Roughly a third of Medicaid non-emergency medical rides in most states are dialysis runs: three times a week, same patient, same clinic, 5:30 a.m. pickup, four hours later a return trip. If you understand that one fact, you understand most of the NEMT business. It is a logistics company with a medical vocabulary, paid mostly by state Medicaid programs through a handful of national brokers, and it lives or dies on whether your vans show up on time.
Learning how to start a NEMT business is mostly learning the credentialing path, because that is what takes three to six months and what stops most people who try. The vehicles, insurance and drivers are straightforward by comparison. This guide is for someone with a clean driving record, $15,000 to $85,000 to invest, and the temperament to sit in a dialysis center parking lot at dawn. It covers trip types and how they pay, state requirements and broker enrollment, the real cost of a wheelchair van and insurance, per-trip rates and the monthly math, how to get your first trips before the broker turns you on, and what changes at three vans.
What running a NEMT company actually looks like
A typical day for an owner-operator with one wheelchair van: first dialysis pickup at 5:15 a.m., two more before 7, clinic appointments and a hospital discharge mid-morning, dialysis returns from 10 to noon, afternoon appointments, then the evening dialysis shift. You will do 8 to 14 one-way trips, drive 120 to 200 miles, and spend a surprising amount of time waiting. Between trips you confirm tomorrow’s riders, upload trip logs to the broker’s app, and juggle a no-show that just freed up 40 minutes.
Demand is steady and close to recession-proof. Dialysis does not stop for holidays, and an aging population means more wheelchair trips every year. Weekdays are full; weekends are quiet except dialysis. The disruption to plan for is a broker contract change, when a state switches brokers and every provider re-credentials.
The economics are tight but predictable. A wheelchair trip paying $60 plus $3 a mile for 12 miles grosses $96; fuel, maintenance and insurance eat $25 to $35 of it, and a driver another $30 to $40 if you are not driving. Operators who thrive are patient with elderly and disabled riders, fanatical about punctuality, and comfortable with paperwork. What kills NEMT companies is a van sitting idle while credentialing drags on, an insurance premium the owner did not budget for, and drivers who no-show riders and get the company suspended.
Step 1: Pick your trip types and payer mix
NEMT has three service levels and four kinds of customers. The combination you choose determines your vehicle and your revenue.
Service levels
- Ambulatory: the rider walks or uses a cane or walker. Any sedan, minivan or SUV. Lowest rates ($20 to $45 base plus mileage), highest competition, fewest requirements.
- Wheelchair: the rider stays in a wheelchair, secured in a van with a ramp or lift. Rates run $45 to $80 base plus mileage. Brokers are frequently short on wheelchair capacity for early dialysis, which is why most new operators should start here.
- Stretcher (gurney): bed-bound riders who do not need medical monitoring. Requires a specially equipped van and two attendants, and in some states an ambulance-service license or a specific stretcher permit. Rates are $150 to $400 per trip. Not a starting point.
Payers
- Medicaid via a broker: 70 to 90 percent of most operators’ trips. Steady volume, fixed rates, slow pay, heavy paperwork. Brokers include ModivCare, MTM, Verida and Access2Care; each state contracts with one or a few. Medicare Advantage plans usually route through the same brokers.
- Facility contracts: dialysis chains, skilled nursing facilities and hospitals paying directly for discharges and transfers. Better rates, fewer trips, requires sales.
- Private pay: families paying $50 to $150 per one-way wheelchair trip. Highest margin, unpredictable volume, ideal fill-in.
Start with one wheelchair van, credential with your state’s broker, and add private pay and one facility contract in the first six months.
Step 2: Form the company and meet your state’s requirements
Entity, EIN, NPI
Form an LLC; you are transporting vulnerable people, and the liability is real. Get an EIN the same day, then apply for a Type 2 (organizational) NPI at the CMS NPPES site. It is free, takes about a week, and every Medicaid enrollment and broker application asks for it. Open a business bank account, because brokers pay by direct deposit to the business.
State NEMT requirements
There is no federal NEMT license. Requirements are set state by state, sometimes county by county, and fall into four buckets:
- Medicaid transportation provider enrollment, through the state Medicaid agency’s provider portal. Search “[state] Medicaid NEMT provider enrollment.”
- A transportation or livery permit from a state agency: the public utilities commission or DOT in some states, the health department in others. Texas routes providers through HHSC’s Medical Transportation Program; Florida providers meet AHCA and county Transportation Disadvantaged rules; California ties NEMT to Medi-Cal enrollment plus local livery permits. Call your state Medicaid agency and ask, “What permits does a new NEMT provider need before broker credentialing?”
- Vehicle requirements: annual inspection, ADA-compliant lift or ramp with a current inspection, four-point wheelchair securement, first aid kit, fire extinguisher, signage, and often a vehicle age or mileage limit (10 years or 250,000 miles is common).
- Driver requirements: a clean motor vehicle record (usually no more than two moving violations in three years), fingerprint background check, pre-employment and random drug testing, CPR and first aid, defensive driving, and passenger assistance training (PASS from CTAA is the common standard).
USDOT number
Vehicles designed for nine or more passengers including the driver, used for compensation across state lines, need a USDOT number. Most wheelchair minivans fall below that threshold, but many states require intrastate registration anyway and brokers frequently ask for the number. It is free and takes 20 minutes on the FMCSA site. Get it.
Watch out: Start the broker application in week one, not after you buy the van. Credentialing takes 60 to 120 days and everything else can happen in parallel. A van payment on an idle vehicle is the most common reason new NEMT companies run out of cash.
Step 3: Buy commercial auto insurance before anything else
Insurance is the biggest recurring cost and the first thing every broker checks. Personal auto policies exclude for-hire passenger transport entirely; do not drive a single paid trip without a commercial policy.
- Commercial auto liability: most brokers and states require a $1,000,000 combined single limit (some accept $500,000 for ambulatory-only, some want $1.5M). Expect $6,000 to $14,000 per vehicle a year, more in Florida, Louisiana, Michigan and New York, less in the Midwest. New operators pay at the top; three clean years bring it down.
- General liability ($1M/$2M): a fall at a pickup, damage at a facility. $500 to $1,200 a year.
- Abuse and molestation coverage: many brokers require it because you transport vulnerable adults. $400 to $1,500 a year.
- Hired and non-owned auto: if a driver ever uses their own vehicle. $300 to $600.
- Workers’ compensation: required in nearly every state once you hire a driver. $2,000 to $5,000 a year for one or two drivers.
Work with an agent who writes NEMT specifically; general commercial agents often cannot place the risk. Get the broker’s exact certificate requirements before you buy, including additional insured wording and 30-day cancellation notice, so the policy passes the first time.
Step 4: Choose and equip your vehicle
How to start a NEMT business with one used van
Your first vehicle decides your trip mix. A used side-entry wheelchair minivan (Toyota Sienna, Chrysler Pacifica or Dodge Grand Caravan conversions by BraunAbility or VMI) with a manual fold-out ramp is the workhorse of one-van NEMT companies. Rear-entry conversions are $8,000 to $15,000 cheaper but the rider cannot exit curbside. Full-size vans with hydraulic lifts carry two wheelchairs but cost more to buy, insure and fuel.
| Item | Lean start (used ambulatory minivan) | Full setup (used wheelchair van) |
|---|---|---|
| Vehicle | $12,000 | $38,000 |
| Wheelchair securement (Q’Straint or Sure-Lok 4-point), lap and shoulder belts | $0 | $1,200 |
| Ramp or lift inspection, first aid, fire extinguisher, signage, backup camera | $400 | $1,200 |
| Vehicle wrap or door lettering with company name and phone | $300 | $1,800 |
| Tablet or phone mount, dash cam, GPS, broker app device | $250 | $600 |
| LLC, EIN, permits, background checks, drug tests, training (owner) | $900 | $1,500 |
| Commercial auto plus general liability (first year, one vehicle) | $7,000 | $10,000 |
| Dispatch/trip software (first year) | $0 | $1,200 |
| Website, business cards, uniform shirts, facility flyers | $400 | $900 |
| Working capital for 60–90 days of broker payment lag | $3,000 | $8,000 |
| Total | $24,250 | $64,400 |
Buy used with a documented conversion and under 100,000 miles, get a pre-purchase inspection that includes the ramp or lift, and confirm the vehicle clears your state’s age and mileage limits with years to spare. Conversion dealers finance new businesses at 8 to 14 percent; a $38,000 van over five years is roughly $800 a month.
Step 5: Understand NEMT rates and do the math
Broker rates are set per state and per contract, not negotiated trip by trip. You will be given a rate sheet during credentialing. Facility and private-pay rates are yours to set. Typical 2026 ranges:
| Trip type | Broker base rate (one way) | Broker per mile | Private pay (one way) |
|---|---|---|---|
| Ambulatory | $20–$45 | $1.50–$3.00 | $35–$75 plus mileage |
| Wheelchair | $45–$80 | $2.50–$4.50 | $60–$150 plus mileage |
| Stretcher | $150–$300 | $4–$8 | $200–$400 plus mileage |
| Wait time (after 15–30 min) | $10–$25 per 15 min | — | $15–$30 per 15 min |
| No-show / late cancel | $0–$25 | — | 50–100% of fare |
Add-ons that brokers or private clients pay for: an extra attendant ($15 to $30 per trip), bariatric wheelchair ($15 to $40 more), after-hours or weekend surcharge (10 to 25 percent), stairs or a second floor with no elevator (private pay only, $25 to $50).
The monthly math for one wheelchair van
Ten one-way wheelchair trips a day at an average of $60 base plus 11 miles at $3 is $93 a trip, or $930 a day. Twenty-one working days is $19,530 in gross revenue. Costs: fuel at 160 miles a day ($900 a month), insurance ($850), van payment ($800), maintenance and tires ($350), software and phone ($150), cancellations and no-shows that pay nothing (assume 10 percent of trips, $1,950). That leaves about $14,500 before the driver. If you drive, that is your income before tax. If you pay a driver $20 an hour for 200 hours ($4,000 plus $600 in payroll taxes and workers’ comp), the van nets about $9,900 a month for the owner.
The 10-trip day is a realistic average once the broker trusts you, but your first two months will be closer to four to six trips a day while dispatch learns your reliability. Budget for it.
Step 6: Get online and pass the trust test
Brokers do not care about your website. Facilities, discharge planners and private-pay families do, and they are your highest-margin customers. A hospital social worker searching “wheelchair transportation [city]” at 3 p.m. to discharge a patient by 5 calls the first company that looks real, answers the phone and states a price.
Your site needs: the service levels you offer and what each includes (door-to-door, attendant, wheelchair provided or not), your service area by county, private-pay starting rates and how wait time is billed, a phone number answered by a person from 5 a.m. to 7 p.m., photos of your actual van and uniformed driver, a short section on driver screening, and a book-a-ride form that captures pickup, destination, appointment time, mobility level and payer. Add a page for facilities explaining standing orders and monthly invoicing.
You can have Restart build it: describe the company, your services and area, your private-pay rates and how you want facilities and families to reach you, and it builds the pages, writes the copy, designs the site and publishes it to a real URL. Change anything afterwards by asking, which you will do the first time you add stretcher service or a new county. Restart’s page on local businesses shows what similar companies have set up.
Set up a Google Business Profile under “Medical transportation,” list your hours honestly, and ask private-pay families and facility contacts for reviews. Reviews from the adult children of dialysis patients are the most persuasive marketing this business has.
Step 7: Get your first paid trips
Broker trips come once you are credentialed, but you can earn before then, and you should be building the payer mix that keeps you from depending entirely on one broker.
Channels that work for NEMT
- Dialysis center social workers. Every center has patients whose rides keep failing. Visit mid-morning with a one-page flyer, your rates and your COI, and ask to be the backup.
- Hospital discharge planners and case managers. They arrange same-day wheelchair and stretcher transport, often family-paid. Ask about their after-hours process.
- Skilled nursing and assisted living facilities. Residents need rides weekly. Offer a facility rate and monthly invoicing.
- Adult day programs, senior centers, home health and hospice agencies. Their staff see families struggling to get to appointments.
- Google Business Profile and your website for private-pay families. Answer the phone.
- Other transport operators. A medical courier or roadside assistance operator sees facilities daily and will refer riders they cannot serve.
What to say and what to charge
For the first five private-pay or facility trips, quote your standard rate with the first trip at 20 percent off and say so: “We’re new in [county] and want you to see how we operate.” Charge a flat $75 to $95 for a wheelchair trip under 10 miles, confirm it in writing before the trip, and collect by card at booking. Arrive 10 minutes early, secure the chair with all four points, text the family on drop-off, and ask the social worker for a Google review by name.
Once the broker turns you on, accept every trip you can for the first 60 days, including the 4:45 a.m. dialysis pickups no one wants. Dispatch systems rank providers by acceptance rate, on-time percentage and complaints; your first two months set your standing.
Tip: Keep a signed trip log for every ride with pickup and drop-off times, odometer readings and the rider’s signature, even for private pay. Brokers audit, Medicaid recoups, and the log is your only defense.
Step 8: Run it tight, then add vans
Daily operations
Confirm tomorrow’s trips by text the afternoon before. Route dialysis pickups so the last rider is dropped 15 minutes before chair time. Keep water and a spare manual wheelchair in the van. Inspect the ramp and securements every morning and log it. Submit trip logs the same day; brokers pay slower on late paperwork and deny trips over 30 to 60 days old.
One van runs on a spreadsheet and the broker’s app. Past that, NEMT-specific dispatch software (RouteGenie, Tobi, Bambi and similar) runs $100 to $300 a month per vehicle and handles broker trip imports, driver apps, GPS timestamps and billing exports.
Hiring your first driver
Your first hire is a second driver for your first van, so it runs 12 hours a day and you can take a day off. Pay $16 to $24 an hour. Recruit retirees, former CNAs and school bus drivers; they have the patience and the clean records. Every driver needs the full screening stack before their first trip. Budget $400 to $700 per hire and two to four weeks.
What three vans looks like
Three wheelchair vans with three drivers and you dispatching grosses $50,000 to $60,000 a month. You are no longer driving; you are managing schedules, chasing denied claims and covering for a driver who quit on a Tuesday. What breaks first is cash flow: broker payments lag 14 to 45 days while payroll is every two weeks, so you need $25,000 to $40,000 in working capital or a line of credit before the third van. What breaks second is insurance: one at-fault accident with an injured rider can push premiums up 30 to 50 percent at renewal. Dash cams and a strict no-phone policy are cheaper.
How much can you make?
| Level | Trips per month | Monthly revenue | Operating costs and driver labor | Owner net before tax |
|---|---|---|---|---|
| Side income (1 ambulatory van, evenings and weekends) | 90 | $4,500 | $2,000 | $2,500 |
| Full-time owner-operator (1 wheelchair van) | 210 | $19,500 | $5,000 | $14,500 |
| Small fleet (3 wheelchair vans, 3 drivers) | 600 | $56,000 | $43,000 | $13,000 |
For most people asking how to start a NEMT business, the owner-operator row is the target. It is the sweet spot for income relative to headaches: $14,000 to $15,000 in a good month, $9,000 in a slow one when a broker shifts volume or your van is in the shop. The three-van figure is what the owner keeps after paying three drivers and nothing for their own dispatching; many operators at this size earn less per hour than they did driving until they reach five or six vans. The ceiling is real, but by then it is a fleet-management business.
Mistakes that sink new NEMT owners
- Buying the van before applying to the broker. Ninety days of payments on an idle vehicle. Apply first, buy when you are 30 days from approval.
- Being 100 percent broker-dependent. When a state changes brokers or your region gets oversupplied, your volume halves overnight. Build facility and private-pay trips to at least 20 percent of revenue in year one.
- Underinsuring or lapsing. A lapsed COI gets you suspended by the broker the same day. Set the premium on autopay and calendar the renewal 60 days out.
- Sloppy trip logs. Missing signatures and odometer readings are denied claims. Complete the log before you pull away from the drop-off.
- Accepting trips you cannot make on time. One late dialysis pickup is a complaint; three is a suspension. Decline what you cannot do and your acceptance rate will still beat the provider who no-shows.
- Skipping the ramp inspection. A ramp that fails with a rider on it is a lawsuit and a lost contract. Inspect it every morning and log it.
- Hiring for availability instead of temperament. A driver who is rude to a confused 80-year-old costs you the facility. Ride along on the first three shifts.
Your first 30 days
Here is how to start a NEMT business in a month; credentialing will run longer, but everything else can be done.
Week 1
- Form the LLC, get the EIN, open the business bank account, apply for a Type 2 NPI.
- Call the state Medicaid agency; write down every permit a new NEMT provider needs.
- Start the broker credentialing application and the state Medicaid provider enrollment.
- Get a USDOT number.
- Build the website on Restart with services, area, private-pay rates and a book-a-ride form.
Week 2
- Get commercial auto quotes from two NEMT-specialist agents using the broker’s COI requirements.
- Complete owner background check, fingerprinting, drug test, CPR and first aid, and PASS training.
- Shop used wheelchair vans; schedule pre-purchase inspections that include the ramp or lift.
- Set up Google Business Profile.
Week 3
- Buy and insure the van; install securements, signage, dash cam, first aid kit and extinguisher.
- Schedule the state vehicle inspection and lift inspection.
- Print facility flyers with rates and COI; visit five dialysis centers and two hospital case management offices.
- Set private-pay rates and a written booking confirmation template.
Week 4
- Run your first private-pay or facility trips; collect signatures and a Google review.
- Submit vehicle and driver documents to the broker; follow up weekly by phone.
- Build the trip log, daily inspection log and confirmation call routine.
- Set aside working capital for the 60 to 90 days between broker approval and steady payments.
