Under Medicare, NEMT services are allowed to be delivered via  ambulance transport to scheduled nonemergency medical services for  some beneficiaries. Medicaid Key Features

Under Medicaid, states must ensure NEMT for beneficiaries who have no  other means of transportation to needed medical services—such as  doctors’ appointments and various types of therapies—and can provide  NEMT in a variety of ways. While the modes of  transportation used for NEMT across states were similar, state officials  reported using a variety of models to administer NEMT, including paying  for NEMT on a fee-for-service basis; contracting with managed care  health plans to provide health care services, including NEMT, for a per- member, per-month fee; and contracting with transportation brokers to  manage all or some aspects of NEMT on states’ behalf. See table 2 for examples of states’ models for administering NEMT. Under Medicaid, CMS uses a range of regular oversight  activities to oversee states’ operations of their NEMT programs, including  reviewing and approving state Medicaid plans and amendments; issuing  guidance; conducting a range of program integrity activities, such as  claims and state program integrity reviews; and offering technical  assistance upon request. CMS Uses Regular Oversight Activities to Monitor NEMT

			Medicare NEMT

CMS oversees Medicare NEMT through CMS’s regular program integrity  activities. CMS Issues Guidance on Medicaid NEMT, but Some Guidance Is Outdated or May Be Otherwise Limited

Although CMS periodically issues NEMT guidance, some guidance is  outdated or may be otherwise limited because legislative and other  changes have affected Medicaid and states’ NEMT programs. However, this guidebook  contains outdated information. However, these materials are targeted for  patients and providers rather than state Medicaid programs. State  Medicaid agencies rely on it when designing and administering their  NEMT programs to help ensure compliance with federal requirements  while incorporating current practices to meet beneficiaries’ needs. Standards for Internal Control in the  Federal Government states that management should ensure that there  are adequate means of communicating with, and obtaining information  from, external stakeholders that may have a significant impact on the  agency’s ability to achieve its goals. Effective communication can take  many forms such as through guidance, training, or publication of best  practices. Selected States Have Taken Steps to Address Some Medicaid NEMT Challenges, and Information on State NEMT Practices Is Available

Through our work, we identified a range of challenges related to providing  NEMT and steps taken by some states to address these challenges. Challenges and steps identified were related to maintaining program integrity,  contracting with and overseeing vendors, and accessing NEMT. Containing Costs

Officials from selected states and stakeholders reported challenges  containing Medicaid NEMT costs due to increased utilization and certain  trip factors. CMS and state auditor reports, officials from selected states, and  stakeholders also identified other program integrity challenges that could  make NEMT vulnerable for fraud, waste, and abuse, including:
Enrolling providers: In annual summary reports of comprehensive  program integrity reviews, CMS identified one state that did not  require and collect key information needed for effective oversight,  such as criminal conviction information from NEMT providers, making  the state vulnerable to enrolling problem providers in its NEMT  program. Other organizations have or are in the process  of collecting information on states’ approaches to administer their  Medicaid NEMT programs. CMS officials reported that the agency is  considering assessing whether additional NEMT guidance is needed, but  has not set any timeframes for conducting that assessment. Recommendations

To ensure states have appropriate and current guidance to assist them in  designing and administering Medicaid NEMT, we recommend the  Secretary of HHS direct CMS to assess current Medicaid NEMT guidance  and update that guidance as needed. HHS concurred with our  recommendation and provided technical comments, which we  incorporated as appropriate. Appendix I: Objectives, Scope, and Methodology

This report addresses non-emergency medical transportation (NEMT)  under Medicare and Medicaid and examines: 1) the key features of  NEMT services under Medicare and Medicaid and how services are  administered; 2) steps that the Centers for Medicare & Medicaid (CMS)  have taken to oversee NEMT under Medicare as well as Medicaid; and 3)  the challenges that exist in providing NEMT under Medicaid and steps  that selected state Medicaid agencies have taken to address those  challenges. We also  reviewed key reports, such as Medicare Payment Advisory Commission,  Department of Health and Human Services-Office of Inspector General  (HHS-OIG), and Transit Cooperative Research Program (TCRP) reports,  and prior GAO reports. In addition, for  Medicaid, we interviewed officials from 15 selected state Medicaid  agencies.
Why GAO Did This Study

Medicare and Medicaid provide NEMT services to eligible beneficiaries who need transportation to scheduled nonemergency care. CMS administers Medicare NEMT benefits and is responsible for overseeing Medicaid at the federal level. Spending on NEMT under these programs was $2.7 billion in 2013—$1.2 billion for Medicare and $1.5 billion for Medicaid. Increased demand for NEMT because of increased Medicaid enrollment has led states to seek ways to more efficiently operate NEMT.
GAO was asked to review NEMT under Medicare and Medicaid. This report examines 1) key features of NEMT services under Medicare and Medicaid and how these services are delivered; 2) steps CMS has taken to oversee NEMT under Medicare as well as Medicaid; and 3) the challenges that exist in providing NEMT under Medicaid and steps that selected state Medicaid agencies have taken to address those challenges.
GAO reviewed key documents and interviewed officials from CMS; 15 selected states that range in terms of Medicaid enrollment and geography; and stakeholders, including transportation brokers, health plans, and health care and transportation industry groups.

What GAO Found

The nonemergency medical transportation (NEMT) benefits offered by Medicare and Medicaid differ. Medicare provides NEMT via ambulance only when other means of transportation, such as a taxi or wheelchair van, would jeopardize the health of the beneficiary. Medicaid NEMT is generally available for beneficiaries who have no other means of transportation to medical services. States are responsible for the daily operations of their Medicaid programs and have discretion in how they deliver NEMT. Officials from 15 selected states reported using a variety of models to administer NEMT, including transportation brokers, which are entities that contract with states to administer NEMT services.
The Centers for Medicare & Medicaid Services (CMS), within the Department of Health and Human Services (HHS), oversees Medicare and Medicaid at the federal level, but this oversight varies by program. CMS generally uses regular program integrity activities—such as claims reviews—to oversee Medicare NEMT. Under Medicaid, CMS also uses regular oversight activities, and these include overseeing states' program integrity activities and periodically issuing guidance. However, some of CMS's guidance is outdated or may be of limited use because of legislative and other changes that affect Medicaid and states' NEMT programs. For example, a 1998 guidebook on NEMT contains outdated information on implementing NEMT transportation broker programs. Other more recent guidance is targeted for patients and providers rather than state Medicaid programs. However, these programs also benefit from updated guidance on strategies to ensure compliance with federal requirements while incorporating current practices to meet beneficiaries' needs. Guidance for state Medicaid programs is particularly important because NEMT is at high risk for fraud and abuse; some selected states and stakeholders GAO interviewed reported that updated guidance could be helpful. Standards for Internal Control in the Federal Government states that management should ensure adequate means of communicating with stakeholders. Effective communications can take many forms, including guidance. CMS officials reported that the agency is considering assessing whether additional NEMT guidance is needed, but has not set time frames for conducting this assessment.
GAO identified four types of challenges related to Medicaid NEMT and several steps taken by states to address some of these challenges. Challenges reported related to containing costs, maintaining program integrity, contracting with and overseeing vendors, and accessing NEMT. For example, states reported challenges containing NEMT costs due to increased NEMT utilization and reported implementing practices to help address these challenges. Such practices include setting fixed provider reimbursement fees that remained relatively constant in recent years. Officials from 7 of the 15 selected states and 6 stakeholders GAO interviewed reported that having information on how states administer NEMT and ways to address challenges could be helpful to states. Some of this information is available; for example, CMS reported collecting information on states' approaches through state Medicaid plans and posting this information on CMS's website. Other organizations, such as the Transit Cooperative Research Program, have or are in the process of collecting such information.

What GAO Recommends

GAO recommends that the Secretary of HHS direct CMS to assess current Medicaid NEMT guidance and update it as needed. HHS concurred with our recommendation and provided technical comments which we incorporated as appropriate.