1115 Waiver Element: NEMT
Medicaid Rules for Covering Non-emergency Medical Transportation (NEMT)
In addition to emergency medical transportation, Medicaid covers non-emergency medical transportation (NEMT). NEMT provides enrollees with transportation to and from scheduled Medicaid-covered services, like physician appointments or dialysis.
Medicaid rules require states to ensure transportation for all Medicaid recipients to and from Medicaid-covered health care services. The Secretary of Health and Human Services has authority to waive Medicaid rules related to benefits, including NEMT. To date, several states have received a waiver of NEMT benefits.
Arguments for keeping NEMT as a Medicaid benefit
NEMT ensures Medicaid enrollees can get the right care at the right time.
- Lack of transportation is a much greater barrier to care for Medicaid enrollees than it is for enrollees in private insurance: A study based on National Health Interview Survey data found that Medicaid enrollees were 10 times more likely to report that transportation was a barrier to accessing timely primary care than were people who were privately insured.
- NEMT helps Medicaid enrollees access the care they need: The Medicaid program is designed to address the unique health care needs of low-income people and improve their access to care. Omitting NEMT does not further this goal. Many low-income individuals do not have cars and cannot afford or access public transportation. That makes it difficult for them to access health care. NEMT is essential to making Medicaid coverage work for them.
Without NEMT, Medicaid enrollees are likely to miss necessary appointments, potentially leading to higher health care costs down the road.
- Reliable transportation is correlated with fewer emergency visits: Studies have consistently shown that providing transportation to non-emergency care results in fewer missed appointments, shorter hospital stays, and fewer emergency room visits.
- Poor access to transportation can increase emergency room use: Alternatively, poor access to transportation is related to lower use of preventive and primary care and increased use of emergency department services. Routine care provided in an ER can be up to three times more expensive than care in an office setting.
Experience shows that Medicaid expansion enrollees need NEMT.
- Without NEMT, the poorest expansion enrollees are those most likely to miss care: Evaluations of Iowa’s Medicaid expansion NEMT waiver show that, without NEMT, some of the lowest-income enrollees are those most likely to miss necessary appointments. A survey of Iowa’s Medicaid expansion enrollees found that unmet need for medical transportation was highly correlated with income and that 13 percent of new enrollees with incomes below 100 percent of poverty could not get transportation to or from a health care visit.
The patients that most frequently use NEMT have severe, high-cost health care needs that are exacerbated by interrupted care.
- NEMT keeps chronically ill patients healthier and in regular care: The majority of NEMT services are used for regularly scheduled, non-emergency medical trips for behavioral health services, substance abuse treatment, and dialysis treatment. Without NEMT, patients with these conditions could miss appointments, making treatment less effective. Chronically ill patients could end up sicker and hospitalized or institutionalized, leading to more expensive care.
NEMT is cost-effective for states.
- By improving access to routine care, NEMT saves states money: Research from the Federal Transit Administration shows that NEMT services directly save states money for some medical conditions, reducing the total cost of treating those conditions.
- NEMT is cost-effective in the long run: Even when NEMT does not produce immediate savings, it is cost-effective in the long run because it decreases future health care costs and improves quality of life.
- NEMT spending has a high rate of return: A study conducted by Florida State University concluded that if only 1 percent of NEMT trips prevented a hospital stay, the return on investment to the state would be 1,108 percent. In other words, the state saved an estimated $11.08 for each $1 invested in non-emergency transportation. A study commissioned by the state of Arkansas echoed these findings, reporting to the legislature that NEMT is “a very cost effective benefit” and recommended the state not eliminate the benefit.
Waiving NEMT does not further the objective of the Medicaid program.
- NEMT helps ensure that Medicaid can address enrollees’ health needs: The Medicaid program is designed to address the unique health care needs of low-income people and improve their access to care. Omitting the NEMT benefit from the program does not further this goal.
- Congress has recognized Medicaid enrollees’ unique need for NEMT: Congress recognized the importance of NEMT for Medicaid enrollees by explicitly listing it as one of the specific Medicaid benefits beyond the essential health benefits that must be included in Medicaid expansion programs.
If you cannot keep NEMT in the Medicaid expansion: Suggestions for minimizing the impact on consumers
Limit the waiver.
- Limit the waiver to higher-income enrollees: Limit the NEMT waiver to expansion enrollees over the poverty level. Given that higher-income enrollees in Iowa experienced less trouble accessing transportation to care than lower-income enrollees, limiting the waiver might have less of an impact on access to care.
- Place a time limit on the NEMT waiver: Place a one-year (or less) limit on the request to waive NEMT and require the state to evaluate the waiver’s impact on access to care. This is consistent with NEMT waivers CMS has approved to date.
- Exclude certain medical conditions from the NEMT waiver: Make specific types of care exempt from the NEMT waiver to ensure that expansion enrollees can access the most critical aspects of their care. Work with medical professionals to identify the conditions and types of care that are vitally important to a patient’s health and cannot be missed or postponed, such as dialysis services and Medication Assisted Treatment for substance use disorder. Under the ACA, every state must ensure that beneficiaries who are “Medically Frail” can receive the regular “state plan” Medicaid benefit package to the extent that other expansion adults do not receive these benefits. Conditions can be excluded from the NEMT waiver either in the terms of the waiver itself or by ensuring that they are part of the required screening for which beneficiaries are medically frail.
Don’t make it hard for enrollees to comply with wellness program requirements.
- Avoid combining NEMT waivers with wellness programs: If the state does not provide medical transportation to and from non-emergency care, it does not make sense to penalize patients who can’t make it to wellness visits.
Monitor the impact.
- Include a robust data collection and evaluation component: Learn from states that have evaluated existing NEMT waivers. Contact researchers and advocates in those states to learn about their approaches for program evaluation. For example, Iowa released a preliminary report tracking the expansion population’s experience with transportation barriers to care. A follow-up analysis will compare this type of data with the experience of traditional Medicaid recipients who do have access to NEMT.
Start making the case to change the program.
- Collect evidence of the impact on consumers: Legislation and waivers can be modified. Document the impact of omitting NEMT on enrollees’ access to care. Use stories from enrollees and providers to help build your case to add NEMT as a benefit.
- Plan a campaign with a broad coalition: Reach out to other groups that might be affected by omitting NEMT, including NEMT and health care providers. Build a coalition to argue for reinstating this Medicaid benefit.
States with Cost Sharing Waiver Element
*Waiver Pending Approval
Update June 29, 2018: the Federal District Court for the District of Columbia vacated CMS’s approval of Kentucky’s waiver, halting implementation of work requirements in that state. See expanded details at the top of the current page.
Update 2/1/2018: CMS approves Indiana waiver containing work requirements and lockout provisions. View our statement.
Update 1/24/2018: With CMS’s approval on January 12, Kentucky became the first state to get work requirements approved in its Medicaid program.
Update 1/12/2018: The Trump Administration announces guidance to state Medicaid directors allowing states to tie Medicaid eligibility to work status using 1115 waivers.
1115 Waiver Resources
Tools for Advocates
A waiver is a state request that the Secretary of Health and Human Services waive certain federal health care program requirements, usually in Medicaid (Section 1115 waivers) or the marketplaces (Section 1332).
- Waiver Strategy Center Home
- Opposing Restrictive Medicaid Waivers in Your State: Advocacy Toolkit
- Get an overview of the process at Waivers 101.
- Dig deeper into the elements of Medicaid that are under attack by section 1115 waivers, including their impact on oral health.
- Read Families USA Comments on state waiver requests.
Our partners in the states are our best resource. If you learn about a waiver being developed in your state, please let us know. Contact Us