	Background

Within the Department of Health and Human Services (HHS), CMS is  responsible for overseeing Medicaid at the federal level, while states are  responsible for the day-to-day operations of their Medicaid programs. For example, states  are not permitted to exclude coverage of mandatory benefits, such as  NEMT, under their state plans, but they may do so by obtaining a waiver  of the requirement under a demonstration. CMS has required those states that  have obtained approval to exclude the NEMT benefit for one year under a  demonstration to submit annual evaluations on the effect of this change  on access to care, which will inform the agency’s decision to approve any  extension requests. We also previously reported that there are many  federal programs, including Medicaid, that provide the NEMT benefit to  the transportation-disadvantaged population. State Efforts to Exclude Medicaid NEMT Benefits Are Not Widespread

Among the 30 states that expanded Medicaid as of September 30, 2015,  25 reported that they did not undertake efforts to exclude the NEMT  benefit for newly eligible Medicaid enrollees and were not considering  doing so. Three states reported pursuing such efforts, and two states  did not respond to our inquiry, although CMS indicated that neither of  these states undertook efforts to exclude the NEMT benefit. 1.) However, only Indiana and Iowa had received approval from HHS for  these waivers as of September 30, 2015, while Arizona was still seeking  approval. Indiana: Indiana’s effort to exclude the NEMT benefit from coverage pre-dates PPACA and is not specific to newly eligible enrollees under the state’s expansion. Evaluations of Efforts to Exclude the NEMT Benefit in Two States Assess Comparability of Access for Enrollees With and Without Benefit

The two states that obtained approval to exclude the NEMT benefit for  newly eligible Medicaid enrollees—Indiana and Iowa—are at different  stages of evaluating the effect this will have on enrollees and have  different time frames for reporting their results. According to a  draft of the evaluation design, the state plans to survey enrollees and  providers to compare the experiences of Medicaid enrollees with and  without the NEMT benefit with respect to missed appointments,  preventative care, and overall health outcomes; the state also seeks to  determine whether enrollees residing in certain parts of the state are  more affected by a lack of this benefit. However, looking within the group of newly eligible enrollees without the  NEMT benefit, the Iowa evaluation found that those with lower incomes— under 100 percent of the FPL—tended to need more transportation  assistance and have more unmet needs than those with higher incomes. Research and Advocacy Groups Raised Concerns Regarding the Implications of Altering the Transportation Benefit for Newly Eligible Enrollees

Officials from the 10 research and advocacy groups we interviewed— which represent Medicaid enrollees, underserved populations, and health  care providers—noted potential concerns of excluding the NEMT benefit  as it relates to enrollee access to services and costs of coverage. Access to Services: Officials from 9 of the 10 groups we interviewed  indicated that excluding the NEMT benefit would impede newly eligible  enrollees’ ability to access health care services, particularly individuals  living in rural or underserved areas, as well as those with chronic health  conditions. The department  provided technical comments, which we incorporated as appropriate.
Why GAO Did This Study

Medicaid, a federal-state health financing program for certain low-income individuals, offers NEMT benefits to individuals who are unable to provide their own transportation to medical appointments. This benefit can be an important safety net for program enrollees as research has identified the lack of transportation as affecting Medicaid enrollees' access to services. Under PPACA, states can opt to expand eligibility for Medicaid to certain adults. However, some states have excluded the NEMT benefit for these newly eligible enrollees by obtaining a waiver of the requirement under the authority of a Medicaid demonstration project.
GAO was asked to explore state efforts to exclude the NEMT benefit for newly eligible Medicaid enrollees, and the potential implications of such efforts. This report examines (1) the extent to which states have excluded this benefit for newly eligible enrollees, and (2) the potential implications of such efforts on enrollees' access to services.
GAO contacted the 30 states that expanded Medicaid under PPACA as of September 30, 2015; reviewed relevant documents and interviewed officials in the 3 states that have taken efforts to exclude the NEMT benefit; reviewed prior research on transportation for disadvantaged populations; and interviewed officials from CMS, the federal agency that oversees Medicaid, and 10 research and advocacy groups based on referrals from subject-matter experts and knowledge of the NEMT benefit.
HHS provided technical comments on a draft of this report, which GAO incorporated as appropriate.

What GAO Found

States' efforts to exclude nonemergency medical transportation (NEMT) benefits from enrollees who are newly eligible for Medicaid under the Patient Protection and Affordable Care Act (PPACA) are not widespread. Of the 30 states that expanded Medicaid as of September 30, 2015, 25 reported that they did not undertake efforts to exclude the NEMT benefit for newly eligible enrollees, 3 states reported pursuing such efforts, and 2 states—New Jersey and Ohio—did not respond to GAO's inquiry. However, the Centers for Medicare & Medicaid Services (CMS), within the Department of Health and Human Services (HHS), indicated that neither New Jersey nor Ohio undertook efforts to exclude the NEMT benefit.
Two of the three states pursuing efforts to exclude the NEMT benefit—Indiana and Iowa—have received waivers from CMS to exclude the benefit, and are in different stages of evaluating the effect these waivers have on enrollees' access to care.
Indiana's draft evaluation design describes plans to survey enrollee and provider experiences to assess any effect from excluding the NEMT benefit.
Iowa's evaluation largely found comparable access between enrollees with and without the NEMT benefit; however, it also found that newly eligible enrollees beneath the federal poverty level tended to need more transportation assistance or have more unmet needs than those with higher incomes.
Officials from the groups that GAO interviewed identified potential implications of excluding the NEMT benefit, such as a decrease in enrollee access to services and an increase in the costs of coverage. For example, nearly all of the groups indicated that excluding the NEMT benefit would impede access to services, particularly for those living in rural areas, as well as those with chronic health conditions.