MSA-4674 in 2027: How to Get Paid for Michigan Fee-for-Service Rides From Local MDHHS Offices

In most of Michigan, a Medicaid member without a health plan gets rides from the local office of the Michigan Department of Health and Human Services (MDHHS). That office approves the trip, and after you drive it, you claim your pay on one form: the MSA-4674, Medical Transportation Statement. This guide follows that form from approval to payment, using the Medicaid Provider Manual dated October 1, 2026 and the MDHHS rate schedule effective July 1, 2026. For CHAMPS enrollment and the health plan brokers, see the Michigan NEMT guide.

Which rides the MSA-4674 covers

The manual calls the office that approves a ride the authorizing party. For fee-for-service members, that is the local MDHHS office in every county except Wayne, Oakland, and Macomb. Each office verifies eligibility, keeps its own network of transportation companies, and books the least costly ride that fits the member’s needs. So the work starts with being in that network: introduce your company, vehicles, and service area to the offices in the counties you cover, using MDHHS’s county office list.

You also need to be enrolled in CHAMPS on the date of service, or the trip is not paid. Taxicabs, public transit, members who drive themselves, family members, and foster parents are exempt.

The MSA-4674 does not apply to:

• Health plan members. Their plan, or the broker it uses, books and pays the ride.
• Fee-for-service members in Wayne, Oakland, and Macomb. Modivcare arranges and pays those rides. See Modivcare in Michigan.
• Nursing home and other long-term care residents. Their facility’s daily rate covers routine van rides.
• Members with Emergency Services Only or Plan First coverage, and members who have not met their spend-down.
• Rides to services at a federally qualified health center (FQHC). The FQHC provides those rides itself, and its encounter rate covers the cost (FQHC chapter, section 2.2, changed October 1, 2026).

This arrangement may not last. Michigan is taking bids for a fee-for-service broker that could cover the whole state; see Michigan’s NEMT broker RFP.

Before the trip: getting the office’s approval

Before it approves a ride, the office checks three things: the member is eligible, the trip is to a service Medicaid covers, and the member has no other way to get there. A trip you drive before the office approves it is not paid. The manual makes two exceptions, where the office may authorize and pay rides after the fact: the member’s Medicaid eligibility was made retroactive and the rides fell in that period, or the member’s health plan authorized the rides and the member was later moved out of the plan retroactively into fee-for-service.

The DHS-5330 for wheelchair, Medi-Van, and attendant pay

A plain mileage ride needs no medical form. The higher-paying special allowances do, and each needs a Medical Verification for Transportation (DHS-5330):

• Wheelchair lift vehicle, for a member who depends on a wheelchair or on life-sustaining equipment a standard vehicle cannot carry.
• Medi-Van, for a member who can walk and transfer but needs door-to-door or curb-to-curb help.
• One attendant riding with the member because of the member’s physical, mental, or developmental condition. Two or more need prior authorization.

The member’s primary care doctor signs it, or a physician assistant or nurse practitioner working under that doctor. When none of them can do it in time, another licensed provider who treats the member can, such as a specialist, a registered nurse, a social worker, or a dentist. The form is renewed every year. If it is not ready before an appointment, the office may still approve and pay the trip when the form arrives within 10 business days of the appointment.

Riders under 18

Children under 12 must ride with a parent, foster parent, caregiver, or legal guardian. From age 12 until 18, a child can ride alone only with a consent letter signed by one of them. The rule does not apply to emancipated minors or to care a minor can consent to alone, such as pregnancy care, treatment for sexually transmitted infections or HIV, substance use treatment, and outpatient community mental health care.

When the trip needs prior authorization

Some trips need prior authorization from the MDHHS Program Review Division before they happen:

• Any trip to a medical provider out of state or beyond the borderland area.
• Care outside the member’s community when comparable care is available locally.
• Meals and lodging for an overnight stay when the medical facility is within 50 miles of the member’s home.
• Overnight stays beyond 14 consecutive nights.
• Advance payment of travel costs.
• Two or more attendants, or relatives or friends, traveling with the member.

The request goes to the division in writing before the service, with the DHS-5330 when one is needed. It names the member and Medicaid ID, the case number, the reason it is medically necessary, the origin and destination, the travel dates, and the diagnosis. Requests sent more than 30 days after the service are not approved. For treatment lasting more than 12 weeks, one approval can cover up to six months of trips. The Program Review Division’s line for NEMT prior authorization is 800-622-0276, or fax 517-241-7813.

How to complete and send the MSA-4674

1. Get blank statements from the approving office. The manual says the forms in its NEMT chapter come through the member’s caseworker and are kept on MI Bridges.
2. Record the miles. Add up the round trip and round the total up to the next whole mile. The total must match an online map or a GPS record, and only loaded miles count. See NEMT mileage billing for how to keep a mileage record that holds up.
3. Attach a receipt for every other cost. Parking, tolls, meals, and lodging need itemized, unaltered, legible receipts. A meal receipt shows the business name, address, date, time, and each item with its price. If the restaurant leaves an item off, you may write it in by hand.
4. Handle a missing Mackinac Bridge receipt on the form. Write the trip’s origin and destination and why the receipt is missing. The office may approve the toll, and it may be reviewed after payment.
5. Charge your usual price. Bill MDHHS the usual and customary fee you charge the public or another payer for the same ride, not a negotiated broker rate. If you give that ride free or at a discount to the public, bill no more than that.
6. Send it within 12 months of the date of service to the office that approved the trip. Fax or secure email is accepted, and originals are optional. Keep a copy of the form and receipts. If something is missing, such as a signature, the office may call you for it, but it will not complete the whole form by phone.

If an approved trip or a payment needs sorting out, call MDHHS Provider Inquiry’s atypical provider line, which answers questions about approved transportation authorizations and payments, at 800-979-4662, weekdays 8 a.m. to 5 p.m. Eastern.

What the rate schedule pays

MDHHS sets maximums, and you are paid the maximum or your usual and customary charge, whichever is less. Under the schedule effective July 1, 2026, a commercial or nonprofit company is paid $0.76 a mile, with no separate fee per trip. A wheelchair lift or Medi-Van vehicle owned by a commercial, nonprofit, or public transit agency adds $35 a round trip on top of the same mileage, and the allowance for a medically necessary attendant is $15.

Here is how one ride works out. A Medi-Van member rides to a clinic and home, and the map shows 37.4 miles round trip. You bill 38 miles: $35 plus 38 miles at $0.76 ($28.88), or $63.88. The same ride for a member who needs no special allowance pays $28.88. If your public price for that Medi-Van ride is $60, you are paid $60.

Since at least 2023, the mileage rate has matched the IRS business standard mileage rate. The schedules paid $0.655 a mile in 2023, $0.67 in 2024, $0.70 in 2025, and $0.725 from January to June 2026, each the IRS rate for the same period, and the $0.76 from July 1, 2026 matches the IRS rate from that date. The $35 wheelchair and Medi-Van amount and the $15 attendant amount were the same in the 2023, 2024, and 2025 schedules as they are now. When the IRS announces a new rate, check the MDHHS page for a new schedule.

Meals and lodging on long trips

On an approved overnight stay, meals and lodging can be authorized for the member and the transportation provider for up to 14 consecutive nights, plus one attendant documented on the DHS-5330. For meals on a day trip, the manual names members, volunteer drivers, and family or friends who drive, not company drivers, so ask the office before you claim a driver’s meal outside an overnight stay. A meal is paid only when the vehicle leaves and returns at these times:

Meal	Leave before	Return after	Maximum
Breakfast	6:00 a.m.	8:30 a.m.	$8.50
Lunch	11:30 a.m.	2:00 p.m.	$8.50
Dinner	5:30 p.m.	8:00 p.m.	$19

The maximums include tax. Lodging pays up to $75 a night. The least expensive adequate lodging must be used, and nonprofit lodging, such as a Ronald McDonald House or rooms through the medical facility, must be checked first. Meals bought in the home city of the person claiming them, alcohol, groceries bought in bulk, and shared meals are not paid, and neither is a meal that came free with the room. Personal errands cannot stretch the departure and return times. For planning these trips, see long-distance medical transport.

What the local office will not pay

The NEMT chapter lists these as not reimbursable, so plan your day around them:

• Waiting time at the medical office. See NEMT wait time billing.
• Unloaded miles for commercial and nonprofit providers, such as the drive to a pickup. See deadhead miles.
• Trips made before the office approved them.
• Several trips for one Medicaid service.
• Trips when the member does not keep the appointment. See no-shows.
• Trips to places Medicaid does not cover, such as a grocery store.
• Routine care outside the member’s community when comparable care is available locally, unless it was prior authorized.

Members who drive themselves, or family and volunteer drivers, are paid mileage on the same schedule. For how that side of the benefit works, see Medicaid mileage reimbursement.