1915(b) waivers: how states route Medicaid riders to one transportation broker
Overview
With a section 1915(b) waiver, a state may suspend parts of federal Medicaid law, chiefly members' free choice of provider, so riders in an area must use one broker or a limited group of companies. NEMT programs rely on the selective contracting authority, (b)(4), sometimes paired with (b)(1). CMS grants two years per approval, or as many as five when dual eligibles are included.
On this page
Section 1915(b) of the Social Security Act is one of the routes a state can take to make riders use a single regional broker for every trip instead of any enrolled company they like. For a transportation company, it explains why a Medicaid provider number alone brings no trips there: the broker’s network is the only way in. The other routes, from a state plan broker to managed care, are compared in our guide to state NEMT delivery models. The history of free choice for riders is in choosing a Medicaid ride company.
What the waiver sets aside
A 1915(b) waiver suspends some state plan requirements of section 1902 where CMS finds the change cost-effective and efficient. The statute lists four purposes. Paragraph (b)(1) allows care management arrangements that restrict which providers members use, and (b)(2) lets a locality act as a central broker for health plan choice. Paragraph (b)(3) lets the state spend savings on extra services. Under (b)(4), called selective contracting, members may use only providers that accept the state’s reimbursement, quality, and utilization standards.
Ride programs lean on (b)(4). Florida’s and Kentucky’s current applications check both (b)(1) and (b)(4). Under 42 CFR 431.55, a selective contracting restriction may not apply in emergencies. It also may not single out a class of providers for reasons unrelated to effectiveness and efficiency, and the state must document the waiver’s effect on access and quality.
A 1915(b) broker answers to fewer federal conditions than a state plan broker under section 1902(a)(70). The 2008 final rule on state plan brokers says the waiver process neither forbids a broker from sending trips to itself nor requires a competitive bid. Kentucky used both routes. It held a (b)(4) waiver from December 1998, ran the program under its state plan from 2006, and then returned to the waiver.
What a waiver application shows a ride company
The approved application is a public rulebook for the state’s broker system. It follows a CMS template: Section A describes the program, access, quality, and operations; B and C set out the monitoring plan and its results; and D proves cost-effectiveness. A few things worth reading for:
- Subcontractor rules. Kentucky’s application quotes its state regulation. A subcontractor needs the Transportation Cabinet’s approval before signing with a broker, may not hand a trip off to any other company, and must hand the broker its operating authority, proof of insurance including workers’ compensation, the signed agreement, any vehicle leases, and its Medicaid enrollment letter. Invoices must reach the broker no more than six months after the trip.
- Who may drive. Florida’s application lets its two NEMT vendors provide rides themselves or subcontract them. The vendors also take the calls, check eligibility, authorize and dispatch trips, and monitor the transportation companies.
- Broker pay. Maine’s 2023 renewal switched to one state-set capitation rate per region rather than letting bidders choose from a range, and came with a new request for proposals, so contractors could change.
- What the state checks. Kentucky’s monitoring results list site visits, broker and provider audits, credentialing and yearly ownership disclosures, and a complaint tracking system that can lead to corrective action plans.
How long a waiver lasts
Section 1915(h) limits each approval to two years, and a state that wants more must request a continuation. A waiver that includes dual eligibles can run five years and renew for five more. Maine’s renewal form says outright that three- to five-year periods require the waiver to serve dual eligibles. These NEMT waivers show both terms in use:
| State | Current approval | Length |
|---|---|---|
| Kentucky | April 1, 2025 to March 31, 2027 | Two years |
| Florida | July 1, 2025 to June 30, 2027 | Two years |
| Maine | April 1, 2023 to March 31, 2028 | Five years |
| Arkansas | April 1, 2023 to March 31, 2028 | Five years |
Renewals are natural points for a state to redesign, as Maine’s 2023 renewal showed. Kentucky’s current approval ends March 31, 2027. Its 2026 law also has a legislative oversight board study how the program is run, from the regional brokers and capitation to models other states use, and report by December 31, 2026. The FTSB guide covers what that 2026 law changed. Arkansas’s brokers are paid as prepaid ambulatory health plans, which subjects them to part of the federal managed care rulebook. For waivers that reshape eligibility or benefits instead, see section 1115 waivers.
Frequently asked questions
- Can a 1915(b) broker drive trips with its own vans?
- Yes, as far as federal rules go. The 2008 final rule on state plan brokers states that a 1915(b) program does not bar a broker from referring trips to itself and does not require choosing the broker by competitive bid. Kentucky's waiver describes regional brokers that coordinate and provide rides in their regions and add subcontractors as needed.
- Is a 1915(b) waiver the same as an 1115 demonstration?
- No. The 1915(b) kind changes how a covered service is delivered, by limiting which providers members may use. A section 1115 demonstration can go further and change who is eligible or which benefits are covered, as Iowa and Georgia did with rides for some adults. The section 1115 entry covers those programs.
- How do I read my state's waiver?
- Medicaid.gov keeps a list of state waivers, and each approved waiver links to the application the state filed. Search by state and filter the authority to 1915(b). The application is the long document with sections A through D, and it is the one to read.
