Medicaid and CHIP Payment and Access Commission (MACPAC) Congressionally Mandated Report on Medicaid’s NEMT Benefit

In June 2021, the Medicaid and CHIP Payment and Access Commission, or MACPAC, released one of its two annual Reports to Congress on Medicaid and CHIP, one chapter of which contained the congressionally mandated report on Medicaid NEMT (as required under the December 2019 Appropriations Limitation.) The congressionally mandated report on Medicaid’s NEMT benefit can be found in chapter five. As a part of the chapter’s development, MACPAC reviewed state policies, conducted interviews with stakeholders, analyzed administrative data and held focus groups to examine beneficiaries’ experience using NEMT and state approaches to administering the benefit. CTAA did contribute to the report’s development through interviews and the provision of comments on the draft report. The findings of the report confirmed many of the opportunities and challenges commonly acknowledged by industry stakeholders. However, as a non-partisan legislative branch agency that provides policy and data analysis and makes recommendations to Congress, MACPAC serves as an importance independent source of information on Medicaid and the Children’s Health Insurance Program (CHIP). The inclusion of NEMT within a MACPAC report provides a level of significance to the findings, and an important level of support for the benefit.

The report presents a pragmatic approach to discussing the strengths and weaknesses of each of the various NEMT delivery models. States typically delivery NEMT using one or more delivery models, including in-house management, third-party brokerage and/or managed care. While many reports exist outlining these models, the MACPAC report takes a balanced approach by weighing both the positive and negative components of each of these models across the stakeholder spectrum.

Within these delivery models, the role of public transportation within Medicaid NEMT varies considerably across, and even within, states. Public transportation was used in only five percent of trips, according to T-MSIS data, perhaps reflecting its limited reach beyond urban areas. Important Note on Data Accuracy: Because public transportation is provided through a variety of different transportation modalities, it is possible that some public transportation ride-days are misclassified, and thus are being undercounted. For example, in rural areas, public transportation is often provided in vans, as opposed to trains or buses.

Data limitations remain a major challenge in understanding the NEMT landscape and available NEMT data does not provide the entire picture. Within this report, MACPAC included some data analysis of Medicaid Claim’s data from the CMS’ Transformed Medicaid Statistical Information System (T-MSIS) database for reporting Medicaid-funded services. T-MSIS collects utilization and claims data as well as other key Medicaid and CHIP program information. MACPAC’s analysis efforts are one of the first, if not the first to attempt to use this NEMT data set, and while helpful, there remains room for improvement. (e.g. NEMT trips are counted as ride-days, instead of actual trips provided, thus not giving the full picture of actual utilization.) In addition, funding and spending information included in the report does not include trips paid for under Medicaid Managed Care, resulting in large underestimates in payments and total costs of the benefit as a whole.

Despite data limitations, the report was clear in its findings around the challenges of NEMT network adequacy. From ensuring adequate network size, other challenges arise such as performance, timeliness, and quality. Network adequacy challenges also include supply of wheelchair vans and other vehicles appropriate for high-need beneficiaries.

In addition, the extent of coordination between NEMT and other programs, varies across states. While some states have prioritized coordination (examples used included Vt., Pa., and Mass.), other states have limited or no coordination across federally assisted transportation programs and cited a range of barriers and challenges that are consistent with findings from past studies by other federal agencies.

The report also de-emphasizes the risks of program integrity and/or fraud concerns within the NEMT benefit. Previous reports by Federal oversight authorities (GAO 216b), and studies by the HHS Office of the Inspector General (OIG, 2021, 2020) have identified NEMT as high risk for fraud, waste, and abuse, and found inadequate oversight and improper payments for trips that did not meet federal and state requirements. However, the MACPAC report, de-emphasizes these risks and outlines that Medicaid officials in most studied states and other interviewees suggested that although there are occasional instances of fraud or misuse by beneficiaries and providers, the issue is not widespread and is appropriately addressed through routine channels.

There are clear steps the federal government can take to help improve NEMT quality and performance. MACPAC’s report concludes by outlining a series of actions that could occur federally to support the provision of NEMT services. These include:

• More visibly and proactively promote sharing of best practices and strategies to address common issues in NEMT administration (beyond what CMS already does on an ad hoc basis);
• Issue additional guidance or implement requirements on how states should publicize the availability of NEMT and encourage use of NEMT services, and work with states to develop strategies to identify beneficiaries who have transportation barriers but are not using NEMT;
• Issue guidance on the use of TNCs in NEMT, including minimum standards and requirements that states could augment; and
• Create incentives to address provider shortages in rural areas.

Overall, transportation remains a key barrier to care. MACPAC found that among the Medicaid population, 5.2 percent reported delaying care due to transportation in 2018. Of those, 60 percent were adults age 19-64, and 39 percent were children age 0-18. Almost all (98 percent) adults who delayed care had either basic action difficulty or complex activity limitations.

Health Management Associates Companion Report on Stakeholder Perspectives on Trends, Challenges and Innovations in Medicaid’s NEMT Benefit

In addition to the June 2021 MACPAC report, Health Management Associates (HMA) released a detailed report covering NEMT trends, challenges, and innovations in August 2021. HMA’s draws from a 50-state scan of NEMT programs and interviews with NEMT stakeholders. CTAA was interviewed for this report as well.

It should be noted that HMA was one of MACPAC’s contractors to assist with their report, and so this research dovetails that work and showcases similar findings. These findings include the importance of NEMT, the significant challenges in maintaining an adequate transportation network and the flexibility within each state Medicaid program to design the NEMT delivery system.

The stakeholders who were interviewed emphasized the importance of the NEMT benefit in helping Medicaid beneficiaries access the health care they need and highlighted the value, or potential value, of NEMT in improving health outcomes and reducing disparities.

Overall, the HMA report works as a second source for the same findings regarding the NEMT benefit. In addition, like the visibility provided by the MACPAC report, this HMA publication is yet another instance of a highly regarded health policy publication studying and reporting on NEMT – showcasing the growing interest in transportation in the health care and health policy space.

So, where do we go from here?

These two reports bring NEMT to the main stages of health policy research- an event which we have been building up to for over half a decade. Within that time, NEMT has undergone massive shifts alongside both the healthcare and transportation systems. From the introduction of TNCs, the proliferation of Medicaid Managed care, the threats to its very existence during the last Administration, as well as rapid shifts due to the COVID-19 Pandemic, the future of NEMT is under construction.

Both MACPAC and HMA have created point in time reports that showcase NEMT as it is now, yet they offer glimpses into what it could be.

NEMT is not only a funding mechanism for many public transportation providers, however it also assists in growing transit ridership, and helps illustrate one of the many value propositions of public transportation, among other benefits. For public transportation, NEMT is likely not going anywhere, anytime soon.

As health policy looks to develop ways to improve services, bolster network adequacy and increase data collection, it is critical for public transportation providers and policy experts to engage in these discussions. The investigation of new models and methods of providing NEMT will likely include new reimbursement strategies, integration of more technology, requirements for increased data collection and sharing, as well as opportunities for innovative pilot programs and services. It is critical for public transportation to look at how they fit within the NEMT model, both as it exists now and where we want to be in the future.