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Non-Emergency Medical Transportation and the Iowa Health and Wellness Plan

On January 1, 2014 Iowa implemented the Iowa Health and Wellness Plan (IHAWP). IHAWP expanded health coverage for low income Iowans through two separate coverage programs - Iowa Wellness Plan and Iowa Marketplace Choice Plan. The Iowa Wellness Plan (IHAWP-WP) is administered by the Medicaid program and covers adults ages 19 to 64 with income up to and including 100% of the Federal Poverty Level (FPL). IHAWP-WP members can choose a provider from the statewide provider network. In the Iowa Marketplace Choice Plan (IHAWP-MPC), adult (ages 19 to 64) members with income from 101-133% of the FPL get health care coverage through private insurers (Coventry Health Care and CoOportunity Health) with plans on the Health Insurance Marketplace and Medicaid pays the members’ premiums for the health plan. IHAWP-MPC members get their health care from providers approved by their private health plan. The IHAWP has been modified in its first 2 years. CoOportunity Health withdrew from the IHAWP-MPC at the end of November 2014. CoOportunity members were automatically transitioned to IHAWP-WP providers on December 1, 2014, however; they retained their designation as IHAWP-MPC members.

Programmatically, the IHAWP was designed to include a benefit structure more like commercial insurance than traditional Medicaid. Specifically, IHAWP benefits were based on the state of Iowa employees’ commercial health insurance plan and therefore does not contain the extensive benefits traditionally associated with Medicaid under the State Plan and, in particular, does not include the non-emergency medical transportation (NEMT) benefit.

Briefly, the Code of Federal Regulations requires States to “specify that the Medicaid agency will ensure necessary transportation for beneficiaries to and from providers.” Thus, all states are required to make NEMT available to their Medicaid beneficiaries. However, the provision of NEMT services and reimbursement methodologies are determined by the individual state Medicaid programs. In Iowa, an NEMT service broker called TMS Management Group is used to manage NEMT services, including the authorization of transportation, verifying member and trip eligibility, processing transportation claims and reimbursements, and auditing trips and claims. 

The Centers for Medicare & Medicaid Services (CMS) initially approved a waiver of the state of Iowa’s responsibility to provide NEMT services for IHAWP members during the first year of the IHAWP (January 1, 2014 – December 31, 2014) with the possibility of extending the waiver based on an evaluation of the impact on member access to care. After CMS reviewed preliminary data on NEMT and access, Iowa’s NEMT waiver for the IHAWP was extended through July 31, 2015 during which time a review of IHAWP member experiences (based on 2014 survey data) regarding transportation and access to care could be conducted. The findings from this data were mixed with somewhat more IHAWP-WP members (who do not have an NEMT benefit) than traditional Medicaid State Plan members (who do have an NEMT benefit) experiencing an unmet need for transportation to or from a health care visit. However, the difference was not statistically significant. Due to these results, CMS extended the NEMT waiver through March 31, 2016 (and subsequently through June 30, 2016) and requested the independent evaluators of the IHAWP conduct an additional survey of IHAWP and Medicaid State Plan (MSP) members regarding transportation and access to health care to provide additional information to consider before granting further extensions of the NEMT waiver. In response to this request, the Public Policy Center fielded a survey to over 30,000 IHAWP-WP, IHAWP-MPC, and MSP members (10,180 from each program) from October 28, 2015 – January 15, 2016. This report includes the findings from the analyses of the survey data and associated administrative claims experiences of the members who responded to the survey.

Bentler, S. E., McInroy, B., Damiano, P., Heeren, T., & Momany, E. Non-Emergency Medical Transportation and the Iowa Health and Wellness Plan. : University of Iowa Public Policy Center.