Brokers and Medicaid
What Is the Medicaid Assurance of Transportation? 42 CFR 431.53 Explained
The Medicaid assurance of transportation is the federal rule, 42 CFR 431.53, that requires every state Medicaid plan to ensure necessary transportation for members to and from providers and to describe how. Congress wrote it into the Social Security Act in the Consolidated Appropriations Act, 2021. It is not a promise to pay for every ride, but members with no other way to covered care must get one.
- Every state must ensure rides to covered care for Medicaid members who have no other way there, and describe its method in the state plan.
- The duty is to ensure a ride, not to pay for every ride. Free rides, a family car, or a bus pass come first when they fit.
- States choose how to meet it: pay ride companies directly, hire a broker, or put rides in health plans. The state stays responsible either way.
- A state cannot drop the duty on its own. Iowa's federal waiver for expansion adults ends December 31, 2026, and their rides start January 1, 2027.
- The rule is why Medicaid ride work exists, and why states must pay enough to keep ride companies in the program.
Every Medicaid ride you give traces back to one short federal rule. It is the reason states pay for rides at all, and it shapes who gets a ride, what kind, and how the state buys it.
What 42 CFR 431.53 says
The rule has two parts. Each state plan must:
- Specify that the Medicaid agency will ensure necessary transportation for members to and from providers.
- Describe the methods the agency will use to meet that requirement.
Until the Consolidated Appropriations Act, 2021, the duty was set by regulation, based on the Social Security Act’s general rule on proper and efficient administration. Section 209 of that law wrote it into the Act itself: section 1902(a)(4)(A) now requires a specification that the state agency “will ensure necessary transportation for beneficiaries under the State plan to and from providers.” CMS calls this the assurance of transportation.
Section 209 added two more pieces:
- A payment condition. No federal money goes to NEMT unless the state plan has methods to keep payments consistent with efficiency, economy, and quality of care, and sufficient to enlist enough providers (section 1903(i)(9), tied to section 1902(a)(30)(A)).
- Minimum standards for ride companies and drivers. Section 1902(a)(87) requires a way, which may be an attestation, to make sure no ride company or driver is excluded from federal health programs, every driver has a valid license, and each company has a process for drug law violations and for reporting each driver’s driving history to the state. Public transit authorities are exempt.
The duty follows members into other benefit packages. States must also assure rides for members in benchmark or benchmark-equivalent plans (42 CFR 440.390), and must offer children in the EPSDT benefit help with transportation and scheduling (42 CFR 441.62). See EPSDT transportation.
What the assurance requires, and what it does not
CMS’s Medicaid Transportation Coverage Guide (SMD 23-006, September 28, 2023) is the federal reading of the rule. Its main points:
| The state must | The state does not have to |
|---|---|
| Make sure every member with no other means of transportation can get to covered care | Pay for a ride when a free one from family, friends, or another agency is available |
| Cover rides to optional benefits the state chose to cover, such as trips to the pharmacy | Pay for rides for people visiting a hospitalized member, which Medicaid does not cover |
| Use the least costly mode that fits the member’s physical and emotional condition | Pay for a costlier mode when a cheaper one fits the member’s condition |
| Generally ensure rides to the nearest qualified provider, unless there is a medical need to go farther | Pay for long trips when closer qualified providers are available and nothing requires the farther one |
| Cover meals, lodging, and an attendant when they are needed to reach care | Buy vehicles or other transportation infrastructure |
| Keep giving rides to members who miss rides or run late, with extra steps such as confirming the ride the night before | Pay for a trip when the member did not show up |
Two of those rows set your daily work. The least costly appropriate mode rule decides whether a rider gets a bus pass, a sedan, or a wheelchair van. The no-show rule means a state cannot drop a rider for missing trips, and CMS says it may build the cost of no-shows into your rates, but federal money does not pay for the missed trip itself. See no-show.
The state may also expect members to drive themselves. CMS says a general expectation that members use their own vehicle is allowed as long as their circumstances do not rule it out, and that maintenance and fuel costs can be such a circumstance. Georgia’s program page puts the test simply: members must have no other means of transportation available.
How states meet the assurance
The rule says “ensure,” not “provide,” so each state picks its method and writes it in Attachment 3.1-D of its state plan. CMS lists the options:
- As an administrative activity. The state claims the cost at the 50 percent administrative match. Rules for medical services, such as free choice of provider and statewide coverage, do not apply, and the state may pay members directly for their travel.
- As an optional medical service. The state gets its regular federal match, which may be higher. It must pay the ride company directly under 42 CFR 440.170(a)(2), and members may choose any qualified company willing to serve them.
- Through a broker. Section 1902(a)(70) lets a state hire a NEMT broker chosen by competitive bid, without a waiver, even if that limits choice or covers only part of the state.
- Through health plans. Rides can be a Medicaid health plan benefit, or the state can carve them out of the plans.
States can mix these by region or group. Whatever the mix, CMS says the state Medicaid agency stays ultimately responsible for making sure members get the rides they need. See how states run NEMT.
Who the assurance does not reach
MACPAC’s June 2021 report describes the ride benefit as available to all members with full Medicaid benefits. Some groups have no Medicaid ride benefit:
- Groups under a federal waiver. A section 1115 demonstration can waive section 1902(a)(4) as it applies to 431.53. Iowa has waived rides for adults in its Iowa Health and Wellness Plan, except members who are medically frail or eligible for EPSDT. Iowa’s page says the waiver sunsets December 31, 2026, and Iowa will cover rides for the whole group starting January 1, 2027. Its September 17, 2026 notice says CMS will no longer approve the waiver beginning January 1, 2027, and proposes adding NEMT to the group’s benefit plan, with comments due October 17, 2026. See Iowa NEMT for expansion adults and section 1115 waiver.
- Georgia Pathways. Georgia’s NEMT manual (version date July 1, 2026) says Pathways to Coverage does not cover NEMT except for members aged 19 and 20.
- Limited benefit groups. Indiana’s transportation module (August 19, 2025) lists fee-for-service benefit plans with no NEMT, including emergency services only, the Family Planning Eligibility Program, and members who get Medicaid help only with Medicare costs. See dual eligible.
Proposals to loosen the duty come up from time to time. MACPAC’s June 2021 report notes that the Trump administration proposed making NEMT an optional benefit in its budgets beginning in fiscal year 2019, and that CMS planned a rule and then a request for information on whether the assurance was still needed, but issued neither. A 2008 rule letting states drop rides from benchmark plans was rescinded and replaced with a policy requiring rides in those plans. Congress then wrote the duty into the Act in the Consolidated Appropriations Act, 2021.
What the assurance means for a NEMT provider
The assurance is the demand behind the business. Your trips exist because a state must get members to care, and CMS’s June 2023 report to Congress found that in 2021 about 14 percent of dual eligible members and 22 percent of section 1915(c) home and community-based services participants used NEMT, against 4 percent of all Medicaid members.
It also sets terms you can point to:
- Rates must keep companies in the program. CMS says states should set ride rates so members have access at least equal to what non-Medicaid riders have nearby, and should make sure a broker does not pay so little that local companies refuse to join.
- You are a Medicaid provider, directly or through a broker. CMS says companies that give Medicaid rides are directly or indirectly Medicaid providers, so program rules follow the trip. You must accept Medicaid’s payment as payment in full (42 CFR 447.15) and may never charge a member for a no-show.
- Riders can complain and appeal. States must monitor access and complaints and make sure drivers are licensed, qualified, competent, and courteous, and members have a right to a fair hearing. See broker rider complaints.
- Some costs can be paid outside the trip rate. Since September 28, 2023, a state may pay wait time or unloaded miles in the limited cases CMS describes, once it submits a state plan amendment covering them. See rural NEMT.
For the full picture of who rides and who pays, see what is NEMT and who pays for NEMT.
Frequently asked questions
Does the assurance of transportation mean Medicaid pays for every ride?
No. CMS guidance SMD 23-006 (September 28, 2023) says it is not a requirement to pay for a ride, but to make sure every member with no other means of transportation can get to covered care. States may first use free rides from family, friends, or other agencies, and may expect members to use their own car unless their circumstances rule it out.
Can a state stop covering NEMT?
Not on its own. The duty is in the Social Security Act and 42 CFR 431.53, so a state needs CMS approval of a waiver to drop it for a group. Iowa's waiver for its expansion adults sunsets December 31, 2026, and Iowa will cover rides for the whole group starting January 1, 2027. Georgia Pathways covers rides only for members aged 19 and 20.
Does the assurance cover members in Medicaid health plans?
Yes. The state stays responsible whether a member is in fee-for-service or a health plan, and whether it runs rides itself or hands them to a broker or plan. When rides are part of a plan's contract, 42 CFR 438.206(a) requires the state to make sure plan members can get covered services in a timely way.
Does the same rule cover emergency ambulance trips?
Yes. CMS says federal Medicaid law does not treat emergency transportation separately. Under 42 CFR 431.53, states must ensure both emergency and non-emergency transportation where it is needed to reach covered services. Federal law also does not require that an emergency trip end at a hospital emergency department.
What is Attachment 3.1-D?
It is the part of each state's Medicaid plan that describes how the state meets the assurance: the types of transportation, who provides them (a broker, health plans, or directly enrolled companies), and how the state claims federal money. It also holds the state's attestation that ride companies and drivers meet the federal minimum standards. Approved changes are posted on Medicaid.gov.
Do children get extra help with rides?
Yes. Under 42 CFR 441.62, states must offer children in the EPSDT benefit, and their families, help with transportation and with scheduling appointments. CMS says that when a child needs someone to go along to care, the state must also cover that person's trip, including out-of-state trips for admission and discharge.