We continue to see a great deal of federal activity focused on the intersection of health and transportation.
While there are efforts happening across the health and transportation spectrum (including legislation and efforts on social determinants of health, rural health, addressing social isolation), this blog will focus on providing updates to national efforts specifically relating to the Medicaid Non- Emergency Medical Transportation (NEMT) Benefit.
FY21 President’s Budget calls for the Medicaid NEMT benefit to be made optional
In the recently released President’s budget, the administration one again called for the NEMT benefit to be made optional The FY 2021 Budget-in-Brief for the Department of Health and Human Services (linked here, p. 117)
“Make Medicaid Non-Emergency Medical Transportation Optional Under current regulations, states must provide Non-Emergency Medical Transportation to all Medicaid beneficiaries. States requested additional flexibility from this requirement due to challenges containing these costs and addressing program integrity concerns. The Budget commits to using regulatory authority to change the provision of this benefit from mandatory to optional to provide greater flexibility to states.”
It is critical to note that Presidential budget requests are not law and Congress has its own budgeting and appropriations process – this means the President’s budget is largely a messaging document. While concerning, this provision is not new – nearly the exact same language was included in the President’s FY19 and FY20 budget requests. The inclusion of the above language in the FY21 budget shows that NEMT is still on the administration’s list of priorities.
In January of this year, CMS released a State Medicaid Director (SMD) letter encouraging states to pursue Block Grants or Per Capita Cap Funding Mechanisms through their Medicaid programs (Accompanying Fact Sheet). This proposal, offered under their new Healthy Adult Opportunity (HAO) initiative would allow states to implement a block grant or per capita cap for certain Medicaid populations, and will grant increased flexibility in administering their state Medicaid program.
For those of us following the administration’s actions around NEMT, this SMD includes a small but critical opening for removal of the benefit by states. While states will be required to cover the ten essential health benefits established under the Affordable Care Act, they are not expected to cover Alternative benefit plan wrap-around service requirements, such as the coverage of NEMT.
As the current administration continue to pursue and propose the transition to Medicaid program flexibility in the form of Block Grants or per capita caps, we need to consider the impact these changes would have on critical life-saving benefits for Medicaid Benefits, such as NEMT.
In comparison to the President’s Budget, Congress has been working on protecting the NEMT benefit through both appropriations and authorization efforts:
Over the past six months, we have seen Congress focus on a two-prong approach to protecting the NEMT Benefit – 1. Using Appropriations to prevent CMS from publishing a Rule that would make NEMT option at the state level and 2. Through policy, writing the NEMT benefit into Medicaid Statute. Below are key updates on each of these two approaches:
In December, the Senate passed an omnibus package of appropriations bills that included report language directing CMS not to publish any regulation restricting NEMT until they commission a study to examine the impact of those restrictions on beneficiaries and wait for its completion. The bill included the below language:
p.104 – “Nonemergency Medical Transportation (NEMT)— The agreement directs HHS to take no regulatory action on availability of NEMT service until the study described under the “Medicaid and CHIP Payment and Access Commission” header of this joint explanatory statement is complete.
p.155 – “MEDICAID AND CHIP PAYMENT AND ACCESS COMMISSION (MACPAC) Non-Emergency Medical Transportation (NEMT).—Within the amount provided, the agreement provides $300,000 for MACPAC to examine, to the extent data are available, the benefits of NEMT from State Medicaid programs on Medicaid beneficiaries, including beneficiaries with chronic diseases including end stage renal disease (ESRD ), substance abuse disorders, pregnant mothers, and patients living in remote, rural areas, and to examine the benefits of improving local coordination of NEMT with public transportation and other Federally- assisted transportation services. The agreement directs HHS to take no regulatory action on availability of NEMT service until the study is completed.”
While this report language is not law, it is as strong as it could be within an “appropriations limitation.” The hope is to delay the publication of any proposed rule restricting NEMT for a least a year while the required MACPAC report is being completed.
In conjunction with the appropriations limitation passed in both the house and senate appropriations bills, bills were introduced in both the House (H.R. 3935) and Senate (S. 2846) that make an effort to codify the NEMT benefit into Medicaid statue. The House bill is led by a bi-partisan group of members in the House and Senate. House co-sponsors include Reps. Tony Cardenas (D-CA-29), Tom Graves (R-GA-14) and Sanford Bishop (D-GA-2). H.R. 3935 will deliver additional and critically-needed protection to the NEMT benefit. On Jan. 8, the House Energy and Commerce Subcommittee on Health held a hearing to discuss seven bills, including H.R. 3935. You can read CTAA’s summary blog highlighting the hearing here.
The Senate bill was introduced in November 2019 by Senators Johnny Isakson (R-GA)and Sherrod Brown (D-OH). Similar to H.R. 3935, the bill looks to permanently authorize the Medicaid NEMT Benefit. However, the Senate version also provides a new requirement for coordination in the planning of transportation services provided with Federal Assistance, while also making CMS a full member of the Coordinating Council on Access and Mobility (CCAM).
While neither of these bills ended up being included in the recent appropriations omnibus, there will be another opportunity in a few months. There will be a package of “health extenders,” or reauthorizations of Department of Health and Human Services (HHS) programs whose funding will expire on May 22. Lawmakers will need to pass an appropriations bill by that date in order for these HHS programs to continue to receive funding. This bill may be an opportunity to include these NEMT protections.
If your system provides NEMT services, contact your U.S. House Representative or U.S. Senator and ask them to co-sponsor H.R. 3935 or S. 2846 respectively. Please let us know if you do, and CTAA can provide contacts for staff at both House and Senate offices.
In follow up to the President’s budget and previous HHS Unified Agenda Items that have all looked to make NEMT optional, CMS has made it clear they planned to publish an RFI on NEMT in December of 2019. This RFI was not published by that date, so we expect publication of this request any week. The information currently available states the following: “planned to publish an RFI on NEMT”
“The request for information will seek public input on whether the Assurance of Transportation in the Medicaid program remains administratively necessary given the delivery of healthcare both in terms of technological advances and the commercial market design. CMS will also request stakeholder comment regarding the merits of the transportation assurance on selected populations and services e.g. maintain the assurance for EPSDT eligible individuals, pregnant women, individuals who are medically frail, and emergency transportation services.”
When the RFI is released, CTAA will be reaching out to members and encouraging both transportation providers and other partners and stakeholders to submit comments that reflect the importance of the NEMT benefit, and why it needs to remain a necessary benefit.
The Community Transportation Association of America (CTAA) and its members believe that mobility is a basic human right. From work and education to life-sustaining health care and human services programs to shopping and visiting with family and friends, mobility directly impacts quality of life.