Section 1115 waivers and NEMT: how states use them to change the ride benefit
A section 1115 waiver, formally a demonstration, lets the federal government set aside parts of Medicaid law so a state can test a different approach. For NEMT, states have used them to drop the ride benefit for certain adults, as Iowa and Georgia did, and to add or reorganize transportation benefits. CMS must judge each project likely to promote the objectives of Medicaid.
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How a demonstration works
Under section 1115, the HHS Secretary can set aside requirements of section 1902, the core Medicaid state plan rules, for an “experimental, pilot, or demonstration project” that the Secretary judges “likely to assist in promoting the objectives” of the program. It can also let a state spend federal Medicaid money on things the plan would not normally cover.
A few conditions come with it:
- Budget neutrality. CMS policy is that federal spending under the demonstration should not exceed what it would have been without it.
- A set term. Demonstrations usually start with a five-year approval, and extensions run three to five years.
- Public input. The state must post notice, take comments for at least 30 days, and hold two or more public hearings before applying. CMS then opens its own 30-day comment period.
For rides, the key point is that the assurance of transportation sits in section 1902(a)(4). A demonstration can waive it for a defined group.
Three ways states use it for rides
| Kind of change | Current example | What a provider sees |
|---|---|---|
| Taking rides away from a group | Iowa Wellness Plan waives the ride assurance for most expansion adults. Members who are medically frail keep rides, and so do EPSDT services. Georgia Pathways to Coverage gives state plan benefits without NEMT, except for members aged 19 and 20, who get EPSDT services | Members who show active Medicaid but cannot book a Medicaid ride |
| Adding a transportation benefit | Hawaii QUEST Integration covers non-medical transportation for members in its 1115 home and community-based services programs, arranged by the health plans | Familiar codes with new modifiers. A May 2026 memo assigns U7 (to) or U8 (from) so these trips are tracked apart from NEMT |
| Moving rides into managed care | CMS lists section 1115 beside 1915(b) waivers and 1932(a) state plan amendments as authorities for covering rides through managed care | Trips arranged by health plans or the brokers they hire, instead of the state |
Iowa’s ride waiver expires December 31, 2026. CMS told the state it will no longer approve it, so Iowa proposed a state plan amendment, SPA IA-26-0010, adding rides for the whole expansion group from January 1, 2027. Georgia’s demonstration runs on a temporary extension through December 31, 2026.
What providers should watch
- Eligibility for the trip. Check the member’s program and status, not only the Medicaid ID. In Iowa, medically frail status changes the answer for members of the same group.
- Billing memos. Read the state’s memo on a new 1115 benefit before the first claim, since it may add modifiers to codes you already use.
- Sunsets and renewals. Demonstrations end or change on fixed dates. Public notices on the state Medicaid site and the Medicaid.gov demonstration list show what is coming.
The Iowa and Georgia guides cover each state’s program in more detail.
When new riders arrive
When a waiver ends and a group gains rides, much of the new work is repeat appointments. In HealthRide, you schedule a recurring ride once and the trips keep appearing, with pauses for hospital stays. See recurring trips.
Frequently asked questions
- Where is NEMT waived through section 1115 right now?
- Iowa and Georgia are two current examples. Iowa's Wellness Plan waives rides for most expansion adults, while members who are medically frail and EPSDT services keep them. Georgia's Pathways to Coverage program leaves out rides for everyone except members eligible for EPSDT. Both approvals run through December 31, 2026, and Iowa plans to cover rides for its whole expansion group from January 1, 2027.
- Can a provider comment on a proposed waiver?
- Yes. A state has to publish notice of a new demonstration or an extension request, take comments for no less than 30 days, and hold two or more public hearings, all before it applies. After CMS receives a complete application, it runs its own 30-day federal comment period.
- How long does a section 1115 demonstration last?
- CMS usually approves a demonstration for five years at first and can extend it by three to five years at a time. It can also grant short temporary extensions while it reviews a renewal. Iowa's and Georgia's demonstrations were both running on temporary extensions in 2026.
- How does a 1915(c) waiver differ from section 1115?
- They do different jobs. States use 1915(c) waivers to fund home and community-based services, and non-medical transportation can be covered under one. A section 1115 demonstration is broader and can change eligibility, benefits, or delivery systems. Some states run home and community-based services under 1115, as Hawaii does.
