Nonemergency Medical Transportation: Updated Medicaid Guidance Could Help States
Released: 2016-03-03T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: Medicare and Medicaid provide NEMT services to eligible beneficiaries who need transportation to scheduled nonemergency care. CMS administers Medicare NEMT benefits and is responsible for overseeing Medicaid at the federal level. Spending on NEMT under these programs was $2.7 billion in 2013—$1.2 billion for Medicare and $1.5 billion for Medicaid. Increased demand for NEMT because of increased Medicaid enrollment has led states to seek ways to more efficiently operate NEMT.

GAO was asked to review NEMT under Medicare and Medicaid. This report examines 1) key features of NEMT services under Medicare and Medicaid and how these services are delivered; 2) steps CMS has taken to oversee NEMT under Medicare as well as Medicaid; and 3) the challenges that exist in providing NEMT under Medicaid and steps that selected state Medicaid agencies have taken to address those challenges.

GAO reviewed key documents and interviewed officials from CMS; 15 selected states that range in terms of Medicaid enrollment and geography; and stakeholders, including transportation brokers, health plans, and health care and transportation industry groups.

section_title: What GAO Found
paragraphs: The nonemergency medical transportation (NEMT) benefits offered by Medicare and Medicaid differ. Medicare provides NEMT via ambulance only when other means of transportation, such as a taxi or wheelchair van, would jeopardize the health of the beneficiary. Medicaid NEMT is generally available for beneficiaries who have no other means of transportation to medical services. States are responsible for the daily operations of their Medicaid programs and have discretion in how they deliver NEMT. Officials from 15 selected states reported using a variety of models to administer NEMT, including transportation brokers, which are entities that contract with states to administer NEMT services.

The Centers for Medicare & Medicaid Services (CMS), within the Department of Health and Human Services (HHS), oversees Medicare and Medicaid at the federal level, but this oversight varies by program. CMS generally uses regular program integrity activities—such as claims reviews—to oversee Medicare NEMT. Under Medicaid, CMS also uses regular oversight activities, and these include overseeing states' program integrity activities and periodically issuing guidance. However, some of CMS's guidance is outdated or may be of limited use because of legislative and other changes that affect Medicaid and states' NEMT programs. For example, a 1998 guidebook on NEMT contains outdated information on implementing NEMT transportation broker programs. Other more recent guidance is targeted for patients and providers rather than state Medicaid programs. However, these programs also benefit from updated guidance on strategies to ensure compliance with federal requirements while incorporating current practices to meet beneficiaries' needs. Guidance for state Medicaid programs is particularly important because NEMT is at high risk for fraud and abuse; some selected states and stakeholders GAO interviewed reported that updated guidance could be helpful. Standards for Internal Control in the Federal Government states that management should ensure adequate means of communicating with stakeholders. Effective communications can take many forms, including guidance. CMS officials reported that the agency is considering assessing whether additional NEMT guidance is needed, but has not set time frames for conducting this assessment.

GAO identified four types of challenges related to Medicaid NEMT and several steps taken by states to address some of these challenges. Challenges reported related to containing costs, maintaining program integrity, contracting with and overseeing vendors, and accessing NEMT. For example, states reported challenges containing NEMT costs due to increased NEMT utilization and reported implementing practices to help address these challenges. Such practices include setting fixed provider reimbursement fees that remained relatively constant in recent years. Officials from 7 of the 15 selected states and 6 stakeholders GAO interviewed reported that having information on how states administer NEMT and ways to address challenges could be helpful to states. Some of this information is available; for example, CMS reported collecting information on states' approaches through state Medicaid plans and posting this information on CMS's website. Other organizations, such as the Transit Cooperative Research Program, have or are in the process of collecting such information.

section_title: What GAO Recommends
paragraphs: GAO recommends that the Secretary of HHS direct CMS to assess current Medicaid NEMT guidance and update it as needed. HHS concurred with our recommendation and provided technical comments which we incorporated as appropriate.

section_title: Letter
paragraphs: Transportation to medical care is essential for many Medicare and  Medicaid beneficiaries. A number of federal programs, including Medicare  and Medicaid, can provide funding for nonemergency medical  transportation (NEMT) service. The Centers for Medicare & Medicaid  Services (CMS), within the Department of Health and Human Services  (HHS), administers the Medicare program, including NEMT benefits. CMS  also oversees the design and operation of state Medicaid programs and  their administration of NEMT benefits, but the states are responsible for  the day-to-day operations of their Medicaid programs, including NEMT  benefits. While NEMT is an important benefit for some beneficiaries,  NEMT expenditures are relatively small compared to overall Medicare  and Medicaid spending. In calendar year 2013, spending on NEMT  under these programs exceeded $2.7 billion—$1.2 billion and $1.5 billion  for Medicare and Medicaid, respectively. Medicare spending on NEMT  has remained relatively stable, but Medicaid spending on NEMT has been  steadily increasing since 2010, when it was 1 billion. In an environment  where Medicaid enrollment and spending on transportation are  increasing, states are continually looking for more efficient ways to deliver  trips to beneficiaries who need them, while at the same time maintaining  program integrity.

You asked that we review NEMT services under Medicare and Medicaid.  This report examines 1) key features of NEMT services under Medicare  and Medicaid and how these services are administered; 2) steps CMS  has taken to oversee NEMT under Medicare as well as Medicaid; and 3)  the challenges that exist in providing NEMT under Medicaid, and steps  that selected state Medicaid agencies have taken to address those  challenges.

To identify key features of NEMT under Medicare and Medicaid, we  reviewed applicable laws, regulations, and CMS guidance. To collect  information on how NEMT is provided under Medicare, we interviewed  CMS officials and stakeholders, including two patient advocacy  organizations and one transportation industry group that are involved in  coordinating transportation and reviewed reports by the Medicare  Payment Advisory Commission (MedPAC) and HHS’s Office of Inspector  General (OIG). To determine how NEMT is provided under Medicaid, the  challenges faced by state Medicaid agencies, and steps that state  Medicaid agencies and CMS are taking to address challenges, we  reviewed HHS-OIG, state auditor, and Transit Cooperative Research  Program (TCRP) reports. We also reviewed other documents, such as  state contracts and utilization and spending data, which were provided to  us during interviews with officials from 15 state Medicaid agencies.  Additionally, we interviewed stakeholders, such as health care  associations involved in Medicaid managed care, patient advocates, and  a transportation industry group. We also visited 2 of the 15 selected  states to obtain more in-depth information about challenges in providing  NEMT, and interviewed officials with three health plans and two  transportation brokers involved in providing NEMT. Appendix I contains a  more detailed discussion of our objectives, scope, and methodology.

We conducted this performance audit from January 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: Medicare and Medicaid are the federal government’s two largest  healthcare programs as measured by expenditures.

Medicare is a healthcare insurance program for seniors, certain  individuals with disabilities, and those with end-stage renal disease  (ESRD), with Medicare expenditures totaling $613.3 billion for 53.8  million beneficiaries in 2014. Under federal law, Medicare insurance  includes hospital, medical, and prescription drug coverage. CMS  administers the program, including safeguarding the program from  loss due to fraud, waste, and abuse. Medicare is paid for through two  trust funds held by the U.S. Treasury.

Medicaid is a joint federal-state health-financing program for low- income and medically needy individuals. For 2014, estimated  Medicaid spending totaled $499 billion for more than 65 million  beneficiaries. Medicaid operates within broad federal parameters,  with states having flexibility in how they operate their programs and  with CMS overseeing the design and operation of states’ Medicaid  programs. Medicaid is jointly financed by the federal government and  the states, with the federal government matching most state Medicaid  expenditures using a statutory formula—the Federal Medical  Assistance Percentage rate—generally based on each state’s per  capita income relative to the national average.

Medicare and Medicaid, and their NEMT programs, are provided under  both fee-for-service and managed care payment systems:

Under fee-for-service, either CMS (for Medicare) or the state Medicaid  agency enrolls NEMT providers. Providers are paid on a per-service  basis.

Under managed care, either CMS (for Medicare) or the state Medicaid  agency contracts with health plans to provide covered health care  services—which can include NEMT—in return for a fixed monthly  payment per enrollee. Under Medicare managed care, private  organizations offer health plans through the Medicare Advantage  program.

GAO has designated both the Medicare and Medicaid programs as high  risk because of concerns about the Medicare program’s size, complexity,  and susceptibility to mismanagement and improper payments, and  because of our concerns about inadequate federal oversight over state  Medicaid programs. We have also reported concerns about program  integrity in Medicaid managed care, specifically with regard to  vulnerabilities in protecting against improper payments.

section_title: Modes of Transportation, Program Eligibility, and other Key NEMT Features Are Different under Medicare and Medicaid
paragraphs: Although Medicare and Medicaid both offer NEMT services to their  beneficiaries, based on the individual program requirements, certain key  features of NEMT operate differently under the two programs, as  described below (see table 1). These differences reflect fundamental  differences between the two programs, Medicare being a healthcare  insurance program administered at the federal level and Medicaid being a  joint federal-state health financing program.

Under Medicare, NEMT services are allowed to be delivered via  ambulance transport to scheduled nonemergency medical services for  some beneficiaries. For example, Medicare NEMT may cover ambulance  transportation for a beneficiary with ESRD for scheduled, repeated, and  nonemergency transports to and from dialysis treatments, if transportation  by ambulance is medically necessary. Similarly, Medicare may cover  ambulance transportation upon discharge from an inpatient hospital for  transport to a skilled nursing facility or to a beneficiary’s home, when  medically necessary. The beneficiary must have a written order from a  doctor stating that ambulance transportation is necessary due to the  beneficiary’s medical condition, and the trip must be to or from the  nearest medical facility. Ambulance providers may be compensated on a  fee-for-service basis or under a managed care arrangement.
subsections: section_title: Medicaid Key Features
paragraphs: Under Medicaid, states must ensure NEMT for beneficiaries who have no  other means of transportation to needed medical services—such as  doctors’ appointments and various types of therapies—and can provide  NEMT in a variety of ways. States have discretion, consistent with federal  requirements, in how they deliver NEMT, including the mode of  transportation used and the model used to provide NEMT. For instance,  state Medicaid officials we interviewed reported covering a variety of  modes of transportation for NEMT trips, including buses, taxi cabs, and  vans. States also reported paying beneficiaries and their family members  or friends’ mileage for using their personal vehicles to provide  transportation to needed medical care. While the modes of  transportation used for NEMT across states were similar, state officials  reported using a variety of models to administer NEMT, including paying  for NEMT on a fee-for-service basis; contracting with managed care  health plans to provide health care services, including NEMT, for a per- member, per-month fee; and contracting with transportation brokers to  manage all or some aspects of NEMT on states’ behalf. Further, some  of our 15 selected states use a mix of models for administering NEMT.  See table 2 for examples of states’ models for administering NEMT.

section_title: CMS Oversight of NEMT Varies by Program, with CMS Using a Range of Activities to Oversee Medicaid NEMT
paragraphs: CMS oversight of NEMT under Medicare and Medicaid varies. CMS  oversees Medicare NEMT using its regular oversights activities—such as  claim reviews. Under Medicaid, CMS uses a range of regular oversight  activities to oversee states’ operations of their NEMT programs, including  reviewing and approving state Medicaid plans and amendments; issuing  guidance; conducting a range of program integrity activities, such as  claims and state program integrity reviews; and offering technical  assistance upon request. While CMS periodically issues NEMT guidance,  some of this guidance is outdated or may be otherwise limited.
subsections: section_title: CMS Uses Regular Oversight Activities to Monitor NEMT
subsections: section_title: Medicare NEMT
paragraphs: CMS oversees Medicare NEMT through CMS’s regular program integrity  activities. These include conducting pre- and post-payment claim reviews  by Medicare Administrative Contractors and calculating the Medicare  improper payment rate through the Comprehensive Error Rate Testing  program. CMS initiated a 3-year Medicare prior authorization  demonstration program in December 2014. This program is intended to  help reduce improper payments for NEMT services. The program  requires prior authorization of scheduled, repetitive nonemergency  ambulance transports to test whether prior authorization helps reduce  expenditures while maintaining or improving quality of care. New  Jersey, Pennsylvania, and South Carolina were selected to initially  implement this program because of their high utilization of nonemergency  ambulance transports under Medicare and improper payment rates.  Subsequently, CMS plans to expand the demonstration program to  include Delaware, the District of Columbia, Maryland, North Carolina,  West Virginia, and Virginia on January 1, 2016, as required by the  Medicare Access and CHIP Reauthorization Act of 2015 and plans to  expand the program to all states beginning January 1, 2017, if the  Secretary of HHS and Chief Actuary determine certain conditions will  occur under the expansion.

section_title: Medicaid NEMT
paragraphs: Under Medicaid, states are responsible for the daily oversight of their  NEMT programs and CMS oversees states’ operations using a range of   regular oversight activities. Within broad federal parameters, states  determine their own processes for overseeing their Medicaid NEMT  programs, including verifying beneficiary eligibility, establishing provider  requirements, and preventing improper payments. To oversee states’  operations of their NEMT programs, CMS conducts a range of oversight  activities, including:

CMS reviews and approves Medicaid plans and state plan  amendments, which outline how states administer their Medicaid  programs, including their NEMT programs.

CMS periodically issues guidance on NEMT requirements. CMS has  issued several pieces of guidance, including a guidebook, letters to  state Medicaid Directors, and a toolkit, on different aspects of NEMT.

CMS conducts a range of program integrity activities. First, CMS  calculates a national-level improper payment error rate through the  Payment Error Rate Measurement program. Second, CMS also  contracts with entities to, among other things, audit claims, identify  overpayments, and educate providers and others on Medicaid  program integrity issues. Third, CMS conducts state program  integrity reviews. For example, CMS conducts program integrity  reviews of state Medicaid agencies—which are done to identify  vulnerabilities in state operations that warrant improvements or  corrections—and has provided assistance to states to address those  vulnerabilities. Agency officials reported that these reviews have  included an assessment of states’ oversight of NEMT providers since  fiscal year 2011. Further, CMS’s ongoing program integrity reviews in  three states include an assessment of risks and vulnerabilities in  NEMT services. CMS also conducts special audits and  investigations of traditionally high-risk areas, including NEMT. For  example, CMS reported collaborating with one state, New York, to  conduct a special investigation of the state’s NEMT program.

CMS provides technical assistance and clarifying guidance upon  request. For example, officials from one selected state reported  working with CMS to identify options for redesigning their NEMT  program that would be consistent with regulations.

section_title: CMS Issues Guidance on Medicaid NEMT, but Some Guidance Is Outdated or May Be Otherwise Limited
paragraphs: Although CMS periodically issues NEMT guidance, some guidance is  outdated or may be otherwise limited because legislative and other  changes have affected Medicaid and states’ NEMT programs. For  example:

CMS issued a guidebook in 1998 on designing and operating a cost- effective Medicaid NEMT program. This guidebook included  information on factors and challenges that could be considered when  designing and operating an NEMT program—describing the  advantages and disadvantages of providing NEMT under a brokerage  system, operating NEMT in a managed care environment, and  strategies to identify and prevent NEMT fraud and abuse—and  suggestions to address these concerns. However, this guidebook  contains outdated information. For example, the guidebook describes  limited cases when state Medicaid programs can use brokerages.  However, the Deficit Reduction Act of 2005 changed the conditions  under which states could use NEMT brokerages, which expanded the  number of states that utilize NEMT brokers. The guidebook does not  address these conditions as discussed further below.

After the Deficit Reduction Act of 2005 was passed, CMS issued a  letter to State Medicaid Directors in 2006 describing changes in the  law, and final rules in 2009 for establishing NEMT brokerage  programs under states Medicaid plans. However, CMS has not  assessed NEMT guidance to determine if updates are needed in light  of recent changes. For example, since 2009, there have been  changes to the Medicaid program such as expanding Medicaid as  allowed under the Patient Protection and Affordable Care Act  (PPACA), and states have made changes to their Medicaid  programs. These changes have increased Medicaid enrollment in  some states resulting in more NEMT trips.

More recently, CMS issued a NEMT program integrity tool kit in June  2014. This toolkit includes educational materials summarizing the  general scope of Medicaid-covered NEMT and key principles  applicable to such coverage, such as trip eligibility and NEMT fraud  and abuse definitions. However, these materials are targeted for  patients and providers rather than state Medicaid programs. However,  state Medicaid programs may also benefit from updated information  on strategies to implement a program integrity program that could  help to prevent NEMT fraud and abuse.

Updated guidance is important because it is a way to communicate an  entity’s objectives to help ensure its objectives are carried out. State  Medicaid agencies rely on it when designing and administering their  NEMT programs to help ensure compliance with federal requirements  while incorporating current practices to meet beneficiaries’ needs.  According to CMS officials, some states do not always understand the  NEMT benefit, in part, because NEMT guidance is not specific to the  benefit. For example, states must generally follow overarching federal  Medicaid requirements in providing NEMT under their state plans, such  as requirements on granting beneficiaries the freedom to choose to obtain  Medicaid services from any provider that is qualified and willing to provide  services, unless states establish an NEMT transportation brokerage  program. Officials from two states reported that clarifying NEMT  requirements would be helpful and three stakeholders (one transportation  broker and two industry groups) reported that additional NEMT guidance  would be helpful. For example, a transportation broker reported that  additional guidance would help prevent states from implementing  unnecessarily stringent requirements, which could restrict the supply of  providers and limit access to NEMT. Standards for Internal Control in the  Federal Government states that management should ensure that there  are adequate means of communicating with, and obtaining information  from, external stakeholders that may have a significant impact on the  agency’s ability to achieve its goals. Effective communication can take  many forms such as through guidance, training, or publication of best  practices. CMS officials reported that the agency is considering assessing  whether additional NEMT guidance is needed, but has not established  time frames for doing so.

section_title: Selected States Have Taken Steps to Address Some Medicaid NEMT Challenges, and Information on State NEMT Practices Is Available
paragraphs: Through our work, we identified a range of challenges related to providing  NEMT and steps taken by some states to address these challenges.  Challenges and steps identified were related to maintaining program integrity,  contracting with and overseeing vendors, and accessing NEMT.

State officials reported that information on the approaches other states  take for administering NEMT and strategies to address challenges could  help them address ongoing challenges. CMS and other organizations,  such as TCRP, have collected or are in the process of collecting such  information.
subsections: section_title: Containing Costs
paragraphs: Officials from selected states and stakeholders reported challenges  containing Medicaid NEMT costs due to increased utilization and certain  trip factors. Officials from nine of our selected states reported that NEMT  utilization increased from 2012 to 2014 and reported varying reasons for  the increase in trips. Reported reasons for increased NEMT utilization  included:  increased Medicaid enrollment caused by expanding Medicaid as  allowed under the PPACA and by the economic downturn; program changes, such as covering NEMT to more types of health  care services, such as dental or mental health care; and greater awareness of the benefit among beneficiaries.

Officials from nine states and three stakeholders (two counties and a  transportation broker) reported that certain trip factors—such as traveling  long distances, needing specialized vehicles, and reaching rural  locations—made it difficult to contain costs. Further, officials from three  states reported that these types of trips are sometimes more costly,  because officials may negotiate higher provider reimbursement rates,  thus making containing costs more difficult.

Officials from selected states reported implementing varying practices to  contain NEMT costs, including using payment mechanisms, coordinating  with stakeholders, and implementing policies. See table 3 for examples  of selected state practices that could address challenges containing  NEMT costs.

section_title: Maintaining Program Integrity
paragraphs: Officials from CMS and selected states identified program integrity  challenges related to improper payments for trips, including paid trips that  did not meet program requirements. According to CMS officials, state  Medicaid officials reported that Medicaid claim reviews revealed that  NEMT providers overbilled and documented trips poorly and that  overpayments tended to occur more frequently in states that delegate  NEMT responsibility to counties where officials may not be familiar with  documentation requirements. Officials from six states also reported  improper payments for NEMT, and three of these states attributed  improper payments to challenges documenting trips. For example, in its  Single Audit Act audit report for the year ending on June 30, 2015, the  Louisiana Legislative Auditor identified payments totaling more than  $850,000 for trips that did not meet established policies, including  requirements for accurately documenting services. Studies have also  identified improper payments for Medicaid NEMT trips. For example,  HHS-OIG conducted reviews of samples of Medicaid claims over a 1 or 2  year period from 2005 through 2011 in five states—California, Hawaii,  Nebraska, New York, and Texas—and found that some paid NEMT trips  did not meet federal and state requirements. HHS-OIG subsequently  recommended that collectively, these states should refund the federal  government about $63 million.

CMS and state auditor reports, officials from selected states, and  stakeholders also identified other program integrity challenges that could  make NEMT vulnerable for fraud, waste, and abuse, including:

Enrolling providers: In annual summary reports of comprehensive  program integrity reviews, CMS identified one state that did not  require and collect key information needed for effective oversight,  such as criminal conviction information from NEMT providers, making  the state vulnerable to enrolling problem providers in its NEMT  program. Further, officials from six states cited challenges obtaining  certain information on NEMT providers that could reduce program  risks. For example, officials from one state reported they cannot  access information on criminal convictions in other states, making it  harder to conduct thorough background checks that could reduce  program risks.

Program inefficiencies: State auditors in six states identified problems  with states’ implementation of NEMT programs that could lead to  program inefficiencies. For example, in 2012 the Washington State  Auditor identified program risks in the state’s Medicaid NEMT  program, such as that the Medicaid agency did not require brokers to  maintain consistent trip data and that the agency lacked written  policies and procedures to ensure clear management and consistent  processes. As a result, the state’s six brokers reported inconsistent  practices, which could lead to overbilling for trips. To address  identified program risks, the state auditor recommended that the state,  among other things, improve oversight, monitoring, and data  analysis.

Verifying eligibility: Officials from selected states reported several  challenges verifying that trips fall within the scope of Medicaid- covered NEMT. First, officials from two states reported challenges  verifying beneficiary eligibility for Medicaid or the need for NEMT  services. For example, the Medicaid agency, broker, and county  officials from one state reported challenges verifying Medicaid  enrollment because the state updates its Medicaid enrollment  database daily; thus, beneficiaries who were enrolled in Medicaid  when trips were requested may not be enrolled on the days trips were  provided. Second, officials from another state reported that it had  challenges verifying that the beneficiary did not have other means of  transportation. Third, officials from seven states reported challenges  verifying that NEMT trips were to needed medical services. For  instance, officials from two states reported challenges verifying the  purpose of NEMT trips to certain pharmacies, including Target and  Walmart, which carry non-medical products, such as food and  clothing, in addition to drugs and medical supplies. In these cases, it  was hard to determine whether NEMT was used appropriately,  particularly when beneficiaries requested multiple NEMT trips to the  pharmacy to pick up prescriptions that could potentially have been  picked-up in a single trip.

Officials from all selected states reported taking at least one step to  address these NEMT program integrity challenges. See table 4 for  examples of selected state practices that could address challenges to  maintaining NEMT program integrity.

section_title: Contracting with and Overseeing Vendors
paragraphs: Officials from four states cited challenges contracting with and overseeing  vendors, such as health plans and transportation brokers, and officials  from two of these states reported that challenges arose during periods of  transition. For example, officials from one state reported that in the first  year of contracting with multiple brokers, challenges with one broker’s  compliance with contractual requirements arose because the broker  underestimated the resources needed to administer NEMT. State officials  explained that under their prior method for delivering NEMT, they did not  have complete information on trip volume or mode, making it difficult to  determine the appropriate level of resources needed when requesting  and evaluating vendors’ contract proposals. Further, these state officials  reported challenges developing metrics to monitor all brokers’ compliance  with certain contract requirements. For instance, brokers are required to  furnish NEMT for all eligible trip requests, but officials in one state  reported that about 1 percent of eligible trips requested by Medicaid  beneficiaries are not provided. Without collecting complete information on  NEMT trips under the state’s previous system, identifying a reasonable  proportion of missed trips under the state’s new system to assess  compliance with contract requirements has been difficult.

Officials from all selected states that contract with health plans or  transportation brokers to provide NEMT reported conducting monitoring  activities, such as performing annual audits and site visits, to address  challenges with contracting and overseeing vendors. See table 5 for  examples of selected state practices that could address challenges  contracting with and overseeing vendors.

section_title: Accessing NEMT
paragraphs: State officials and stakeholders reported challenges ensuring access to  NEMT when the demand for trips exceeded the supply of NEMT  providers. Officials generally identified four factors that affected the  supply of NEMT providers—geographic location, specialty providers,  provider requirements, and beneficiary and provider no-shows.  Specifically, officials from seven states and nine stakeholders reported a  low supply of NEMT providers in rural areas, and officials from seven  states and four stakeholders reported a low supply of specialty vehicles,  such as stretcher or wheelchair vans. Officials from two states and three  stakeholders reported that state transportation provider requirements may  limit the number of or deter providers from entering the Medicaid provider  pool. Lastly, officials from seven states and five stakeholders reported  that beneficiaries or providers sometimes did not show-up or were late for  trips, thus tying-up NEMT resources.

Officials from selected states reported taking steps to address access  challenges, including broadening the provider networks and reviewing  state provider requirements. See table 6 for examples of selected state  practices that could address NEMT access challenges.

section_title: Information on Leading Practices
paragraphs: Officials from seven selected states and six stakeholders reported that  having information on how other states administer NEMT and address  challenges could help them address ongoing challenges. For example,  officials from one state reported that they plan to make changes to the  state’s NEMT program to address ongoing challenges and that they have  spoken to officials from other states to learn about how they administer  NEMT. In spite of these efforts, officials from this state reported that they  could not identify any state NEMT programs that could accommodate all  beneficiaries well and that information on current leading practices for  developing a robust NEMT program would be helpful. An official from  another state reported that having information on leading practices would  help to identify approaches for improving NEMT program integrity.

Some information on approaches for administering NEMT and leading  practices is available. CMS reported that it collects information on state  approaches for administering NEMT through state Medicaid plans and  state plan amendments and maintains this information on Medicaid.gov.  Further, CMS collects information on Medicaid programs and noteworthy  program integrity practices, including those related to NEMT, as part of its  program integrity reviews. Other organizations have or are in the process  of collecting information on states’ approaches to administer their  Medicaid NEMT programs. For example, TCRP is conducting a study  evaluating the effects of different options for providing Medicaid NEMT on  access and coordination. As part of this work, TCRP officials reported  collecting information from all 50 states and the District of Columbia on  their approaches for administering NEMT.

section_title: Conclusions
paragraphs: For some Medicaid beneficiaries, NEMT is a critical service to ensure that  they are able to travel to medical appointments. Although a small  proportion of total Medicaid spending, increases in the number of  Medicaid beneficiaries and other factors have led to increased demand  and spending on Medicaid NEMT. States take different approaches to  administering Medicaid NEMT and rely on CMS guidance when designing  their NEMT programs to ensure compliance with federal requirements.  While CMS periodically issues guidance on NEMT, current guidance may  be out of date or otherwise limited. For example, CMS issued a NEMT  guidebook in 1998, but this guidebook does not include current guidance  on implementing a transportation brokerage program under a state  Medicaid plan. Some selected states and stakeholders told us that  clarifying NEMT guidance would be helpful. As described in Standards for  Internal Control in the Federal Government, management should ensure  adequate means of communicating with, and obtaining information from,  external stakeholders. CMS officials reported that the agency is  considering assessing whether additional NEMT guidance is needed, but  has not set any timeframes for conducting that assessment.

section_title: Recommendations
paragraphs: To ensure states have appropriate and current guidance to assist them in  designing and administering Medicaid NEMT, we recommend the  Secretary of HHS direct CMS to assess current Medicaid NEMT guidance  and update that guidance as needed.

section_title: Agency Comments
paragraphs: We provided a copy of the draft to HHS. HHS concurred with our  recommendation and provided technical comments, which we  incorporated as appropriate. HHS’s comments are reprinted in appendix  II.

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section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: This report addresses non-emergency medical transportation (NEMT)  under Medicare and Medicaid and examines: 1) the key features of  NEMT services under Medicare and Medicaid and how services are  administered; 2) steps that the Centers for Medicare & Medicaid (CMS)  have taken to oversee NEMT under Medicare as well as Medicaid; and 3)  the challenges that exist in providing NEMT under Medicaid and steps  that selected state Medicaid agencies have taken to address those  challenges.

To determine the key features of NEMT under Medicare and Medicaid  and how services are administered, as well as to determine steps that  CMS has taken to oversee NEMT under Medicare and Medicaid, we  reviewed applicable laws, regulations, and CMS guidance. We also  reviewed key reports, such as Medicare Payment Advisory Commission,  Department of Health and Human Services-Office of Inspector General  (HHS-OIG), and Transit Cooperative Research Program (TCRP) reports,  and prior GAO reports. Additionally, we conducted searches in  bibliographic databases—including Medline, National Technical  Information Service, WorldCat PAIS International, and Social Services  Abstracts—to identify additional literature on NEMT under Medicare and  Medicaid. We screened search results and identified studies for relevance  to our research objectives and selected those that focused on delivery of  NEMT services under Medicaid and Medicare. We interviewed CMS and  HHS-OIG officials, as well as two patient advocates and a transportation  industry group involved in coordinating transportation. In addition, for  Medicaid, we interviewed officials from 15 selected state Medicaid  agencies. We selected a non-probability sample of states based on a mix  of considerations, including Medicaid enrollment and spending, the  approaches states use to deliver NEMT, geographic distribution, and  whether or not states have expanded Medicaid under the Patient  Protection and Affordable Care Act (PPACA). The selected states were:  Arizona, California, Colorado, Connecticut, District of Columbia, Georgia,  Illinois, Louisiana, Maine, Michigan, Missouri, New York, Ohio,  Tennessee, Washington, and Wyoming. We also reviewed documents  from states, such as contracts with health plans and organizations  providing NEMT, and utilization and spending data.

To determine the challenges that exist in providing NEMT and steps that  state Medicaid agencies are taking, we screened and identified studies  from the sources identified above, and selected and reviewed studies that  focused on challenges in providing NEMT under Medicaid, as well as  HHS-OIG and state auditor reports. We also interviewed CMS and HHS- OIG officials, two patient advocates, and a transportation industry group  that are involved in coordinating transportation, two healthcare industry  associations that are knowledgeable about providing NEMT under  Medicaid, including Medicaid managed care, and officials from the 15  selected state Medicaid agencies. In order to obtain more in-depth  information about challenges, we visited two states—Louisiana and  Colorado—to interview officials involved in providing NEMT. We selected  these two states because they use more than one model to provide  NEMT, including using at least one broker, and have both rural and urban  populations. In Louisiana, we interviewed officials from two health plans  that had contracts with the state for more than 1 year and serve more  than 50 percent of the Medicaid beneficiaries enrolled in managed care,  as well as the two transportation brokers that provide NEMT. In  Colorado, we interviewed the transportation broker Colorado uses for the  Denver metropolitan area, a health care plan that serves Medicaid  beneficiaries in Colorado and officials in two counties outside of the  Denver metropolitan area that are responsible for providing NEMT to their  residents.

section_title: Appendix II: Comments from the Department of Health and Human Services

section_title: Appendix III: GAO Contacts 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 Heather MacLeod, Assistant Director; Kristin Ekelund, Lynn  Filla-Clark, Julie Flowers, Jacquelyn Hamilton, Bonnie Pignatiello Leer,  Amy Rosewarne, and Betsey Ward-Jenks.


Question-summary annotations: questions: question: What NEMT benefits do Medicare and Medicaid offer?
answer: The nonemergency medical transportation (NEMT) benefits offered by Medicare and Medicaid differ.
child_questions: question: When does Medicare provide NEMT via ambulance?
answer: Medicare provides NEMT via ambulance only when other means of transportation, such as a taxi or wheelchair van, would jeopardize the health of the beneficiary.

question: When does Medicaid provide NEMT via ambulance?
answer: Medicaid NEMT is generally available for beneficiaries who have no other means of transportation to medical services.

question: What authority do states have regarding NEMT?
answer: States are responsible for the daily operations of their Medicaid programs and have discretion in how they deliver NEMT.
child_questions: question: What different models are used?
answer: Officials from 15 selected states reported using a variety of models to administer NEMT, including transportation brokers, which are entities that contract with states to administer NEMT services.

questions: question: What do the Centers for Medicare & Medicaid Services oversee?
answer: The Centers for Medicare & Medicaid Services (CMS), within the Department of Health and Human Services (HHS), oversees Medicare and Medicaid at the federal level, but this oversight varies by program.
child_questions: question: How does CMS conduct its oversight of Medicare?
answer: CMS generally uses regular program integrity activities—such as claims reviews—to oversee Medicare NEMT.

question: How does CMS conduct its oversight of Medicaid?
answer: Under Medicaid, CMS also uses regular oversight activities, and these include overseeing states' program integrity activities and periodically issuing guidance.

question: What are the limits to CMS's guidance?
answer: However, some of CMS's guidance is outdated or may be of limited use because of legislative and other changes that affect Medicaid and states' NEMT programs.
child_questions: question: What is an example?
answer: For example, a 1998 guidebook on NEMT contains outdated information on implementing NEMT transportation broker programs.

question: Why else is CMS's guidance limited?
answer: Other more recent guidance is targeted for patients and providers rather than state Medicaid programs.
child_questions: question: Why do these programs benefit from guidance?
answer: However, these programs also benefit from updated guidance on strategies to ensure compliance with federal requirements while incorporating current practices to meet beneficiaries' needs.
child_questions: question: Why is guidance for state Medicaid programs particularly important?
answer: Guidance for state Medicaid programs is particularly important because NEMT is at high risk for fraud and abuse; some selected states and stakeholders GAO interviewed reported that updated guidance could be helpful.

question: What is CMS currently assessing?
answer: CMS officials reported that the agency is considering assessing whether additional NEMT guidance is needed, but has not set time frames for conducting this assessment.

question: What does Standards for Internal Control in the Federal Government state?
answer: Standards for Internal Control in the Federal Government states that management should ensure adequate means of communicating with stakeholders.
child_questions: question: What is one example of effective communication?
answer: Effective communications can take many forms, including guidance.

questions: question: What did GAO identify in its report?
answer: GAO identified four types of challenges related to Medicaid NEMT and several steps taken by states to address some of these challenges.
child_questions: question: What challenges were reported?
answer: Challenges reported related to containing costs, maintaining program integrity, contracting with and overseeing vendors, and accessing NEMT.
child_questions: question: What is an example of challenges related to containing costs?
answer: For example, states reported challenges containing NEMT costs due to increased NEMT utilization and reported implementing practices to help address these challenges.
child_questions: question: What is one response to cost containment challenges?
answer: Such practices include setting fixed provider reimbursement fees that remained relatively constant in recent years.

question: What did interviewed officials report?
answer: Officials from 7 of the 15 selected states and 6 stakeholders GAO interviewed reported that having information on how states administer NEMT and ways to address challenges could be helpful to states.
child_questions: question: Where is such information available?
answer: Some of this information is available; for example, CMS reported collecting information on states' approaches through state Medicaid plans and posting this information on CMS's website. Other organizations, such as the Transit Cooperative Research Program, have or are in the process of collecting such information.

questions: question: To whom do Medicare and Medicaid provide NEMT services?
answer: Medicare and Medicaid provide NEMT services to eligible beneficiaries who need transportation to scheduled nonemergency care.
child_questions: question: How much did these programs spend on NEMT?
answer: Spending on NEMT under these programs was $2.7 billion in 2013—$1.2 billion for Medicare and $1.5 billion for Medicaid.

question: What agency administers Medicare NEMT benefits?
answer: CMS administers Medicare NEMT benefits and is responsible for overseeing Medicaid at the federal level.

question: How have states responded to increased demand for NEMT?
answer: Increased demand for NEMT because of increased Medicaid enrollment has led states to seek ways to more efficiently operate NEMT.