By Alex King

Federal Health Care and Transportation Policy Update: Looking back on what we missed in November and December

February 2, 2021

The end of 2020 was a whirlwind for many, and while multiple different news stories dominated the headlines, two major health and transportation policy updates flew under the radar. In this the first installment in a new monthly blog series, CTAA will provide updates on two major federal policy decisions that have ramifications for the NEMT industry as well as those public transportation providers working at the intersection of health care and transportation.

CMS Approves National Expansion of Repetitive, Scheduled, Non-Emergent Ambulance Transportation (RSNAT) Prior Authorization Model

In November 2020, the Centers for Medicare and Medicaid Services (CMS) announced the national expansion of the Repetitive, Scheduled, Non-Emergent Ambulance Transportation (RSNAT) Prior Authorization Model to all states. While the program model is focused on ambulance transportation, it has implications that could reverberate across the NEMT industry.

The RSNAT Prior Authorization Model has been in operation under CMS since December 2014. It began in New Jersey, Pennsylvania, and South Carolina, and just over a year later was expanded to Delaware, the District of Columbia, Maryland, North Carolina, Virginia, and West Virginia. The approved expansion would make it a national program.

One of the original goals of the RSNAT prior authorization model was to test whether prior authorization helps reduce expenditures within the Medicare system, while maintaining or improving access to and quality of care. According to CMS, the assumption was that using a prior authorization process can help ensure services are provided in compliance with Medicare rules and regulations before services are provided and claims are paid. In implementing prior authorization, CMS is requesting information earlier in the payment and claims process. No documentation requirements actually changed as a part of this model (either initial phases or the upcoming national expansion). The national expansion announced in November is occurring as the model has met all expansion criteria previously required under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The documentation leading up to this decision included two different interim evaluation reports and an actuarial report that certified that the nationwide expansion of the model would reduce net program spending under the Medicare Program. The included graph (from CMS Model Status Update Report) illustrates the cost savings seen within the model by comparing the two groups of model states, to non-model states.

Specifically, the Second Interim Evaluation Report found that, “the model was successful in reducing repetitive, scheduled non-emergent ambulance transport spending and total Medicare spending while maintaining overall quality of and access to care. “

Due to COVID, the national expansion will be delayed; however, any states currently implementing the model can continue to do so without interruption. CMS has clarified that they will provide public notice before implementing the model in additional states – this will likely occur once the pandemic has subsidized a considerable amount.

This program currently does not rely on public transportation or non-ambulance non-emergency medical transportation providers. However, its findings could have significant implications for the future delivery of NEMT service. The key takeaway from this announcement, is that CMS has proven the cost effectiveness of incorporating prior authorization requirements into the non-emergent ambulance transportation benefit under Medicare. Whether those findings can be replicated in other forms of NEMT service (though non-ambulance non-emergency medical transportation in Medicaid) remains to be seen. However, these findings, in conjunction with a general industry trend towards prior authorization, means that prior authorization is likely on its way to becoming a commonplace if not required practice. Whether the results of this model will influence discussions of creating a non-ambulance NEMT benefit in Medicare are unknown at this time.

HHS Office of Inspector General Revised Local Transportation Anti-Kickback Statute Safe Harbor

In December 2020, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) published a final rule titled, “Revisions to the Safe Harbors Under the Anti-Kickback Statute and Civil Monetary Penalty Rules Regarding Beneficiary Inducements.”

This recently issued final rule revises the Anti-Kickback Statute’s Safe Harbors, including amendments specifically to the local transportation safe harbor.

To provide a quick review of key programs, statutes, and regulations related to this ruling:

  • The federal anti-kickback statute was created to prohibit intentional payments (money or in-kind) in exchange for patient referrals or other health care program business.
  • The Safe Harbor regulations are identified and defined payment and businesses practices that may potentially fall under anti-kickback statutes, yet are not treated as offenses.
  • The beneficiary inducements Civil Monetary Penalty (CMP) is another statute that prohibits knowingly offering something of value of a program beneficiary to induce them to select a particular provider or supplier. (Source: U.S. Federal Register)

The 2020 Final Rule was part of HHS’s Regulatory Sprint to Coordinated Care (Regulatory Sprint), which “aimed to reduce regulatory barriers to care coordination and accelerate the transformation of the health care system into one that better pays for value and promotes care coordination.”

Prior to announcement of the final rule, OIG had an open comment for the proposed ruling. In response to the notice of proposed rulemaking, OIG received over 300 public comments. CTAA joined the Medical Transportation Access Coalition’s (MTAC) Comment Letter as a part of the open comment period on this now final rule. (See letter here.)

Looking back, in 2016, a safe harbor was created for health care providers offering free transportation to their patients under certain circumstances. The 2020 amendment updates the 2016 regulation. The previously created transportation safe harbor allows health care providers to provide transportation to established patients within the providers primary service area.

The 2020 final rule implemented seven new safe harbors, modifies four existing safe harbors, and codifies one new exception under the Beneficiary Inducements CMP. The local transportation safe harbor was one of the four that was modified under the final rule.

Modifications include:

  • An expanded mileage allowance for patients residing in rural areas from a 50-mile radius to a 75-mile radius.
  • The elimination of the mileage limitation for patients being discharged from an inpatient facility.
  • An allowance for ride sharing services to advertise that free or discounted transportation may be available and urge riders/patients to contact their medical providers for more information (Note: they cannot advertise which medical providers).
  • The creation of a safe harbor the provision of shuttle service to and from certain locations. Similar to local transportation, shuttle service is limited to a 25/75-mile urban/rural radius. One key difference is that shuttle service may be provided to patients who are not “established” patients.

It is clear from the information published by HHS that as intended by Congress, the update of the Safe Harbor rules seeks to better reflect changing business practices and technologies. It is also clear, that HHS feels these changes fit into the overall agency’s policy aim of reducing regulatory barriers to care coordination.

For transportation providers, these rule changes have a few implications. First of all, due to increased flexibility, we may see more health care providers take advantage of these safe harbor options to provide transportation. This is particularly true as we also have seen increasing research and programs illustrating the value that transportation benefits can in terms of both reducing costs and improving health outcomes.

Transportation providers have an opportunity to leverage these Safe Harbor amendments to build new health care partnerships. Steps towards building these partnerships include:

  1. Read additional details regarding the Safe Harbor Local Transportation revisions. Additional specifics can be found on this insight summary, as well as in the HHS Final Rule Fact Sheet, and the Federal Register.
  2. Consider which option covered under the transportation safe harbor may be a good fit for your service type, such as contracting for one-off trips or working to develop the newly approved shuttle service model.
  3. Research and review what local health care provider are located within the mile radius limits provided in the statutes (25-mile urban/ 75 mile rural)
  4. From here identify hospital or clinic contacts and reach out to determine if they are already implementing any of these services, or if they would be interested in doing so.

Overall, these rule changes illustrate the growing federal and health care provider acknowledgement of the important role that transportation plays in health care. Transportation providers have an opportunity to leverage this changing perspective to build new partnerships, programs, and services.


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.