Medicaid: Efforts to Exclude Nonemergency Transportation Not Widespread, but Raise Issues for Expanded Coverage
Published: 2016-01-15T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Medicaid, a federal-state health financing program for certain low-income 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.
section_title: What GAO Found
paragraphs: 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.
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.

section_title: Letter
paragraphs: 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. 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. Another study noted  that for poorer populations, which tend to encounter more barriers to  accessing health care generally, transportation can be a significant issue   to accessing care. 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, non- pregnant adults who are not eligible for Medicare, and whose incomes  are at or below 133 percent of the federal poverty level (FPL). 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. Under this  authority, states may obtain a waiver to exclude the NEMT benefit for  newly eligible enrollees. As of September 2015, 30 states had expanded  Medicaid eligibility, some through demonstrations.
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  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.
subsections: section_title: Background
paragraphs: 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. 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  NEMT, under their state plans, but they may do so by obtaining a waiver  of the requirement under a demonstration.
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. 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. 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  hospitalizations. We also previously reported that there are many  federal programs, including Medicaid, that provide the NEMT benefit to  the transportation-disadvantaged population. 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.
section_title: State Efforts to Exclude Medicaid NEMT Benefits Are Not Widespread
paragraphs: 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. 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.)
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 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. 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. 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.
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  exclude the NEMT benefit. 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. 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.
Of the remaining 25 Medicaid expansion states, 14 offered reasons for  why they did not exclude the NEMT benefit for newly eligible enrollees.
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.
section_title: Two States are Evaluating Implications of Excluding NEMT; Researchers and Advocates Raised Concerns about Altering the Benefit
paragraphs: 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.
subsections: section_title: Evaluations of Efforts to Exclude the NEMT Benefit in Two States Assess Comparability of Access for Enrollees With and Without Benefit
paragraphs: 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. 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.
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. 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  (who do not have the NEMT benefit). 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 transportation- related issues. 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. 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,
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.
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. 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  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. 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. 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.
section_title: Research and Advocacy Groups Raised Concerns Regarding the Implications of Altering the Transportation Benefit for Newly Eligible Enrollees
paragraphs: 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. 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.
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  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.
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.
section_title: Agency Comments
paragraphs: 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.
section_title: Appendix I: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: 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.