Medicaid state plan amendments: how states change the NEMT benefit and rates
Overview
A state plan amendment (SPA) is the filing a state sends CMS to change its Medicaid state plan, the federally approved rulebook for eligibility, benefits, and payment. NEMT changes usually land in Attachment 3.1-D, which explains how rides are delivered, and Attachment 4.19-B, which explains payment. Unless CMS objects or asks for more within 90 days, it counts as approved, and some changes can reach back to earlier trips.
On this page
Federal rules require a state to amend its Medicaid plan whenever it makes a material change in law, policy, or operations (42 CFR 430.12). So an amendment sits behind changes to a fee-for-service ride program such as a new broker model, a benefit added or cut, or a new way of paying the broker. Each one is approved by CMS and posted with its dates, so a ride company can see what changed and from when. The options a state chooses among are compared in how states run NEMT. This entry is about the filing itself.
Where ride rules sit in a state plan
For rides, the key pages are two attachments. Attachment 3.1-D describes the ride program in narrative form: the delivery model, the kinds of providers, whether the state claims rides as an administrative cost or as a medical service, and which managed care or demonstration authority covers anything run outside the plan. Attachment 4.19-B holds the payment method. SMD 23-006, the 2023 CMS guide to Medicaid transportation, also points to Attachments 3.1-A and 3.1-B for the amount, duration, and scope of rides covered as a medical service. A further 3.1-D page carries the driver attestation explained under assurance of transportation.
Three amendments that changed rides
Recent transportation amendments show the range of what one filing can do:
- New York 23-0005. It moved New York’s NEMT program from an administrative-services model to a risk-based broker under section 1902(a)(70). The new 3.1-D pages say the broker is picked by competitive bidding, does not provide transportation itself, and has no financial tie to any transportation company. Received September 29, 2023, approved December 12, 2023, effective August 1, 2023.
- Puerto Rico 24-0010. It made NEMT a covered optional medical service. Every NEMT trip needs prior authorization. Allowable providers are Puerto Rico-licensed transportation companies under contract with a managed care organization, plus ambulance providers. Effective July 1, 2024.
- Mississippi 23-0026. It revised how the state pays its NET broker to match an emergency contract that began October 1, 2023. CMS received it November 28, 2023 and approved it January 30, 2024, with the October 1 effective date.
The cover sheet tells you the money
An approval package opens with CMS’s letter, then Form CMS-179, then the approved pages. The CMS-179 gives the transmittal number, the pages replaced, the proposed effective date, and the state’s estimate of how federal spending will change over two federal budget years. A figure in parentheses means lower federal spending.
That estimate shows which way the money is expected to move. New York’s broker amendment projected federal spending $4,250,000 lower for August and September 2023 and $17,000,000 lower for fiscal 2024. Puerto Rico’s new benefit projected $4,691,500 more in fiscal 2024 and $18,766,000 more in fiscal 2025. The footer of every approved page names the amendment that put it there and the older one it replaced, with its approval and effective dates.
How approval and timing work
CMS reviews each filing. Under 42 CFR 430.16, it is approved unless CMS disapproves it or asks for more information within 90 days of receipt. A request restarts the 90 days when the state answers.
The effective date can come first. Under 42 CFR 430.20 and 447.256, a change that adds services, raises payments, or alters payment methods can reach back to the start of the quarter in which it was filed, but no further. That is how Puerto Rico’s amendment, filed in September 2024, took effect July 1. Significant rate method changes also need public notice before they take effect, which how NEMT rates change covers.
To find amendments, use the Medicaid.gov list of approved state plan amendments: choose a state and the Transportation topic, sort by approval date, and open the package. Rides run by health plans or under a 1915(b) waiver change through those authorities instead.
Frequently asked questions
- Will an approved amendment cover trips I already drove?
- It can. A change that adds services, raises payments, or alters payment methods may reach back to the start of the three-month quarter in which it was filed, though no earlier. Puerto Rico filed its NEMT amendment on September 5, 2024, CMS approved it November 20, 2024, and it runs from July 1, 2024. So an approval can arrive months after the date it governs.
- Do rides run by health plans change through amendments too?
- Sometimes. A state can put rides into health plans with a section 1932(a) amendment, which CMS approves for an indefinite period. It can also use a 1915(b) waiver, renewed every two years or five when dual eligibles are included, or a section 1115 demonstration, and then the details live in that approval and the plan contracts. Either way, CMS expects the transportation pages of the state plan to describe the setup and say where to look.
- Can I learn about a change before CMS approves it?
- Watch the state's public notices. A significant change in how the state sets payment rates needs a published notice before it takes effect, and the notice tells you where to send written comments. The state register and the Medicaid agency's notice page are the usual places.
