Medicaid State Plan Amendment (SPA): Where Your State Writes Its NEMT Rules

Your state’s ride rules sit in a document most owners never open: its Medicaid state plan. It says who arranges Medicaid rides, whether a broker runs them, and how the state pays for them. Every change to it is a state plan amendment, and each approved one is posted with its dates, so you can see what changed and when it took effect.

What a state plan and a state plan amendment are

Federal rule 42 CFR 430.10 calls the state plan a comprehensive written statement of the nature and scope of a state’s Medicaid program, with the state’s promise to run it by federal rules. CMS’s approval is what lets the state claim federal matching money. Medicaid.gov sums up what the plan holds: the groups covered, the services provided, how providers are paid, and the program’s administrative work.

When a state wants to change any of that, it sends CMS a state plan amendment, often called a SPA. Under 42 CFR 430.12, the plan must be amended whenever federal law, regulations, policy, or court decisions change, and whenever the state makes a material change in its own law, organization, policy, or operations.

Each approved amendment comes with a cover form, CMS-179, the Transmittal and Notice of Approval of State Plan Material. It carries:

• The transmittal number, such as Alaska’s 25-0009, which the approved pages repeat in their footers.
• The proposed effective date and, once approved, the dates CMS received and approved it.
• The federal budget impact for two federal fiscal years.
• The plan pages it changes and the pages they replace.
• A short subject, the plainest summary of what changed.

An amendment works inside the federal rules. A section 1115 waiver or a 1915(b) waiver lets a state set some of them aside, and when rides run under one, CMS asks the state plan to point to it.

Where NEMT sits in your state plan

CMS’s Medicaid Transportation Coverage Guide, SMD 23-006 (September 28, 2023), lists where states usually describe rides:

• Attachments 3.1-A and 3.1-B. When a state covers rides as a medical service, these pages set the amount, duration, and scope, such as when air travel is allowed.
• Attachment 3.1-D, methods of transportation. The narrative of how members get rides: the types of transportation, who provides them (a broker, vendors, health plans, or a network of drivers), and whether the state claims the cost as an administrative expense or a medical service.
• The 3.1-D attestation page. The state’s promise that ride companies and drivers meet the federal minimums. The assurance of transportation page covers what it requires.
• Attachment 4.19-B. How the state pays, including the rate method. For plan pages filed after SMD 23-006, a broker’s payment method belongs here too, not only in the coverage pages.

Other pages can matter for some members. Iowa’s proposed amendment IA-26-0010 would add NEMT for its Medicaid expansion adults on pages 32 and 33 of its Alternative Benefit Plan, the separate benefit package that group gets (notice of September 17, 2026).

Two states show what these pages tell you.

Mississippi posts its whole state plan, each attachment, and lists of approved and proposed amendments on its Medicaid website. Its Attachment 3.1-D says the state runs non-emergency rides through one statewide broker chosen by competitive bid, without free choice of provider. The broker is paid each month at its bid rate per trip leg, by trip type, plus an administrative fee capped at 15 percent of the month’s trip leg payment (page approved August 14, 2025). It may pay ride companies through any arrangement both sides agree to, including a sub-capitation, as long as it gets data for every trip. Nursing facility residents are outside the broker program, and their rides are paid as part of the long-term care benefit. A van owner reads that and knows the broker contract, not a state fee schedule, sets the pay.

Maryland’s Attachment 3.1-D, approved May 20, 2026 and effective January 1, 2026, says the state funds rides as an administrative expense through grants to local agencies, which screen requests and contract with ride companies. Screening and driving must be done by separate entities unless the local jurisdiction drives the rides itself, and the state uses no rideshare companies. The amendment added meals, lodging when a trip needs an overnight stay, and on those trips an attendant’s costs. The local agency approves the need for meals and lodging before travel, though the department or the local agency may pay without that approval in extraordinary circumstances. The page also lists 18 costs the grants will not pay, including wheelchair van service for riders who can walk. See how states run NEMT for the other delivery models.

How an amendment is approved and when it takes effect

1. Public notice, for rate method changes. Under 42 CFR 447.205, a significant proposed change in how a state sets payment rates needs a public notice before it takes effect, with an address for written comments. Changes made to match Medicare or a court order are exempt. How providers use that notice to push for a raise is in NEMT rate increases.
2. The governor’s review. The Medicaid agency sends the amendment to the governor or a designee for comment before it goes to CMS, unless the designee heads the Medicaid agency (42 CFR 430.12).
3. CMS review. CMS has 90 days to approve, disapprove, or ask for more information. If it does none of these, the amendment counts as approved. A request for more information starts a new 90 days once CMS gets the answer (42 CFR 430.16).
4. The effective date. An amendment that adds services, raises payment amounts, makes more people eligible, or changes how payment is set can take effect no earlier than the first day of the calendar quarter in which the state files it (42 CFR 430.20 and 447.256). Other amendments take effect on the date the state asks for, if CMS agrees.

That fourth step means an approval can reach back months, so a rule or rate can apply to rides you already ran. Three ride amendments show the gap:

Amendment	What it changed	Approved	Effective
California 22-0039	Set the $20.30 wheelchair van and $1.50 van mileage rates	December 16, 2022	July 1, 2022
Alaska 25-0009	Let tribal health organizations bill taxis, wheelchair vans, rideshare, lodging, and meals	December 18, 2025	July 1, 2025
Maryland 26-0002	Added meals and lodging, and an attendant’s costs on overnight trips	May 20, 2026	January 1, 2026

California’s amendment was received September 26, 2022 and Alaska’s September 29, 2025, so each reached back to July 1, the first day of the quarter it was filed in. California’s rates apply to fee-for-service trips on or after July 1, 2022, and Medi-Cal’s ground transportation codes page (updated September 2023) still lists them as the maximums for rides that need a Medi-Cal TAR. The Alaska change is covered in the Alaska tribal travel amendment.

How to find and read your state’s NEMT amendments

1. Search Medicaid.gov. On the state plan amendments page, filter by your state and the Transportation topic. Each result shows the transmittal number, a one-line summary, the approval date, the effective date, and a link to the approval document.
2. Open the approval document. It holds the approval letter, the CMS-179, and the approved pages, in that order.
3. Read the footers. Each approved page shows its transmittal number, the number it supersedes, and its approval and effective dates. Follow the superseded number back to see what changed.
4. Go by the approval letter and CMS-179, not the listing. As of October 6, 2026, Medicaid.gov’s listing showed July 1, 2024 as the effective date of Alaska’s 25-0009, while its approval letter and CMS-179 say July 1, 2025.
5. Read the whole plan on your state’s site. Approved amendments show only the pages that changed, so the full current plan, where your state posts one, is the easier read.
6. Watch for proposed changes. Read your state’s public notices and send comments by the deadline. Iowa’s notice for IA-26-0010 explains that CMS will no longer approve the waiver that left expansion adults without NEMT, starting January 1, 2027; see Iowa’s plan for expansion adults.

While you read, look for what changes your business: who arranges rides, the unit the state pays on (a trip, a leg, a mile), what it will not pay for, and whether it pays wait time or unloaded miles. SMD 23-006 lets a state build the cost of wait time and unloaded miles into its usual rates. It can also pay them as their own charge: wait time when a long trip makes it cheaper for the driver to wait at the clinic, and unloaded miles when the most economical provider faces extraordinary costs its usual rate does not cover. For that, the state must file an amendment with coverage and payment pages before it claims federal money. To compare the rates themselves, see Medicaid fee schedule.