CMS-10190 nem3 1d

Supersedes TN No. ________________
Revision:

ATTACHMENT 3.1-D
Page
OMB No.:

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT
MEDICAL ASSISTANCE PROGRAM
State/Territory: ________________________

3.1D Transportation is provided as an administrative activity in
accordance with 1902(a)(4)(A) of the Act and 42 CRF 431.53
Not Provided
Provided (If the State attests that transportation is provided as
an administrative activity, then a text box with
header appears for the State to supply supplemental
information.)
Instructions: Describe how the NEMT program operates
including services provided, any limitations, and the payment
methodology. Describe emergency and non-emergency
transportation separately. Include any inter-agency or
cooperative agreements with other agencies and contracts.

TN#_____
Supersedes TN # _____

Approval Date_________
Effective Date ____