Consolidated Appropriations Act

As discussed in previous CTAA blogs, the recently passed Consolidated Appropriations Act of 2021, included a component that codified the Non-Emergency Medical Transportation (NEMT) benefit in Medicaid into statute.

The Consolidated Appropriations Act was signed into law in December of 2020, and officially codified the long-standard regulatory requirement for states to provide Medicaid non-emergency medical transportation benefits. This provision is based off of a number of previously introduced house and senate bills (H.R. 3935 and S. 2846 Protecting Patients Transportation to Care Act) looking to take similar action to protect and guarantee the benefit (Read blog summarizing HR 3935 here). Prior to this, the transportation benefit was provided through federal regulations making it subject to interpretation, challenge, or waivers at the state level.

In addition to codifying the NEMT benefit into law, the Act also establishes new program integrity requirements and activities as well as requiring additional federal studies and efforts to better understand the NEMT benefit. The Act:

• Updates NEMT provider and driver requirements that require states ensure that providers of NEMT services (and individual drivers) have not been excluded from participation from the Medicare or Medicaid programs; have a valid driver’s license; have processes in place to protect against violation of drug laws; and have a process to disclose the driving history of drivers employed by the provider.
• Clarifies that State Medicaid agencies looking to implement a NEMT brokerage program have the ability to consult with relevant stakeholders including patients, medical providers, MCOs, NEMT brokers, and transportation providers.
• Requires the Government Accountability Office (GAO) to conduct a 50-state plus D.C. study of Medicaid NEMT by December 2022 identifying safeguards to prevent NEMT fraud and abuse
• Requires CMS to convene a series of stakeholder meetings to obtain input about leading practices for improving program integrity of NEMT services.
• Tasks CMS with analyzing and submitting to Congress a report on the nation-wide data set under the Transformed Medicaid Statistical Information System (T-MSIS) to make any recommendations relating to NEMT coverage

Generally, the above program requirements and activities can be seen as efforts to further clarify guardrails around the benefit to prevent fraud waste and abuse through unnecessary utilization and to ensure that payments are consistent with efficiency, economy, and quality of care and sufficient to promote access.

There are a few potential impacts that providers will feel from this limitation, but overall, they will be minimal. First, is a positive impact of greater security in the benefit. For those who are providers in states that were considering waivers or other cuts to NEMT, this show of support via codification of the benefit illustrates that the elimination or removal of the benefit is overall less likely. While the legislation does not explicitly eliminate the opportunity to waive the benefit, it seems unlikely between the language in the legislation as well as the new administration.

In terms of daily NEMT trips, the impact is even less prominent. Particularly for public transportation providers who also provide NEMT trips. Public transportation providers should already be meeting the driver requirements based on what they are already required to do under the FTA, so no additional steps or changes should be necessary.

The one area to keep in mind is the added component clarifying state Medicaid agency stakeholder engagement. This potentially could provide greater opportunity for public transportation and other NEMT providers to engage and provide feedback to state Medicaid agencies looking to implement or update a NEMT brokerage.

Overall, this bill showcases the strong bipartisan support for the NEMT benefit and could also offer ideas on future support for legislation on transportation and health topics in the future.

American Rescue Plan Act

The current administration signed the American Rescue Plan Act into law just last week on March 11. While the $1.9 trillion-dollar legislative package includes a variety of more high-profile components, it also included a provision related to NEMT. Specifically, effective April 1, 2021 the American Rescue Plan Act increases the Federal Medical Assistance Percentage (or FMAP) to 100 percent for Medicaid-covered COVID-19 vaccine administrative costs, including the vaccine as well as its administration. The language within the legislation does not explicitly state what is covered under these administrative related costs, therefore the full extent of the implications for NEMT services is unknown.

That said, public transportation and NEMT providers have played an invaluable role during the COVID-19 pandemic as they continue to support community access to daily services, as well as the additional services related to the pandemic such as food delivery, vaccine access, and other updates.

Given CTAA’s rural roots, it is important to note that rural communities face unique challenges in accessing health care, particularly with regards to the distance needed to receive services. Between 2013 and 2020 over 100 rural hospitals have closed across the United States. A recent report by the GAO found that when rural hospitals closed, rural residents then had to travel around 20 miles farther for common services. The COVID-19 pandemic has impacted rural areas at an alarming rate, and ensuring the vaccination of all residents, but particularly Medicaid residents in these regions on a wide scale is critical to achieving herd immunity and mitigating the impacts of the COVID-19. If included under this FMAP increase, NEMT services will be a key tool to facilitating access to the vaccine across the country by reducing potential transportation barriers.

Based on a recently released CMS Vaccine Toolkit (PDF), CMS intends to provide additional guidance to states on implementation of the 100 percent FMAP available for payments to providers for administering the COVID-19 vaccines. Until further information is made available, CTAA recommends that NEMT providers, state officials, and other stakeholders look to existing models for coordinating transportation and COVID-19 support such as the Arizona Medicaid coverage of NEMT services to vaccine appointments.