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

Letter

Background

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.

Modes of Transportation, Program Eligibility, and other Key NEMT Features Are Different under Medicare and Medicaid

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.

Medicaid Key Features

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.

CMS Oversight of NEMT Varies by Program, with CMS Using a Range of Activities to Oversee Medicaid NEMT

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.

CMS Uses Regular Oversight Activities to Monitor NEMT

Medicare NEMT

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.

Medicaid NEMT

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.

CMS Issues Guidance on Medicaid NEMT, but Some Guidance Is Outdated or May Be Otherwise Limited

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.

Selected States Have Taken Steps to Address Some Medicaid NEMT Challenges, and Information on State NEMT Practices Is Available

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.

Containing Costs

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.

Maintaining Program Integrity

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.

Contracting with and Overseeing Vendors

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.

Accessing NEMT

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.

Information on Leading Practices

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.

Conclusions

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.

Recommendations

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.

Agency Comments

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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Appendix I: Objectives, Scope, and Methodology

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.

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

Appendix III: GAO Contacts and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

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.