Trends in Non-Emergency Medical Transportation During Medicaid Transformation in North Carolina

In 2021, North Carolina implemented Medicaid transformation, shifting from fee-for-service (FFS) to Managed Care,1 radically changing non-emergency medical transportation (NEMT) services. Research has examined experiences of beneficiaries and providers in navigating this new system, but there has not been a systematic analysis of trends in NEMT usage during the transformation.

We analyzed North Carolina NEMT Medicaid claims data between 2019 and 2023. We examined trends in service provision and cost 1) overall, 2) by travel mode, 3) by public versus private provider, and 4) by urban versus rural geography. The database infrastructure used for this project was supported by the Cecil G. Sheps Center for Health Services Research and the CER Strategic Initiative of the University of North Carolina's Clinical and Translational Science Award (5-UL1-TR002489-05).

There were increased NEMT claims through both recovery from the COVID-19 pandemic and Medicaid expansion, but these were unevenly distributed across providers and geographies. We found faster growth among private providers, especially those serving Managed Care Organization (MCO) claims rather than fee-for-service claims. We also found disparities between urban versus rural geographies.

Our unit of analysis is the Medicaid claim, not NEMT trip or beneficiary. We were limited to broad beneficiary geographic information, which we matched to Department of Health and Human Services (DHHS) county classifications. Medicaid transformation and pandemic recovery occurred simultaneously, complicating separation of their effects.

Concentrated growth among urban and private claims highlights difficulty in providing expedient, cost-effective rural NEMT. Increases in cost per claim suggest the new system should be monitored as it pursues its goal of increasing efficiency through transformation.