Letter to Xavier Becerra, HHS Secretary - Preserve Nonemergency Medical Transportation for Communities in Need

Statement

Dear Mr. Secretary:

We are writing to seek your assistance to help avoid possible unintended consequences that could occur when the Centers for Medicare and Medicaid Innovation's (CMMI) Repetitive Scheduled Non-Emergent Ambulance Transport (RSNAT) model is expanded nationwide on December 1st, 2021 -- just a few weeks away. The RSNAT model is an important program integrity initiative that saves the Medicare Trust Fund money by using prior authorization to deny ambulance services to beneficiaries that do not meet Medicare's qualifying criteria. Without modifications, however, it has the potential to leave vulnerable Medicare beneficiaries without access to lower cost nonemergency medical transportation (NEMT) to dialysis and wound care services.

Since 2015, there has been a demonstration of the RSNAT model in nine states along the East Coast. Currently, half of Medicare ambulance rides are nonemergency to dialysis or wound care services ostensibly because patients are too ill or too frail to travel by means other than NEMT. The patients also are using ambulances because there is no lower cost and more clinically appropriate Medicare NEMT benefit available. While we agree that ambulances are an expensive and inappropriate mode of transport to dialysis and wound care for almost all Medicare patients, it also is the case that RSNAT has highlighted the need for another transportation option for these vulnerable Medicare beneficiaries.

At least half of the Medicare beneficiaries who lose ambulance service are low-income, disabled or elderly. They face many barriers related to these social determinants of health. In CMMI's own RSNAT evaluation, beneficiaries reported having to often choose between medical transportation and rent or food.

To date, RSNAT has resulted in a shifting of transport service to Medicaid NEMT for full dual eligibles. In fact, data from the demonstration states show increased spending for Medicaid stretcher and wheelchair van transports immediately following the implementation of RSNAT. Medicaid NEMT, however, is only available to full dual eligible beneficiaries; it is not available to partial dual eligible beneficiaries. While NEMT can fill in gaps for full dual eligibles as RSNAT is implemented, other highly vulnerable beneficiaries are still in need of transportation. These include the partial dual eligibles who make up almost 20% of the target population and who have incomes either below 135% of the federal poverty level or less than $24,000 annually for a two-person household.

In order to address the potential access issues this demonstration could create, we believe CMMI should consider a low-cost NEMT benefit that can be added to the RSNAT model prior to its national implementation to fill "gaps" when beneficiaries lack other means of transportation. Under CMMI authority, CMS could test whether this additional service could improve or maintain quality and produce savings for Medicare by improving access to important, lower-cost transportation services. Most NEMT rides cost less than $40, a fraction of the cost of the ambulance trips they would replace. Several studies document that NEMT is a net cost-saver to Medicaid for certain beneficiaries, especially those with ESRD.

In addition, since NEMT is now a statutorily required Medicaid benefit, the infrastructure already exists to deliver it in every state. Almost all state Medicaid NEMT programs have prior authorization processes in place to ensure that NEMT is only provided to individuals who lack transportation to medically necessary services. Approximately 5% of Medicaid beneficiaries require NEMT, and dialysis facilities are among the most common destinations. The majority of Medicaid programs hire benefits managers or brokers to ensure that NEMT is provided in the most cost-efficient manner. As a result, Medicaid NEMT is well-suited as a comprehensive benefit for the population left with no transportation to vital health services by RSNAT.

We greatly appreciate your attention to our concerns. We strongly urge that HHS address the potential gaps the RSNAT model could create prior to any national expansion,