New CMS Rules for Non-Emergency Transportation: Who wins? Who loses?
Are you confused whether new CMS rules are supporting or cutting non-emergency medical transportation (NEMT)? Could both of these seemingly opposing statements be true?
- Thanks to a new CMS rule supporting more non-medical support services, Lyft is expanding its partnerships with BCBS Institute and Humana to provide more non-emergency medical transportation services.
- CMS is developing a rule that could curtail non-emergent medical transportation access by making it easier for states to stop paying for benefits — a move that could impact the healthcare of many low-income Americans and drastically cut into providers’ revenues.
While transportation is a critical component of healthcare delivery and one of the key social determinants of health, non-emergency medical transportation may soon be cut for Medicaid. Over 3.6 million people miss or delay medical care because they lack appropriate transportation. However, NEMT is expanding under Medicare Advantage plans and attracting new technology players and ride-sharing services.
What is NEMT?
For many Americans, non-emergency medical transportation is a critical government benefit. Forty-two programs across six US federal departments provide NEMT funding, and HHS oversees or administers 21 of these programs — including Medicare, Housing and Urban Development, Transportation, and Veterans Affairs. But the bulk of NEMT costs are attributed to Medicaid — approximately $1.3 to $3 billion, according to some estimates.
Medicaid transportation at risk in some states
Since 1966, states have been required to provide NEMT benefits for qualified Medicaid beneficiaries. However, the new administration is threatening the future of NEMT through Medicaid. A notice of proposed rulemaking for NEMT with a date of 05/00/2019 would cut federal funding and give states more power to eliminate services they consider unaffordable.
Kaiser Family Foundation provides a table of NEMT benefits across the country detailing any limitations set by each state. Iowa and Indiana are the only states with a waiver to opt out of providing transportation. Kentucky and Massachusetts have waivers pending. Kentucky has received a lot of criticism for its Kentucky HEALTH plan and a federal judge has been asked to block its Medicaid overhaul.
Skipped healthcare appointments
A recent study by Health Services Insights, says it’s too early to cut transportation benefits for Medicaid enrollees. Among low-income populations surveyed, 24–51 percent report missing or rescheduling an outpatient appointment because of unreliable transportation. NEMT access is especially critical for rural patients. Medicaid client Fallon Kunz of Indiana relies on her wheelchair for mobility. The 29-year old lives at home with her father, but outside the route of a Medicaid transit van.
Community health workers, who can travel to patients’ homes, and telehealth can be potential alternatives to reduce the need for some in-person medical care at a doctor’s office.
Opponents to NEMT
Proponents of limiting Medicaid NEMT claim the strategy will cut escalating costs and more closely mirror private insurance benefits. They also cite the risk of fraud in the system. It may surprise some to know that the fraud is not limited to individuals or some businesses. The North Carolina Department of Health and Human Services improperly claimed millions of dollars in reimbursement for NEMT from the federal government.
ROI of NEMT
Recent research by the Medical Transportation Access Coalition says NEMT actually provides a substantial ROI. MTAC estimates Medicaid savings of $40 million per month based on Medicaid data for just three high-cost chronic conditions — end-stage renal disease, diabetic wound care, and treatment for substance abuse disorders. One NEMT provider, Circulation, claims adherence for substance abuse programs improved by 20 percent, and hospital readmissions rates reduced to 9 percent.
But even more cost savings could be realized with advances in technology. New research in the American Journal of Public Health estimates modern NEMT saves $268 per expected user utilizing digital transportation networks. Twenty-eight states do not even coordinate transportation with their Medicaid agency. Without a state coordinating council, a separate vehicle may be sent to a disabled veteran, a Medicaid patient, and someone who needs ADA paratransit, despite patients living within a block of one another.
NEMT providers
Medicaid is required to provide NEMT services using the most appropriate and least costly form of transportation. Most states rely on NEMT brokers or managed-care organizations (who typically subcontract NEMT brokers) to coordinate transportation by taxi, van, or public transit. Increasingly, health insurers and systems are partnering directly or indirectly with Uber and Lyft to address transportation gaps with ride-sharing services.
The next generation of NEMT brokers specializes in ‘on-demand’ services and increase access to transportation through connectivity.
- Veyo says it uses data and technology to automatically adjust for service and fleet demand issues.
- Two-year old startup Circulation recently merged with LogistiCare, the nation’s largest NEMT broker. The companies expect their synergies will improve efficiencies enough for LogistiCare to recoup its $46 million investment in 36 months.
- Kaizen Health, Ride Health, Roundtrip, Hitch Health have all signed contracts with health systems or managed care organizations across multiple states.
Why are on-demand NEMT providers expanding?
While the transportation benefit in Medicaid may be at risk in some states, NEMT represents growing area of interest for Medicare Advantage plans. Health plans are beginning to realize the benefits of NEMT in delivering better outcomes for value-based care, and CMS provides new flexibility in what Medicare Advantage plans may cover as “supplemental health care benefits.” Insurers are being advised to differentiate their Medicare Advantage plans with NEMT by:
- Introducing community trips as a value-added benefit
- Focusing on technology, and
- Encompassing all modes of transportation.
New NEMT tech companies are poised to scale and solve transportation inefficiencies with artificial intelligence (AI) technologies, but AI can also address public transit inefficiencies. In Canada, Toronto-based Pantonium proved that public transit can run on-demand without fixed bus routes. Pantonium’s AI technology created journeys based on passenger demand. After three months, its pilot program saw a 300 percent increase in monthly ridership and a per vehicle increase from 6 riders per hour to over 30 riders per hour.
Upcoming NEMT legislation
Healthcare providers may need to address possible NEMT Medicaid changes before May 2019. CMS may not have the authority to make this change to transportation benefits, according to Eliot Fishman, senior director of health policy at Families USA. “If the administration goes in that direction, I expect there will be a legal challenge,” he says.
HHS/CMS is open to public input on the new NEMT rule. You can submit a comment to the agency contact listed here.
Written by Angela Dunn for Patchwise Labs.
