits 

offered to newly eligible Medicaid enrollees. Although states are required 

to ensure necessary transportation to and from providers for newly 

eligible enrollees covered through their state plans, some states have 

received approval to expand Medicaid coverage through demonstration 

projects under section 1115 of the Social Security Act.5 Under this 

authority, states may obtain a waiver to exclude the NEMT benefit for 

 3

See J Community Health, Traveling Toward Disease: Transportation Barriers to Health 

Care Access, vol. 38, Issue 5 (October 2013), 976 – 993.

4

PPACA also imposes a 5 percent income disregard when calculating modified adjusted 

gross income, which, in effect, raises this income limit to 138 percent of the FPL. 

5

A Medicaid state plan is an agreement between a state and the federal government 

describing how that state administers its Medicaid program. When a state wishes to make 

a change to its program policies or operational approach, it may submit a state plan 

amendment that is reviewed for approval by CMS.
Page 3 GAO-16-221 Medicaid Nonemergency Transportation Access

newly eligible enrollees.6 As of September 2015, 30 states had expanded 

Medicaid eligibility, some through demonstrations.7

Given that states are making decisions about whether to expand 

Medicaid and how to structure their programs, you asked us to explore 

state efforts to exclude the NEMT benefit for newly eligible Medicaid 

enrollees. This report examines

1. the extent to which states have undertaken efforts to exclude the 

NEMT benefit for newly eligible enrollees; and

2. what is known about the potential implications of excluding the NEMT 

benefit on newly eligible enrollees’ access to Medicaid services.

To examine the extent to which states have undertaken efforts to exclude 

the NEMT benefit for newly eligible enrollees, we interviewed officials 

from the Centers for Medicare & Medicaid Services (CMS) and contacted 

the 30 states that expanded Medicaid as of September 30, 2015. In the 

states that reported undertaking efforts to exclude the NEMT benefit, we 

interviewed Medicaid officials and reviewed relevant documents, including 

special terms and conditions associated with their demonstrations and 

related approval letters, if available.

To examine what is known about the potential implications of excluding 

the NEMT benefit on newly eligible enrollees’ access to Medicaid 

services, we reviewed states’ waiver evaluation designs, methodologies, 

and any related reports. Additionally, we evaluated the methodology that 

one state used in its evaluation of the effect of excluding NEMT for newly 

 6

States that wish to alter their Medicaid programs in ways that depart from federal 

requirements may seek approval to implement Medicaid demonstration projects under 

section 1115 of the Social Security Act. This provision authorizes the Secretary of Health 

and Human Services (HHS) to waive certain federal Medicaid requirements and allow 

costs that would not otherwise be eligible for federal matching funds for experimental, 

pilot, or demonstration projects that, in the Secretary’s judgment, are likely to assist in 

promoting Medicaid objectives. See 42 U.S.C. § 1315(a). For example, states may seek a 

waiver of Medicaid’s NEMT regulation, which requires state plans to ensure necessary 

transportation for beneficiaries to and from providers. See 42 C.F.R. § 431.53. In this 

report, we use the term “demonstration” to refer to state demonstration projects authorized 

by CMS under section 1115, whereas we use the term “waiver” when referring to waivers 

of the NEMT requirement under such a demonstration.

7

For purposes of this report, “state” includes the District of Columbia. Montana has also 

opted to expand Medicaid, but its expansion does not go into effect until January 1, 2016.
Page 4 GAO-16-221 Medicaid Nonemergency Transportation Access

eligible Medicaid enrollees. We also interviewed CMS officials regarding 

their oversight of these states’ efforts, including their role in assessing 

and approving them. In addition, based on referrals from subject-matter 

experts and knowledge of the organizations’ roles related to Medicaid’s 

NEMT benefit, we identified 10 national and local research and advocacy 

groups to interview, which included groups offering enrollee, underserved 

population, and provider perspectives on changes to the NEMT benefit. 

We also reviewed GAO and other research on transportation services for 

disadvantaged populations, and the role of transportation in the Medicaid 

expansion population’s efforts to obtain health care services.

We conducted this performance audit from June 2015 to January 2016 in 

accordance with generally accepted government auditing standards. 

Those standards require that we plan and perform the audit to obtain 

sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that 

the evidence obtained provides a reasonable basis for our findings and 

conclusions based on our audit objectives.

Within the Department of Health and Human Services (HHS), CMS is 

responsible for overseeing Medicaid at the federal level, while states are 

responsible for the day-to-day operations of their Medicaid programs. 

Under section 1115 of the Social Security Act, the Secretary of HHS may 

waive certain Medicaid requirements to allow states to implement 

demonstrations through which states can test and evaluate new 

approaches for delivering Medicaid services that, in the Secretary’s 

judgment, are likely to assist in promoting Medicaid objectives.8 Prior to 

the enactment of PPACA, states that wanted to expand Medicaid 

coverage to childless adults could do so only under a demonstration. 

While states may now expand their programs to cover these individuals 

through a state plan amendment, some states have expanded coverage 

under demonstrations in order to tailor coverage for this group in a 

manner that differs from what federal law requires. For example, states 

are not permitted to exclude coverage of mandatory benefits, such as 

 8

See 42 U.S.C. § 1315(a). Generally, demonstrations are approved for an initial 5-year 

period and can be extended for additional years.

Background
Page 5 GAO-16-221 Medicaid Nonemergency Transportation Access

NEMT, under their state plans, but they may do so by obtaining a waiver 

of the requirement under a demonstration.9

Recently, the Secretary of HHS approved various states’ demonstrations 

to test alternative approaches, such as allowing states to use Medicaid 

funds to provide newly eligible enrollees with premium assistance to 

purchase private health plans in their respective state marketplace, or to 

exclude from coverage certain mandatory Medicaid benefits, such as 

NEMT, for newly eligible enrollees.10 CMS has required those states that 

have obtained approval to exclude the NEMT benefit for one year under a 

demonstration to submit annual evaluations on the effect of this change 

on access to care, which will inform the agency’s decision to approve any 

extension requests.

Evaluations by research organizations identified the lack of transportation 

as a barrier to care that can affect costs and health outcomes. For 

example, a survey of adults in the National Health Interview Survey found 

that limited transportation disproportionally affected Medicaid enrollees’ 

access to primary care.11 A study by the Transportation Research Board 

found that individuals who miss medical appointments due to 

transportation issues could potentially exacerbate diseases, thus leading 

to costly subsequent care, such as emergency room visits and 

 9

While state plans may not exclude coverage of NEMT services, states may place 

appropriate limits on a service based on such criteria as medical necessity or on utilization 

control procedures. See 42 C.F.R. § 440.230(d). For example, CMS approved a state plan 

amendment in Arkansas that requires most newly eligible Medicaid enrollees to obtain 

prior authorization after eight NEMT trips. According to Arkansas officials, after the eighth 

trip, such enrollees must call into the designated NEMT contractor and answer a series of 

questions to demonstrate their need for transportation. This prior authorization 

requirement does not apply to newly eligible Medicaid enrollees that are deemed 

medically frail, which account for about 10 percent of the state’s newly eligible enrollees, 

according to Arkansas officials. States have some flexibility to define who is medically frail; 

however, they must, at a minimum, include individuals who have (1) disabling mental 

disorders; (2) chronic substance use disorders; (3) serious and complex medical 

conditions; (4) a disability determination based on Social Security criteria or more 

restrictive state criteria, if applicable; or individuals (5) who are described in 42 C.F.R. § 

438.50(d)(3), such as those who are dually eligible. 42 C.F.R. 440.315(f).

10Marketplaces are a single point-of-access for individuals to enroll in private health 

insurance plans and apply for income-based financial assistance.

11Cheung, P., J. Wiler, R. Lowe, A. Ginde, “National Study of Barriers to Timely Primary 

Care and Emergency Department Utilization Among Medicaid Beneficiaries,” Annals of 

Emergency Medicine (July 2012).
Page 6 GAO-16-221 Medicaid Nonemergency Transportation Access

hospitalizations.12 We also previously reported that there are many 

federal programs, including Medicaid, that provide the NEMT benefit to 

the transportation-disadvantaged population.13 However, in this work we 

found that coordination of NEMT programs at the federal level is limited, 

and there is fragmentation, overlap, and the potential for duplication 

across NEMT programs. As a result, individuals who rely on these 

programs may encounter fragmented services that are narrowly focused 

and difficult to navigate, possibly resulting in NEMT service gaps.14

Among the 30 states that expanded Medicaid as of September 30, 2015, 

25 reported that they did not undertake efforts to exclude the NEMT 

benefit for newly eligible Medicaid enrollees and were not considering 

doing so.15 Three states reported pursuing such efforts, and two states 

did not respond to our inquiry, although CMS indicated that neither of 

these states undertook efforts to exclude the NEMT benefit. (See fig. 1.)

12Transit Cooperative Research Program, Cost Benefit Analysis of Providing NonEmergency Medical Transportation, October 2005, accessed on September 15, 2015, 

http://onlinepubs.trb.org/onlinepubs/tcrp/tcrp_webdoc_29.pdf. 

13The transportation-disadvantaged population generally includes those individuals who 

cannot provide their own transportation due to age, disability, or income constraints.

14For example, see GAO, Transportation Disadvantaged Populations: Nonemergency 

Medical Transportation Not Well Coordinated, and Additional Federal Leadership Needed, 

GAO-15-110 (Washington, D.C.: Dec. 10, 2014); and Transportation Disadvantaged 

Populations: Federal Coordination Efforts Could be Further Strengthened, GAO-12-647 

(Washington, D.C.: June 20, 2012).

15As part of Pennsylvania’s efforts to expand Medicaid under a demonstration, the state 

received approval to exclude the NEMT benefit for its newly eligible enrollees; however, 

the state ultimately did not implement this waiver. Thus, newly eligible enrollees remained 

eligible for the NEMT benefit. 

State Efforts to 

Exclude Medicaid 

NEMT Benefits Are 

Not Widespread
Page 7 GAO-16-221 Medicaid Nonemergency Transportation Access

Figure 1: State-Reported Actions to Exclude Medicaid’s Nonemergency Medical 

Transportation (NEMT) Benefit for Newly Eligible Enrollees, September 2015

a

As part of Pennsylvania’s efforts to expand Medicaid under a demonstration, the state received 

approval to exclude the NEMT benefit for its newly eligible enrollees; however, the state ultimately did 

not implement this waiver. Thus, newly eligible enrollees remained eligible for the NEMT benefit.

b

Although we did not receive responses from New Jersey and Ohio, the Centers for Medicare & 

Medicaid Services provided information about these states’ efforts related to the NEMT benefit.

Three states (Indiana, Iowa, and Arizona) reported undertaking efforts to 

exclude the NEMT benefit under a demonstration as part of a broader 

health care initiative to expand Medicaid in their respective states. 

However, only Indiana and Iowa had received approval from HHS for 

these waivers as of September 30, 2015, while Arizona was still seeking 

approval.

• Indiana: Indiana’s effort to exclude the NEMT benefit from coverage

pre-dates PPACA and is not specific to newly eligible enrollees under

the state’s expansion. Beginning in February 2015, Indiana expanded

Medicaid under a demonstration that provides two levels of coverage

for newly eligible enrollees, depending on their income level and

payment of premiums. As part of this demonstration, the state

received approval to exclude the NEMT benefit for newly eligible
Page 8 GAO-16-221 Medicaid Nonemergency Transportation Access

enrollees. Indiana’s efforts to implement its Medicaid expansion are 

based, in part, on another demonstration that the state has had in 

place since 2008.16 Under this older demonstration, which provided 

authority for the state to offer Medicaid coverage to certain uninsured 

adults, NEMT was not a covered benefit for this population.

• Iowa: Iowa expanded Medicaid in response to PPACA through two 

demonstrations beginning in January 2014. Under these 

demonstrations, the state offers two separate programs for newly 

eligible enrollees: one that offers Medicaid coverage administered by 

the state to enrollees with incomes up to 100 percent of the FPL, and 

a second that offers premium assistance to purchase private 

coverage through the state’s health insurance marketplace for those 

enrollees with incomes from 100 to 133 percent of the FPL.17 For both 

of these demonstrations, the state received approval to exclude the 

NEMT benefit. Similar to Indiana, Iowa’s effort to exclude the NEMT 

benefit for a portion of its Medicaid population pre-dates PPACA. In 

July 2005, Iowa expanded Medicaid to certain populations under a 

demonstration with limited benefits that did not include NEMT.18

• Arizona: When Arizona expanded Medicaid in January 2014, it had 

not sought to exclude the NEMT benefit for newly eligible enrollees. 

However, when the state submitted a request on September 30, 2015, 

to extend its longstanding demonstration, it sought approval to 

 16Indiana’s Medicaid expansion is called the Healthy Indiana Plan (HIP) 2.0—which is 

based, in part, on a previous section 1115 demonstration called HIP 1.0. While HIP 1.0 

covered certain health services, it did not offer the NEMT benefit to enrollees. 

17Iowa’s Medicaid expansion is called the Iowa Health and Wellness Plan. Within this 

program, enrollees with incomes under 100 percent of the FPL are enrolled in the 

Wellness Plan, and enrollees with incomes from 101 to 138 percent of the FPL are 

enrolled in the Marketplace Choice Plan. Because there is only one health plan 

participating in the program, Marketplace Choice enrollees, as of December 2014, are no 

longer required to enroll in premium assistance as a condition of eligibility, but may 

choose to participate in the Wellness Plan. 

18Iowa’s 2005 demonstration—called IowaCare—provided Medicaid coverage for 

individuals aged 19 through 64 with incomes up to 200 percent of the FPL and pregnant 

women with incomes up to 300 percent of the FPL who have incurred medical expenses 

that reduced their income to 200 percent of the FPL. This demonstration also required 

enrollees to obtain services from certain provider networks.
Page 9 GAO-16-221 Medicaid Nonemergency Transportation Access

exclude the NEMT benefit.19 Arizona’s proposed extension would 

require newly eligible adults, including those with incomes from 100 to 

133 percent of the FPL, to enroll in a new Medicaid program that 

includes enrollee contributions into an account that can be used for 

non-covered services and an employment incentive program.20 The 

proposed extension, including the request to exclude the NEMT 

benefit, was under review, as of November 2015.

Officials from these three states cited several reasons for their efforts to 

exclude the NEMT benefit, including a desire to align Medicaid benefits 

with private insurance plans, which typically do not cover this benefit.

• Indiana officials indicated that when the state initially developed its 

demonstration in 2008, they designed benefits for a low-income 

population that tended to be employed. Thus, under that 

demonstration they offered benefits that resembled private insurance 

in an effort to familiarize enrollees with private coverage. This 

experience largely influenced the state’s decision under its current 

demonstration to exclude the NEMT benefit for newly eligible 

enrollees.

• Iowa officials reported that when the state expanded Medicaid, they 

wanted Medicaid benefits to look like a private insurance plan—with 

the hope of limiting disruptions in service as fluctuations in income 

could result in changes to enrollees’ coverage.

• While Arizona officials also cited the state’s intent to align Medicaid 

benefits with private health insurance, they also noted that excluding 

the NEMT benefit would be one way to contain costs.

 19Since 1982, Arizona has offered Medicaid coverage through a demonstration that 

established the Arizona Health Care Cost Containment System. This demonstration 

allowed Arizona to mandate managed care, provide long term care services in home and 

community-based settings, and implement administrative simplifications, among other 

things. It is scheduled to expire on September 30, 2016. 

20Arizona’s demonstration application specifically excludes from the NEMT benefit waiver 

individuals with a serious mental illness, American Indians and Alaska Natives, individuals 

who are medically frail (to be defined through discussion with CMS), and individuals who 

serve as caregivers to an individual who is elderly or disabled. Similarly, Indiana’s and 

Iowa’s approved waivers of the NEMT benefit exempt individuals that the states define as 

medically frail. 
Page 10 GAO-16-221 Medicaid Nonemergency Transportation Access

Of the remaining 25 Medicaid expansion states, 14 offered reasons for 

why they did not exclude the NEMT benefit for newly eligible enrollees.21

• Officials from 8 states reported they did not pursue such efforts 

because they considered the NEMT benefit critical to ensuring 

enrollees’ access to care.

• Officials from an additional 4 states reported that they wanted to align 

benefits for the newly eligible enrollees with those offered to enrollees 

covered under the traditional Medicaid state plan.

• Officials from 2 other states reported that the newly eligible Medicaid 

enrollees did not significantly increase their program enrollment, and 

therefore, there was no need to alter this benefit.

The two states that excluded the NEMT benefit are in different stages of 

completing required evaluations of the effect of this exclusion on access 

to care. Research and advocacy groups indicated that excluding the 

NEMT benefit could affect enrollees’ access to services and costs of 

coverage, and could set a precedent for the Medicaid program moving 

forward.

 21While we did not specifically ask officials in these 25 states for the reasons that they did 

not seek to exclude the NEMT benefit for newly eligible Medicaid enrollees, 14 states 

offered reasons for their decisions to maintain the benefit. 

Two States are 

Evaluating

Implications of 

Excluding NEMT; 

Researchers and 

Advocates Raised 

Concerns about 

Altering the Benefit
Page 11 GAO-16-221 Medicaid Nonemergency Transportation Access

The two states that obtained approval to exclude the NEMT benefit for 

newly eligible Medicaid enrollees—Indiana and Iowa—are at different 

stages of evaluating the effect this will have on enrollees and have 

different time frames for reporting their results. Indiana officials indicated 

that the state is currently working with CMS on the design of its evaluation

and must submit results to CMS by February 29, 2016.

22 According to a 

draft of the evaluation design, the state plans to survey enrollees and 

providers to compare the experiences of Medicaid enrollees with and 

without the NEMT benefit with respect to missed appointments, 

preventative care, and overall health outcomes; the state also seeks to 

determine whether enrollees residing in certain parts of the state are 

more affected by a lack of this benefit.23

Similarly, Iowa, which excluded the NEMT benefit for all newly eligible 

enrollees beginning in January 2014, was required to submit a series of 

independent analyses to CMS and recently received approval to continue 

its exclusion of this benefit until March 2016.24 The state conducted an 

analysis to determine whether newly eligible enrollees’ access to services 

was affected and reported its results in April 2015. Developed in close 

consultation with CMS, the analysis focused on the comparability of 

experiences of enrollees covered under the Medicaid state plan (who 

have the NEMT benefit) with newly eligible Medicaid expansion enrollees 

 22In working with the state, CMS recently approved a temporary extension of the NEMT

waiver through November 30, 2016.

23Indiana officials indicated that because the state had excluded the NEMT benefit for a 

segment of its Medicaid population since 2008 under its initial demonstration, it had 

already studied the effect that this waiver had on enrollees’ access to services. In a 2012 

survey conducted by researchers retained by the state, 800 enrollees were asked why 

they had not visited a doctor for a routine check-up in the last 12 months and 2.33 percent 

of respondents indicated that it takes too long to get there or they had a transportation 

problem in 2012.

24The state contracted with the University of Iowa, Public Policy Center to conduct this 

analysis. Researchers from the Public Policy Center indicated that they have worked with 

Iowa’s Department of Human Services on a number of evaluations for 25 years—and thus 

have developed expertise with the state’s Medicaid administrative claims and enrollment 

data. 

Evaluations of Efforts to 

Exclude the NEMT Benefit 

in Two States Assess 

Comparability of Access 

for Enrollees With and 

Without Benefit
Page 12 GAO-16-221 Medicaid Nonemergency Transportation Access

(who do not have the NEMT benefit).25 With such a focus, the analysis 

sought to determine whether excluding the NEMT benefit presented more 

of a barrier to obtaining services than an enrollee would have otherwise 

experienced under the state’s Medicaid state plan. Using enrollee 

surveys, the analysis found little difference in the barriers to care 

experienced by the two groups of enrollees as a result of transportationrelated issues.26 For example, the analysis noted that about 20 percent of 

enrollees in both groups reported usually or always needing help from 

others to get to a health care appointment.27 Additionally, the analysis 

identified comparability between both groups of enrollees in terms of their 

reported unmet need for transportation to medical appointments (about 

12 percent of both groups) and reported worry about the ability to pay for 

the associated costs (13 percent of both groups).

However, looking within the group of newly eligible enrollees without the 

NEMT benefit, the Iowa evaluation found that those with lower incomes—

under 100 percent of the FPL—tended to need more transportation 

assistance and have more unmet needs than those with higher incomes. 

For example,

 25Researchers from the Public Policy Center told us that they worked closely with CMS for 

6 months to develop the evaluation methodology, and although Iowa Medicaid officials 

were included in the meetings with CMS, they generally did not participate in the 

methodological discussions. Additionally, the researchers noted that under its contract 

with the state, the state is provided 30 days to review the Public Policy Center’s report for 

accuracy, but does not have the ability to edit the content.

For the results of Iowa’s evaluations, see The University of Iowa Public Policy Center, 

Evaluation of the Iowa Health and Wellness Plan, Member Experiences in the First Year

(April 2015); The University of Iowa Public Policy Center, Non-emergency Transportation 

Services for IHAWP Members: The Early Experiences of Iowa Health and Wellness Plan 

Members, A Policy Brief (March 2015); and The University of Iowa Public Policy Center, 

First Look at Iowa’s Medicaid Expansion: How Well Did Members Transition to the Iowa 

Health and Wellness Plan from IowaCare (October 2014).

26The Iowa analysis also included a geographical assessment of distance to primary care 

providers based on a geocoding/mapping technique. To compare Medicaid state plan 

enrollees and newly eligible enrollees with incomes under 100 percent of the FPL, 

enrollees in both groups with at least one claim for preventive care were mapped to the 

provider who provided this care, and those without a claim for services were mapped to 

the closest primary care provider. The results from this analysis indicate no practical 

difference in the distance to a primary care provider in miles or minutes between newly 

eligible enrollees and enrollees under the state plan. 

27Specifically, survey results indicated that about 20 percent of enrollees with the NEMT 

benefit and 22 percent of newly eligible enrollees without the NEMT benefit reported 

usually or always needing help from other sources to get to health care appointments. 
Page 13 GAO-16-221 Medicaid Nonemergency Transportation Access

• 25 percent of newly eligible enrollees with incomes under 100 percent 

of the FPL reported needing help with transportation, compared with 

11 percent of higher income newly eligible enrollees;

• 15 percent of newly eligible enrollees with incomes under 100 percent 

of the FPL reported an unmet need for transportation, compared with 

5 percent of higher income newly eligible enrollees; and

• 14 percent of newly eligible enrollees with incomes under 100 percent 

of the FPL reported that they worried a lot about paying for 

transportation, compared with 6 percent of higher income newly 

eligible enrollees that reported that they worried a lot about paying for 

transportation.

HHS recently approved Iowa’s amendment to continue its waiver of the 

NEMT benefit, although it noted concern about the lower income 

enrollees’ experience. In approving the state’s request, HHS cited the 

need for Iowa to continue evaluating the effects of the waiver in light of 

survey results on the type of transportation that newly eligible enrollees 

reported using to get to health care appointments. These results showed 

that newly eligible enrollees tended to rely on others, such as family and 

friends, to reach health care appointments more so than Medicaid state 

plan enrollees.28

Researchers who conducted the evaluation of Iowa’s program indicated 

that they plan to conduct additional analyses, which include some—but 

not all—of the suggestions we have offered.29 For example, our review of 

Iowa’s evaluation methodology suggests that linking survey responses 

from both groups of enrollees directly to their claims could improve the 

state’s understanding of enrollees’ patterns of utilization and the 

implications of transportation difficulties. The researchers indicated that 

they will link claims data with survey responses in the next evaluation and 

use regression modeling to determine which group of enrollees was more 

 28See HHS approval letter dated July 31, 2015.

29The researchers emphasized that the evaluation was not specific to the NEMT benefit, 

but was an evaluation of the impact of the state’s entire 1115 demonstration. The 

researchers acknowledged that if their focus was on the NEMT benefit, they may have 

structured the survey questions and analyses differently. They further noted that in their 

continued evaluation, keeping the questions similar to those asked previously will allow 

them to compare the results over time. 
Page 14 GAO-16-221 Medicaid Nonemergency Transportation Access

likely to have an unmet need due to transportation issues. Additionally, 

we noted that the small sample size could limit their ability to detect 

differences between the enrollees. The researchers indicated that their 

next evaluation will survey a larger sample of Medicaid enrollees covered 

under the state plan who have the NEMT benefit and newly eligible 

enrollees who do not in an effort to increase their ability to detect these 

differences. We agree that increasing the sample size could strengthen 

confidence in the results. We also noted that the researchers did not 

consider whether survey respondents lived in a rural or urban area, which 

can be important because research shows that the need to travel longer 

distances and the lack of public transportation in rural areas can pose 

challenges for individuals seeking services. The researchers indicated 

that they did not stratify the groups by rural or urban areas because of a 

concern about inadequate sample sizes in certain counties and because 

the need for transportation in Iowa is not unique to the pursuit of health 

care services, but also poses a challenge in other aspects of residents’ 

lives.30 While stratifying survey results by rural and urban areas could be 

relevant in evaluating enrollees’ access to care or unmet need, the 

researchers do not plan to include a rural and urban stratification in the 

next evaluation.31 CMS officials recognized the value of a rural and urban 

distinction, but indicated that there is a need to balance further analysis 

with the ability to generate results expeditiously and facilitate decision 

making on the waiver.

 30Additionally, the researchers noted that they are not considering stratifying results by 

rural and urban location, in part, because the evaluation is focused on whether there are 

any differences in experiences between the comparison groups and not on who is or is not 

receiving the NEMT benefit.

31The researchers indicated that they plan to survey about 30,000 enrollees, which will 

consist of those in the Medicaid state plan who have the NEMT benefit and the newly 

eligible who do not, and report the results to CMS in the spring of 2016. This is a larger 

sample than the previous survey, which consisted of 4,050 Medicaid state plan enrollees 

with the NEMT benefit and 6,750 enrollees without it. For the prior survey, 19 percent of 

the enrollees with the NEMT benefit responded to the survey, while 30 percent of 

enrollees without the NEMT benefit responded. 
Page 15 GAO-16-221 Medicaid Nonemergency Transportation Access

Officials from the 10 research and advocacy groups we interviewed—

which represent Medicaid enrollees, underserved populations, and health 

care providers—noted potential concerns of excluding the NEMT benefit 

as it relates to enrollee access to services and costs of coverage.

Access to Services: Officials from 9 of the 10 groups we interviewed 

indicated that excluding the NEMT benefit would impede newly eligible 

enrollees’ ability to access health care services, particularly individuals 

living in rural or underserved areas, as well as those with chronic health 

conditions.32 For example, officials from one national group that 

represents underserved populations indicated that the enrollees affected 

by the lack of the NEMT benefit will be those living in rural areas that 

must travel long distances for medical services. Another group that 

represents providers in Iowa also cited the difficulty faced by enrollees 

that live in rural areas by noting that some of the patients they served 

have had to cancel their medical appointments because the patients do 

not have a car, money to pay for gas, or access to public transportation. 

With respect to enrollees with chronic health conditions, one group that 

represents transportation providers (and others who support mobility 

efforts) noted that transportation can be a major barrier for individuals 

who are chronically ill and need recurring access to life-saving health 

services. Similarly, another group that represents community health 

centers specified that those with mental health conditions are particularly 

vulnerable due to a lack of transportation.33

Costs of Coverage: Officials from 5 of the 10 groups we interviewed also 

noted that efforts to exclude the NEMT benefit can have implications on 

the costs of care because patients without access to transportation may 

forgo preventive care or health services and end up needing more 

expensive care, such as ambulance services or emergency room visits. 

For example, a national group that represents providers of services for 

 32While certain newly eligible enrollees with chronic conditions in Indiana and Iowa may 

qualify for the NEMT benefit by being determined medically frail, officials from some of the 

groups we spoke with cited limitations in terms of who can qualify as medically frail, as 

well as long wait times for such determinations. 

33We previously cited Substance Abuse and Mental Health Administration estimates that 

approximately 3 million (17 percent) of the 17.8 million low-income, uninsured adults 

nationwide had a behavioral health condition prior to the Medicaid expansion in 2014. See 

GAO, Behavioral Health: Options for Low-income Adults to Receive Treatment in Selected 

States, GAO-15-449 (Washington, D.C.: June 19, 2015).

Research and Advocacy 

Groups Raised Concerns 

Regarding the Implications 

of Altering the 

Transportation Benefit for 

Newly Eligible Enrollees
Page 16 GAO-16-221 Medicaid Nonemergency Transportation Access

low-income populations noted that for people who are receiving regular 

substance abuse treatments, missing appointments can make them 

vulnerable to relapsing, which ultimately drives up the cost of their care. 

Another national group that represents underserved populations indicated 

that they have seen low-income individuals who do not have a car and 

cannot afford public transportation use higher-cost care from emergency 

rooms for their medical problems because they cannot otherwise access 

care. One other group that represents providers noted that by driving up 

the cost of care, a lack of transportation will ultimately trickle down to 

lower reimbursement rates for providers.

Despite these potential implications, officials from 9 of the 10 groups we

interviewed acknowledged various advantages of a state expanding 

Medicaid even with a more limited benefit. For example, officials from 4 

groups remarked that some coverage is better than no coverage in light 

of the significant health care needs among low-income populations. 

These groups recognized the political challenges that have driven state 

decisions whether to expand Medicaid and the concessions that are 

needed for an expansion to occur. For example, officials from a group 

that represents providers in Iowa indicated that although introducing 

variations in Medicaid programs adds complexity for providers, patients, 

and the state, flexibility is important in helping a state find a coverage 

solution that works in its political climate. Similarly, an advocacy group 

from one state acknowledged that an expansion with full traditional 

Medicaid benefits was never going to be achieved in that state, given the 

political environment. As such, groups within that state’s provider 

community broadly supported the state’s effort to expand Medicaid—even 

without the NEMT benefit—because so much of the population was 

uninsured and needed this coverage.

However, while acknowledging their preference for states to expand 

Medicaid, three groups we spoke with maintained their concerns about 

the effects of such efforts on enrollees’ access to care. Officials from two 

of these groups said that improvements in the number of people covered 

should not be achieved by eroding essential services, while an official 

from the other group questioned the value of having health coverage if an 

enrollee is unable to get to the location where services are provided. 

Further, officials from six of the groups we interviewed were concerned 

that HHS’s approvals of state efforts to exclude the NEMT benefit 

potentially provide other states with an incentive to pursue similar efforts. 
Page 17 GAO-16-221 Medicaid Nonemergency Transportation Access

These six groups raised concerns that every time HHS approves such an 

effort, a new baseline is created for what states may request in an effort 

to exclude core Medicaid services.34

We provided a draft of this report to HHS for comment. The department 

provided technical comments, which we incorporated as appropriate.

As agreed with your office, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 30 days from the 

report date. At that time, we will send copies to the Secretary of Health 

and Human Services and other interested parties. In addition, the report 

will be available at no charge on the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact 

Carolyn L. Yocom at (202) 512-7114 or yocomc@gao.gov, or Mark L. 

Goldstein at (202) 512-2834 or goldsteinm@gao.gov. Contact points for 

our Offices of Congressional Relations and Public Affairs may be found 

on the last page of this report. GAO staff who made key contributions to 

this report are listed in appendix I.

Carolyn L. Yocom

Director, Health Care

Mark L. Goldstein

Director, Physical Infrastructure

 34In particular, officials from two of the six groups pointed to Arizona’s recent request to 

exclude the NEMT benefit from coverage for newly eligible enrollees. Arizona had not 

sought to do so when it initially expanded Medicaid under its demonstration, but then 

pursued this option after other states were approved to do so.

Agency Comments
Appendix I: GAO Contact and Staff 

Acknowledgments

Page 18 GAO-16-221 Medicaid Nonemergency Transportation Access

Carolyn L. Yocom, (202) 512-7114, yocomc@gao.gov

Mark L. Goldstein, (202) 512-2834, goldsteinm@gao.gov

In addition to the individuals named above, other key contributors to this 

report were Susan Anthony, Assistant Director; Julie Flowers; Sandra 

George; Drew Long; Peter Mann-King; JoAnn Martinez-Shriver; Bonnie 

Pignatiello Leer; Laurie F. Thurber; and Eric Wedum.

Appendix I: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(291283)
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