Medicaid's assurance of transportation: the federal rule behind every NEMT ride
The assurance of transportation is the federal requirement, in 42 CFR 431.53 and section 1902(a)(4)(A) of the Social Security Act, that every state Medicaid plan ensure necessary transportation to and from providers and describe how it will do so. CMS reads it as a duty to make sure members with no other way to get there can reach covered care, not a promise to pay for every ride.
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What the rule requires
The regulation is two lines long. 42 CFR 431.53 says a state plan must “specify that the Medicaid agency will ensure necessary transportation for beneficiaries to and from providers” and “describe the methods that the agency will use to meet this requirement.” The Consolidated Appropriations Act, 2021 then wrote the same duty into the statute, in section 1902(a)(4)(A) of the Social Security Act.
CMS set out its reading of the rule in a 2023 letter to state Medicaid directors, SMD 23-006. The duty covers emergency and non-emergency transport. It applies whether rides run through fee-for-service, managed care, or a broker, and the state agency stays responsible even when it hands the work to someone else. States may set operating limits, but a limit cannot be so tight that it blocks a member from covered care.
What riders can count on
- A ride to any covered service when they have no other way to get there, including optional benefits the state covers.
- A mode that fits their needs. CMS gives the example that a wheelchair user must be carried in a wheelchair-accessible vehicle.
- No penalty for missed rides. Rides cannot be denied for no-shows or lateness, and the member cannot be charged for a no-show.
- Extra help for children. Members eligible for EPSDT must be offered help with rides and with scheduling appointments, and a parent or other escort’s trip is covered when the child needs one.
The assurance has limits too. States pay for the least costly mode that is appropriate for the member, generally to the nearest qualified provider, and they can expect members to use their own car when nothing prevents it. Rides for relatives visiting a hospitalized member are not covered.
How states carry it out
Each state describes its methods in the transportation pages of its state plan, usually Attachment 3.1-D. The main choices are:
| Approach | Federal match | What changes |
|---|---|---|
| Administrative activity | 50 percent | The state may pay members directly, and the free-choice and statewide rules do not apply |
| Optional medical service | The state’s regular FMAP | Payment must go straight to the provider, and the member picks any qualified provider |
| Broker under section 1902(a)(70) | The state’s regular FMAP | A broker arranges rides, without the free-choice, statewide, and comparability rules |
| Managed care | The state’s regular FMAP, built into capitation | Health plans arrange rides for their members |
Many states use more than one. Our guide to how states run NEMT covers each model.
The statute also sets a floor for who drives. Section 1902(a)(87) makes each state put a check in place, which may be an attestation, covering four points. Neither the company nor any of its drivers may be barred from federal health care programs or appear on the Inspector General’s exclusion list. Every driver needs a valid license. The company needs a process for dealing with state drug law violations. The company must also have a way to share each driver’s driving record, traffic violations included, with the state Medicaid program. Public transit authorities are exempt.
When a state waives it
A section 1115 waiver can release a state from the assurance for some groups. Iowa’s Wellness Plan waiver drops rides for most expansion adults but keeps them for members who are medically frail and for EPSDT services. That waiver ends December 31, 2026. After CMS said it would stop approving it, Iowa posted notice on September 17, 2026 of a state plan amendment that covers rides for the whole group. Georgia’s Pathways program also leaves out rides, except for members eligible for EPSDT.
Keeping driver records ready
The 1902(a)(87) rules turn on valid licenses and up-to-date driver records. HealthRide tracks license and credential expiration dates for every driver and vehicle, sends reminders before they lapse, and flags anything expired before a trip is assigned. See fleet and credentials.
Frequently asked questions
- Did Congress change the assurance recently?
- It made it statute. Section 209 of the Consolidated Appropriations Act, 2021 wrote the long-standing regulation into section 1902(a)(4)(A) of the Social Security Act. It also added section 1902(a)(87), the minimum screening rules for NEMT providers and drivers, and applied the assurance to Alternative Benefit Plans. The core duty itself did not change.
- Can a state refuse rides to a member who keeps missing pickups?
- No. Under CMS guidance, repeated no-shows or late arrivals are not grounds to stop a member's rides, and neither the state nor a provider may charge a member for a no-show. A state can add steps instead, such as counseling, requiring the member to confirm each ride the night before or that morning, or assigning one provider. CMS says the state should first send the member a letter describing its efforts to accommodate them and the behavior behind the new step.
- Does the assurance cover rides to the pharmacy?
- Yes, when the state covers prescription drugs. The assurance applies to optional benefits a state chooses to cover as well as mandatory ones. CMS lets a state skip pharmacy rides when a reliable mail order or delivery option exists, and suggests adding a pharmacy stop to the return trip from an appointment.
- Can the assurance be waived?
- Yes, through a section 1115 demonstration. Iowa used one to drop rides for most adults in its expansion group and Georgia used one for its Pathways program. Both kept rides for members eligible for EPSDT. Iowa's waiver ends on December 31, 2026, and the state plans to cover rides for the whole group from January 1, 2027.
