The new NEMT owners I meet that go on to make it are the ones that obsess about trips. Not vans. They're asking who in their town needs rides, who pays for them, and how do they become the company that gets called. This guide will walk you through the exact steps to line up trips, file paperwork, make the right purchases, and get started.
What does a NEMT business do, and who pays for the rides?
A NEMT company runs wheelchair vans, ambulatory vehicles (regular cars and minivans for riders who can walk), and sometimes stretcher vans, taking riders to medical appointments they'd otherwise miss. The money comes from three places: Medicaid trips assigned through state-contracted brokers, direct contracts with facilities like dialysis clinics and nursing homes, and private-pay riders and families who book directly.
Medicaid is the volume. NEMT is a required Medicaid benefit in every state [1], but in most states you can't bill Medicaid directly for van transports. The state hires a broker (companies like Modivcare, MTM, Verida, or WellTrans), and you enroll in the broker's network. The broker assigns trips and pays you, usually at the lowest rates you'll see.
Facilities are the stability. One rehab hospital or dialysis clinic that trusts you can fill a van's whole day, and it keeps paying straight through a broker shakeup.
Private pay is the margin. Families booking directly pay 25 to 50 percent above broker rates [2], and the money arrives when the trip runs, not 45 days later.
I hear this confusion on demos constantly: software companies like Duet aren't brokers. A broker holds a state contract and assigns trips. Software is the tool you run trips on. Nobody's software sends you riders by itself.
How much does it cost to start a NEMT business?
Plan on $10,000 to $45,000 to get one vehicle on the road legally, with insurance as the number that surprises people. Where you land in that range depends less on your state than on your model. A broker-first launch is the floor: a clean used vehicle, the state paperwork, driver certifications, and an insurance down payment, with minimal branding because the broker sends the riders. A private-pay launch costs more up front: branding, a real website, marketing spend, and a vehicle nice enough to be the product.
| Line item | Typical range |
|---|---|
| Entity, EIN, NPI, state and local registrations | $100 to $600 (the EIN and NPI are free) |
| Driver certifications (CPR, first aid, securement, sensitivity) | $300 to $1,500 per driver |
| Commercial auto insurance | $5,000 to $12,000 per vehicle per year for wheelchair vans; down payment around 15 percent |
| Vehicle | Used wheelchair van $15,000 to $40,000; ambulatory sedan or minivan far less |
| Website, phone system, branding | $200 to $300 a month is a workable floor |
| Working capital | 3 to 6 months of expenses; broker payments arrive about 30 days after you invoice (net-30), sometimes slower |
Two numbers deserve your respect. Insurance: only a handful of carriers write NEMT commercial auto, new ventures pay a first-year surcharge, and brokers and facilities commonly ask for general liability ($1 million per claim, $2 million per year) on top, with workers' comp arriving at your first hires. Get quotes before you buy anything.
And the cash. First revenue has taken operators anywhere from 2 to 18 months, because licensing, getting your insurance active (binding), and getting approved by the broker (credentialing) all have queues you don't control. Break-even comes months after that, and even paying customers pay slowly: a facility may send your money 60 days after the trip. The $10,000 to $45,000 only puts the vehicle on the road, so save 3 to 6 months of expenses on top of it to cover the gap between running trips and getting paid, and keep the day job until the trips say otherwise.
What are the steps to start a NEMT business?
Starting a non-emergency medical transportation business takes twelve steps, ordered so the big commitments (the vehicle, the insurance) come after the steps that prove you'll have trips.
- Identify your demand. There's no point filing paperwork until you know where your trips will come from. Are you going after broker trips? Does your area have plenty of private-pay riders? Is your cousin a nurse whose facility is desperate for a reliable transport company? Then learn your market's rates: call the transport companies in town and price a wheelchair trip like a customer would.
- Read your state's actual application. Find your state's NEMT provider application (usually at the state Medicaid agency, its transportation broker, or the public service commission) and read it before you spend a dollar. It tells you the insurance minimums, vehicle rules, driver requirements, and disqualifiers. The state guides below walk the states we've mapped.
- Form the business. An LLC through your Secretary of State (typically $50 to $300), then a free EIN from the IRS. Takes a day.
- Get your NPI. An NPI is the ID number the healthcare system uses for your company. Apply at NPPES: pick Type 2 (organization) and taxonomy 343900000X, non-emergency medical transport [3]. It's free, and usually issued within days. Third-party sites charge $500 or more to fill it out; don't be the person who pays that. Private-pay-only operators can technically skip it, but skipping it closes broker, health-plan, and VA doors, so get it anyway.
- Line up state operating authority. Many states require a permit to carry passengers for money before you can run trips; states call it motor carrier registration, operating authority, a certificate, or a permit. Some cities and counties layer their own licenses on top, and some states exempt small medical-transport vehicles entirely. It's the step people most often discover late.
- Price your insurance before you commit to anything. Call an agent who actually writes NEMT (ask other operators who they use). Know your real premium, the broker's required limits, and the down payment. Some jurisdictions won't issue your local license until insurance is active.
- Validate demand in person. Before the van, check what you found in step 1 on foot: walk into facilities and talk to the social workers, nurses, and discharge planners who book rides, and to residents and their families. Ask the broker where its network has need. If your area is saturated, you want to know before you're holding a $40,000 vehicle.
- Set up your website and Google Business Profile. Build both around the trips you found in step 1: if your area needs dialysis runs, say that on the homepage; if it's private-pay families, put the booking number front and center. You can build a site yourself with AI for very cheap, or we'll build you one optimized to show up on Google and ChatGPT. Add profiles on Yelp, Facebook, and the other directories too, especially if you're skipping the brokers.
- Buy the vehicle. Used and mechanically sound beats new debt for a first van. Match the vehicle to your model: a spotless late-model van if you're selling premium private pay, a workhorse if brokers will send the volume.
- Hire and certify drivers, or certify yourself. Most states don't require a CDL under 16 passengers [4], but background checks, drug testing, and certifications like CPR, first aid, wheelchair securement, and HIPAA privacy training come standard, whether the state requires them or your broker does. Screen yourself and every driver against the OIG exclusion list and SAM.gov (the federal lists of people banned from Medicaid work); brokers check, and it's free.
- Spread the word and collect reviews. Tell your family and friends, and post about the business on your personal social media. Offer friends and family free or deeply discounted rides in exchange for an honest Google review. Ten glowing reviews make it much easier to win private-pay and facility work from strangers; your reviews are your references.
- Enroll with payers and start selling. Apply to the broker network and start facility outreach the same week. Broker credentialing takes weeks to months; sell while you wait.
Should you start with broker trips, facility contracts, or private pay?
Start selling facilities and private pay from day one, and treat broker enrollment as the safety net that fills empty slots. Broker trips are the easiest to get and the easiest to lose, and the operators who build entire schedules on one broker keep learning the same lesson.
Christopher Buell built his company into his state broker's top-ranked provider, and was dropped in a week. His rule now: let a broker be about 10 percent of your capacity, maybe 15 in year two. "You're a glorified employee of that broker," he told me on our podcast [5]. "You get to buy the tires and deal with the employees, without the benefits."
Broker trips do have real value early. They generate revenue while your facility relationships grow, they teach you dispatch on someone else's marketing dollar, and in thin markets they may be most of what exists. One operator eleven years in holds a 60/40 private-to-broker mix on purpose, and in states with several brokers, some operators run four or five broker contracts so no single loss sinks the schedule. The failure mode isn't taking broker trips. It's building a company where one contract you don't control decides whether you exist. In 2026 alone, at least seven states changed Medicaid NEMT brokers or announced they would, and Georgia's transition stranded a statewide pool of providers who were all-in on the loser. Here's who runs your state now.
To run the facility motion, start with how to win NEMT facility contracts; for the direct-booking side, the private pay guide covers pricing and marketing.
How long until a NEMT business is profitable?
Expect a lean first year. One owner-operator projected $25,000 to $30,000 in year-one revenue on one van and made about half that. Nothing about the business was broken. That's what year one looks like when you're learning to fill a schedule.
The benchmark I give new providers: it takes a couple of months minimum to reach 100 trip legs a month (a leg is one one-way ride), and one van roughly tops out there. Growing past it means a second vehicle. From there, the operators who make it grow on capacity triggers, not hope: add the vehicle when you're turning down trips, add the driver when the schedule overflows, take a salary when the margin supports it.
And the upside is real. I've interviewed operators who went from zero to five vans in a year, and I've seen companies crawl for years at a vehicle or two before revenue multiplied tenfold. NEMT scales. It just scales on systems and trip sources rather than on vehicles bought ahead of demand. And the demand is coming to meet you: by 2034, adults 65 and older are projected to outnumber children in America for the first time [6].