CMS Issues Guidance on Medicaid Transportation Assurance

For many individuals in the Medicaid program, lack of transportation can be a significant barrier to health care access. As a result, Medicaid transportation benefits are a critical component of effective care. On September 28, 2023, the Centers for Medicare and Medicaid Services (CMS) issued new, comprehensive guidance on these benefits: Assurance of Transportation: A Medicaid Transportation Coverage Guide.[1] This guidance consolidates existing and new Medicaid transportation policy, much of which focuses on three key areas (each described in more detail below):

(1) Providing further clarity on the scope of transportation services

(2) Emphasizing the importance of meeting the two main transportation access requirements and

(3) Improving access to necessary transportation for special populations, especially those experiencing complex scenarios (e.g., extended wait times or long-distance trips).

Scope of Services: CMS’s new guidance begins by providing important clarity on the scope of Medicaid transportation services. As outlined in the guidance, Medicaid coverage includes two key transportation benefits: emergency and non-emergency medical transportation (NEMT). Both benefits are established via Medicaid’s transportation assurance: an element of Medicaid law and regulations that requires states to provide access to transportation for Medicaid beneficiaries who have no other means of transportation to receive a covered service.[2]

Access Requirements: While the guidance explains that states have significant flexibility in how to provide transportation benefits—based on the operational limits of the state as well as the type of terrain and geography in which the state is operating—it emphasizes that states must provide transportation services that meet two main requirements. First, the services must be the least costly and most appropriate mode suited to the needs of the beneficiary. Second, the services must provide transport to the nearest qualified provider.[3]

In meeting these requirements, CMS indicates that states must often balance the Medicaid program’s needs for efficiency and cost containment with the rights and needs of beneficiaries. For example, in instances where the cost of transportation is similar for both a near and a distant provider—or where a distant provider has special capabilities/capacities—the state runs the risk of violating the beneficiary’s freedom of choice if it tries to implement the nearest qualified provider concept too strictly.

Special Populations: As part of the new guidance, CMS also outlines requirements and considerations when providing transportation for special populations.[4] These populations include but are not limited to beneficiaries with disabilities, beneficiaries with behavioral health needs, American Indian and Alaska Native (AI/AN) beneficiaries, and more generally, beneficiaries living in rural areas. For example, the guidance outlines the following policies and approaches specific to these populations:

Beneficiaries with Disabilities: States are required to consider a beneficiary’s support needs in determining the most appropriate mode of transportation. For example, if a beneficiary uses a wheelchair, the state must ensure that the transportation provider transports the beneficiary in a wheelchair-accessible vehicle.

Beneficiaries with Behavioral Health Needs: States are encouraged to cover transportation services that are specifically tailored to beneficiaries with behavioral health needs and can require transportation providers to be trained and credentialed in serving beneficiaries with such needs.

Tribal Transportation: Many tribal communities and Medicaid beneficiaries may face barriers unique to their communities’ experiences with transportation such as not having a formal street address, living in homes that are isolated from roadways, and using unpaved and rugged roadways that cannot be traveled without special vehicles. States, therefore, have the flexibility to design transportation benefits to meet the unique needs of beneficiaries who experience such barriers and encourage drivers to use odometer readings or GPS coordinates to navigate a location and calculate mileage.

Rural Areas: In areas where public transportation is generally absent or difficult to access, transportation providers have to travel for longer distances to help beneficiaries reach covered services and medical providers. As a result, individual transportation providers may be limited in how many beneficiaries they are able to accommodate in a given day. In such instances, CMS gives states the flexibility to set higher base rates or establish supplemental payments to recognize the higher cost of doing business in rural areas.

In addition, the new guidance provides critical information on current Medicaid policy when providing transportation under a wide range of circumstances, such as: Early and Periodic Screening, Diagnostic and Treatment (EPSDT) transportation; transportation for the direct benefit of children under 21; transportation for visitation; transportation for optional benefits; transportation for beneficiaries dually eligible for Medicaid and Medicare; school-based transportation; coverage of emergency transportation for individuals who do not have a qualifying[5] immigration status; coverage of transportation to services not provided by a Medicaid provider; Ground Emergency Medical Transportation (GEMT); treatment at the scene without transport; law enforcement as a mode of transportation; and Transportation Network Companies (TNCs), also known as Ridesharing Organizations.[6]

Taken together, the new guidance serves as a powerful tool to advance the health-related social needs of Medicaid beneficiaries, especially those most affected by deteriorating health outcomes. CHLPI applauds this effort by CMS to expand the scope of essential transportation services by clarifying the flexibilities that exist to effectively accommodate and integrate both beneficiaries and their providers in the health care system. We hope that states benefit from this guidance by utilizing existing and new policies and programs that improve and advance access to necessary medical transportation and that CMS continues to provide similar support to advance a range of health-related social needs.

[1] The Medicaid Transportation Coverage Guide serves to satisfy the requirements of section 209(b)(3) of the Consolidated Appropriations Act and has been informed by feedback from interested parties, technical assistance requests from states, listening sessions conducted by CMS, and suggestions, recommendations, and innovations submitted to CMS on ways to improve non-emergency medical transportation (NEMT) for Medicaid beneficiaries.

[2] Assurance of Transportation: A Medicaid Transportation Coverage Guide, CMS (September 28, 2023), pg. 7.

[3] Assurance of Transportation: A Medicaid Transportation Coverage Guide, CMS (September 28, 2023), pg. 13-14.

[4] Assurance of Transportation: A Medicaid Transportation Coverage Guide, CMS (September 28, 2023), pg. 16-17.

[5] The language used in the CMS guidance is “unsatisfactory immigration status,” which we have reworded to “individuals who do not have a qualifying immigration status.”

[6] Assurance of Transportation: A Medicaid Transportation Coverage Guide, CMS (September 28, 2023), pg. 17-23.